Internet-delivered cognitive behavioral therapies for late-life depressive symptoms: a systematic review and meta-analysis

Layperson-Supported, Web-Delivered Cognitive Behavioral Therapy for Depression in Older Adults: Randomized Controlled Trial

BACKGROUND

Depression is the most prevalent mental health condition in older adults. However, not all evidence-based treatments are easily accessible. Web-delivered cognitive behavioral therapy (wCBT) facilitated by laypersons is a viable treatment alternative.

OBJECTIVE

This randomized controlled trial aims to evaluate the efficacy of a novel wCBT program, Empower@Home, supported by trained lay coaches, against a waitlist attention control. Empower@Home is among the very few existing wCBT programs specifically designed for older adults. The primary objective was to assess the efficacy of the intervention compared with attention control. The secondary objective was to evaluate the program's impact on secondary psychosocial outcomes and explore potential change mechanisms.

METHODS

Older adults (N=70) were recruited via web-based research registries, social media advertisements, and community agency referrals and randomly assigned to either the intervention or control group in a 1:1 allocation ratio. The intervention group received access to Empower@Home, which included 9 web-delivered self-help lessons and weekly telephone coaching sessions by a trained layperson over 10 weeks. The control group received weekly friendly phone calls and depressive symptom monitoring. The primary clinical outcome was the severity of depressive symptoms assessed using the Patient Health Questionnaire-9. The secondary clinical outcomes included anxiety, anger, social isolation, insomnia, pain intensity, and quality of life. Linear mixed modeling was used to determine the treatment effects on depression, and 2-tailed t tests were used to assess within-group changes and between-group differences.

RESULTS

Most participants in the intervention group completed all 9 sessions (31/35, 89%). The usability and acceptability ratings were excellent. The intervention group had a large within-group change in depressive symptoms (Cohen d=1.22; P<.001), whereas the attention control group experienced a medium change (Cohen d=0.57; P<.001). The between-group effect size was significant, favoring the intervention group over the control group (Cohen d=0.72; P<.001). In the linear mixed model, the group-by-time interaction was statistically significant (b=-0.68, 95% CI -1.00 to -0.35; P<.001). The treatment effects were mediated by improvements in cognitive behavioral therapy skills acquisition; behavioral activation; and satisfaction with the basic psychological needs of autonomy, competence, and relatedness. Furthermore, the intervention group showed significant within-group improvements in secondary psychosocial outcomes, including anxiety (P=.001), anger (P<.001), social isolation (P=.02), insomnia (P=.007), and pain (P=.03). By contrast, the control group did not experience significant changes in these outcome domains. However, the between-group differences in secondary outcomes were not statistically significant, owing to the small sample size.

CONCLUSIONS

Empower@Home, a wCBT program supported by lay coaches, was more efficacious in reducing depressive symptoms than friendly telephone calls and depression symptom monitoring. Future studies should examine the effectiveness of the intervention in community and practice settings using nonclinician staff already present in these real-world settings as coaches.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05593276; https://clinicaltrials.gov/ct2/show/NCT05593276.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/44210.

Efficacy of Internet-Based Cognitive Behavioral Therapy for Subthreshold Depression Among Older Adults in Institutional Long-Term Care Settings: Pragmatic Randomized Controlled Trial

BACKGROUND

Subthreshold depression (sD) is prevalent in older populations in long-term care (LTC) settings, but psychological therapy in LTC settings in China is not readily available. Thus, internet-based cognitive behavioral therapy (ICBT) may be suitable for this population, but research on the efficacy of ICBT for older adults with sD, especially those living in LTC settings, is limited.

OBJECTIVE

This study aimed to evaluate the efficacy and acceptability of ICBT treatment for sD among LTC residents in China. We also examined whether ICBT is as effective as group-based cognitive behavioral therapy (CBT) for treating sD in this population.

METHODS

We conducted a pragmatic randomized controlled trial, which included 18 LTC institutions. A total of 354 participants were randomized to ICBT, group-based CBT, or a waiting list and were followed up for 12 months. The primary outcome was self-reported depressive symptoms on the Center for Epidemiological Studies Depression Scale (CES-D). Secondary outcomes were the scores of the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7-Item (GAD-7), and Geriatric Depression Scale (GDS). A mixed-effects model was used to assess the efficacy of ICBT.

RESULTS

The ICBT group showed a significant improvement in self-reported depressive symptoms, which was maintained at the 12-month follow-up (all P<.001). The ICBT group exhibited a significantly larger reduction in the scores of the CES-D (Cohen d=0.07, 95% CI 0.04-0.09; P=.01), PHQ-9 (d=0.30, 95% CI 0.28-0.33; P<.001), GDS (d=0.10, 95% CI 0.08-0.13; P<.001), and GAD-7 (d=0.19, 95% CI 0.17-0.22; P<.001) compared with a waiting list at postintervention. ICBT had significantly stronger effects than CBT on the PHQ-9 and GAD-7 at postintervention (d=0.15, 95% CI 0.13-0.17; P<.001 and d=0.21, 95% CI 0.19-0.23; P<.001, respectively), 6-month follow-up (d=0.18, 95% CI 0.16-0.21; P<.001 and d=0.18, 95% CI 0.15-0.21; P<.001, respectively), and 12-month follow-up (d=0.15, 95% CI 0.11-0.19; P<.001 and d=0.18, 95% CI 0.14-0.21; P<.001, respectively).

