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University of Alabama
The efficacy of home-delivered cognitive-behavioral therapy (CBT) in improving quality of life and
reducing psychological symptoms in older adults was examined in this study. One hundred thirty-four
participants, predominately African American and characterized as primarily rural, low resource, and
physically frail, were randomly assigned to either CBT or a minimal support control condition. Results
indicate that CBT participants evidenced significantly greater improvements in quality of life and
reductions in psychological symptoms. Mediation of treatment through cognitive and behavioral variables was not found despite the acceptable delivery of CBT by research therapists. These data suggest
that treatment can be effective with a disadvantaged sample of older adults and extend efficacy findings
to quality of life domains. Creating access to evidence-based treatments through nontraditional delivery
is an important continuing goal for geriatric health care.
Keywords: quality of life, rural, CBT, older adults
Editors Note.
article.RTZ
Forrest Scogin and Martin Morthland, Department of Psychology, University of Alabama; Allan Kaufman, School of Social Work, University of
Alabama; Louis Burgio, Department of Psychology and the Center for
Mental Health and Aging, University of Alabama; William Chaplin and
Grace Kong, Department of Psychology, St. Johns University.
This research was supported by National Institute on Aging Grant
AG16311. We thank Peggye Dilworth-Anderson, Larry Beutler, and
Grover Wedgeworth of the Alabama Department of Public Health for their
contributions to this project.
Correspondence concerning this article should be addressed to Forrest
Scogin, Department of Psychology, University of Alabama, Tuscaloosa,
AL 35487-0348. E-mail: fscogin@as.ua.edu
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SCOGIN ET AL.
658
Method
Participants and Recruitment
Inclusion criteria for participation were as follows: (a) age of 65
years or older, (b) a T score of 55 or below on the Quality of Life
Measures
Background information. Information was obtained on age,
gender, race, marital status, educational attainment, income, and
subjective financial burden.
Functional impairment. Functional impairment was measured
by a compilation of the 23-item Functional Assessment of Physical
Functioning (Ettinger et al., 1994) and seven items from the
Functional Independence Measure (Granger & Hamilton, 1987).
This 30-item scale measures activities of daily living and instrumental activities of daily living. Item responses range from Usually did with no difficulty to Unable to do with an option for an
unscored Never did. The average of all scored items is the
functional impairment index. Cronbachs alpha at Time 1 was .95.
Health status. Health status was evaluated through several
means. We used a self-reported one-item rating of general health
and asked participants about the presence of seven common comorbid medical conditions (Wisniewski et al., 2003). The general
health rating ranged from 1 poor to 6 excellent. The seven
comorbid medical conditions were arthritis, high blood pressure,
heart condition, chronic lung disease, diabetes, cancer, and stroke.
Procedure
Persons interested in participating were contacted by telephone
and given a brief overview of the project. For those with continued
interest, potential eligibility was ascertained by administering four
items from the QOLI and 10 items from the SCL-90-R. For those
with probable inclusive scores, an in-home Time 1 assessment was
scheduled. The Time 1 assessment included a detailed description
of study procedures and participant informed consent, followed by
gathering of sociodemographic information and counterbalanced
administration of the outcome and mediator measures.
Research assistants conducted standardized assessments in participants homes. Measures were read to participants to minimize
problems associated with low literacy and sensory limitations.
Response cards were used to aid participants. Participants received
659
a $25 gift card for the completion of each assessment. All assessments were audiotaped, and 20% were reviewed to ensure adherence to the assessment protocol.
Participants were randomized to CBT or the minimal support
condition (MSC) following baseline assessment. The randomization process involved stratifying participants on the basis of two
variables: site location (Tuscaloosa or Montgomery) and race
(African American or Caucasian). Among each of the four stratified groups, assignment to CBT or the MSC was decided on the
basis of a random number table. Research assistants were blind to
assignment at the time of baseline assessment.
Following randomization, participants in the CBT condition
were assessed on outcome and mediator variables at midtreatment
and immediately posttreatment (Time 2). The midtreatment assessment was undertaken to allow testing of temporal relations between mediator and outcome measures; this assessment also
served as an endpoint for those who received partial treatment.
