Effectiveness of CBT vs. Usual Care in Elderly Depression: Healthcare

This report presents a literature review investigating the effectiveness of Cognitive Behavioral Therapy (CBT) compared to usual care in treating depression among the elderly (75 years and older) residing in aged care facilities in Australia. The study aims to assess the impact of CBT on reducing depre...Read More

Running head: Healthcare 1
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Table of Contents
Introduction...............................................................................................................................................3
Background................................................................................................................................................4
Rational......................................................................................................................................................5
Gaps in Knowledge:..................................................................................................................................7
Aims:..........................................................................................................................................................7
Research Questions:..................................................................................................................................7
Methods:.....................................................................................................................................................8
Identification and selection of studies..................................................................................................8
Inclusion and Exclusion Criteria........................................................................................................10
Ethical Consideration..........................................................................................................................10
Data Analysis plan...............................................................................................................................10
Significance..............................................................................................................................................11
Results......................................................................................................................................................11
Screening...............................................................................................................................................12
Included.................................................................................................................................................12
Eligibility................................................................................................................................................12
Identification.........................................................................................................................................12
Quality Assessment..................................................................................................................................20
Discussion.................................................................................................................................................21
Limitation.................................................................................................................................................22
Conclusion................................................................................................................................................23
References................................................................................................................................................24
References................................................................................................................................................24

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Abstract
Background
Australia is a developed country with an advanced healthcare system but there are still multiple
cases of depression. Australia is characteristic of an ageing population and high number of
residential age care places. Moreover, the elderly is significantly affected by depression (AIHW.,
2013).
Aim
To ascertain the effectiveness of Cognitive Behavioral Therapy compared with usual care in
Depression among the Elderly in Age care aged 75 years and above in Australia.
Methodology
This was a literature review of relevant literature on effectiveness of CBT compared with usual
care in treating depression in elderly aged 75 years and above in Australia. The researcher
conducted a literature search on electronic databases using appropriate key terms and an
inclusion criterion. The extracted data was recorded, analyzed and presented under appropriate
themes. A PRISMA flow diagram was used as a guide in the selection and analysis of articles
Results
90 studies were generated from PubMed, PsychINFO and Web of Science databases and 55
articles were excluded because they were irrelevant articles after analyzing the titles and
abstracts, 15 for having an inappropriate population, and 8 for having an intervention not of
interest. The remaining with 12 which were analysed. There was a consensus across all the
studies that CBT was an effective approach in treating depression. Patients who had undergone
CBT reported positive significant association. Moreover, CBT was culturally adaptable thus
making it to become widely accepted globally. The intervention was found to be much more
effective than the usual methods due to its lack of side effects.
Conclusion
The major outcome of this review is that CBT is effective in treating depression among the
elderly of Australia and of other cultures as well. The increasing population of the elderly in

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Australia requires an urgent use of CBT to help improve the quality of life and reduce its
prevalence

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Effectiveness of cognitive Behavioral Therapy compared with usual care in
the elderly aged 75 years and older with Depression living in the aged care in
Australia.
Introduction
Depression is often a chronic disease that leads to disability especially among the elderly
with over 74% of patients experiencing recurring depression 12 months after detection (World
Health Organization, 2012). The elderly are the most affected group by major depression (MD)
or major depressive disorder (MDD) with an incidence of 7% among the aged and 1.6% cases of
severe disability among those aged sixty years and above (Institute for Health Metrics and
Evaluation, 2010). Studies have shown that untreated depression leads to physical and social
impairment and lastly to morbidity; all which have a socioeconomic burden (Gould, Coulson, &
Howard, 2012). Approximately 1 million depressive people commit suicide each year on a
global scale (WHO, 2012). Estimates of an increasingly ageing population in developed
countries is an indication of a possible increase in the demand for treatments and therapies that
deal with the unique needs of the elderly.
Due to the magnitude of depressive disorder among the elderly, multiple treatment
options exist such as usual care and physiological therapies such as CBT, electroconvulsive
therapy, and behavioral activation among others (Gold et al., 2017). Most of the existing
treatment methods of depression have been examined for their effectiveness. For instance, the
usual care is effective in reducing the suicide rates in most the countries (Rihmer & Gonda,
2011). Over 50% of patients with depressive symptoms have been found to positively respond to
the usual care (Gold et al., 2017). However, some researcher opines that the use of

Healthcare 6
antidepressants in usual care by the elderly leads to cardiovascular side effects thus making them
inappropriate for them (Kennedy, 2013). Psychological therapies such as Cognitive behavioral
therapy are the most effective in alleviating depression symptoms in all ages. Kivi et al. (2014)
examined the effectiveness of CBT and usual care. The study found out that 56% of the patients
who received CBT and completed all the treatment modules had experienced low depressive
symptoms. There are no known adverse effects in the use of CBT as opposed usual care.
Moreover, there is a dearth of information on the effectiveness of CBT in treating depression
among the elderly in the context of Australia. This study purposes to assess the effectiveness of
behavioral therapy compared with usual care in Depression among the Elderly in Age care aged
75 years and above in Australia. A critical review of relevant literature will be carried out using a
Prisma flow diagram and an analysis conducted using a thematic approach and the results
presented.
Background
Australia is a developed country with an advanced healthcare system but there are still
multiple cases of depression. The findings of epidemiological studies suggest an increased rate of
mental disorders among teenagers and older people. Generally, the incidence of mental disorders
decreases significantly with the increase in age, however, this relationship is converse in the case
of elderly people with most older people experiencing acute psychological stress (ABS, 2012).
According to the Australian Institute of Health and Welfare carried out in 2007, Australians aged
25-34 years have the highest levels of mental illnesses (24%) and those aged 75-85 years have a
prevalence of only 6% (AIHW, 2015). According to Courtin and Knapp (2017), about 10-15% if
older Australian who reside in the community exhibit depressive symptoms. Nevertheless, some
studies have indicated that some sub-groups of the elderly population are more vulnerable to