CONCLUSIONS

ICBT is a relatively effective and acceptable intervention for reducing depressive symptoms among Chinese LTC residents with sD. These findings indicate the usefulness of ICBT application for sD in LTC settings.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000030697; https://www.chictr.org.cn/showproj.aspx?proj=50781.

The latest developments with internet-based psychological treatments for depression

INTRODUCTION

Internet-based psychological treatments for depression have been around for more than 20 years. There has been a continuous line of research with new research questions being asked and studies conducted.

AREAS COVERED

In this paper, the author reviews studies with a focus on papers published from 2020 and onwards based on a Medline and Scopus search. Internet-based cognitive behavior therapy (ICBT) programs have been developed and tested for adolescents, older adults, immigrant groups and to handle a societal crisis (e.g. COVID-19). ICBT works in regular clinical settings and long-term effects can be obtained. Studies on different treatment orientations and approaches such as acceptance commitment therapy, unified protocol, and tailored treatments have been conducted. Effects on quality-of-life measures, knowledge acquisition and ecological momentary assessment as a research tool have been reported. Factorial design trials and individual patient data meta-analysis are increasingly used in association with internet intervention research. Finally, prediction studies and recent advances in artificial intelligence are mentioned.

EXPERT OPINION

Internet-delivered treatments are effective, in particular if therapist guidance is provided. More target groups have been covered but there are many remaining challenges including how new tools like artificial intelligence will be used when treating depression.

Internet-delivered psychological interventions for older adults with depression: A scoping review

BACKGROUND

Depression is prevalent among older adults, and internet-delivered psychological interventions (IDPIs) have emerged as a promising solution.

AIM

To explore the landscape of IDPIs for late-life depression, examining current characteristics, psychotherapies, intervention strategies, facilitators, and barriers.

METHOD

Guided by a PRISMA-guided scoping review, we systematically searched five electronic databases.

RESULTS

25 relevant studies were identified. IDPIs were used for treatment, prevention, and assessment. Internet-based cognitive behavioral therapy was the most common psychotherapy. Seven strategies to provide tailored services include psychotherapy courses, professional involvement, mood and progress tracking, virtual community, timed reminders, additional learning resources, and gamification elements. Barriers contained cognitive impairment, low digital literacy, device inaccessibility, limited depression awareness, adherence issues, and acclimation time, while facilitators included prior treatment experience, real-life character stories, strong client-worker bonds, and integration into daily care routines.

CONCLUSION

IDPIs present an accessible and convenient avenue for older adults. Future directions suggest exploring minimalist interventions, diverse strategies, and optimized implementation to amplify IDPIs impact among this vulnerable group.

Predictors of Dropout Among Psychosomatic Rehabilitation Patients During the COVID-19 Pandemic: Secondary Analysis of a Longitudinal Study of Digital Training

BACKGROUND

High dropout rates are a common problem reported in web-based studies. Understanding which risk factors interrelate with dropping out from the studies provides the option to prevent dropout by tailoring effective strategies.

OBJECTIVE

This study aims to contribute an understanding of the predictors of web-based study dropout among psychosomatic rehabilitation patients. We investigated whether sociodemographics, voluntary interventions, physical and mental health, digital use for health and rehabilitation, and COVID-19 pandemic-related variables determine study dropout.

METHODS

Patients (N=2155) recruited from 4 psychosomatic rehabilitation clinics in Germany filled in a web-based questionnaire at T1, which was before their rehabilitation stay. Approximately half of the patients (1082/2155, 50.21%) dropped out at T2, which was after the rehabilitation stay, before and during which 3 voluntary digital trainings were provided to them. According to the number of trainings that the patients participated in, they were categorized into a comparison group or 1 of 3 intervention groups. Chi-square tests were performed to examine the differences between dropout patients and retained patients in terms of sociodemographic variables and to compare the dropout rate differences between the comparison and intervention groups. Logistic regression analyses were used to assess what factors were related to study dropout.

RESULTS

The comparison group had the highest dropout rate of 68.4% (173/253) compared with the intervention groups' dropout rates of 47.98% (749/1561), 50% (96/192), and 42.9% (64/149). Patients with a diagnosis of combined anxiety and depressive disorder had the highest dropout rate of 64% (47/74). Younger patients (those aged <50 y) and patients who were less educated were more likely to drop out of the study. Patients who used health-related apps and the internet less were more likely to drop out of the study. Patients who remained in their jobs and patients who were infected by COVID-19 were more likely to drop out of the study.

CONCLUSIONS

This study investigated the predictors of dropout in web-based studies. Different factors such as patient sociodemographics, physical and mental health, digital use, COVID-19 pandemic correlates, and study design can correlate with the dropout rate. For web-based studies with a focus on mental health, it is suggested to consider these possible dropout predictors and take appropriate steps to help patients with a high risk of dropping out overcome difficulties in completing the study.

Application and Mechanisms of Internet-Based Cognitive Behavioral Therapy (iCBT) in Improving Psychological State in Cancer Patients

This review article is an overview of the effectiveness of internet-based cognitive behavioral therapy (iCBT) in Improving Psychological State in Cancer Patients. iCBT's effectiveness has been investigated in treating and managing conditions like depression, psychiatric disorders, generalized anxiety disorder (GAD), panic disorder, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), adjustment disorder, bipolar disorder, chronic pain, and phobias. iCBT's role in the treatment of medical conditions such as diabetes mellitus with comorbid psychiatric illnesses was also explored. We conducted a thorough literature search using PubMed, Embase, Google Scholar, and Wanfang with no restrictions on the date. iCBT's role in treating and controlling psychiatric illnesses in cancer patients has been established in the literature. Development and popularization of iCBT, treament forms of iCBT, platforms for iCBT, application of iCBT, strategies and efficacy of iCBT for insomnia in cancer patients, current status of iCBT application, and genetic researches on iCBT for anxiety disorders were all reviewed and discussed in this review. From the data compiled, we conclude that iCBT is useful in treating or improving psychological state in cancer patients.