Those assigned to the MSC were assessed a second time approximately 3 months following randomization. Thus, the controlled
comparison in this study was between the Time 1 and Time 2
assessments for the two conditions. Following Time 2 assessment,
MSC participants received CBT as outlined above. These data are
not included in the results presented here. All participants were
assessed a final time 6 months following the CBT intervention.
These data will be presented in a separate article.
Treatment
The therapists were five licensed Masters of Social Work
(MSW) clinical social workers (two African Americans and three
Caucasians) without prior CBT experience. We chose masterslevel therapists to accentuate external validity and translation of
the intervention as these are the persons who would most likely be
the personnel to administer the intervention in current service
agencies. Training of the therapists was conducted by the principal
investigators and consultants over four sessions that included 12 hr
of didactic instruction and 12 hr of experiential training. Feedback
was provided until competency was achieved on the basis of the
Cognitive Therapy Scale (CTS; Young & Beck, 1980). Weekly
group supervision was conducted with the therapists.
CBT. Treatment followed the manual developed by L. W.
Thompson, Gallagher-Thompson, and Dick (1995) for the delivery
of CBT to older adults. The standard course of treatment was 16
sessions with the opportunity to extend treatment to 20 sessions if
needed. Twice-weekly sessions were planned for the 1st month
with weekly sessions planned for the remainder of the treatment.
Major components of the treatment included activity scheduling,
identifying and changing unhelpful thoughts, relaxation, and assertiveness. The treatment protocol developed by L. W. Thompson
et al. included modifications of traditional CBT for use with older
adults, such as providing in-session cue cards as memory aids,
slowing down the pace of the intervention process, and simplification of homework assignments. We made a further modification
for use with our largely frail sample by encouraging the inclusion
of an intervention facilitator where available. Our rationale for the
facilitator was that we anticipated that many of our participants
would have difficulty in enacting treatment recommendations
without the aid of another because of physical and cognitive
limitations. We also believed that having an indigenous facilitator
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SCOGIN ET AL.
Results
Participants
Figure 1 shows the flow of participants through the study. One
hundred thirty-four persons completed a baseline (Time 1) assessment and were randomized to the experimental conditions. Characteristics of the sample are presented in Table 1, and dependent
and mediational variable means and standard deviations by time
and condition are presented in Table 2. This sample is mostly
female (83%), predominately African American (57%), and somewhat older (M 75.4 years) than typically seen in community
intervention studies with older adults. The average MMSE score
(M 24.9) and educational levels (M 9.6 years) are also
relatively low, whereas the self-rated health status of the participants is relatively poor, consistent with our recruitment strategy.
Participants indicated they were experiencing on average three of
the seven comorbid chronic health conditions we assessed. The
participants reported moderate functional impairment as illustrated
by a mean score of 4.24 on the item Climbing several flights of
stairs and a mean score of 2.79 on the item Preparing your own
meals. There were no differences at Time 1 between the experimental conditions on any variables. African American and White
participants were also compared on Time 1 variables, and only
differences in years of education and MMSE scores were statistically different, with African American participants having lower
values.
Attrition
Statistical Analyses
All analyses used a critical alpha level of .05 for determining
statistical significance; exact levels are reported unless they are
661
70 Not Interested
55 Ineligible
134 Randomized
Time 1 (Baseline)
7 Did Not
Begin CBT
70 CBT
64 MSC
14 Withdrew
12 Withdrew
Time 2
CBT
51 Assessed
MSC
50 Assessed
Figure 1. Flow of participants through study. Withdrew indicates participants discontinued for reasons
including (a) moved in with family, lost interest, no time/too busy, family reasons; (b) died, became too
medically frail, moved into an institutional setting; or (c) moved with no trace, lost contact. Time 2 for the
cognitive-behavioral therapy (CBT) condition is the endpoint assessment, either the midtreatment or posttreatment assessment. MSC minimal support condition.
