Cognitive behavioral therapy administered online can effectively treat symptoms of depression in older people with knee osteoarthritis, according to results from the first randomized trial of its kind.
The benefits of the 10-week program extended to improving pain, stiffness, physical functioning, and self-efficacy, reported Kathleen A. O’Moore, PsyD, of St. Vincent’s Hospital, Sydney, Australia, and her colleagues (Arthritis Care Res. 2017 April 20. doi: 10.1002/acr.23257).
The investigators became motivated to conduct the trial by the fact that about one in five older people with osteoarthritis (OA) experience depression, yet many do not seek treatment, and depression in this population has been associated with an increased use of pain medication, reduced adherence to treatment recommendations, and, when recommendations are followed, reduced treatment benefits.
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The investigators randomized the participants to the 10-week Internet cognitive behavioral therapy (iCBT) Sadness Program in addition to usual treatment or to a control group that received usual treatment. Participants were followed up at 1 week and 3 months after the intervention. The iCBT Sadness Program consists of six online lessons representing best practice CBT, as well as regular homework assignments and access to supplementary resources. The program has been validated in several clinical efficacy and effectiveness trials.
The iCBT program proved superior to usual treatment on the primary outcomes of depression as measured by the Patient Health Questionnaire (PHQ-9) and psychological distress (measured using Kessler-10). In particular, a large between-group effect size was seen for PHQ-9 scores (Hedge’s g = 1.01; 95% confidence interval [CI], 0.47-1.54) and a medium effect size for the Kessler-10 score (Hedge’s g = 0.75, 95% CI, 0.23-1.28).
At 3-month follow-up, large between-group effect sizes developed between the iCBT group and the usual treatment-only group on the PHQ-9 (Hedge’s g = 0.90, 95% CI, 0.36-1.44) and Kessler-10 (Hedge’s g = 0.94, 95% CI, 0.41-1.48).
In the iCBT group, the intervention produced large effect-size reductions in depression and distress from pre- to posttreatment and from pretreatment to 12-week follow-up, but in the usual treatment-only group, the effect-size reductions were small and not significant.
In terms of clinical significance, the authors noted that 21 (47.7%) of the participants in the iCBT group “reliably improved,” compared with 3 participants (12%) in the usual treatment-only group.
At 3-month follow-up, 33 participants (84.6%) in the iCBT group no longer met the criteria for major depression, compared with 11 (50%) of the control group.
The intervention also improved the secondary outcomes of OA-specific pain, stiffness, and physical functioning on the Western Ontario and McMaster Osteoarthritis Index and Arthritis Self-Efficacy Scale score, but this was seen by the research team only at the 3-month follow-up. They suggested that further studies should evaluate whether the intervention reduced pain-related catastrophic cognitions or sensitivity to pain and improved a patients’ estimation of their own ability and/or adherence to pain management.
“The outcomes of these studies may provide insight into why there were no significant changes in global physical functioning and no between-group differences for arthritis-related self-efficacy, pain, stiffness, and physical function directly following the program, yet differences emerged 3 months later,” the researchers noted.
They suggested that changes in OA-specific variables such as pain or self efficacy likely required time to interact with cognitive change mechanisms that occur through iCBT.
“It is possible that reduced depressive symptoms result in flow-on effects to OA variables over time and perhaps programs that specifically target OA management may show more immediate effects,” they added.
The researchers concluded that a biopsychosocial approach to managing people with OA was consistent with the recent emphasis on a holistic assessment of older patients with OA.
“These findings are significant given iCBT programs can overcome barriers to receiving face-to-face psychological and/or pharmacological treatment in this population, such as cost, lack of accessibility, and pharmacological side-effects and interactions,” the study authors wrote.
“Medical management of OA of the knee could be supplemented with integrated evidence-based depression treatment, including iCBT, to maximize functional status and mental health well-being,” they added.
The study was funded by grants from the Australian National Health and Medical Research Council. The authors declared no relevant conflicts of interest.