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depression. For instance, by 2012 over 50% of all permanent residents of aged care had mild,
average or severe depressive symptoms (AIHW, 2013).
CBT is believed to be the most effective and appropriate approach in the treatment of
depression among the elderly. Cognitive behavior therapy (CBT) is an objective intervention
founded on the fact that cognitions affect feelings and behaviors, and successive conduct and
feelings can affect cognitions. The practitioner assists patients to ascertain harmful thoughts,
feelings and conduct. There are two features of CBT: cognitive therapy and behavior therapy.
Behavior therapy is premised on the assumption that behavior is learned and thus can be
modified. Some behavioral procedures are contact, activity planning, relaxation, and behavior
change. On the other hand, cognitive therapy is premised on the supposition that worrying
feelings and restrictive conducts are due to wrong ways of thinking. Thus, CBT interventions
such as cognitive restructuring and individual instructional training are focused at substituting
harmful thoughts with much more beneficial thoughts, which are important in dealing with
worrying thoughts, feelings and conduct (Australian Psychological Society, 2010).
Age care is critical because the older folk are physically and mentally worn out and thus
unable to undertake general life duties, thus making them total dependents. This great burden of
care necessitates the need for aged care centres (AIHW., 2013). The increasing number of
residential aged care places is also an indication of the rise in the demand for quality care needs
of older people with depression.
Rational

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The majority of the Australian population consists of older people. According to AIHW
(2015), 1 out 7 people were aged 65 years and above and are expected to live for an additional 20
years in the case of men and 22 years in the case of women. In other words, 15% of the
Australian population (3.8 million) were aged 65 years and above. This ratio is expected to grow
progressively in the future. The care needs for the elderly with depression are critical and require
special attention, hence the reason for the high number of residential aged care in Australia.
According to AIHW (2012), there were approximately 185,500 residential aged care centres
which are an increase by 2,600 centres in the previous year. Approximately 52% (85,200)
permanent residents reported cases of depression in 2011. The number of aged people increased
from 36% to 50%. The care needs for the elderly with depression varies depending on the level
of severity, environment among other factors. However, most of the elderly people admitted to
these care centres are diagnosed with varying depression levels. For instance, 45% of the patients
admitted to permanent aged care were diagnosed with depression, 13% had average symptoms
and 11% had server depressive symptoms (AIHW, 2013). Depression levels are on the increase
despite the existence of multiple treatment approaches such as the use of antidepressants and
psychological therapies.
The use of antidepressants has been examined and found to be relatively effective in
alleviating depression symptoms among the elderly in aged-care. Kivi et al. (2014) found out that
the use of gomelatine and alprazolam were effective in alleviating acute depression symptoms.
However, the unwillingness of the patients to take drugs in addition to side effects limited the
effectiveness of pharmacotherapy approach. There are no known adverse effects in the use of
CBT as opposed to antidepressants. However, the researcher is not aware of any study on the
effectiveness of CBT in aged care residents in Australia. This study purposes to assess the

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effectiveness of cognitive behavioral therapy and usual care in Depression among the Elderly in
Age care aged 75 years and above in Australia.
Gaps in Knowledge:
Multiple studies have examined the use of alternative methods in the treatment of
depression among the elderly on a global scale. These treatment methods include psychosocial
interventions, antidepressants and somatic treatments. The efficacy of antidepressants as a
treatment method for depression vary depending on the age, and gender. Male patients with
depressive symptoms seem to have a lower rate to multiple antidepressants just like the elderly.
Moreover, antidepressants were found to have significant side effects on the elderly and require a
longer duration to respond positively (Linde et al., 2015).
Psychotherapeutic interventions such as CBT, interpersonal psychotherapy among others are
more effective in alleviating depressive symptoms and with no side effects. CBT is aimed to
identify maladaptive believe systems and improve the outcomes by focusing on behavioural
skills to overcome maladaptive conduct (Avasthi & Grover, 2018). Despite the existence of
literature on the effectiveness of different treatment options for depression, there is minimal
literature that focuses on the effectiveness of CBT in treating depression among the elderly in
Australia. It is this gap that the current review tends to fill.
Aims:
To ascertain the effectiveness of Cognitive Behavioral Therapy in Depression among the
Elderly in Age care aged 75 years and above in Australia.
Research Questions:
Is CBT compared with usual methods effective for treating depression among Elderly in
Age care aged 75 years and above in Australia?