Depression and Suicide Risk Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Depression is common and associated with substantial burden. Suicide rates have increased over the past decade, and both suicide attempts and deaths have devastating effects on individuals and families.

Objective

To review the benefits and harms of screening and treatment for depression and suicide risk and the accuracy of instruments to detect these conditions among primary care patients.

Data Sources

MEDLINE, PsychINFO, Cochrane library through September 7, 2022; references of existing reviews; ongoing surveillance for relevant literature through November 25, 2022.

Study Selection

English-language studies of screening or treatment compared with control conditions, or test accuracy of screening instruments (for depression, instruments were selected a priori; for suicide risk, all were included). Existing systematic reviews were used for treatment and test accuracy for depression.

Data Extraction and Synthesis

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Findings were synthesized qualitatively, including reporting of meta-analysis results from existing systematic reviews; meta-analyses were conducted on original research when evidence was sufficient.

Main Outcomes and Measures

Depression outcomes; suicidal ideation, attempts, and deaths; sensitivity and specificity of screening tools.

Results

For depression, 105 studies were included: 32 original studies (N=385 607) and 73 systematic reviews (including ≈2138 studies [N ≈ 9.8 million]). Depression screening interventions, many of which included additional components beyond screening, were associated with a lower prevalence of depression or clinically important depressive symptomatology after 6 to 12 months (pooled odds ratio, 0.60 [95% CI, 0.50-0.73]; reported in 8 randomized clinical trials [n=10 244]; I2 = 0%). Several instruments demonstrated adequate test accuracy (eg, for the 9-item Patient Health Questionnaire at a cutoff of 10 or greater, the pooled sensitivity was 0.85 [95% CI, 0.79-0.89] and specificity was 0.85 [95% CI, 0.82-0.88]; reported in 47 studies [n = 11 234]). A large body of evidence supported benefits of psychological and pharmacologic treatment of depression. A pooled estimate from trials used for US Food and Drug Administration approval suggested a very small increase in the absolute risk of a suicide attempt with second-generation antidepressants (odds ratio, 1.53 [95% CI, 1.09-2.15]; n = 40 857; 0.7% of antidepressant users had a suicide attempt vs 0.3% of placebo users; median follow-up, 8 weeks). Twenty-seven studies (n = 24 826) addressed suicide risk. One randomized clinical trial (n=443) of a suicide risk screening intervention found no difference in suicidal ideation after 2 weeks between primary care patients who were and were not screened for suicide risk. Three studies of suicide risk test accuracy were included; none included replication of any instrument. The included suicide prevention studies generally did not demonstrate an improvement over usual care, which typically included specialty mental health treatment.

Conclusions and Relevance

Evidence supported depression screening in primary care settings, including during pregnancy and postpartum. There are numerous important gaps in the evidence for suicide risk screening in primary care settings.

Comprehensive Geriatric Care in Older Hospitalized Patients with Depressive Symptoms

BACKGROUND/OBJECTIVES

Depressive symptoms (DS) may interfere with comprehensive geriatric care (CGC), the specific multimodal treatment for older patients. In view of this, the aim of the current study was to investigate the extent to which DS occur in older hospitalized patients scheduled for CGC and to analyze the associated factors. Furthermore, we aimed to investigate whether DS are relevant with respect to outcomes after CGC.

METHODS

For this retrospective study, all patients fulfilling the inclusion criteria were selected by reviewing case files. The main inclusion criterion was the completion of CGC within the defined period (May 2018 and May 2019) in the geriatrics department of the Diakonie Hospital Jung-Stilling Siegen (Germany). The Geriatric Depression Scale was used to asses DS in older adults scheduled for CGC (0-5, no evidence of DS; 6-15 points, DS). Scores for functional assessments (Timed Up and Go test (TuG), Barthel Index, and Tinetti Gait and Balance test) were compared prior to versus after CGC. Factors associated with the presence of DS were studied.

RESULTS

Out of the 1263 patients available for inclusion in this study, 1092 were selected for the analysis (median age: 83.1 years (IQR 79.1-87.7 years); 64.1% were female). DS (GDS > 5) were found in 302 patients (27.7%). The proportion of female patients was higher in the subgroup of patients with DS (85.5% versus 76.3%, p = 0.024). Lower rates of patients diagnosed with chronic pulmonary obstructive disease were detected in the subgroup of patients without DS (8.0% versus 14.9%, p = 0.001). Higher rates of dizziness were observed in patients with DS than in those without (9.9% versus 6.2%, p = 0.037). After CGC, TuG scores improved from a median of 4 to 3 (p < 0.001) and Barthel Index scores improved from a median of 45 to 55 (p < 0.001) after CGC in both patients with and without DS. In patients with DS, the Tinetti score improved from a median of 10 (IQR: 4.75-14.25) prior to CGC to 14 (IQR 8-19) after CGC (p < 0.001). In patients without DS, the Tinetti score improved from a median of 12 (IQR: 6-7) prior to CGC to 15 (IQR 2-20) after CGC (p < 0.001).

CONCLUSIONS

DS were detected in 27.7% of the patients selected for CGC. Although patients with DS had a poorer baseline status, we detected no difference in the degree of improvement in both groups, indicating that the performance of CGC is unaffected by the presence of DS prior to the procedure.

