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Am J Geriatr Psychiatry 11:53-61, February 2003
© 2003 American Association for Geriatric Psychiatry

Regular Article

The Relationship Between Homework Compliance and Treatment Outcomes Among Older Adult Outpatients With Mild-to-Moderate Depression

David W. Coon, Ph.D., and Larry W. Thompson, Ph.D.

Received December 20, 2001; revised October 2, October 25, 2002; accepted October 28, 2002. From the Institute on Aging, San Francisco, CA (DWC), the Older Adult and Family Center, VA Palo Alto Health Care System and Stanford University School of Medicine (DWC,LWT), and the Pacific Graduate School of Psychology, Palo Alto, CA (LWT). Address correspondence to Dr. Coon, Institute on Aging, 3330 Geary Blvd., 2 East, San Francisco, CA 94118. e-mail: dcoon{at}ioaging.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: The authors extend previous research on homework in psychotherapy by examining the relationship between homework compliance and therapeutic outcome among depressed older adult outpatients (N=63), addressing previous limitations by using session-by-session therapist ratings of homework compliance and including both interviewer ratings and patient self-reports of outcomes. METHODS: Patients were participants in a randomized clinical trial evaluating the efficacy of desipramine versus cognitive/behavioral therapy-alone (C/B-Alone) versus a combination of the two (Combined). Given the current study's focus on homework compliance, only patients assigned to conditions with assigned homework in the clinical trial (i.e., C/B-Alone and Combined conditions) were included. RESULTS: Results of hierarchical regression analyses indicated that homework compliance contributed significantly to posttreatment outcome as measured by both interviewer-administered and patient self-report measures of depression. A separate series of ANOVAs also found significant differences in pre–posttreatment change between patients scoring above and below the median of reported homework compliance. Findings were similar for patients in the C/B-Alone and Combined conditions. CONCLUSION: The study's results call for additional research on issues related to homework compliance with older adult patients.

Key Words: Depression • Cognitive Therapy • Treatment Compliance


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The advent of cognitive-, behavioral-, and cognitive/behavioral (C/B)-focused therapies substantially enhanced the regular use of "homework," or self-help, assignments in psychotherapy.1–4 The skills-based nature of these theories assumes that homework directly reduces emotional distress by teaching patients skills to manage unhelpful thinking and behavior patterns. It also posits that homework helps change patient behavior and support therapeutic gains between psychotherapy sessions. Thus, homework has remained both a traditional and integral component of contemporary manual-based C/B therapy approaches.

Several recent reviews of therapy-outcome studies have helped establish C/B as an efficacious intervention for a variety of mental health disorders, including depression, in older adults.5–8 Also, a growing number of empirical studies,9–12 as well as a recent meta-analysis of 27 research studies,13 support the contentions that homework assignments facilitate therapeutic improvement and that homework compliance is a significant predictor of positive therapeutic outcomes. However, none of these studies focused on the use of homework in psychotherapy with older adults. Therefore, research focused on older adults in C/B therapy, who may face additional challenges to homework completion, is warranted.14

One previous study with depressed older adult outpatients explored the relationship between maintenance of therapeutic gains and homework helpfulness through the use of patient retrospective ratings of homework and skills-acquisition. The results of the study suggested that homework helpfulness was significantly related to improvement ratings in mood and overall functioning 2 months posttreatment.15 Still, retrospective homework ratings alone may prove problematic with either therapists who observed patient improvement automatically attributing this improvement to homework compliance or patients who experienced improvement unintentionally inflating their homework compliance.10,13,16 Moreover, we need studies of homework compliance using session-by-session ratings across the entire therapeutic course.16 This article investigates the relationship between homework compliance and therapeutic outcome by use of a session-by-session compliance rating with older adult outpatients with mild-to-moderate depression. The main hypothesis states that homework compliance will be positively associated with patient posttreatment improvement on both interviewer-rated and patient self-report of depression.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Procedures
The procedures for this study have been described in detail in a previous publication.17 Briefly, the study involved a randomized clinical trial designed to compare the effectiveness of desipramine, individual C/B therapy (C/B-Alone), and a combination of both (Combined) in the treatment of mild-to-moderate depression in individuals over 60 years of age. Older adult outpatients with a diagnosis of major depression, as defined by Research Diagnostic Criteria (RDC),18 were randomly assigned to one of these three conditions. They received treatment for 3–4 months (16–20 individual sessions). The actual number of sessions was determined by the therapist and patient. Additional sessions were held if patients were uncertain about a specific skill introduced during the course of therapy and needed additional reinforcement to acquire that skill. At the end of the 16 to 20 individual sessions, patients were re-evaluated, and then treatment was continued in a cross-over design. In order to minimize confounding factors, only baseline (pretreatment) data and data collected at the 3- to 4-month follow-up assessment (immediate posttreatment) are presented in this report.