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Methods:
Identification and selection of studies
Electronic databases were searched for relevant studies including an evaluation of the
titles, and abstracts. The electronic databases include PubMed, PsychINFO and Web of Science.
The researcher combined the key terms indicative of cognitive-behavioral therapy and Australian
elderly with depressive symptoms. The specific keywords used include cognitive behavioral
therapy, depression, elderly. The search was carried out from July to August 2019. Some other
records were searched manually by checking the reference list of the studies included in the
review.

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Effectiveness (AND)
cognitive
behavioral
therapy
(AND)
Depression
(AND)
Elderly
(AND)
Aged
care
(AND)
Usual
care
“Effectiveness”
OR
“Impact”
OR
“Efficacy”
“Cognitive
behavioral
thera**”
OR
“CBT”
“cognitive
therapy”
Depressio*
OR
“Anxiety”
Elderly
OR
“Old age”
OR
“Senior
citizen”
OR
“Age”
“Aged
Care”
OR
“Old
care”
OR
“Elderly
care”
“Usual
Care”
OR
“Routine
Care”
OR
“Usual
Car*”
Types of studies
PICO was used as follows:
 POPULATION – elderly people with depression (75 year and above) in aged care
 INTERVENTION – CBT that will help alleviate depression symptoms
 CONTROL/COMPARISON – CBT against Usual care
 CONTROL – elderly people do not receive any treatment
 OUTCOME – reduced depressive symptoms

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Inclusion and Exclusion Criteria
The studies were viable for analysis if they were published within the last ten years,
examined the effectiveness of CBT, used a sample of Australian elders, included depression and
any other control condition.
Ethical Consideration
The study was submitted for review to the University’s ethical review committee. Since
the study did not directly deal with human subjects, it was exempted for detailed review. The
researcher did not have any conflict of interest to reveal for this study.
Data Analysis plan
The researcher extracted data from the studies included for analysis and was recorded and
ordered using Excel spreadsheets. The extracted data included a description of CBT, the mean
and sample size, the research design, the overall findings of the study. Both numerical and
thematic analysis was carried out to completion using the extracted data. Under the numerical
analysis, the number of studies searched and recorded were identified, the year of publication,
and the general nature of the study. The obtained data was used during thematic analysis to
ascertain the overall evidence of the effectiveness of CBT and to ascertain any knowledge gaps
based on the evidence. The studies were identified using unique numbers both in the numerical
and thematic analysis.

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Significance
The findings of this review will be very important to the Australian Institute of Health
and Welfare and other Australian health departments. The departments can use the outcomes of
the study to reduce the prevalence of depression among the elderly and to obtain information on
the current trend in the rate of depression among the elderly. The outcomes of the study could
also be important to the administration of the residential aged care in Australia because they
would determine whether CBT is most effective in addressing depression among the elderly and
discard other alternative ineffective methods. The study can also be a basis for further research to
compare the effectiveness of CBT with other psychotherapy methods of treating depression. The
Australian government can also use the outcome of this study to make appropriate changes to the
current Public health policy on healthcare services for the aged to improve the quality of life of
the aged and help reduce depression levels.
Results
Literature search generated 86 records, and 4 additional records were manually identified
from the list of references of the selected articles. The researcher excluded 55 irrelevant articles
after analyzing the titles and abstracts, 15 for having an inappropriate population, and 8 for
having an intervention not of interest. The remaining 12 full-text articles were retrieved and a
further study was excluded for different reasons as presented in the Prisma flow diagram (Figure
1). Lastly, 12 studies were included for review after meeting the inclusion criteria.

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Database search(n =86 )
ScreeningIncluded Eligibility Identification Additional sources through
manual search in the list of
references =4(n = 3 )
Studies after exclusion due to
duplication(n = 90)
Studies screened(n
=90)
Excluded irrelevant title
(n = 55)
Full-texts assessed for
eligibility(n = 35)
Excluded full texts -
inappropriate population
=15intervention not of
interest =8
Studies included in
qualitative synthesis(n
=12 )
Studies included in quantitative synthesis (meta-analysis)(n = 12)
Dear, B. F., Zou, J. B., Ali, S., Lorian, C. N., Johnston, L., Terides, M. D., ... & Titov, N. (2015a).
Dear, B. F., Zou, J. B., Ali, S., Lorian, C. N., Johnston, L., Sheehan, J., ... & Titov, N. (2015b).
Wuthrich, V. M., & Rapee, R. M. (2013).
Glozier, N., Christensen, H., Naismith, S., Cockayne, N., Donkin, L., Neal, B., ... & Hickie, I. (2013).
Dear, B. F., Zou, J., Titov, N., Lorian, C., Johnston, L., Spence, J., ... & Knight, R. G. (2013).
Pasieczny, N., & Connor, J. (2011).
Choi, I., Zou, J., Titov, N., Dear, B. F., Li, S., Johnston, L., ... & Hunt, C. (2012).
Solomon, D., Proudfoot, J., Clarke, J., & Christensen, H. (2015).
Newby, J. M., Mackenzie, A., Williams, A. D., McIntyre, K., Watts, S., Wong, N., & Andrews, G.
(2013).
Bell, C. J., Colhoun, H. C., Carter, F. A., & Frampton, C. M. (2012)
Spence, J., Titov, N., Dear, B. F., Johnston, L., Solley, K., Lorian, C., ... & Schwenke, G. (2011).
Seitz, D. C. M., Knaevelsrud, C., Duran, G., Waadt, S., Loos, S., & Goldbeck, L. (2014).

