The manuscript contains original unpublished work that had not been submitted for publication elsewhere. This report has been adapted from the first author's (WM) doctoral thesis, completed for DClinPsych qualification in Clinical Psychology at the University of Edinburgh. The results of this study were also presented at the PSIGE national conference in June 2012 with an abstract included in the conference programme.
Computerised cognitive behavioural therapy for depression and anxiety with older people: a pilot study to examine patient acceptability and treatment outcome†
Article first published online: 14 MAR 2013
Copyright © 2013 John Wiley & Sons, Ltd.
International Journal of Geriatric Psychiatry
Volume 28, Issue 11, pages 1147–1156, November 2013
How to Cite
McMurchie, W., Macleod, F., Power, K., Laidlaw, K. and Prentice, N. (2013), Computerised cognitive behavioural therapy for depression and anxiety with older people: a pilot study to examine patient acceptability and treatment outcome. Int. J. Geriat. Psychiatry, 28: 1147–1156. doi: 10.1002/gps.3935
Ethical approval: Prior to the commencement of the study, a research proposal was submitted to the National Research Ethics Service (NRES) via an IRAS application. The study was subsequently granted ethical approval by the East of Scotland Research Ethics Service, NHS Tayside Committee on Medical Research Ethics B.
- Issue published online: 4 OCT 2013
- Article first published online: 14 MAR 2013
- Manuscript Accepted: 22 JAN 2013
- Manuscript Revised: 4 JAN 2013
- Manuscript Received: 1 AUG 2012
- computerised cognitive behaviour therapy;
- older people;
- Beating the Blues
The study objective was to determine the acceptability and treatment outcome of using Beating the Blues (BTB) with older people (65+ years). Specific aims included identifying the treatment uptake and drop-out rate, and describing the role of basic demographics in therapy uptake.
Fifty-eight participants, experiencing symptoms of depression, were given a free choice of receiving treatment as usual (TAU) plus BTB (TAU + BTB) or TAU alone. All participants completed demographic questionnaires and a range of outcome measures at baseline, 2 months after baseline (end of treatment) and 3 months after baseline (follow-up).
Thirty-three participants (56.9%) opted to receive BTB and reported having more experience and confidence using a computer than those who declined BTB. Twenty-four participants (72.7%) went on to complete all eight BTB sessions. Statistical analysis found significant differences between the two treatment groups, with the TAU + BTB group showing greater improvements in their symptoms of depression and anxiety than the TAU group by the end of treatment and at follow-up. Furthermore, the TAU + BTB group had a significantly higher percentage of participants who met criteria for clinically significant improvement in their symptoms of depression by the end of treatment and at follow-up.
Although further research is required, including a randomised controlled trial, the results of this initial pilot study provide evidence that BTB may offer an acceptable and effective treatment option for older people. Copyright © 2013 John Wiley & Sons, Ltd.
Demographic change affects all nations of the world with unprecedented growth in the numbers of older people (65+ years) more evident now than in the whole of human history (UN, 2010). Although depression and anxiety are major causes of mental health problems for older people, prevalence rates of these disorders in later life may be lower than rates reported for working aged adults (Blazer, 2010). Nevertheless, depression and anxiety remain common psychological difficulties experienced by older people (Djernes, 2006; Steffens et al., 2009). The increasing numbers of older people in the population may have important implications for services providing treatment for these disorders. Laidlaw and Pachana (2009) suggested that if the prevalence rates of depression and anxiety remain stable, then the increasing numbers of older people may translate into large increases in the demand for treatment for these disorders in this population. Furthermore, Knight et al. (2009) suggested that newer cohorts of older people may be more receptive to receiving treatment from mental health services than previous cohorts, which may further increase demand for treatment with this population.