Treatment Conditions
The C/B-Alone condition followed a structured manual based on Beck and colleagues' conceptual model1 and modified for older adults.19 Modifications included strategies to facilitate learning, such as repeated presentation of material by use of multiple modalities, slower rates of presentation, greater use of in-session practice, and increased instances of structure and modeling behavior. C/B-Alone patients were seen individually by a clinical psychologist who taught them to identify, monitor, and challenge negative cognitions about themselves, their situations, and their future, and then develop and replace negative thinking with more helpful and adaptive cognitions. When appropriate, patients were also taught to monitor and increase pleasant daily events in their lives by use of behavioral treatment practices.4 In the Combined condition, patients not only followed the same procedures outlined in the C/B-Alone condition, but also met with a psychiatrist, who completed a brief (approximately 15 minutes) review of symptoms and check on medication usage.

Homework
Homework assignments typically included the use of pencil-and-paper Dysfunctional Thought Records that ask patients to 1) describe a situation that led to their unpleasant emotions; 2) identify and record their cognitions in the situation; 3) identify and record their related feelings; 4) challenge and replace any negative cognitions associated with the situation with more adaptive thinking, and write them down; and 5) identify and record changes in mood after challenging their negative cognitions. Behavioral homework assignments usually asked patients to identify pleasurable activities for themselves and track both their participation in those activities as well as changes in their daily mood states. This particular homework assignment helped demonstrate the relationship between participation in fewer pleasant events and depressed mood and was used as a catalyst to increase patient participation in additional pleasant activities. A variety of strategies were used to promote homework compliance. These included prioritization and review of homework at every session, collaboration between patient and therapist in the development of assignments, breaking down homework assignments into realistic steps that matched patient skill levels, and in-session preview and rehearsal of assignments. Homework also appeared to work best when constructed collaboratively with patients and tied closely to their individual goals and relevant themes identified in therapy.14

Subjects
The study was conducted at the Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine, in a clinic specializing in the treatment of older adults with affective disorders. Study subjects were required to meet the following inclusion criteria: 1) age 60 years or older; 2) a current diagnosis of Major Depressive Disorder (MDD), as determined by the RDC18 applied to the Schedule for Affective Disorders and Schizophrenia (SADS);20 3) a score of 14 or greater on the Hamilton Rating Scale for Depression (Ham-D);21 4) a score of 16 or greater on the Beck Depression Inventory (BDI);22 5) a score of 26 or greater on the Mini-Mental State Exam;23 6) no medical or psychiatric contraindications; 7) no evidence of serious alcohol abuse; 8) no evidence of a psychotic disorder; 9) no evidence of bipolar disorder; 10) no immediate suicide risk; 11) not taking another medication for the treatment of depression; and 12) adequate transportation to reach the outpatient clinic.

One hundred and two patients (N=102) met inclusion and exclusion requirements and were enrolled in the randomized clinical trial. Two of these subjects dropped out after randomization, but before receiving any treatment. Ineligible or uninterested subjects and dropouts were offered referrals to local clinics, physicians, psychiatrists, psychotherapists, and other research studies to help address their needs. During their course of treatment, several subjects continued to receive C/B Alone or the Combined treatment, even though they no longer met the criteria for the ongoing randomized clinical trial. These "off-protocol" subjects resulted from the fact that the study consent form stated that subjects could continue to receive treatment even if they chose not to continue in the trial. For example, any subject in the Combined condition who was having negative side effects from the medication could refuse to take the drug but still remain in therapy. Similarly, any subject in the C/B Alone condition who felt strongly that he or she needed more than psychotherapy alone could request psychotropic medication from their primary care physician and still receive C/B therapy.

Given the current study's focus on homework compliance, only patients randomized to conditions with assigned homework (i.e., C/B Alone and Combined conditions; [N=63]) are included in analyses. These 63 subjects included 58 subjects who continued in one of the two conditions and 5 who dropped out completely from the randomized clinical trial. Details concerning the number and reasons for off-protocol subjects and dropouts were reported in an earlier study,17 which found no differences in this regard among the randomized clinical trial's treatment conditions.