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Table 2 Characteristics of included studies.
Type of study country Study design size Intervention Primary
outcome
Dear, B. F., Zou, J.
B., Ali, S., Lorian,
C. N., Johnston, L.,
Terides, M. D., ... &
Titov, N. (2015).
Examining self-
guided internet-
delivered cognitive
behavior therapy for
older adults with
symptoms of
anxiety and
depression: Two
feasibility open
trials
Australia Open trials 47
participants
self-guided internet-
delivered cognitive
behavior therapy
There was
statistical
improvements
in the health-
associated
quality of life
compared to
the high cost
incurred in the
treatment of
depression and
anxiety trial
Dear, B. F., Zou, J.
B., Ali, S., Lorian,
C. N., Johnston, L.,
Sheehan, J., ... &
Titov, N. (2015).
Clinical and cost-
effectiveness of
therapist-guided
internet-delivered
cognitive behavior
therapy for older
adults with
symptoms of
anxiety: a
randomized
controlled
trial. Behavior
Therapy, 46(2), 206-
217.
Australia RCT 72 Internet-Delivered
Cognitive Behavior
Therapy
iCBT is an
effective and
cost-effective
treatment
alternative for
older adults
with anxiety
symptoms. The
intervention
group had
relatively
higher costs
and quality of
adjusted life
years
Wuthrich, V. M., &
Rapee, R. M.
(2013). Randomised
controlled trial of
group cognitive
behavioural therapy
Australia RCTs 62 Group CBT There was
significant
reduction in the
symptoms of
depression and
anxiety after

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for comorbid
anxiety and
depression in older
adults. Behaviour
Research and
Therapy, 51(12),
779-786.
controlling for
cognitive
ability. Group
CBT is
efficacious in
minimizing
comorbid
anxiety and
depression
geriatric
patients within
three months
Glozier, N.,
Christensen, H.,
Naismith, S.,
Cockayne, N.,
Donkin, L., Neal,
B., ... & Hickie, I.
(2013). Internet-
delivered cognitive
behavioural therapy
for adults with mild
to moderate
depression and high
cardiovascular
disease risks: a
randomised
attention-controlled
trial. PloS one, 8(3),
e59139.
Australia Randomised
attention-
control trial
562 adults iCBT/ internet-
delivered attention
control health
information package
internet- and
mobile-based
interventions
relatively
minimized
depression
symptoms and
CVD risk
factors in
adults with
depression at
the conclusion
of the treatment
and follow-up
evaluations
when compared
with waitlist
conditions.
Dear, B. F., Zou, J.,
Titov, N., Lorian,
C., Johnston, L.,
Spence, J., ... &
Knight, R. G.
(2013). Internet-
delivered cognitive
behavioural therapy
for depression: a
feasibility open trial
for older
adults. Australian &
New Zealand
Journal of
Psychiatry, 47(2),
169-176.
Australia Open trial 20 older
adults
ICBT The programe
was high rated
as acceptable
by participants.
the outcomes
indicated and
support
potential value
of iCBT in
alleviating
depressive
symptoms in
older adults

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17
Pasieczny, N., &
Connor, J. (2011).
The effectiveness of
dialectical
behaviour therapy in
routine public
mental health
settings: An
Australian
controlled
trial. Behaviour
Research and
Therapy, 49(1), 4-
10.
Australia RCT 43 demonstrated
dialectical behaviour
therapy (DBT)/ wait
list group receiving
treatment as usual
(TAU)
DBT showed
greater
reduction in the
depressive
symptoms such
as suicidal
ideation, and
sel-f harm.
DBT is both
clinically
effective and
cost effective.
Choi, I., Zou, J.,
Titov, N., Dear, B.
F., Li, S., Johnston,
L., ... & Hunt, C.
(2012). Culturally
attuned Internet
treatment for
depression amongst
Chinese
Australians: a
randomised
controlled
trial. Journal of
affective
disorders, 136(3),
459-468.
Australia RCT 55 iCBT program Intervention
group reported
significantly
reduced
symptoms of
depression on
the Chinese
version of
CBDI. The
participants
voted the
procedure as
acceptable and
benefits were
maintained
within three
months follow-
up.
Solomon, D.,
Proudfoot, J.,
Clarke, J., &
Christensen, H.
(2015). e-CBT
(myCompass),
antidepressant
medication, and
face-to-face
psychological
treatment for
depression in
Australia RCT 4,356
adults
ECBT/
antidepressant
medication
An internet
based CBT is
more cost
effective in the
treatment of
depressive
symptoms due
to easy
accessibility.

