Improving Quality of Life in Diverse Rural Older Adults: A RandomizedTrial of a Psychological Treatment

Forrest Scogin, Martin Morthland, Allan Kaufman,and Louis Burgio

University of Alabama

William Chaplin and Grace KongSt. Johns University

The efficacy of home-delivered cognitive-behavioral therapy (CBT) in improving quality of life andreducing psychological symptoms in older adults was examined in this study. One hundred thirty-fourparticipants, predominately African American and characterized as primarily rural, low resource, andphysically frail, were randomly assigned to either CBT or a minimal support control condition. Resultsindicate that CBT participants evidenced significantly greater improvements in quality of life andreductions in psychological symptoms. Mediation of treatment through cognitive and behavioral vari-ables was not found despite the acceptable delivery of CBT by research therapists. These data suggestthat treatment can be effective with a disadvantaged sample of older adults and extend efficacy findingsto quality of life domains. Creating access to evidence-based treatments through nontraditional deliveryis an important continuing goal for geriatric health care.

Keywords: quality of life, rural, CBT, older adults

Access to healthcare services is problematic in rural areas,particularly so for older adults. Basic mental health services areeven more difficult to access for rural dwellers, and specializedgeriatric mental health services are almost nonexistent. It is withinthis context that we undertook an investigation of the efficacy of awell-established psychological treatment, cognitive-behavioraltherapy (CBT), in improving quality of life (QOL) and reducingpsychological symptoms of a sample of rural older adults.

QOL evolved from the constructs of life satisfaction and sub-jective well-being, topics that have enjoyed a long and rich re-search focus in social gerontology (Lawton, 1975; Neugarten,Havighurst, & Tobin, 1961). QOL as used in this study has beendefined as an individuals subjective interpretation of the extent towhich his or her most important needs, goals, and desires havebeen satisfied (Frisch, 1998). It represents the persons overallsatisfaction or happiness in life and may reflect internal processesthat help maintain the persons daily life functioning by increasing

motivation (e.g., sense of purpose, energy, confidence, hope, andcompassion) to persevere and to perform well in stressful, boring,or even affectively neutral situations (Frisch, 1998). According tothis definition, objective factors, such as physical health, func-tional ability, and life circumstances, are cognitively mediatedaspects of QOL. QOL has been found to be a significant predictorof subsequent physical illness, psychological disorders, and health-care costs (Moreland, Fowler, & Honaker, 1994; Schnurr, Hayes,Lunney, McFall, & Uddo, 2006; Stewart, Ware, Sherbourne, &Wells, 1992; Vitaliano, Dougherty, & Siegler, 1994; Ware, 1986).The measurement and definition of QOL among older adults lacksconsensus, with some investigators more interested in health-related QOL (e.g., de Vreede et al., 2007) as measured by instru-ments, such as the Short Form Health Survey (Ware, 1986), andother investigators more interested in global QOL or subjectivewell-being (Diener, Suh, Lucas, & Smith, 1999). Our interest wasin the latter conception of QOL, and it served as an indicant ofpositive outcome different than the psychological symptom-reduction focus measured by our other outcome measure, theSymptoms Checklist-90 (Derogatis, Rickels, & Rock, 1976).There have been repeated calls to investigate strategies to improvesubjective well-being or QOL (e.g., Strupp, 1996), and there hasbeen an upsurge in investigations that make QOL the primaryintervention-outcome endpoint (e.g., Eng, Coles, Heimberg, &Safren, 2001; Petry, Alessi, & Hanson, 2007).

Improving QOL for older adults is an important goal for thereasons outlined above. One approach to improving QOL is to useevidence-based interventions shown to improve several closelyrelated disorders. CBT has a strong evidentiary base in the treat-ment of geriatric anxiety (Ayers, Sorrell, Thorp, & Wetherell,2007), geriatric depression (Scogin, Welsh, Hanson, Stump, &Coates, 2005), caregiver distress (Gallagher-Thompson & Coon,2007), and geriatric insomnia (McCurry, Logsdon, Teri, & Vi-tiello, 2007) and thus is a strong candidate as an intervention for

Editors Note. Bob G. Knight served as the action editor for thisarticle.RTZ

Forrest Scogin and Martin Morthland, Department of Psychology, Uni-versity of Alabama; Allan Kaufman, School of Social Work, University ofAlabama; Louis Burgio, Department of Psychology and the Center forMental Health and Aging, University of Alabama; William Chaplin andGrace Kong, Department of Psychology, St. Johns University.

This research was supported by National Institute on Aging GrantAG16311. We thank Peggye Dilworth-Anderson, Larry Beutler, andGrover Wedgeworth of the Alabama Department of Public Health for theircontributions to this project.