There is therefore an increasing need for acceptable and effective treatments to be available for older people experiencing depression. Cognitive behavioural therapy (CBT) is the most systematically researched psychological treatment approach for depression in later life (Laidlaw et al., 2003) and has been consistently proven to be efficacious with older people (Cuijpers et al., 2009; Wilson et al., 2008). In the first UK evaluation of CBT for late-life depression, Laidlaw et al. (2008) randomly allocated participants to CBT alone or treatment as usual (TAU). Laidlaw et al. (2008) reported benefits in depression outcome for CBT alone and TAU, at the end of treatment and at 6 months follow-up. A more recent study by Serfaty et al. (2009) compared (1) CBT plus TAU, (2) a talking control intervention plus TAU and (3) TAU alone. CBT participants achieved better treatment outcomes compared with the talking control intervention and TAU alone, with 33% of those receiving CBT recording a 50% or greater reduction in symptoms of depression, compared with 23% and 21%, respectively, for those receiving TAU and the talking control intervention. Importantly, Serfaty et al. (2009) concluded that their results discredit the myth that depressed older people are lonely and simply need a listening ear, as those in the talking control group did less well than those in the CBT treatment group. These studies taken together suggest that CBT is an efficacious treatment option for older people experiencing depression.
Despite this, a historical problem has been that patients of all ages have had difficulties in accessing psychological treatment in a timely manner, due partly to inadequate numbers of trained therapists (Layard, 2006). Although a number of initiatives have been implemented in the UK, which have significantly improved access to psychological treatment (DOH, 2011; Wells et al., 2010), some evidence suggests that this still remains a disproportionate problem for older people (Clark et al., 2009; DOH, 2011).
One of the more recent innovations to improve access to psychological treatment has been the development of computerised cognitive behavioural therapy (CCBT) packages. Such packages are regarded as self-help treatments that make use of interactive multimedia technology, which teach patients CBT techniques to help them manage symptoms of depression and anxiety. Without the requirement of a trained clinician, CCBT can be offered to large numbers of patients, typically with mild–moderate levels of symptomatology, as a first-line treatment. Resources for more intensive treatments, such as face-to-face psychological therapy, can therefore be targeted to those with more severe symptoms or those failing to respond to less intensive treatments including CCBT.
A number of CCBT packages have been developed (see Kaltenthaler et al., 2008). However, the NICE guidelines for depression state that at present, Beating the Blues (BTB) is the only CCBT programme with an established evidence base that warrants a recommendation for treating depression (NICE, 2006). Three randomised controlled trials (Proudfoot et al., 2003; Proudfoot et al., 2004; Grime, 2004) and eight treatment outcome studies (van den Berg et al., 2004; Hunt, 2006; Cavanagh et al., 2006; Mitchel and Dunn, 2007; Learmonth and Rai, 2007; Learmonth and Rai, 2008; Learmonth et al., 2008; Cavanagh et al., 2011) have provided evidence supporting BTB's use for treating depression. However, to the best of the author's knowledge, no study to date has evaluated its use with older people in clinical practice. No conclusions can therefore be made about the effectiveness of this treatment with older people. However, assumptions may be made that CCBT may not be an acceptable mode of treatment delivery with older people. Elsegood and Powell (2008) surveyed the opinions of NHS mental health older adult service users (aged 65+ years) about their willingness to use CCBT with 45% stating an interest in this compared with 34% who stated that they would not be interested. Evidently, Elsegood and Powell (2008) reported on a small and opportunistic sample, and much larger more rigorous surveys are necessary. Nonetheless, these data are intriguing and provide the basis for optimism that CCBT can be an option for use with older people.
Participants were recruited from Older People Community Mental Health Teams (OPCMHT) across Tayside. The inclusion criteria were as follows: (i) ≥65 years; (ii) referred with symptoms of depression or depression co-morbid with anxiety; and (iii) scoring 8 or above on the depression subscale of the Hospital Anxiety and Depression Scale (Snaith and Zigmond, 1983). The exclusion criteria were as follows: (i) currently presenting with psychotic symptoms or suicidal ideation; (ii) having a diagnosis of dementia; (iii) unable to read English; (iv) currently receiving psychological treatment; and (v) current difficulties with alcohol or drug dependence.
Patients attending an appointment with the OPCMHT, and meeting the inclusion/exclusion criteria, were informed of the study and, if they agreed, were referred to the first author (WM) for a recruitment meeting where they were given full details of the study requirements and shown a demonstration video of BTB. Those who agreed to participate were given a free choice of receiving the following: (i) TAU (the TAU group); or (ii) TAU plus BTB (the TAU + BTB group).