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18
Australia: A cost-
effectiveness
comparison. Journa
l of medical Internet
research, 17(11),
e255.
Newby, J. M.,
Mackenzie, A.,
Williams, A. D.,
McIntyre, K., Watts,
S., Wong, N., &
Andrews, G. (2013).
Internet cognitive
behavioural therapy
for mixed anxiety
and depression: a
randomized
controlled trial and
evidence of
effectiveness in
primary
care. Psychological
Medicine, 43(12),
2635-2648.
Australia RCT 235 adults Icbt/ Wait-List
Control
iCBT programe
was more
effective than
WLC. The
iCBT program
was beneficial
at a three-
month follow-
up
Bell, C. J., Colhoun,
H. C., Carter, F. A.,
& Frampton, C. M.
(2012).
Effectiveness of
computerised
cognitive behaviour
therapy for anxiety
disorders in
secondary
care. Australian &
New Zealand
Journal of
Psychiatry, 46(7),
630-640.
Australia Observational 166 adults CCBT/WLC The CCBT
group had
significant
improvement
within 12 and
24 weeks with
average effect
sizes. CCBT is
beneficial even
in secondary
care settings
and is self-
reliant even in
primary care
settings
Spence, J., Titov,
N., Dear, B. F.,
Johnston, L., Solley,
K., Lorian, C., ... &
Australia RCT 42 adults CBT Large pre-to
post treatment
effect sizes
were observed
in the

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19
Schwenke, G.
(2011). Randomized
controlled trial of
Internet‐delivered
cognitive behavioral
therapy for
posttraumatic stress
disorder. Depressio
n and anxiety, 28(7),
541-550.
intervention
group on
assessments of
PTSD
symptoms.
CBT is
effective in the
treatment of
adults with
PTSD
symptoms
Seitz, D. C. M.,
Knaevelsrud, C.,
Duran, G., Waadt,
S., Loos, S., &
Goldbeck, L.
(2014). Efficacy of
an internet-based
cognitive-behavioral
intervention for
long-term survivors
of pediatric cancer:
a pilot
study. Supportive
Care in
Cancer, 22(8),
2075-2083.
Australia Quantitative 20 CBT There was
observed
significant
decline in of
anxiety, fear,
and depression
at the end of
the treatment.
CBT is
efficacious in
minimizing the
symptoms of
post-traumatic
stress and
anxiety.
The table above shows the 12 different studies that were used in the analysis of this
paper regarding the effectiveness of CBT compared with usual care in treating depression
among the elderly adults. These studies consist of RCTs and quantitative studies carried out
in Australia, using different study designs and with different sample sizes. Included in the
table are the interventions used for the studies conducted as well as the primary outcomes.
Table 3 Quality Assessment of Included Studies.
Author Criteria 1 Validity
(representativeness;
target population
representativeness;
Criteria 2
Precision
(minimal
nonresponse bias;
Criteria 3
Applicability
(suitable for
local context)
Total score

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20
random selection or
census undertaken)
acceptable case
definition used;
valid and reliable
study instrument
used; some mode
of data collection
for all subjects)
Dear, B. F., Zou,
J. B., Ali, S.,
Lorian, C. N.,
Johnston, L.,
Terides, M.
D., ... & Titov, N.
(2015).
1 1 0 2
Dear, B. F., Zou,
J. B., Ali, S.,
Lorian, C. N.,
Johnston, L.,
Sheehan, J., ...
& Titov, N.
(2015).
1 1 1 3
Glozier, N.,
Christensen, H.,
Naismith, S.,
Cockayne, N.,
Donkin, L., Neal,
B., ... & Hickie, I.
(2013).
1 1 1 3
Wuthrich, V. M.,
& Rapee, R. M.
(2013)
1 1 1 3
Dear, B. F., Zou,
J., Titov, N.,
Lorian, C.,
Johnston, L.,
Spence, J., ... &
Knight, R. G.
(2013).).
0 1 0 1
Pasieczny, N., &
Connor, J.
(2011).
1 1 1 3
Choi, I., Zou, J.,
Titov, N., Dear,
B. F., Li, S.,
Johnston, L., ...
& Hunt, C.
(2012
1 1 1 3
Solomon, D., 1 1 1 3

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21
Proudfoot, J.,
Clarke, J., &
Christensen, H.
(2015).
Newby, J. M.,
Mackenzie, A.,
Williams, A. D.,
McIntyre, K.,
Watts, S.,
Wong, N., &
Andrews, G.
(2013).
1 1 1 3
Bell, C. J.,
Colhoun, H. C.,
Carter, F. A., &
Frampton, C. M.
(2012).
0 1 0 1
Spence, J.,
Titov, N., Dear,
B. F., Johnston,
L., Solley, K.,
Lorian, C., ... &
Schwenke, G.
(2011).
1 1 1 3
Seitz, D. C. M.,
Knaevelsrud, C.,
Duran, G.,
Waadt, S., Loos,
S., & Goldbeck,
L. (2014).
0 1 1 2
0=POOR QUALITY; 1= MEDIUM QUALITY; 3= HIGH QUALITY
The above table shows quality assessment of the included studies using using a 3-
point scale, 0 =poor quality, 1 = medium quality and 3 = high quality. This assessment was
based on 3 criteria, Validity, Precision and Applicability. Out of the 12 studies 2 had a
medium score of 2 (medium quality), 2 studies had poor quality score (poor quality) and, 8
had a high-quality score of 3 (high quality). Based on the table above, majority of the studies
were of high quality
Review and analysis of the selected literature on the effectiveness of CBT articles
concluded that CBT was much more effective in addressing depression among the elderly