Measures
Three measures of depression were collected at baseline (pretreatment) and at the conclusion of the 16–20 sessions of psychotherapy (posttreatment). These included two measures of depressive symptoms, the BDI, a self-report measure, and the 17-item version of the (interviewer-rated) Ham-D, as well as the RDC diagnosis obtained through the interviewer-administered SADS–Change interview.24 Also, therapists rated the percent of homework that patients completed appropriately at each session. These ratings were used to calculate a measure of homework compliance that consisted of the average percent of homework completed across the total number of psychotherapy sessions attended.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Table 1 lists the sociodemographic characteristics for patients randomized to the C/B Alone and the Combined conditions. There were no significant differences between the two conditions in terms of age, education, gender, marital status, or occupation (as measured on an ordinal scale described in Table 1 that ranges from 1: executive/professional to 7: unskilled labor). On average, subjects were in their mid-60s and had completed some college. Most subjects self-identified as White, and the ratio of women to men was 3:1.


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  		TABLE 1. Sociodemographic characteristics for patients in the C/B Therapy and C/B+Desipramine therapy groups, including dropouts
 
Mean ratings of homework compliance for the two separate treatment conditions appear in Table 2. Treatment group differences were examined both with and without study dropouts included. Homework compliance ratings were not significantly different between conditions for comparisons that either included (t[61]=0.424; p=0.673) or excluded dropouts (t[56]=0.955; p=0.344). The average percent of homework completed across all sessions for all subjects, including dropouts, was 77.5% (standard deviation [SD]: 20.6). The average percent rose only slightly when dropouts were excluded (80.2%; SD: 16.5). Because patients in the treatment conditions did not differ significantly on sociodemographic variables or ratings of homework compliance, study subjects from the two treatment groups were pooled in subsequent analyses.


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  		TABLE 2. Homework completed (percent) across all sessions for patients in the C/B Therapy and C/B+Desipramine therapy conditions
 
The correlations in Table 3 provide an initial description of the relationship between homework compliance and pre–posttreatment change. Pre–post change was calculated by taking the difference between pre- and posttreatment scores on the Ham-D or BDI, dividing this difference by the Ham-D or BDI pretreatment score, and then multiplying the result by 100. Statistically significant associations between homework compliance and positive outcome, as measured by pre–post improvement on the measures of depression, were modest regardless of whether or not study dropouts were included (r[61]=0.311; p<0.05 for the BDI) or excluded (r[56]=0.366; p<0.005 for the BDI; r[56]=0.323; p<0.01 for the Ham-D). Similar results were found between homework compliance and pre–post change in RDC diagnosis (a 6-point ordinal scale ranging from 1: Major Depressive Disorder to 6: Not Currently Mentally Ill) when including dropouts (r[61]=0.312; p<0.05) as well as excluding dropouts (r[56]=0.278; p<0.05). The significance level reported for each correlation is uncorrected.


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  		TABLE 3. Correlations between percent of homework completed across the total number of sessions and pre–posttreatment changea for the BDI and Ham-D
 
In an effort to examine the relationship between homework compliance and pre–post improvement more closely, separate ANOVAs were conducted on the measure of change from pre- to posttreatment for BDI and Ham-D scores to determine whether the change in depression was significantly different for patients above and below the median of homework compliance. Separate tests were conducted to include and then subsequently exclude study dropouts. The descriptive statistics and F ratios appear in Table 4 for each analysis, along with eta-squared ({eta}2) as an "effect-size" statistic to reflect the proportion of variability accounted for by the grouping factor. When all subjects, including dropouts, were considered, significant differences were found between patients above and below the median of homework compliance in their pre–post change on BDI scores (F[1, 61]=9.176; p=0.004) and Ham-D (F[1, 61]=5.431; p=0.023). An examination of pre- and posttreatment means suggests that patients above the median score of homework compliance reported an average reduction of over 11 points on the BDI and over 8 points on the Ham-D. This is in contrast to patients below the median, who reported an average reduction of just over 6 points on the BDI and slightly less than 5 points on the Ham-D. Similar results were found when dropouts were excluded from the analyses.