Treatment as usual was provided by the OPCMHT. No constraints were placed on what could be provided other than participants could not receive formalised face-to-face psychological treatment. Clinicians were instructed to provide whatever was necessary as part of routine care and treatment. Prior to commencement of the study, the OPCMHTs were consulted regarding the types of treatment typically offered. Based on the information received, this was hypothesised to include one or more of the following: (i) psychiatric assessment/review; (ii) psychotropic medication; (iii) social support/advice; (iv) relaxation training; (v) day hospital attendance; and (vi) referral to another specialist (e.g. occupational therapist).
TAU + BTB
Participants in this group also received TAU as detailed in the previous TAU section. In addition, they were offered BTB, which comprises eight CCBT sessions, completed weekly, each lasting 60 min. Each session includes video clips, case vignettes, animations, interactive tasks and homework assignments, which are designed to provide the user with information and techniques to understand and manage symptoms of depression and anxiety. A full description of the content of BTB can be found in Proudfoot et al. (2003).
The first author (WM) attended session one to support participants in the technical use of BTB. No specific guidance was provided regarding completing tasks involved in the treatment. Participants completed the remaining seven sessions independently on a weekly basis. Session completion was monitored by the first author (WM) through an administrator's account. Participants were provided with contact numbers if they had specific problems with using BTB and required assistance. If a participant did not complete a session, they were contacted by the first author (WM) to ascertain if they wished to continue BTB and if so were encouraged to complete the session at a time later in the week. Those who completed all eight sessions were defined as treatment completers, whereas those who discontinued before the eighth BTB session were defined as dropouts.
At the recruitment meeting, participants completed a pack of standardised measures, including a demographics questionnaire. Specific questions relating to participants' experience and confidence in using a computer (i.e. 0–10 point Likert scales) were utilised in this pilot. The following outcome measures were completed at baseline, 2 months after baseline (end of treatment) and 3 months after baseline (1 month follow-up).
- The Geriatric Depression Scale (GDS; Yesavage et al., 1983), a 30-item self-report measure designed for assessing symptoms of depression in older people.
- The Geriatric Anxiety Inventory (GAI; Pachana et al., 2007), a 20-item self-report measure designed for assessing symptoms of anxiety in older people.
- The Clinical Outcomes in Routine Evaluation (CORE-34: Evans et al., 2000), a 34-item self-report measure developed for evaluating outcomes from psychological therapies. The results of the CORE-34 are separated into five domains: wellbeing, problems/symptoms, life functioning, risk and a total composite.
Means and standard deviations (SD) were calculated for all continuous variables, and numbers and percentages were calculated for categorical data. The latter was used to identify and describe the treatment uptake and drop-out rates, which are compared with what has been found in previous research on BTB in the discussion.
Comparisons between the two treatment groups in terms of demographic variables, baseline scores on outcome measures and drop-out rates were made with independent t-tests (or Mann–Whitney U tests when the data violated assumptions of normality), for continuous data and Chi-square tests for categorical data.
Treatment outcome was analysed using a series of 2 (Treatment group) × 3 (Time) ANOVAs with time as the repeated measure. As there were only two treatment groups, post hoc analyses to examine any significant time × group interactions were made using independent t-tests, which do not inflate the familywise error rate (Field, 2009). All analyses were intention-to-treat using last observation carried forward (LOCF). The number and percentages of participants where LOCF was used to complete missing assessment data are shown in Figure 1. End of treatment and 1 month follow-up effect sizes were calculated between the two groups using Cohen's d (Cohen, 1988). An examination of the clinical significance of the results was also made using criteria set out by Jacobson and Truax (1991). This involves examining whether participants scores on the outcome measures at the end of treatment fall at least two SDs (in the direction of improvement) below the pre-treatment mean. G*Power 3 (Faul et al., 2007) was used to estimate the sample size required to detect statistically significant differences between the two groups. A sample size of 64 (32 per group) was calculated to be required to detect a significant difference between the groups at 0.80 power and with an alpha of 0.05.
BTB uptake rate
Figure 1 shows the flow of participants through the study.