Correspondence concerning this article should be addressed to ForrestScogin, Department of Psychology, University of Alabama, Tuscaloosa,AL 35487-0348. E-mail: fscogin@as.ua.edu

Psychology and Aging Copyright 2007 by the American Psychological Association2007, Vol. 22, No. 4, 657665 0882-7974/07/$12.00 DOI: 10.1037/0882-7974.22.4.657

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improving QOL in older adults. CBT is based on the premise thatnegative affect and emotional distress are related to maladaptiveinformation processing and lowered rates of engagement in re-warding activities. We reasoned that targeted intervention on thesemediating factors should bring about improvements in QOL in thesame way that it has been associated with improvements in anxietyand depression in studies of clinically disordered older adults.Moreover, difficulties experienced in domains of QOL, such asself-regard, friendships, and relationships with children, have beenprimary targets for CBT interventions designed to foster greateracknowledgement of personal achievements, less harsh judgments,and decreased rumination.

In this study, we were particularly interested in the effects CBTwould have on QOL and psychological symptoms in a low resource,ethnically diverse, and medically frail sample of elders. These factorshave been emphasized as important gaps in the intervention literature(V. Thompson, Bazile, & Akbar, 2004; U.S. Department of Healthand Human Services, 2001). Most studies of psychological interven-tions with older adults and CBT, specifically, have been with olderadults of above average socioeconomic status and little apparentdiminishment of cognitive ability. For example, studies by our re-search group (Floyd, Scogin, McKendree-Smith, Floyd, & Rokke,2004) and others (L. W. Thompson, Coon, Gallagher-Thompson,Sommer, & Koin, 2001) have recruited samples with a mean educa-tional level of 14 years and mean Mini-Mental State Examination(MMSE) scores of greater than 26 (Folstein, Folstein, & McHugh,1975). To recruit our target population, we provided CBT in thehomes of participants thus enabling persons with physical and finan-cial limitations to more readily receive services. We also concentratedon recruiting persons residing in rural areas and those receivingservices from home health-care agencies and other community-basedservice organizations. Because most studies of the efficacy of CBTwith older adults have included relatively few African Americanparticipants, a goal of our study was to recruit enough African Amer-ican elders to test for differential outcomes on the basis of race.

We predicted that participants receiving in-home CBT would showsignificantly greater improvement in QOL and reductions in psycho-logical symptoms than would participants randomly assigned to aminimal support control condition. We chose this type of experimen-tal design to control for the attention provided for by continuingassessment and contact with the project. As this was an initial eval-uation of the effects of CBT delivered in-home to a more disadvan-taged sample, we did not employ a more rigorous placebo or com-parative treatment design. Furthermore, we expected that nostatistically significant differences in treatment effects would be foundbetween African American and White participants because our studyprocedures included the use of both African American and Whitetherapists, stratified random assignment to experimental conditions byrace, and attunement to ethnic differences with regard to the deliveryof the CBT intervention. Given the characteristics of our sample, thesefindings would extend the efficacy of CBT to both a broader outcomethan depression or anxiety and to a more disadvantaged group of olderadults.

MethodParticipants and Recruitment

Inclusion criteria for participation were as follows: (a) age of 65years or older, (b) a T score of 55 or below on the Quality of Life

Inventory (QOLI; Frisch, 1992), (c) a T score of greater than 45 onthe Global Severity Index (GSI) of the Symptoms Checklist-90-Revised (SCL-90-R; Derogatis et al., 1976) using norms for non-patient adults, and (d) residence outside of the cities of Tuscaloosa(AL) and Montgomery (AL). Fifteen participants residing in thecity limits of Tuscaloosa and Montgomery were randomized intothe study because they otherwise met inclusion criteria and wererecruited through existing referral mechanisms. Additionally, 4participants with QOLI scores above 55 were randomized as were2 participants 64 years of age. Though violating inclusion criteria,we reasoned that we would remove these participants from thesample when conducting analyses. However, we realized later thatto do so would violate the random assignment status of all partic-ipants who followed these allocations. We therefore decided toinclude these participants in analyses rather than exclude them tomaintain the integrity of our random assignment (e.g., Friedman,Furberg, & DeMets, 1998). All analyses were conducted twice,with these participants included and then excluded, and there wereno meaningful differences. All results are therefore reported on thefull randomized sample.

Exclusion criteria were as follows: (a) self-reported history ofschizophrenia, bipolar disorder, or current substance abuse; (b)receiving psychotherapy currently; or (c) significant cognitiveimpairment as indicated by a score of 23 or less (16 or less forthose with less than a ninth-grade education) on the MMSE (Fol-stein et al., 1975).