Layperson-Facilitated Internet-Delivered Cognitive Behavioral Therapy for Homebound Older Adults With Depression: Protocol for a Randomized Controlled Trial

BACKGROUND

Depression in older adults has serious biological, psychological, and social consequences. Homebound older adults experience a high burden of depression and significant barriers to accessing mental health treatments. Few interventions to address their specific needs have been developed. Existing treatment modalities can be challenging to scale up, are not tailored to unique population concerns, and require significant staffing support. Technology-assisted, layperson-facilitated psychotherapy has the potential to overcome these challenges.

OBJECTIVE

The aim of this study is to assess the efficacy of a layperson-facilitated internet-delivered cognitive behavioral therapy program tailored for homebound older adults. The novel intervention, Empower@Home, was developed based on user-centered design principles and partnerships between researchers, social service agencies, care recipients, and other stakeholders serving low-income homebound older adults.

METHODS

This 2-arm, 20-week pilot randomized controlled trial (RCT) with a waitlist control crossover design aims to enroll 70 community-dwelling older adults with elevated depressive symptoms. The treatment group will receive the 10-week intervention immediately, whereas the waitlist control group will cross over and receive the intervention after 10 weeks. This pilot is part of a multiphase project involving a single-group feasibility study (completed in December 2022). This project consists of a pilot RCT (described in this protocol) and an implementation feasibility study running in parallel with the pilot RCT. The primary clinical outcome of the pilot is the change in depressive symptoms after the intervention and at the 20-week postrandomization follow-up. Additional outcomes include acceptability, adherence, and changes in anxiety, social isolation, and quality of life.

RESULTS

Institutional review board approval was obtained for the proposed trial in April 2022. Recruitment for the pilot RCT began in January 2023 and is anticipated to end in September 2023. On completion of the pilot trial, we will examine the preliminary efficacy of the intervention on depression symptoms and other secondary clinical outcomes in an intention-to-treat analysis.

CONCLUSIONS

Although web-based cognitive behavioral therapy programs are available, most programs have low adherence and very few are tailored for older adults. Our intervention addresses this gap. Older adults, particularly those with mobility difficulties and multiple chronic health conditions, could benefit from internet-based psychotherapy. This approach can serve a pressing need in society while being cost-effective, scalable, and convenient. This pilot RCT builds on a completed single-group feasibility study by determining the preliminary effects of the intervention compared with a control condition. The findings will provide a foundation for a future fully-powered randomized controlled efficacy trial. If our intervention is found to be effective, implications extend to other digital mental health interventions and populations with physical disabilities and access restrictions who face persistent disparities in mental health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05593276; https://clinicaltrials.gov/ct2/show/NCT05593276.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/44210.

Remote cognitive behavioral therapy for older adults with anxiety symptoms: A systematic review and meta-analysis

INTRODUCTION

In-person cognitive behavioral therapy (CBT) can reduce self-reported anxiety in older adults. However, studies are limited for remote CBT. We assessed the effectiveness of remote CBT in mitigating self-reported anxiety in older adults.

METHODS

We conducted a systematic review and meta-analysis based on a literature search of PubMed, Embase, PsycInfo, and Cochrane databases up to March 31, 2021, for randomized controlled clinical trials comparing the effectiveness of remote CBT versus non-CBT controls on mitigating self-reported anxiety in older adults. We calculated within-group pre-to-post-treatment standardized mean difference using Cohen's d, obtained the difference between a remote CBT group and a non-CBT control group as our effect size for cross-study comparison, and conducted a random-effects meta-analysis. Changes in scores on self-reported anxiety symptoms (Generalized Anxiety Disorder-7 item Scale, Penn State Worry Questionnaire, or Penn State Worry Questionnaire - Abbreviated), and self-reported depressive symptoms (Patient Health Questionnaire-9 item Scale or Beck Depression Inventory) were primary and secondary outcomes, respectively.

RESULTS

Six eligible studies, containing 633 participants with a pooled mean age of 66.6 years, were included in the systematic review and meta-analysis. There was a significant mitigating effect of intervention on self-reported anxiety, favoring remote CBT over non-CBT controls (between-group effect size: -0.63; 95% CI: -0.99 to -0.28). We also found a significant mitigating effect of intervention on self-reported depressive symptoms (between-group effect size: -0.74; 95% CI: -1.24 to -0.25).

DISCUSSION

Remote CBT is more effective in reducing self-reported anxiety and depressive symptoms than non-CBT control in older adults.

Telephone-Based Behavioral Activation with Mental Imagery for Depression in Older Adults in Isolation During the covid-19 Pandemic: Long-term Results from a Pilot Trial

OBJECTIVES

The covid-19 pandemic has highlighted the need for psychological interventions for depression that can be delivered remotely to older adults. Pellas et al. (2022) conducted a pilot trial on the preliminary effectiveness of a four-week telephone-delivered Behavioral Activation with Mental Imagery (BA-MI) intervention to N= 38 adults 65 years and older with clinically significant depressive symptoms living in isolation due to covid-19 in Sweden. This study assessed the feasibility of follow-up assessments and within-group symptom change over a six-month post-intervention period.

METHODS

Retention rates at post-intervention and follow-up assessments of depressive symptoms (MADRS-S) at five time points were assessed (baseline, post-intervention, 1-, 3-, and 6-month follow-up). Effect sizes (Hedges' g) for within-group change scores were calculated between each time point.