A total of 77 individuals met the inclusion/exclusion criteria, and 58 agreed to be referred to the study and subsequently participated. The demographic characteristics of participants are shown in Table 1.
|Variable||TAU + BTB (N = 33)||TAU (N = 20)||Comparison|
|Age||71.58||4.43||75.55||6.27||t(51) = 2.70, p < 0.01|
|Years of education||11.70||2.56||10.25||1.88||Mann–Whitney U = 198, p < 0.01|
|Number of co-morbid physical illnesses||2.45||1.46||2.45||1.50||t(51) = 0.01, p = 0.991 (ns)|
|Self-reported confidence using computers (0–9 scale)||5.33||2.70||1.30||2.65||Mann–Whitney U = 101, p < 0.001|
|Self-reported experience using computers (0–9 scale)||4.67||2.67||1.40||2.83||Mann–Whitney U = 135, p < 0.001|
|Access to Internet at home:|
|Currently taking psychotropic medication:|
|Previous psychiatric history:|
|Duration of current treatment episode:|
|Deprivation category (DepCat):|
As can be seen in Figure 1, 65.5% of participants chose to receive BTB and were allocated to the TAU + BTB group. The remaining 34.5% were allocated to the TAU group. After group allocation, five participants in the TAU + BTB group did not begin their first BTB session or complete any pre-treatment assessments. Two of these participants experienced significant deteriorations in their physical health, diagnosed after recruitment, which rendered them unable to participate. One participant was unknowingly also referred for face-to-face psychological therapy and chose to begin this rather than continue to participate. Two participants did not provide any reasons for dropping out. These five participants were excluded from subsequent analyses. From the total number of participants recruited to the study (58), the total number who opted for BTB and then started at least one session was 33, resulting in an uptake rate of 56.9%.
Characteristics influencing uptake
As can be seen in Table 1, there were significant differences between the two treatment groups on the following variables: age (t(51) = 2.70, p < 0.01), years of education (Mann–Whitney U = 198, p < 0.01), self-reported confidence in using a computer (Mann–Whitney U = 101, p < 0.001), self-reported experience with using a computer (Mann–Whitney U = 135, p < 0.001) and whether they had the Internet at home (χ2(1) = 7.92, p < 0.01). Analysis of the means highlights that in comparison with the members of the TAU group, members of the TAU + BTB group were younger, had more years of education, were more likely to have the Internet at home and reported having more experience and confidence in using a computer.
BTB drop-out rates
As can be seen from Figure 1, nine (27.3%) BTB + TAU participants dropped out prior to the final session. Four participants dropped out of the TAU group (20%). This difference between the groups was not statistically significant (χ2(1) = 0.356, p = 0.744).
Table 2 illustrates the means and SDs for the two treatment groups on the outcome measures at baseline, 2 months after baseline (end of treatment) and 3 months after baseline (1 month follow-up).
|Outcome measure||TAU + BTB (N = 33)||TAU (N = 20)|
|Geriatric Depression Scale|
|2 months after baseline (end of treatment)||12.88||8.92||19.70||6.60|
|3 months after baseline (follow-up)||12.91||8.26||19.30||7.83|
|Geriatric Anxiety Inventory|
|2 months after baseline (end of treatment)||8.70||5.94||12.05||5.46|
|3 months after baseline (follow-up)||8.52||6.36||12.75||5.95|
|2 months after baseline (end of treatment)||37.33||17.82||51.75||16.66|
|3 months after baseline (follow-up)||34.82||20.46||47.05||20.08|
|2 months after baseline (end of treatment)||6.58||3.87||8.50||3.67|
|3 months after baseline (follow-up)||6.24||4.66||8.60||3.93|
|2 months after baseline (end of treatment)||17.09||7.70||25.00||9.14|
|3 months after baseline (follow-up)||16.48||9.51||22.10||10.34|
|2 months after baseline (end of treatment)||.88||1.51||.35||.99|
|3 months after baseline (follow-up)||.85||1.56||.55||1.37|
|2 months after baseline (end of treatment)||12.03||7.05||17.90||6.34|
|3 months after baseline (follow-up)||11.36||7.85||15.60||5.42|
Independent t-tests were conducted between the two treatment groups on the baseline outcome measures. The results showed that the two treatment groups did not significantly differ at the baseline assessment point: GDS: t(51) = 0.08, p = 0.93; GAI: t(51) = 0.40, p = 0.68; CORE-Total: t(51) = 0.56, p = 0.57; CORE-F: t(51) = 0.04, p = 0.97; CORE-P: t(51) = 0.22, p = 0.83; CORE-W: t(51) = 0.74, p = 0.46 (ns). This suggests that both treatment groups had equivalent levels of psychopathology at the start of the study.