We recruited participants using several different methods. Olderadults were recruited at public and private home health-care agen-cies, senior centers, church organizations, hospitals with associatedhome health-care groups, and service providers, such as physiciansand pharmacists. In addition, advertisements and feature storieswere placed in local print media. These recruitment efforts em-phasized that the study was designed to evaluate the effects of aprogram to improve QOL among rural older adults. An acronym,PEARL (Project to Enhance Aged Rural Living), was used toencourage interest in the study.

Measures

Background information. Information was obtained on age,gender, race, marital status, educational attainment, income, andsubjective financial burden.

Functional impairment. Functional impairment was measuredby a compilation of the 23-item Functional Assessment of PhysicalFunctioning (Ettinger et al., 1994) and seven items from theFunctional Independence Measure (Granger & Hamilton, 1987).This 30-item scale measures activities of daily living and instru-mental activities of daily living. Item responses range from Usu-ally did with no difficulty to Unable to do with an option for anunscored Never did. The average of all scored items is thefunctional impairment index. Cronbachs alpha at Time 1 was .95.

Health status. Health status was evaluated through severalmeans. We used a self-reported one-item rating of general healthand asked participants about the presence of seven common co-morbid medical conditions (Wisniewski et al., 2003). The generalhealth rating ranged from 1 poor to 6 excellent. The sevencomorbid medical conditions were arthritis, high blood pressure,heart condition, chronic lung disease, diabetes, cancer, and stroke.

658 SCOGIN ET AL.

Use of formal health care and services was assessed by amodified version of the 21-item form developed for the Resourcesfor Enhancing Alzheimers Caregiver Health (REACH I) project(Wisniewski et al., 2003). This form lists in-home, community,physician, and hospital services that may have been used withinthe past month. Each item has a follow-up question as to thenumber of times the service was used. The measure of health-careuse was the sum of these items.

Outcome measures. The QOLI (Frisch, 1992) was used tomeasure self-reported overall QOL. Sixteen domains are assessedwith the QOLI: health, self-regard, philosophy of life, standard ofliving, work, recreation, learning, creativity, helping, love relation-ship, friendships, relationships with children, relationships withrelatives, home, neighborhood, and community. Each domain israted for importance on a 3-point Likert scale and for satisfactionon a 6-point Likert scale. The cross-product is summed, and thisscore is converted to T scores based on adult, community-dwellingnorms. Cronbachs alpha in the normative study was .79 (Frisch,1992) and, in the present study, .65 at Time 1.

The SCL-90-R (Derogatis et al., 1976) was used as a measure ofoverall psychological symptomatology. The 90 items of the SCL-90-R comprise nine subscales: Anxiety, Depression, Psychoticism,Paranoid Ideation, Phobic Anxiety, Somatization, Obsessive Com-pulsivity, Hostility, and Interpersonal Sensitivity. We used the GSIas an indicant of overall symptom distress. Cronbachs alpha forthe 90 items at Time 1 assessment was .96.

Mediators. Two measures were used to assess possible medi-ation of effects associated with CBT. The Beck HopelessnessScale (BHS; Beck, Weissman, Lester, & Trexler, 1974) is a20-item measure that assesses negative attitudes and expectationsabout the future. Example items are I look forward to the futurewith hope and enthusiasm and I have enough time to accomplishthe things I want to do. Responses are true or false. Totalsummed scores indicate degree of hopelessness. Cronbachs alphawas .81 at Time 1 assessment. The BHS score was expected tochange as a result of the cognitive focus in CBT.

An abbreviated version of the Older Adult Pleasant EventsSchedule (OAPES; Teri & Lewinsohn, 1982) was used to test thepossible mediating role of changes in behavioral activation result-ant to the behavior focus in CBT. The total score is the average ofthe cross-products of frequency and enjoyability for each item.Twenty items were selected from the original 66 to ease respon-dent burden. Cronbachs alpha at Time 1 was .81.

Procedure

Persons interested in participating were contacted by telephoneand given a brief overview of the project. For those with continuedinterest, potential eligibility was ascertained by administering fouritems from the QOLI and 10 items from the SCL-90-R. For thosewith probable inclusive scores, an in-home Time 1 assessment wasscheduled. The Time 1 assessment included a detailed descriptionof study procedures and participant informed consent, followed bygathering of sociodemographic information and counterbalancedadministration of the outcome and mediator measures.

Research assistants conducted standardized assessments in par-ticipants homes. Measures were read to participants to minimizeproblems associated with low literacy and sensory limitations.Response cards were used to aid participants. Participants received

a $25 gift card for the completion of each assessment. All assess-ments were audiotaped, and 20% were reviewed to ensure adher-ence to the assessment protocol.