RESULTS

Retention rates over time were 95, 82, 89, and 84%. Mean MADRS-S score was 18.26 at baseline, 13.69 at post-intervention (g= .68), 13.42 at 1 month (g= .74), 13.82 at 3 months (g= .74), and 15.59 at 6 months (g= .41).

CONCLUSIONS

Long-term follow-ups were feasible. Within-group decreases in depressive symptoms were maintained with medium effect sizes at 6 months post-intervention.

CLINICAL IMPLICATIONS

Telephone-based BA-MI may be a feasible intervention for depressive symptoms in older adults in isolation with maintained effects over time.

Understanding the Role of Support in Digital Mental Health Programs With Older Adults: Users' Perspective and Mixed Methods Study

BACKGROUND

Digital mental health interventions have the potential to increase mental health support among isolated older adults. However, the older adult population can experience several barriers to accessing and using digital health resources and may need extra support to experience its benefits.

OBJECTIVE

This paper aimed to understand what older adults experience as an important aspect of support during engagement in a digital mental health program. The program entailed 3 months of staff support to participate in digital literacy training and engage with the digital mental health platform myStrength, which offers support for a range of mental health challenges, including depression and anxiety.

METHODS

A total of 30 older adults participated in surveys and interviews to assess their experience of participating in a digital mental health program provided by county mental health services. As part of the program, participants attended 4 classes of digital literacy training, had access to the digital mental health platform myStrength for 2 months with staff support (and 10 months after the program without support), and received support from program staff during the entire 3-month program. Survey data were analyzed using descriptive statistics, and interview data were analyzed using thematic analysis.

RESULTS

A thematic analysis of the interview data revealed that participants valued ongoing support in 3 main areas: technical support to assist them in using technology, guided support to remind them to use myStrength and practice skills they had learned, and social support to enable them to connect with others through the program. Furthermore, participants reported that social connections was the most important aspect of the program and that they were mainly motivated to participate in the program because it was recommended to them by trusted others such as a community partner or because they believed it could potentially help others.

CONCLUSIONS

Our findings can be used to inform the design of future digital mental health programs for older adults who may have unique support needs in terms of dedicated technical support and ongoing guided support to use technology and social support to increase social connectedness.

The relationship between gender, marital status and depression among Chinese middle-aged and older people: Mediation by subjective well-being and moderation by degree of digitization

The purposes of this study were to investigate the effects of gender and marital status on depression among middle-aged and older people in China, and to explore the mediating effect of subjective well-being and the moderating effect of degree of digitization in the relationship between subjective well-being and depression. A total of 15,586 Chinese middle-aged and older people (≥ 45 years old) were included in the study using data from the 2018 China Health and Retirement Longitudinal Survey (CHARLS). T-test, ANOVA, hierarchical regression and Bootstrap methods were adopted to test the mediating role of subjective well-being and the moderating role of degree of digitization. The results showed that middle-aged and older women were more likely to suffer from depression than men, and married middle-aged and older people were less likely to be depressed than those who were separated or divorced, widowed and never married. Subjective well-being partially mediated the relationship between gender and depression, and masked the relationship between marital status and depression, and all five dimensions it contains also played a mediating role. Degree of digitization moderated the effect of subjective well-being on depression. Simple slope tests indicated that the effect of subjective well-being on depression increased as degree of digitization increased. In conclusion, to address the mental health problems of middle-aged and older people brought about by the ageing and digital society, we should start by improving their subjective well-being and promoting their integration into the digital society.

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.

Digital interventions for depression and anxiety in older adults: a systematic review of randomised controlled trials

One in five older adults experience symptoms of depression and anxiety. Digital mental health interventions are promising in their ability to provide researchers, mental health professionals, clinicians, and patients with personalised tools for assessing their behaviour and seeking consultation, treatment, and peer support. This systematic review looks at existing randomised controlled trial studies on digital mental health interventions for older adults. Four factors have been found that contributed to the success of digital mental health interventions: (1) ease of use; (2) opportunities for social interactions; (3) having human support; and (4) having the digital mental health interventions tailored to the participants' needs. The findings also resulted in methodological considerations for future randomised controlled trials on digital mental health interventions: (1) having a healthy control group and an intervention group with clinical diagnoses of mental illness; (2) collecting data on the support given throughout the duration of the interventions; (3) obtaining qualitative and quantitative data to measure the success of the interventions; and (4) conducting follow-up interviews and surveys up to 1 year post-intervention to determine the long-term outcomes. The factors that were identified in this systematic review can provide future digital mental health interventions researchers, health professionals, clinicians, and patients with the tools to design, develop, and use successful interventions for older users.

Effect of internet-delivered cognitive behavioral therapy on insomnia in convalescent patients with COVID-19: Protocol for a systematic review and meta-analysis

Introduction

Coronavirus Disease 2019 (COVID-19) has made a serious public health threat worldwide. Recent evidence has indicated that COVID-19 patients in convalescence frequently experience insomnia, which reduces their quality of life and causes unknown risks. The positive effect of cognitive behavior on insomnia has been well addressed in previous studies. Given the high infectivity and epidemicity of COVID-19, Internet-delivered intervention may be safer than face-to-face treatment. However, whether Internet-delivered cognitive behavioral therapy can effectively improve the insomnia of COVID-19 patients in convalescence has not been completely determined yet. Therefore, we conducted a meta-analysis and systematic review to evaluate the effects of Internet-delivered cognitive behavioral therapy on insomnia in COVID-19 patients in convalescence, with the aim to confer some guidance for its clinical application.