Outcomes
Examination of score distributions on the QOLI and GSI variables revealed several extreme values or outliers, and winsorizing
(Dixon & Tukey, 1968) transformations were used to minimize the
effects of these extreme scores on the analyses. Winsorizing has
been suggested as a data cleaning tool that maintains the size of the
sample and minimally affects the mean of a distribution while
reducing its variability. We used mixed regression analyses to test
the effect of treatment on the outcomes. For the QOLI, the model
parameters for the test of the interaction were 1.2 for time, indicating a general increase in the QOLI of 1.2 points between each
assessment time for both groups; 0.46 for treatment group, indicating a baseline difference of about half a point between the
groups; and, most critically, for the Time Treatment interaction,
the parameter estimate was 4.75 (z 4.25, p .001), indicating
an additional increase in the QOLI score of close to five points
between each assessment time for the CBT group compared to the
MSC group. For the GSI, the parameter estimates were 2.0 for
Time, indicating a general decrease in the GSI of two points
between each assessment time; 1.5 for Group, indicating a
1.5-point difference between the groups at baseline; and, most
critically, for the Time Treatment interaction the parameter
estimate was 1.91 (z 2.37, p .02), indicating an additional
decrease in the GSI at each assessment time for the CBT group
compared to the MSC group. The effect sizes associated with the
CBT versus MSC endpoint comparisons, expressed as d, are 0.62
for the QOLI and 0.46 for the GSI. These are considered to be of
moderate magnitude. Figures 2 and 3 show the estimated mean
values across time for the QOLI and GSI as a function of experimental assignment.
We were able to conduct analyses to determine whether the
treatment effects differed by ethnicity, as would be indicated by
Ethnicity Time Experimental Condition interactions, because
there were adequate numbers of both African American and White
participants in the sample. There was a significant three-way
interaction on the QOLI, with African American participants
showing a stronger response to treatment than the White participants. The parameter estimate for the three-way product was
4.59 (z 2.08, p .04) indicating that the increase in QOL
due to treatment was about 4.5 points lower for the White participants than for the African American participants. Subgroup analyses indicated that both African American and White participant
groups showed significant improvements in QOL. There was no
moderation by ethnicity on the GSI, nor did gender or mental
status moderate either of the outcome variables.
Mediators
CBT is theorized to produce beneficial effects through mechanisms that include increased engagement in pleasant events and
decreases in dysfunctional thinking. In the present study, we used
the OAPES and BHS to explore the role of these variables in the
treatment response. First, we were interested in whether there was
a significant change in OAPES and BHS scores as a function of
treatment. The Time Experimental Condition interactions were
not significant, indicating that the treatment did not impact these
mediators. There was no further testing of mediation given these
nonsignificant findings.
SCOGIN ET AL.
662
Table 1
Pretreatment Sample Characteristics
M SD or (N%)
Variable
75.4 7.1
Age
Gender
Women
Men
Race/ethnicity
African American/Black
Caucasian/White
Years of education
08
911
12
1316
1720
Income
$0$4,999
$5,000$9,999
$10,000$14,999
$15,000$19,999
$20,000$49,999
$50,000$70,000
Income adequacy
Not difficult
Not very difficult
Somewhat difficult
Very difficult
Marital status
Never married
Married
Widowed
Divorced
Separated
Self-reported level of health
Poor
Fair
Good
Very good
Excellent
Comorbidity
MMSE
111 (82.8)
23 (17.2)
77 (57.5)
57 (42.5)
49 (36.6)
33 (24.6)
29 (21.6)
20 (14.9)
3 (2.2)
3 (2.2)
59 (44.0)
25 (18.7)
9 (6.7)
11 (8.2)
3 (2.2)
14 (10.4)
17 (12.7)
50 (37.3)
49 (36.6)
8 (6.0)
27 (20.1)
78 (58.2)
12 (9.0)
8 (6.0)
46 (34.3)
60 (44.8)
18 (13.4)
6 (4.5)
2 (1.5)
3.05 (1.3)
24.9 3.5
Health Status
We were also interested in the effects of CBT on health status.
For the Time Treatment interaction on the general health rating,
the parameter estimate was 0.29 (z 3.79, p .001), indicating
an additional increase in perceived health of 0.29 on the rating
scale between assessments. CBT participants reported improvement in their general health status, whereas MSC participants
basically were unchanged. The effect size on this variable was
0.76, considered of moderate magnitude. We did not find significant interactions on our measure of health-care use.