Participants were randomized to CBT or the minimal supportcondition (MSC) following baseline assessment. The randomiza-tion process involved stratifying participants on the basis of twovariables: site location (Tuscaloosa or Montgomery) and race(African American or Caucasian). Among each of the four strati-fied groups, assignment to CBT or the MSC was decided on thebasis of a random number table. Research assistants were blind toassignment at the time of baseline assessment.

Following randomization, participants in the CBT conditionwere assessed on outcome and mediator variables at midtreatmentand immediately posttreatment (Time 2). The midtreatment assess-ment was undertaken to allow testing of temporal relations be-tween mediator and outcome measures; this assessment alsoserved as an endpoint for those who received partial treatment.Those assigned to the MSC were assessed a second time approx-imately 3 months following randomization. Thus, the controlledcomparison in this study was between the Time 1 and Time 2assessments for the two conditions. Following Time 2 assessment,MSC participants received CBT as outlined above. These data arenot included in the results presented here. All participants wereassessed 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 threeCaucasians) without prior CBT experience. We chose masters-level therapists to accentuate external validity and translation ofthe intervention as these are the persons who would most likely bethe personnel to administer the intervention in current serviceagencies. Training of the therapists was conducted by the principalinvestigators and consultants over four sessions that included 12 hrof didactic instruction and 12 hr of experiential training. Feedbackwas provided until competency was achieved on the basis of theCognitive Therapy Scale (CTS; Young & Beck, 1980). Weeklygroup supervision was conducted with the therapists.

CBT. Treatment followed the manual developed by L. W.Thompson, Gallagher-Thompson, and Dick (1995) for the deliveryof CBT to older adults. The standard course of treatment was 16sessions with the opportunity to extend treatment to 20 sessions ifneeded. Twice-weekly sessions were planned for the 1st monthwith weekly sessions planned for the remainder of the treatment.Major components of the treatment included activity scheduling,identifying and changing unhelpful thoughts, relaxation, and as-sertiveness. The treatment protocol developed by L. W. Thompsonet al. included modifications of traditional CBT for use with olderadults, such as providing in-session cue cards as memory aids,slowing down the pace of the intervention process, and simplifi-cation of homework assignments. We made a further modificationfor use with our largely frail sample by encouraging the inclusionof an intervention facilitator where available. Our rationale for thefacilitator was that we anticipated that many of our participantswould have difficulty in enacting treatment recommendationswithout the aid of another because of physical and cognitivelimitations. We also believed that having an indigenous facilitator

659IMPROVING QUALITY OF LIFE IN OLDER ADULTS

would aid in the translation of intervention material in a culturallysensitive manner. The average number of sessions attended byCBT participants was 11.7. The average time to complete treat-ment was 5.3 months.

Participants were asked to identify a family member or friendthat could serve as a treatment facilitator. The only inclusioncriterion for facilitators was an MMSE score of 24 or higher (or 16or higher for those with up to an eighth-grade education). Involve-ment of a facilitator was not a requirement for participation in thestudy as many of the participants could not identify someone toserve in this role but were otherwise eligible. Thirty-six percent ofthe participants involved a facilitator who completed at least aTime 1 assessment. For MSC participants, facilitators completedassessments only. For CBT participants, facilitators engaged in acombination of individual and conjoint sessions. Four individualsessions with each facilitator were planned within the 1st month ofthe participants treatment. The first two sessions were on ways inwhich to facilitate the participants attainment of CBT goals, suchas reminding them to complete unhelpful thought diaries or iden-tify pleasant events. Sessions 3 and 4 were devoted to teachingfacilitators general problem-solving skills that could be applied tothe facilitation role. Additionally, the facilitators attended fourconjoint sessions with the older adult participant in which he or shewas made familiar with the specific treatment goals. These ses-sions were spaced as evenly as possible across the course oftreatment. The average number of sessions attended by the 26facilitators was 2.5 (range 08).

We compared the responses of participants who had a facilitatorand those who did not on the QOLI, SCL-90-R (GSI), BHS, andOAPES and found no differences. We therefore did not considerthis in subsequent analyses.

MSC. Participants in this condition received brief weekly tele-phone calls from project staff. These supportive contacts weremade over the course of 3 months. These calls served both as ameans to monitor participants for deteriorating mental health andas an incentive for continued participation in the project. CBTtechniques were not administered during these calls.