Methods and analysis

This systematic review and meta-analysis has been registered in the International Prospective Register of Systematic Reviews (PROSPERO). Two researchers will retrieve the relevant literature on Internet-delivered cognitive behavioral therapy for insomnia in convalescent patients with COVID-19 in PubMed, Web of Science, Embase, MEDLINE, Cochrane Library, Clinical Trials gov, Chinese Biomedical Literature Database (CBM), and Chinese National Knowledge Infrastructure (CNKI) from inception to 11th of December. In addition, we will review the relevant trials and references of the included literature and manually searched the grey literature. The two researchers will independently extracted data and information and evaluated the quality of the included literature. The Review Manager software (version 5.3) and Stata software (version 14.0) will be used for data analysis. The mean difference or the standardized mean difference of 95% CI will be used to calculate continuous variables to synthesize the data. In addition, I² and Cochrane will be used for heterogeneity assessment.

Trial registration

PROSPERO registration number CRD42021271278.

The Effects of a Digital Well-Being Intervention in Older Adults: An Analysis of Real-World User Data (Preprint)

Background

Digital interventions have been shown to be effective for a variety of mental health disorders and problems. However, few studies have examined the effects of digital interventions in older adults; therefore, little is known about how older adults engage with or benefit from these interventions. Given that adoption rates for technology among people aged ≥65 years remain substantially lower than in the general population and that approximately 20% of older adults are affected by mental health disorders, research exploring whether older adults will use and benefit from digital interventions is needed.

Objective

This study aimed to examine the extent to which older adults engaged with a digital well-being intervention (Happify) and whether engaging with this program led to improvements in both subjective well-being and anxiety symptoms.

Methods

In this retrospective analysis, we analyzed data from 375 real-world Happify users aged ≥65 years who signed up for the platform between January 1, 2019, and December 23, 2021. Changes in well-being and anxiety symptoms across 42 to 182 days were assessed using responses to the in-app assessment, which users were prompted to take every 2 weeks, and were compared among users who engaged with the program at the recommended level (ie, 2 or more activities per week) or below the recommended level.

Results

In all, 30% (113/375) of the sample engaged with the platform at the recommended level (ie, completed an average of 2 or more activities per week), and overall, users completed an average of 43.35 (SD 87.80) activities, ranging from 1 to 786, between their first and last assessment. Users were also active on the platform for an average of 19.36 (SD 27.16) days, ranging from 1 to 152 days. Moreover, older adults who engaged at the recommended level experienced significantly greater improvements in subjective well-being (P=.002) and anxiety symptoms (P<.001) relative to those who completed fewer activities.

Conclusions

These data provide preliminary evidence that older adults engage with and benefit from digital well-being interventions. We believe that these findings highlight the importance of considering older adult populations in digital health research. More research is needed to understand potential barriers to using digital interventions among older adults and whether digital interventions should be modified to account for this population’s particular needs (eg, ensuring that the intervention is accessible using a variety of devices). However, these results are an important step in demonstrating the feasibility of such interventions in a population that is assumed to be less inclined toward digital approaches.

Technology-Assisted, Group-Based CBT for Rural Adults' Depression: Open Pilot Trial Results

PURPOSE

This pilot study assesses the association of Raising Our Spirits Together (ROST), a technology-assisted, group-based cognitive behavioral therapy for depression, with rural adults' depressive symptoms and anxiety.

METHOD

Nine adults from rural Michigan participated in an open pilot of ROST. Clergy facilitated pilot groups. The pilot began in February 2020 in-person. Due to COVID-19, the pilot was completed virtually.

RESULTS

Mean depressive symptom scores, based on the PHQ-9, significantly decreased from pre-treatment (M = 14.4) to post-treatment (M = 6.33; t (8) = 6.79; P < .001). Symptom reduction was maintained at 3-month follow-up (M = 8.00), with a significant pattern of difference in depressive symptoms over time (F(2) = 17.7; P < .001; eta-squared = .689). Similar patterns occurred for anxiety based on the GAD-7. Participants attended an average of 7.33 of 8 sessions. Fidelity ratings were excellent.

DISCUSSION

ROST is a potentially feasible intervention for rural adults' depressive symptoms. ROST offers a promising model for increasing treatment access and building capacity in rural areas.

Efficacy of internet-based interventions for common mental disorder symptoms and psychosocial problems in older adults: A systematic review and meta-analysis

BACKGROUND

Although a high proportion of older adults suffer from common mental disorder symptoms and psychosocial problems, only a small number of older individuals seek psychological treatment. Internet-based interventions have the potential to bridge this treatment gap. However, while there is extensive literature on internet-based treatments in younger to middle-aged adults, research on older individuals is lacking.

OBJECTIVE

We aimed to summarize narratively and empirically the existing literature on the efficacy of internet-based interventions for the treatment of common mental disorder symptoms and psychosocial problems (loneliness, stress) in older individuals.

METHODS

This systematic review and meta-analysis was registered in PROSPERO (registration number: CRD42021235129). Systematic literature searches were conducted in PsycInfo, Ageline, Medline, CINHAL, and Psyndex. Studies were eligible for inclusion if they a) focused on older adults, b) assessed the efficacy of an internet-delivered psychological intervention, c) included a control condition and d) assessed common mental disorder symptoms or psychosocial problems as outcomes. Meta-analyses were conducted based on studies that included a passive, minimally active or placebo control condition to estimate pooled effects on overall symptom severity as well as on specific psychological outcomes.