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22
than usual care. Two feasibility open trials were carried out by Dear et al. (2015a) to assess
the efficacy of independently-guided CBT for older adults with depressive and anxiety
symptoms. Over 90% of the participants rated the intervention as appropriate with significant
reductions in anxiety (d = 1.17; 95% CI: 0.55 to 1.75) and depression (d = 1.06; 95% CI: 0.33
to 1.73) reported. Furthermore, CBT was found to be cost effective in the treatment of both
depression and anxiety symptoms ($69.84 and $54.98) respectively. Dear et al. (2015b) and
Solomon, Proudfoot, Clarke, and Christensen (2015) also found CBT to be cost effective.
Dear et al. (2015b) reported significant low scores on measures of depression and anxiety
(d = 1.79; 95% CI: 1.21 – 2.3 and d = 1.43; 95% CI: 0.89 – 1.93 respectively) on the
intervention groups. These lower scores were sustained over a period of three months. Group
cognitive behavioural therapy was also found to be efficacious in minimizing comorbid
anxiety and depression among older adults and the benefits were sustainable for at least three
months (Wuthrich, & Rapee, 2013) as in the case of Dear et al. (2015). The effectiveness of
internet delivered CBT has been observed across multiple studies when compared with usual
care (Glozier et al., 2013; Dear et al., 2013; Choi et al., 2013; Solomon, Proudfoot, Clarke, &
Christensen, 2015; and Newby et al., 2013). The above studies also found out that the
implementation period for different forms of CBT was short ranging between three months to
six months. For instance, the study by Spence et al. (2011) found out that CBT was effective
in eight weeks, and 12 and 24 weeks by Bell, Colhoun, Carter, and Frampton (2012).
Quality Assessment
Quality assessment of the articles for review was carried out using Cochrane
checklist. A Cochrane tool for meta-analysis, reviews and RCTs were used to assess the
quality of the study. This involved identification of a clinical problem, assessment of a review

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protocol such as inclusion and exclusion criteria, presence of detailed research design among
others. Cochrane risk of bias tool was also used to assess the quality of the articles included
in the study. Empirical evidence was searched for each assertion in addition to the assessment
of the validity of the outcomes, that is the possibility that researchers may overestimate or
understated
Discussion
The literature review purposed to examine the efficacy of the use of CBT compared to
usual care in the treatment of depression among the elderly. The outcomes show that CBT
was generally effective in the treatment of depression in adults. The research promoting the
use of CBT among the elderly is persuasive, and it is the most recommended first-line
intervention with level I evidence for effectiveness (Lopez & Basco, 2015). Existing
literature supports the effectiveness of different forms of CBT on the Australian elders. The
present study shows that different forms of CBT are effective in depressive individuals from
all nations. These findings are consistent with those carried. These findings are consistent
with those carried by Gould et al. (2012) and Jayasekara et al. (2015) who found out that all
the three types of CBT (reminiscence therapy, and general psychotherapy (GPT)) were more
effective for the elderly because they do not have side effects when compared with the usual
drug treatment.
The study by Solomon et al. (2015) reported that the use of computer-based
CBT was more effective than other usual methods such pharmacotherapy. The study
by Cox and D’Oyley (2011) found out that there was a significant difference
supporting the use of CBT compared to other methods. CBT does not only treat
mental health illnesses such as depression but is also critical in preventing the
development of depression which is common in older adults. However, these findings

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are in contrary to those of Cuijpers, Beekman, and Reynolds (2012), who found out
that the use of CBT in combination with other interventions such as some
antidepressants led to the greater positive response that when medication is used
alone. This implies that antidepressants are ineffective when used alone as compared
to when they are combined with psychotherapy methods.
Similar findings were reported by Kennedy (2013) who found out that CBT was more
effective among young adults and in the old when combined with medications such as
antidepressants. Seitz et al. (2015) found out that internet-based CBT was more effective among old
paediatric cancer patients. CBT was also effective and attractive to patients who never wanted to take
drugs. The study by Dear et al. (2015a) observed a high acceptability for self-guided iCBT among
older adults. Similar outcomes were reported by Dear et al. (2015b); Choi et al. (2012) and Solomon
et al. (2015).
Choi et al. (2012) reported that group CBT was much more effective compared to usual
methods. Consistent with the estimation of the researcher, this study found out that CBT led
to a better therapeutic efficacy due to its adaptability to multiple cultures. These outcomes
agree with the review by Benish, Quintana, & Wampold (2011) who demonstrated that
psychotherapy treatment methods that were culturally adapted resulted to improved efficacy
both in the long-term and short-term.
Limitation
Despite the findings of this study regarding the efficacy of CBT compared with usual
treatment on depression among the elderly in aged care centers, its interpretation should be
undertaken given some limitations. This systematic literature review aimed at assessing
existing evidence on the effectiveness of CBT. It aimed at demonstrating the existing weight
of evidence to ascertain any knowledge gap. As a result of this research design, the review