Treatment delivery. Treatment delivery was assessed throughreviews of audiotaped CBT sessions. An early (Sessions 28) andlate (Sessions 916) session was randomly selected and reviewedby an independent team using the CTS (Young & Beck, 1980).The CTS is an 11-item measure with two subscales. The GeneralTherapeutic Skills subscale assesses areas such as therapist under-standing, interpersonal effectiveness, and pacing of the session.The Specific Cognitive Therapy Skills subscale assesses areassuch as focus on key cognitions and behaviors, application ofcognitive-behavioral techniques, and quality of homework as-signed. Each item is rated on a scale from 0 poor to 6 excellent, with 3 indicating satisfactory administration. The resultsof these reviews suggested that the CBT was delivered compe-tently. The mean scores across therapists on the General Thera-peutic Skills subscale was 3.9, and the mean score on the SpecificCognitive Therapy Skills subscale was 3.7. There were no signif-icant differences among the therapists on the CTS.

Statistical Analyses

All analyses used a critical alpha level of .05 for determiningstatistical significance; exact levels are reported unless they are

less than .001. The characteristics of the experimental and controlconditions at Time 1 were compared to establish that randomiza-tion was successful. All continuous variables were compared si-multaneously with a multivariate analysis of variance, and cate-gorical variables were compared with chi-square techniques.

Mixed regression analyses (SAS PROC MIXED, Version 9.0)were used to evaluate the effects of the intervention on QOL andpsychological symptoms. We conducted analyses to test for theinteraction of Time Experimental Condition on the QOLI andthe GSI using the intent-to-treat sample. Models including possibletreatment moderators were also tested. These moderators weregender, race (African American/White), and MMSE score. Mod-eration would be suggested by the three-way interaction of TimeExperimental Condition Moderator.

Attrition was examined by dummy coding participants as com-pleters (1) or dropouts (0) and assessing the associations betweenthis measure and the outcome and mediator variables. Addition-ally, this variable was included as a moderator in the primaryintent-to-treat analyses. The purpose of these analyses was todetermine whether degree of study completion was related totrends in response. We tested a three-way interaction using com-pletion status, time, and experimental condition. Significant inter-actions would suggest that findings were dependent on completionstatus. There were no interactions of missing data patterns and theprimary variables.

Results

Participants

Figure 1 shows the flow of participants through the study. Onehundred thirty-four persons completed a baseline (Time 1) assess-ment and were randomized to the experimental conditions. Char-acteristics of the sample are presented in Table 1, and dependentand mediational variable means and standard deviations by timeand condition are presented in Table 2. This sample is mostlyfemale (83%), predominately African American (57%), and some-what older (M 75.4 years) than typically seen in communityintervention studies with older adults. The average MMSE score(M 24.9) and educational levels (M 9.6 years) are alsorelatively low, whereas the self-rated health status of the partici-pants is relatively poor, consistent with our recruitment strategy.Participants indicated they were experiencing on average three ofthe seven comorbid chronic health conditions we assessed. Theparticipants reported moderate functional impairment as illustratedby a mean score of 4.24 on the item Climbing several flights ofstairs and a mean score of 2.79 on the item Preparing your ownmeals. There were no differences at Time 1 between the experi-mental conditions on any variables. African American and Whiteparticipants were also compared on Time 1 variables, and onlydifferences in years of education and MMSE scores were statisti-cally different, with African American participants having lowervalues.

Attrition

Figure 1 provides information about attrition from the study.Reasons for withdrawing from the study were varied, with mostrelated to becoming too medically frail to continue and/or moving

660 SCOGIN ET AL.

in with family or into an institutional setting. The attrition rate(25%) for the randomized sample is comparable to other similarstudies (e.g., Arean et al., 2005). There were no significant differ-ences in attrition between the two conditions.

OutcomesExamination of score distributions on the QOLI and GSI vari-

ables revealed several extreme values or outliers, and winsorizing(Dixon & Tukey, 1968) transformations were used to minimize theeffects of these extreme scores on the analyses. Winsorizing hasbeen suggested as a data cleaning tool that maintains the size of thesample and minimally affects the mean of a distribution whilereducing its variability. We used mixed regression analyses to testthe effect of treatment on the outcomes. For the QOLI, the modelparameters for the test of the interaction were 1.2 for time, indi-cating a general increase in the QOLI of 1.2 points between eachassessment time for both groups; 0.46 for treatment group, indi-cating a baseline difference of about half a point between thegroups; and, most critically, for the Time Treatment interaction,the parameter estimate was 4.75 (z 4.25, p .001), indicatingan additional increase in the QOLI score of close to five pointsbetween each assessment time for the CBT group compared to theMSC group. For the GSI, the parameter estimates were 2.0 forTime, indicating a general decrease in the GSI of two pointsbetween each assessment time; 1.5 for Group, indicating a1.5-point difference between the groups at baseline; and, mostcritically, for the Time Treatment interaction the parameterestimate was1.91 (z2.37, p .02), indicating an additionaldecrease in the GSI at each assessment time for the CBT groupcompared to the MSC group. The effect sizes associated with theCBT versus MSC endpoint comparisons, expressed as d, are 0.62

for the QOLI and 0.46 for the GSI. These are considered to be ofmoderate magnitude. Figures 2 and 3 show the estimated meanvalues across time for the QOLI and GSI as a function of exper-imental assignment.