RESULTS

11 Studies met inclusion criteria, with the majority of interventions focusing on depression or anxiety symptoms and being based on CBT principles. Significant large effect of internet-based interventions for older adults were found for overall symptom severity (depression, anxiety, PTSD, stress) as well as for depression symptom severity. No significant effects were found for anxiety symptom severity.

DISCUSSION

Our findings provide preliminary support that internet-based interventions might be a feasible and effective intervention method for the treatment of common mental disorder symptoms and stress in older adults. However, research in this area is still at an early stage. More studies are needed to shed light on the role of various treatment and patient characteristics in the efficacy of internet-delivered treatments.

Virtual versus Face-to-Face Cognitive Behavioral Treatment of Depression: Meta-Analytic Test of a Noninferiority Hypothesis and Men's Mental Health Inequities

Global rates of depression have increased significantly since the beginning of the COVID-19 pandemic. It is unclear how the recent shift of many mental health services to virtual platforms has impacted service users, especially for the male population which are significantly more likely to complete suicide than women. This paper presents the findings of a rapid meta-analytic research synthesis of 17 randomized controlled trials on the relative efficacy of virtual versus traditional face-to-face cognitive behavioral therapy (CBT) in mitigating symptoms of depression. Participants' aggregated depression scores were compared upon completion of the therapy (posttest) and longest follow-up measurement. The results supported the noninferiority hypothesis indicating that the two modes of CBT delivery are equally efficacious, but the results proved to be significantly heterogeneous indicating the presence of moderating effects. Indirect suggestive evidence was found to support moderation by gender; that is, depressed males may benefit more from virtual CBT. Perhaps, this field's most telling descriptive finding was that boys/men have been grossly underrepresented in its trials. Future trials ought to oversample those who have been at this field's margins to advance the next generation of knowledge, allowing us to best serve people of all genders, those who live in poverty, Indigenous, Black, and other Peoples of Colour, as well as any others at risk of being marginalized or oppressed in contemporary mental health care systems.

Impact of Internet Use on Mental Health among Elderly Individuals: A Difference-in-Differences Study Based on 2016-2018 CFPS Data

The number of elderly Internet users has increased significantly in the past few years. However, the impact of Internet use on mental health remains unclear. In this study, we performed a difference-in-differences analysis using data from the 2016 and 2018 waves of the China Family Panel Studies (CFPS) to evaluate the impact of Internet usage on mental health among elderly individuals. A total of 5031 validated respondents were included to explore the relationship between Internet use and reduced levels of depression as well as improved life satisfaction among elderly individuals. The results showed that Internet use significantly reduced depression levels. Unexpectedly, Internet use was not found to improve life satisfaction. Moreover, discontinuing Internet use was not significantly associated with improvements in depression or life satisfaction. More research is needed to fully elucidate the relationship between Internet use and depression levels, as well as life satisfaction among elderly individuals.

Internet-Based Psychotherapy Intervention for Depression Among Older Adults Receiving Home Care: Qualitative Study of Participants' Experiences

BACKGROUND

Depression is common among homebound older adults. Internet-based cognitive behavioral therapy (iCBT) is a promising but understudied approach for treating depression among older adults with disabilities.

OBJECTIVE

This study aims to understand the experiences of homebound older adults who participated in a pilot feasibility trial of an iCBT for depression.

METHODS

The participants included 21 homebound older adults who participated in a generic iCBT program that was not specifically designed for older adults and 8 home care workers who assisted in the iCBT program. Informants completed semistructured individual interviews, which were transcribed verbatim and analyzed using methods informed by grounded theory. A hierarchical code structure of themes and subthemes was developed after an iterative process of constant comparisons and questionings of the initial codes. The data analysis was conducted by using dedoose, a web app for mixed methods research.

RESULTS

Three themes and various subthemes emerged related to participants' experience of the iCBT intervention, as follows: intervention impact, which involved subthemes related to participants' perceived impact of the intervention; challenges and difficulties, which involved subthemes on the challenges and difficulties that participants experienced in the intervention; and facilitators, which involved subthemes on the factors that facilitated intervention use and engagement.

CONCLUSIONS

iCBT is a promising intervention for homebound older adults experiencing depression. Home care workers reported improved relationships with their clients and that the program did not add a burden to their duties. Future programs should involve accessible technical features and age-adapted content to improve user experience, uptake, and adherence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04267289; https://clinicaltrials.gov/ct2/show/NCT04267289.

Internet-based cognitive behavioral therapy for psychological distress in older adults without cognitive impairment living in nursing homes during the COVID-19 pandemic: A feasibility study

BACKGROUND

The COVID-19 pandemic has had a detrimental effect on the mental health of older adults living in nursing homes. Very few studies have examined the effects of Internet-based Cognitive Behavioral Therapy (ICBT) on older adults living in nursing homes during the pandemic. We conducted a feasibility study using a single-group design, to explore the effectiveness of ICBT on psychological distress in 137 older adults (without cognitive impairment) from 8 nursing homes in 4 southeast cities in China, between January and March 2020.

METHODS

Symptoms of depression, anxiety, general psychological distress, and functional disability were measured at baseline, post-treatment (5 weeks) and at a 1-month follow-up. Mixed-effects model was used to assess the effects of ICBT.

RESULTS

Statistically significant changes with large effect sizes were observed from pre- to post-treatment on the PHQ-9 (p < .001, Cohen's d = 1.74), GAD-7 (p < .001, d = 1.71), GDS (p < .001, d = 1.30), K-10 (p < .001, d = 1.93), and SDS (p < .001, d = 2.03). Furthermore, improvements in treatment outcomes were sustained at 1-month follow-up, and high levels of adherence and satisfaction were indicated.