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doesn’t address the quality of the evidence analyzed. Therefore, only general
recommendations can be useful for practice or as a basis for further studies. Additionally, the
studies included multiple forms of CBT and randomized trials thus making comparison and
generalization difficult. This study did not specify the type of CBT and thus making it
difficult during practical application. Some of the studies included in the review had small
sample sizes, different demographics of participants, and multiple forms of CBT
interventions. These makes the generalization to other wider populations of old adults
difficult. Further studies are required to examine the impact of different forms of CBT on
depressive symptoms among the elderly.
Conclusion
The major outcome of this review is that CBT is effective in treating depression
among the elderly of Australia that usual methods. The increasing prevalence of depression
among elders can be attributed to the lack of efficacy of usual methods. The Australian
ageing population is on the rise as well as the number of residential aged care. The elderly are
at a critical age and they easily develop depression which if not treated in time could lead to
other complications such as physical and social impairment and even morbidity. Other
common treatment options such as the use of antidepressants are ineffective especially for the
elderly due to potential Side effects. On the contrary, cognitive behavioural therapy has no
side effects and is culturally adaptable thus making it more effective and can be used by
diverse cultures

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References
References
AIHW (Australian Institute of Health and Welfare). (2013). Depression in residential aged
care
2008–2012. Aged care statistics series No. 39. Cat. no. AGE 73. Canberra: AIHW.
Australian Psychological Society. (2010). Evidence‐based psychological interventions in the
treatment of mental disorders: A literature review. Victoria: Australian Psychological
Association.
Australian Bureau of Statistics (ABS). (2012). Australian Health Survey 2011–12. ABS cat.
no.
4364.0. Canberra: ABS.
Australian Institute of Health and Welfare (AIHW). (2012). Older Australia at a glance. Cat.
no: AGE. 87. Canberra: AIHW. Retrieved from
https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/
demographics-of-older-australians
Australian Institute of Health and Welfare (AIHW). (2015). Australia’s welfare 2015.
Australia’s
welfare series no. 12. Cat. no. AUS 189. Canberra: AIHW.
Avasthi, A., & Grover, S. (2018). Clinical practice guidelines for management of depression
in
elderly. Indian journal of psychiatry, 60(Suppl 3), S341.

Healthcare
27
Bell, C. J., Colhoun, H. C., Carter, F. A., & Frampton, C. M. (2012). Effectiveness of
computerised cognitive behaviour therapy for anxiety disorders in secondary
care. Australian & New Zealand Journal of Psychiatry, 46(7), 630-640.
Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy and
the
legitimacy of myth: a direct-comparison meta-analysis. Journal of Counseling
Psychology, 58(3), 279.
Courtin, E., & Knapp, M. (2017). Social isolation, loneliness and health in old age: a scoping
review. Health & social care in the community, 25(3), 799-812.
Choi, I., Zou, J., Titov, N., Dear, B. F., Li, S., Johnston, L., ... & Hunt, C. (2012). Culturally
attuned Internet treatment for depression amongst Chinese Australians: a randomised
controlled trial. Journal of affective disorders, 136(3), 459-468.
Cox, D., & D’Oyley, H. (2011). Cognitive-behavioral therapy with older adults. British
Columbia Medical Journal, 53(7), 348-352.
Cuijpers, P., Beekman, A. T., & Reynolds, C. F. (2012). Preventing depression: a global
priority. Jama, 307(10), 1033-1034.
Dear, B. F., Zou, J. B., Ali, S., Lorian, C. N., Johnston, L., Sheehan, J., ... & Titov, N.
(2015b).

Healthcare
28
Clinical and cost-effectiveness of therapist-guided internet-delivered cognitive
behavior therapy for older adults with symptoms of anxiety: a randomized controlled
trial. Behavior Therapy, 46(2), 206-217.
Dear, B. F., Zou, J. B., Ali, S., Lorian, C. N., Johnston, L., Terides, M. D., ... & Titov, N.
(2015a). Examining self-guided internet-delivered cognitive behavior therapy for
older adults with symptoms of anxiety and depression: Two feasibility open
trials. Internet Interventions, 2(1), 17-23.
Dear, B. F., Zou, J., Titov, N., Lorian, C., Johnston, L., Spence, J., ... & Knight, R. G. (2013).
Internet-delivered cognitive behavioural therapy for depression: a feasibility open trial
for older adults. Australian & New Zealand Journal of Psychiatry, 47(2), 169-176.
Glozier, N., Christensen, H., Naismith, S., Cockayne, N., Donkin, L., Neal, B., ... & Hickie, I.
(2013). Internet-delivered cognitive behavioural therapy for adults with mild to
moderate depression and high cardiovascular disease risks: a randomised attention-
controlled trial. PloS one, 8(3), e59139.
Gold, S. M., Enck, P., Hasselmann, H., Friede, T., Hegerl, U., Mohr, D. C., & Otte, C.
(2017).
Control conditions for randomised trials of behavioural interventions in psychiatry: a
decision framework. The Lancet Psychiatry, 4(9), 725-732.
Gould, R. L., Coulson, M. C., & Howard, R. J. (2012). Cognitive behavioral therapy for