A series of 2 (Treatment Group) × 3 (Time) ANOVAs, with time as the repeated measure, were conducted in order to examine treatment outcome over time on each outcome measure (Table 3).
|Time (df)||Time × Group (df)||Group (df)|
|(1.53, 78.24)a||(1.53, 78.24)a||(1, 51)|
|(2, 102)||(2, 102)||(1, 51)|
|(1.84, 93.81)a||(1.84, 93.81)a||(1, 51)|
|(2, 102)||(2, 102)||(1, 51)|
|(2, 102)||(2, 102)||(1, 51)|
|(2, 102)||(2, 102)||(1, 51)|
The most relevant results for comparing treatment outcome between the groups were the significant time × group interactions for the GDS (F(1.53, 78.24) = 14.02, p < 0.001), the GAI (F(2, 102) = 5.09, p < 0.01), the CORE-Total (F(1.84, 93.81) = 14.88, p < 0.001), the CORE-W (F(2, 102) = 6.75, p < 0.01), the CORE-P (F(2, 102) = 12.29, p < 0.001) and the CORE-F (F(2, 102) = 7.76, p < 0.01). These results suggest a significant difference in how the two treatment groups responded over time on each of these outcome measures.
Post hoc analysis to examine these interactions showed statistically significant differences between the TAU + BTB and TAU groups by the end of treatment assessment point (2 months after baseline) on the GDS (t(51) = 2.96, p < 0.01), the GAI (t(51) = 2.05, p < 0.05) and the CORE-Total (t(51) = 2.92, p < 0.01) with the TAU + BTB group having significantly lower scores than the TAU group on each of these measures, indicating greater improvement in their symptoms by the end of treatment. Effect sizes in favour of TAU + BTB over TAU were moderate to large (GDS: d = 0.85; GAI: d = 0.59; CORE-Total d = 0.84).
A similar pattern was found at the 1 month follow-up point (3 months after baseline) with the TAU + BTB group having significantly lower scores than the TAU group on the GDS (t(51) = 2.78, p < 0.01), the GAI (t(51) = 2.40, p < 0.05) and the CORE-Total (t(51) = 2.23, p < 0.05). Effect sizes in favour of TAU + BTB over TAU were moderate to large (GDS: d = 0.80; GAI: d = 0.69; CORE-Total d = 0.61).
Clinically significant improvement
Table 4 shows the number and percentages of participants who met criteria for clinically significant improvement.
|BTB + TAU||TAU||Summary statistics|
|Yes (%)||No (%)||Yes (%)||No (%)||χ2||df||p|
|End of treatment|
|GDS||13 (39.4)||20 (60.6)||2 (10)||18 (90)||5.30||1||0.021|
|GAI||6 (18.2)||27 (81.8)||0 (0)||20 (100)||4.10a||1||0.072 ns|
|CORE-T||5 (15.2)||28 (84.8)||0 (0)||20 (100)||3.34a||1||0.144 ns|
|GDS||14 (42.4)||19 (57.6)||2 (10)||18 (90)||7.18||1||0.007|
|GAI||9 (27.3)||24 (72.7)||1 (5)||19 (90)||4.03a||1||0.070 ns|
|CORE-T||6 (18.2)||27 (81.8)||1 (5)||19 (90)||1.88a||1||0.233 ns|
As can be seen in Table 4, in comparison with the TAU group, a significantly greater number of participants in the BTB + TAU group met criteria for clinically significant improvement on the GDS by the end of treatment assessment point (χ2(1) = 5.30, p < 0.05) and by the 1 month follow-up assessment point (χ2(1) = 7.18, p < 0.01). Similarly, in comparison with the TAU group, a higher percentage of participants in the BTB + TAU group met criteria for clinically significant improvement on the GAI and the CORE-Total, at the end of treatment and at 1 month follow-up, but these differences were not statistically significant.
Although a number of studies have suggested that BTB is an effective treatment for depression with adults of working age, until now, no study has examined its use with older people despite their apparent openness to this treatment modality (Elsegood and Powell, 2008). The main purpose of the current study was to examine whether BTB is an acceptable and effective treatment for this population. Although the design of the study, with no randomisation used for group allocation, means that interpretation of the results should be treated with caution, the overall findings are favourable and suggest the need for further studies.