CONCLUSION

ICBT was effective in reducing psychological distress in older adults without cognitive impairments living in nursing homes during the COVID-19 pandemic. Thus, it could be applied in improving the mental health of this vulnerable group during the pandemic.

Evidence Synthesis of Digital Interventions to Mitigate the Negative Impact of the COVID-19 Pandemic on Public Mental Health: Rapid Meta-review

Background

Accumulating evidence suggests the COVID-19 pandemic has negative effects on public mental health. Digital interventions that have been developed and evaluated in recent years may be used to mitigate the negative consequences of the pandemic. However, evidence-based recommendations on the use of existing telemedicine and internet-based (eHealth) and app-based mobile health (mHealth) interventions are lacking.

Objective

The aim of this study was to investigate the theoretical and empirical base, user perspective, safety, effectiveness, and cost-effectiveness of digital interventions related to public mental health provision (ie, mental health promotion, prevention, and treatment of mental disorders) that may help to reduce the consequences of the COVID-19 pandemic.

Methods

A rapid meta-review was conducted. The MEDLINE, PsycINFO, and CENTRAL databases were searched on May 11, 2020. Study inclusion criteria were broad and considered systematic reviews and meta-analyses that investigated digital tools for health promotion, prevention, or treatment of mental health conditions and determinants likely affected by the COVID-19 pandemic.

Results

Overall, 815 peer-reviewed systematic reviews and meta-analyses were identified, of which 83 met the inclusion criteria. Our findings suggest that there is good evidence on the usability, safety, acceptance/satisfaction, and effectiveness of eHealth interventions. Evidence on mHealth apps is promising, especially if social components (eg, blended care) and strategies to promote adherence are incorporated. Although most digital interventions focus on the prevention or treatment of mental disorders, there is some evidence on mental health promotion. However, evidence on process quality, cost-effectiveness, and long-term effects is very limited.

Conclusions

There is evidence that digital interventions are particularly suited to mitigating psychosocial consequences at the population level. In times of physical distancing, quarantine, and restrictions on social contacts, decision makers should develop digital strategies for continued mental health care and invest time and efforts in the development and implementation of mental health promotion and prevention programs.

Internet-Based Cognitive Behavior Therapy Only for the Young? A Secondary Analysis of a Randomized Controlled Trial of Depression Treatment

BACKGROUND

Late-life depression is a major public health concern, driving the development of complementary treatment options. This study investigates the effectiveness and acceptability of internet-based Cognitive Behavioral Therapy (iCBT) in older individuals (60+ years) compared to younger age groups.

MATERIALS AND METHODS

Secondary analysis of a cluster-randomized controlled trial with 647 (18-82 years; mean 43.9) mild to moderately severe depressed primary care patients receiving either iCBT + treatment as usual (TAU) or TAU alone. Severity of depression was measured by the Beck Depression Inventory (BDI-II) at baseline, 6 weeks and 6 months. Intention-to-treat analysis in three age groups (18-39 years, n = 264; 40-59 years, n = 300; 60+ years, n = 83) was performed, using mixed-effects regression models to quantify treatment effect.

RESULTS

No age differences in the effectiveness of iCBT were found. Patients in the intervention group consistently showed a greater reduction in depression severity than controls in all three age groups and at both follow-ups. Effect sizes ranged from d = 0.30 (40-59 years, 6 weeks) to d = 1.91 (60+ years, 6 months). Uptake of the intervention was banded around 70% with no differences between age groups (χ² = 0.18, p = .915). The mean number of completed modules increased with age (χ² = 18.99, p = .040).

DISCUSSION

iCBT is equally effective in both younger and older individuals, thus providing a valuable complementary element of routine late-life depression care.

CLINICAL TRIAL REGISTRATION

DRKS-ID: DRKS00005075 https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005075.

Challenges and Benefits of an Internet-Based Intervention With a Peer Support Component for Older Adults With Depression: Qualitative Analysis of Textual Data

Background

Technological interventions provide many opportunities for improving the health and quality of life of older adults. However, interaction with new technologies can also cause frustration. Although these themes have been explored in extant research, much remains to be learned with regard to how the challenges of aging and technology use and the experiences of participating in a social and learning environment are interrelated.

Objective

This study aimed to perform a qualitative analysis of data collected from MoodTech, a pilot study of an internet-based intervention with a peer support component for older adults with symptoms of depression, to better understand the participants’ experience of using technological interventions, including the challenges and benefits that they experienced over the course of these interventions.

Methods

We employed an inductive qualitative analysis method based on grounded theory methodology and interpretative phenomenological analysis to analyze participant textual data. These textual data were of 3 main types: (1) assignments in which participants challenged their negative thoughts, (2) status updates, and (3) comments in the peer support component of the intervention.

Results

We have presented the results through 3 main themes: (1) the challenges of aging as seen through the participants’ comments, (2) the difficulties experienced by the participants in using MoodTech, and (3) the benefits they derived from participating.

Conclusions

This paper offers several contributions concerning study participants’ experiences with internet-based cognitive behavioral therapy (iCBT) interventions with a peer support component and design considerations for developing complex technological interventions that support the challenges participants experience due to aging and cognitive difficulties. First, technical issues encountered by older adults within the context of the intervention can interact with and exacerbate the insecurities they experience in life, and it is important to consider how intervention components might be designed to mitigate these issues. Second, peer support can be employed as a mechanism to facilitate communication, support, and collaborative problem solving among participants in an intervention. The insights from this paper can inform the design of iCBT interventions for older adults.