Discussion
The results of this study indicate that home-delivered CBT
improved QOL and reduced psychological symptoms for a sample
663
Table 2
Means (SDs) of Predictor and Outcome Variables by Time and Condition
Time 1
Measures
QOLI
SCL-90 (GSI)
BHS
OAPES
General health rating
Formal care & services
Functional impairment
Time 2
CBT
MSC
CBT
MSC
42.64 (9.22)
(n 70)
60.00 (7.05)
(n 70)
5.93 (4.15)
(n 70)
2.72 (0.63)
(n 69)
2.00 (0.95)
(n 70)
1.58 (1.09)
(n 69)
2.80 (0.85)
(n 69)
42.88 (8.83)
(n 64)
61.05 (7.91)
(n 64)
5.66 (3.31)
(n 64)
2.53 (0.62)
(n 64)
1.84 (0.83)
(n 62)
1.70 (1.12)
(n 63)
3.13 (0.95)
(n 64)
53.76 (13.94)
(n 51)
53.96 (8.12)
(n 50)
5.39 (4.29)
(n 51)
2.80 (0.64)
(n 51)
2.64 (0.98)
(n 42)
1.45 (1.18)
(n 40)
2.49 (0.84)
(n 42)
45.26 (13.42)
(n 50)
58.42 (10.88)
(n 50)
5.29 (3.88)
(n 48)
2.62 (0.59)
(n 48)
1.91 (0.95)
(n 47)
1.78 (1.31)
(n 49)
3.06 (1.03)
(n 48)
Note. CBT cognitive-behavioral therapy; MSC minimal support condition; QOLI Quality of Life
Inventory; SCL-90 (GSI) Symptoms Checklist-90 (Global Severity Index); BHS Beck Hopelessness Scale;
OAPES Older Adult Pleasant Events Schedule.
60
70
MSC
CBT
40
60
MSC
CBT
50
20
Time 1
Time 2
40
Time 1
Time 2
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SCOGIN ET AL.
Limitations
Several limitations to this study should be noted. First, the
design of the study does not allow us to unequivocally ascribe the
improvements made by the participants to the ingredients of CBT.
For example, the effects may have been due to the attention and
concern provided by the research therapists rather than the specific
focus of CBT on behavioral activation and cognitive processes.
These common factors are known to be important aspects of
psychotherapy change. The lack of significant change on the BHS
and OAPES is also consistent with this explanation. A more formal
test of the specificity of CBT would control for such factors.
Another limitation of the study was that some participants received
CBT with the assistance of facilitation, whereas other participants
did not have an available or willing facilitator. Although we found
no evidence in our analyses that the presence of the facilitator
impacted outcome, this was an uncontrolled factor and warrants
further investigation. Another limitation was that a relatively high
percentage of participants received only partial treatment rather
than the full course of CBT. However, we still found a significant
effect for treatment even with these participants included, on the
basis of intent-to-treat principles, in the primary analyses. Although the effect of treatment may have been stronger had participants received all sessions, our results suggest that a more abbreviated course of treatment may still be effective for populations
similar to those involved in this study. Indeed, many service
agencies may not have the resources to offer 16 20 sessions to
their consumers. Extracting the most essential aspects of the intervention would assist this process of translation from a research
study to the field, but efforts to shorten the protocol must be
sensitive to the extra time needed by some older adults to understand and act on treatment recommendations. As always, treatment
should be as brief as possible but not too brief.
Another limitation is the unknown durability of the effects
evidenced by participants. Analyses of follow-up data will be
forthcoming and reported in a subsequent article.
Summary
In summary, CBT was more effective, compared to those in the
MSC group, in improving the QOL and psychological symptoms
of this sample of older adults. This finding adds to a substantial
body of literature supporting the efficacy of this intervention with
anxiety (Ayers et al., 2007), depression (Scogin et al., 2005),
caregiver distress (Gallagher-Thompson & Coon, 2007), sleep
(McCurry et al., 2007), and several other disorders and problems
frequently experienced by older adults. The broad efficacy base for
CBT and similar psychological treatments corresponds well to a
growing recognition that many older adults report a preference for
such treatments (Gum et al., 2006; Rokke & Scogin, 1995). Attention to such patient preferences is a cornerstone of evidencebased practice according to the American Psychological Association (APA Presidential Task Force on Evidence-Based Practice,
2006). The other elements of evidence-based practice, such as use
of evidence-based treatments by skilled clinicians, comport well
with the results of this study and suggest that CBT delivered by
trained providers can improve the well-being of an often overlooked portion of the population. The particular way in which
treatment was delivered in this study will need translation to more
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