Uptake and drop-out rates from BTB: treatment acceptability
Kaltenthaler et al. (2008) argued that patient acceptability is a key consideration when examining the viability of CCBT, with important indicators being the treatment uptake and drop-out rate. Examining patient acceptability is particularly relevant with older people, where assumptions have been made that CCBT would be unacceptable to this population (Elsegood and Powell, 2008).
Examination of previous studies of BTB with adults of working age shows a wide range in the treatment uptake rate: from 30.9% (Grime, 2004) to 100% (Mitchel and Dunn, 2007). The findings of the current study, with an uptake rate of 56.9%, falls well within this range and provide some evidence to challenge the blanket assumption that CCBT will not be acceptable for older people. Based on the results of the current study, a more balanced argument could be that CCBT will be acceptable for at least half of the older people that are offered it.
The finding that older people opting to receive BTB tended to be more confident and experienced in using computers offers optimism for the future in terms of CCBT becoming an increasingly more acceptable treatment modality for older people. For example, data from the Office for National Statistics (Randall, 2010) suggest that increasing numbers of older people are using computers, with a 26% rise between the years 2000 and 2008. This trend is expected to continue with initiatives to increase marginalised groups, such as older people, getting access to the Internet and computer technology (The Scottish Government, 2011). A qualitative study by the Office of Communications (Ofcom, 2006) also highlighted that the majority of older people, who were not currently using computers, would consider learning how to use one if they were provided with support. This could suggest that interventions, potentially offered as introductory sessions to CCBT, targeted at developing older people's confidence in using a computer may boost the uptake rate of CCBT within this population.
A further important index of treatment acceptability is the drop-out rate. Examination of the drop-out rate from BTB found in the current study (27.3%) falls within the range of what has been found in previous studies of BTB with adults of working age (Mitchel and Dunn, 2007 = 16.7 to Cavanagh et al., 2011 = 47.1). This provides further evidence to challenge the assumption that CCBT is a significantly less acceptable treatment modality for older people compared with younger adults. Furthermore, there was no significant difference in the drop-out rate found between the two groups in the current study, which would indicate that the acceptability of the interventions offered in both treatment groups was similar. This also lends evidence to challenge the view that CCBT is a significantly less acceptable intervention than other treatments that are currently routinely offered to older people.
The results of this initial pilot study provide evidence supporting the effectiveness of BTB with older people, with those receiving it showing significantly greater statistical and clinical improvements in psychopathology, when compared with those who declined it. As mentioned previously, interpretation of these results should, however, be treated with a degree of caution.
Limitations and areas for further research
The lack of randomisation potentially biases the results in favour of those receiving BTB, as they may have been highly motivated to receive this treatment. The choice of the methodology used did, however, allow an accurate determination of the treatment uptake and drop-out rate, and provides support for examining the treatment efficacy with an older people population in a randomised control trial. Such a trial should also take into account the health economics involved in providing this treatment.
A further limitation was the relatively short follow-up period (1 month after treatment ended), which limits any conclusions that can be drawn regarding the long-term benefits of using BTB. Previous research has indicated individuals who receive CCBT continue to improve after the treatment has finished. Future research could examine whether this is the case with an older people population using longer follow-up periods.
A further area of research, which is currently been undertaken with the same group of participants, is qualitative studies examining the decision-making process involved in whether participants opted to receive BTB. This may also identify factors influencing whether participants completed treatment or dropped out, which could in turn identify ways of improving compliance with the treatment (e.g. having a member of staff available to provide support).
Although further research is required, the results of this initial pilot study provide some evidence that BTB may offer an acceptable and effective treatment option for older people.
Conflict of interest
- When given a choice of receiving TAU or TAU+BTB, 56.9% of participants opted for the latter.
- 72.7% went on to complete all 8 sessions of BTB.
- Participants who opted for TAU+BTB gained both statistically and clinically significant greater improvements in psychopathology compared to those opting for TAU.
- Although caution is required, the results suggest BTB is an acceptable and effective treatment for older people.
- These findings warrant further research into the use of CCBT with older people including a randomised trial.
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