Healthcare
29
depression in older people: A meta‐analysis and meta‐regression of randomized
controlled trials. Journal of the American Geriatrics Society, 60(10), 1817-1830.
https://www.aihw.gov.au/reports/aged-care/residential-aged-care-in-australia-2010-
11/contents/table-of-contents
Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of
cognitive behavioral therapy: A review of meta-analyses. Cognitive therapy and
research, 36(5), 427-440.
Institute for Health Metrics and Evaluation. (2010). Global burden of disease study.
Retrieved
from: http://ghdx.healthdata.org/globalburden-disease-study-2010-gbd-2010-data-
downloads
Jayasekara, R., Procter, N., Harrison, J., Skelton, K., Hampel, S., Draper, R., & Deuter, K.
(2015). Cognitive behavioural therapy for older adults with depression: a
review. Journal of Mental Health, 24(3), 168-171.
Josephine, K., Josefine, L., Philipp, D., David, E., & Harald, B. (2017). Internet-and mobile-
based depression interventions for people with diagnosed depression: a systematic
review and meta-analysis. Journal of affective disorders, 223, 28-40.
Kennedy, S. H. (2013). A review of antidepressant therapy in primary care: current practices
and
future directions. The primary care companion for CNS disorders, 15(2).
Kivi, M., Eriksson, M. C., Hange, D., Petersson, E. L., Vernmark, K., Johansson, B., &

Healthcare
30
Björkelund, C. (2014). Internet-based therapy for mild to moderate depression in
Swedish primary care: short term results from the PRIM-NET randomized controlled
trial. Cognitive behaviour therapy, 43(4), 289-298.
Koenig, H. G., Pearce, M. J., Nelson, B., Shaw, S. F., Robins, C. J., Daher, N. S., ... &
Rosmarin,
D. H. (2015). Religious vs. conventional cognitive behavioral therapy for major
depression in persons with chronic medical illness: A pilot randomized trial. The
Journal of nervous and mental disease, 203(4), 243-251.
Linde, K., Rücker, G., Sigterman, K., Jamil, S., Meissner, K., Schneider, A., & Kriston, L.
(2015). Comparative effectiveness of psychological treatments for depressive
disorders in primary care: network meta-analysis. BMC family practice, 16(1), 103.
Lopez, M. A., & Basco, M. A. (2015). Effectiveness of cognitive behavioral therapy in public
mental health: comparison to treatment as usual for treatment-resistant
depression. Administration and policy in mental health, 42(1), 87–98.
doi:10.1007/s10488-014-0546-4
Newby, J. M., Mackenzie, A., Williams, A. D., McIntyre, K., Watts, S., Wong, N., &
Andrews,
G. (2013). Internet cognitive behavioural therapy for mixed anxiety and depression: a
randomized controlled trial and evidence of effectiveness in primary
care. Psychological Medicine, 43(12), 2635-2648
Newby, J., Robins, L., Wilhelm, K., Smith, J., Fletcher, T., Gillis, I., ... & Andrews, G.
(2017).

Healthcare
31
Web-based cognitive behavior therapy for depression in people with diabetes
mellitus: a randomized controlled trial. Journal of medical Internet research, 19(5),
e157.
Ng, T. K., & Wong, D. F. K. (2018). The efficacy of cognitive behavioral therapy for
Chinese
people: A meta-analysis. Australian & New Zealand Journal of Psychiatry, 52(7),
620-637.
Okumura, Y., & Ichikura, K. (2014). Efficacy and acceptability of group cognitive behavioral
therapy for depression: a systematic review and meta-analysis. Journal of affective
disorders, 164, 155-164.
Pasieczny, N., & Connor, J. (2011). The effectiveness of dialectical behaviour therapy in
routine
public mental health settings: An Australian controlled trial. Behaviour Research and
Therapy, 49(1), 4-10.
Rihmer, Z., & Gonda, X. (2011). Antidepressant-resistant depression and antidepressant-
associated suicidal behaviour: the role of underlying bipolarity. Depression research
and treatment, 2011.
Seitz, D. C. M., Knaevelsrud, C., Duran, G., Waadt, S., Loos, S., & Goldbeck, L. (2014).
Efficacy of an internet-based cognitive-behavioral intervention for long-term
survivors of pediatric cancer: a pilot study. Supportive Care in Cancer, 22(8), 2075-
2083.

Healthcare
32
Solomon, D., Proudfoot, J., Clarke, J., & Christensen, H. (2015). e-CBT (myCompass),
antidepressant medication, and face-to-face psychological treatment for depression in
Australia: A cost-effectiveness comparison. Journal of medical Internet
research, 17(11), e255.
Spence, J., Titov, N., Dear, B. F., Johnston, L., Solley, K., Lorian, C., ... & Schwenke, G.
(2011).
Randomized controlled trial of Internet‐delivered cognitive behavioral therapy for
posttraumatic stress disorder. Depression and anxiety, 28(7), 541-550.
World Health Organization. (2012). Depression. Retrieved from: http://
www.who.int/mediacentre/factsheets/fs369/en/
Wuthrich, V. M., & Rapee, R. M. (2013). Randomised controlled trial of group cognitive
behavioural therapy for comorbid anxiety and depression in older adults. Behaviour
Research and Therapy, 51(12), 779-786.