We were able to conduct analyses to determine whether thetreatment effects differed by ethnicity, as would be indicated byEthnicity Time Experimental Condition interactions, becausethere were adequate numbers of both African American and Whiteparticipants in the sample. There was a significant three-wayinteraction on the QOLI, with African American participantsshowing a stronger response to treatment than the White partici-pants. The parameter estimate for the three-way product was4.59 (z 2.08, p .04) indicating that the increase in QOLdue to treatment was about 4.5 points lower for the White partic-ipants than for the African American participants. Subgroup anal-yses indicated that both African American and White participantgroups showed significant improvements in QOL. There was nomoderation by ethnicity on the GSI, nor did gender or mentalstatus moderate either of the outcome variables.

MediatorsCBT is theorized to produce beneficial effects through mecha-

nisms that include increased engagement in pleasant events anddecreases in dysfunctional thinking. In the present study, we usedthe OAPES and BHS to explore the role of these variables in thetreatment response. First, we were interested in whether there wasa significant change in OAPES and BHS scores as a function oftreatment. The Time Experimental Condition interactions werenot significant, indicating that the treatment did not impact thesemediators. There was no further testing of mediation given thesenonsignificant findings.

259 Phone Screened

70 Not Interested

55 Ineligible 134 Randomized

Time 1 (Baseline)

Time 2

70 CBT

14 Withdrew

MSC50 Assessed

64 MSC

12 Withdrew

CBT51 Assessed

7 Did Not Begin CBT

Figure 1. Flow of participants through study. Withdrew indicates participants discontinued for reasonsincluding (a) moved in with family, lost interest, no time/too busy, family reasons; (b) died, became toomedically frail, moved into an institutional setting; or (c) moved with no trace, lost contact. Time 2 for thecognitive-behavioral therapy (CBT) condition is the endpoint assessment, either the midtreatment or posttreat-ment assessment. MSC minimal support condition.

661IMPROVING QUALITY OF LIFE IN OLDER ADULTS

Health StatusWe 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), indicatingan additional increase in perceived health of 0.29 on the ratingscale between assessments. CBT participants reported improve-ment in their general health status, whereas MSC participantsbasically were unchanged. The effect size on this variable was0.76, considered of moderate magnitude. We did not find signif-icant interactions on our measure of health-care use.

DiscussionThe results of this study indicate that home-delivered CBT

improved QOL and reduced psychological symptoms for a sample

of medically frail, low resource, and primarily rural older adults.These findings are important for several reasons. First, althoughCBT has been shown to be effective in treating mental disorders inolder adults, the generalization of this efficacy to the improvementof QOL suggests that CBT need not be restricted to those with adiagnosable mental disorder. Mental disorders are associated withlowered QOL, but there are many elders who experience dimin-ished QOL although they evidence subsyndromal or minimalpsychopathology, especially in the presence of chronic healthconditions and functional disability. The results of this studysuggest that psychological intervention may aid these persons inimproving their mental health and life satisfaction. Second, thesefindings extend the use of CBT to a more cognitively compro-mised (MMSE M 24.9) and less educated (education years M 9.6) sample than typically seen in community-based studies ofmental health interventions. Third, these data suggest that home-delivered CBT is a viable alternative to more traditional clinic oroffice-based administration and may be particularly suited for useby rural-based service agencies in communities that lack special-ized geriatric mental health resources. For many of our partici-pants, access to treatment would have been too difficult had theybeen required to travel to receive the intervention. Medical frailty,transportation difficulties, and stigma are among the factors thathave been identified as barriers that were to various degreessurmounted with the present home-delivered approach. Finally,these findings suggest that CBT can be effective with ethnicallydiverse older adults. The majority of participants in this study wereAfrican American, and improvement in QOL was actually signif-icantly better for these participants than for White participants. Thereduction in psychological symptoms did not differ as a function ofethnicity. These data thus begin to address the generality of psy-chotherapeutic benefit (in particular CBT) to older African Amer-icans. This is one of the few studies to investigate the response ofolder African Americans to CBT, and our findings are encouragingwith respect to efficacy.

The greater improvement in QOL by African American partic-ipants was unexpected. We explored baseline differences in thetwo groups for possible explanations and found that only years ofeducation and MMSE scores differentiated the groups, with Afri-can American participants scoring significantly lower on both. Ifanything, these differences might argue for a less robust responsefor African American participants. Further research to replicateand better understand this finding would be helpful.

With regards to health status, participation in CBT resulted insignificant improvement in self-rated general health but did notproduce statistically significant changes in the use of formal healthcare and services. These findings suggest that improvements inQOL and reductions in psychological symptoms may have pro-duced concurrent improvements in subjectively experienced gen-eral health status.

In a more methodological vein, this is the first study with olderadults to exclusively use people with MSWs as research CBTtherapists. Their competent delivery of CBT in often challengingcircumstances suggests that CBT would be an appropriateevidence-based treatment for mastery development by practitio-ners from this discipline. Those planning studies with CBT mayalso find justification in the use of MSW therapists on the basis ofour experience.

Table 1Pretreatment Sample Characteristics

Variable M SD or (N%)

Age 75.4 7.1Gender

Women 111 (82.8)Men 23 (17.2)

Race/ethnicityAfrican American/Black 77 (57.5)Caucasian/White 57 (42.5)

Years of education08 49 (36.6)911 33 (24.6)12 29 (21.6)1316 20 (14.9)1720 3 (2.2)

Income$0$4,999 3 (2.2)$5,000$9,999 59 (44.0)$10,000$14,999 25 (18.7)$15,000$19,999 9 (6.7)$20,000$49,999 11 (8.2)$50,000$70,000 3 (2.2)

Income adequacyNot difficult 14 (10.4)Not very difficult 17 (12.7)Somewhat difficult 50 (37.3)Very difficult 49 (36.6)

Marital statusNever married 8 (6.0)Married 27 (20.1)Widowed 78 (58.2)Divorced 12 (9.0)Separated 8 (6.0)

Self-reported level of healthPoor 46 (34.3)Fair 60 (44.8)Good 18 (13.4)Very good 6 (4.5)Excellent 2 (1.5)

Comorbidity 3.05 (1.3)MMSE 24.9 3.5

Note. Includes 134 randomized participants who completed baseline.Missing data for participants in the following categories are as follows:income (24), income adequacy (4), marital status (1), self-reported level ofhealth (2), and comorbidity (7). Comorbidity is the number of reportedchronic health conditions from a list of seven. MMSEMini-Mental StateExamination.

662 SCOGIN ET AL.

A recent study by Arean et al. (2005) found that combining CBTwith case management conferred some efficacy advantage overCBT alone with respect to reducing depressive symptoms. In thisstudy, we explicitly instructed our MSW therapists to refrain fromcase-management activities to ensure a more focused test of theeffects of CBT. It was evident that many of our participantsexperienced significant case-management needs in health care,housing, and finances, among others. It is likely that combiningcase-management services with populations such as those servedin our study would also benefit from this form of multicomponentintervention, and MSW therapists or psychologists would be well-equipped to provide this intervention.

Our focus on QOL as a primary outcome is also noteworthy.Most studies of CBT or psychological treatments have targetedmental disorders, such as depression. This study examined theeffects of this well-established treatment on improving overall lifesatisfaction or QOL and found that improvements were seen in this

important outcome. Targeting QOL as a primary outcome mayprove useful in other studies with older adults.

Interestingly, changes on theory-relevant mediators of CBTwere not significant despite significant changes in QOL and psy-chological symptoms. Put differently, CBT did not producechanges in hopelessness and pleasant events as would be expected.This suggests that either the treatment is working through differentmeans, such as more general therapeutic factors, or the specificmeasures used to assess mediation were weak. Studies isolatingtherapeutic factors via dismantling or comparative designs may beneeded to address this issue. Scores on the BHS were rather low atTime 1, and thus this floor effect may have attenuated opportuni-ties to observe change and thus mediation on this variable. It is alsopossible that hopelessness is a poor target for mediation in CBT,and more traditional measures of dysfunctional thinking mayprove more fruitful. The lack of findings on pleasant events is alsodifficult to understand and suggests that greater efforts need to beundertaken to find the active ingredients at work in CBT with olderadults.

Table 2Means (SDs) of Predictor and Outcome Variables by Time and Condition

Measures

Time 1 Time 2

CBT MSC CBT MSC

QOLI 42.64 (9.22) 42.88 (8.83) 53.76 (13.94) 45.26 (13.42)(n 70) (n 64) (n 51) (n 50)

SCL-90 (GSI) 60.00 (7.05) 61.05 (7.91) 53.96 (8.12) 58.42 (10.88)(n 70) (n 64) (n 50) (n 50)

BHS 5.93 (4.15) 5.66 (3.31) 5.39 (4.29) 5.29 (3.88)(n 70) (n 64) (n 51) (n 48)

OAPES 2.72 (0.63) 2.53 (0.62) 2.80 (0.64) 2.62 (0.59)(n 69) (n 64) (n 51) (n 48)

General health rating 2.00 (0.95) 1.84 (0.83) 2.64 (0.98) 1.91 (0.95)(n 70) (n 62) (n 42) (n 47)

Formal care & services 1.58 (1.09) 1.70 (1.12) 1.45 (1.18) 1.78 (1.31)(n 69) (n 63) (n 40) (n 49)

Functional impairment 2.80 (0.85) 3.13 (0.95) 2.49 (0.84) 3.06 (1.03)(n 69) (n 64) (n 42) (n 48)

Note. CBT cognitive-behavioral therapy; MSC minimal support condition; QOLI Quality of LifeInventory; SCL-90 (GSI) Symptoms Checklist-90 (Global Severity Index); BHS Beck Hopelessness Scale;OAPES Older Adult Pleasant Events Schedule.

20

40

60

Time 1 Time 2

MSC

CBT

Figure 2. Adjusted Quality of Life Inventory means from mixed models.MSC minimal support condition; CBT cognitive-behavioral therapy.

40

50

60

70

Time 1 Time 2

MSC

CBT

Figure 3. Adjusted Global Severity Index means from mixed models.MSC minimal support condition; CBT cognitive-behavioral therapy.

663IMPROVING QUALITY OF LIFE IN OLDER ADULTS

Limitations

Several limitations to this study should be noted. First, thedesign of the study does not allow us to unequivocally ascribe theimprovements made by the participants to the ingredients of CBT.For example, the effects may have been due to the attention andconcern provided by the research therapists rather than the specificfocus of CBT on behavioral activation and cognitive processes.These common factors are known to be important aspects ofpsychotherapy change. The lack of significant change on the BHSand OAPES is also consistent with this explanation. A more formaltest of the specificity of CBT would control for such factors.Another limitation of the study was that some participants receivedCBT with the assistance of facilitation, whereas other participantsdid not have an available or willing facilitator. Although we foundno evidence in our analyses that the presence of the facilitatorimpacted outcome, this was an uncontrolled factor and warrantsfurther investigation. Another limitation was that a relatively highpercentage of participants received only partial treatment ratherthan the full course of CBT. However, we still found a significanteffect for treatment even with these participants included, on thebasis of intent-to-treat principles, in the primary analyses. Al-though the effect of treatment may have been stronger had partic-ipants received all sessions, our results suggest that a more abbre-viated course of treatment may still be effective for populationssimilar to those involved in this study. Indeed, many serviceagencies may not have the resources to offer 1620 sessions totheir consumers. Extracting the most essential aspects of the in-tervention would assist this process of translation from a researchstudy to the field, but efforts to shorten the protocol must besensitive to the extra time needed by some older adults to under-stand and act on treatment recommendations. As always, treatmentshould be as brief as possible but not too brief.

Another limitation is the unknown durability of the effectsevidenced by participants. Analyses of follow-up data will beforthcoming and reported in a subsequent article.

Summary

In summary, CBT was more effective, compared to those in theMSC group, in improving the QOL and psychological symptomsof this sample of older adults. This finding adds to a substantialbody of literature supporting the efficacy of this intervention withanxiety (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 problemsfrequently experienced by older adults. The broad efficacy base forCBT and similar psychological treatments corresponds well to agrowing recognition that many older adults report a preference forsuch treatments (Gum et al., 2006; Rokke & Scogin, 1995). At-tention to such patient preferences is a cornerstone of evidence-based practice according to the American Psychological Associa-tion (APA Presidential Task Force on Evidence-Based Practice,2006). The other elements of evidence-based practice, such as useof evidence-based treatments by skilled clinicians, comport wellwith the results of this study and suggest that CBT delivered bytrained providers can improve the well-being of an often over-looked portion of the population. The particular way in whichtreatment was delivered in this study will need translation to more

typical practice environments. For example, our providers traveledmany miles and spent considerable time reaching participants, andthis might not be practical outside a research context. Futurestudies should examine the effectiveness of CBT or similar inter-ventions when the intervention is delivered in-home but by moreindigenous providers with less monitoring of treatment delivery.Such providers could be colocated in primary care settings or otherservice entry points to promote case identification. In that much ofthe CBT provided in this study emphasized more behavioral as-pects of the intervention as therapists flexibly accommodatedlower literacy and cognitive impairment, a comparison of behav-ioral activation versus the full-package CBT seems indicated.Studies with depressed middle-aged adults suggest that the osten-sibly simpler behavioral activation may do as well or better thanCBT (Dimidjian et al., 2006; Jacobson et al., 1996). Coupling asimpler yet effective treatment with case management might proveeven more effective in improving the QOL of disadvantaged olderadults. Providing access to such services remains a challenge forthose committed to the well-being of older adults.

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Received December 1, 2006Revision received May 24, 2007

Accepted June 4, 2007

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