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  		TABLE 4. Pre–posttreatment changea in depression level for patients, grouped according to homework compliance, mean (SD)
 
Finally, the main hypothesis was tested by use of hierarchical regression analyses to predict patients' posttreatment BDI and Ham-D scores in the treatment completers (n=58). In Table 5, Model 1 included subjects' pre-treatment BDI or Ham-D scores as well as their levels of occupation and years of education as predictors of outcome. Education and occupation were included because they were significantly correlated with both BDI (r[56]=0.374; p<0.01 for education; r[56]=0.321; p<0.05 for occupation) and Ham-D change scores (r[56]=0.281; p<0.05 for education; r[56]=0.338; p<0.01 for occupation). The ANOVA for Model 1 was highly significant for both the BDI: F[3, 54]= 7.89; p<0.001) and the Ham-D: F[3, 54]=4.04; p<0.02. When total percent homework completed was included in Model 2, the analyses were still significant for the BDI: F[3, 54]=8.57; p<0.001 and for the Ham-D: F[3, 54]=4.69; p<0.01. Total percent of homework completed was added in Model 2 of the analyses to demonstrate the increment in variance accounted for by homework compliance. In support of the hypothesis, homework compliance contributed significantly to outcome in Model 2, accounting for approximately 8% of the variance in posttreatment BDI (R2=0.088; F[1, 53]=7.69; p<0.01) and Ham-D scores: (R2=0.078; F[1, 53]=5.63; p<0.05). Results were comparable when two subjects with large leverage were deleted from the analyses.


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  		TABLE 5. Regression analyses of variables predicting posttreatment BDI and Ham-D scores for subjects in both treatment conditions, excluding dropouts (n=58)
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The current study adds to growing empirical evidence supporting the use of homework in psychotherapy and helps to substantiate the theoretical claims of homework advocates.1 It extends previous research on homework by examining the relationship between homework compliance and therapeutic outcome among a sample of depressed older adults. The study addresses limitations raised regarding previous research with younger adults10,13 by using therapist ratings of homework compliance collected at each psychotherapy session, rather than a single retrospective rating of compliance during treatment or posttreatment, and by using both interviewer-administered ratings (Ham-D and RDC diagnosis) and patient self-reports of depression (BDI) as therapeutic outcomes.

Consistent with previous research involving younger adults,9,10,12,16,25,26 older adult patients who completed more homework reported significantly greater reductions in depression than those who were less homework-compliant. Similar patterns of improvement were found on both self-report and interview-administered measures for patients in the C/B Alone and Combined (C/B-plus-desipramine) treatment conditions. Results were also comparable whether or not study dropouts were included in the sample.

Similar to findings in other homework studies,10 correlations between compliance and outcomes in the current study, although statistically significant, were modest. However, the study's effect size values for the relationship between compliance and treatment outcome were smaller than those reported with younger populations.13 The mean reduction in BDI scores of between 11 and 12 points among patients who were more homework-compliant is lower than the 14 to 16 points reported in compliance studies with younger populations. In contrast, the average reduction in BDI of approximately 6 points among patients who were less compliant is higher than in other studies.10,12 Also, ratings of patient homework compliance reported here are slightly higher than those in some studies with younger populations.27 These differences could be due to a number of reasons, including cohort differences, different definitions of compliance, alternative measures of homework compliance, and variations in entry criteria for study participants (e.g., the willingness to enter a randomized clinical trial).

The findings of the current study have clinical implications that suggest addressing barriers to homework compliance may be particularly important in C/B therapy. Previous studies indicate that lower homework compliance is associated with poorer outcomes, as well as patient dropout.12,16 These findings suggest that clinicians need to address compliance immediately and implement strategies to overcome obstacles to homework completion over the course of treatment.

Increasing homework compliance requires considerable planning, practice, and persistence by both clinicians and their patients. Emerging clinical reports and reviews point to several methods to facilitate homework completion among older adults.14,28–30 Clearly, prioritization is a key to success.30 However, increasing homework compliance also relies heavily on valuing the personal histories and sociocultural contexts of older patients and on collaborating with patients in the development of assignments. Patient individual-difference variables can shape help-seeking behavior and substantially affect the enactment of prevention, surveillance, and treatment activities, including relevant homework activities.14,31,32 For example, successful homework completion among physically ill or cognitively impaired older adults typically requires several other adaptations. These can include modifications such as additional emphasis on teamwork among the patients' formal and informal support system; removal of practical barriers (e.g., providing large-print material for visually impaired patients); briefer, more frequent therapy sessions, coupled with smaller homework assignments, to minimize fatigue or overload; and homework that helps these patients distinguish between the limitations imposed by disease and any added amount of disability exacerbated by their emotional distress (i.e., "excess disability").28,29

Although the main hypothesis was supported, and results were significant, the study has several limitations. First, the findings presented here are most relevant for homework administered to depressed older adults in outpatient settings that use manualized treatments, and may not necessarily generalize to clinical practice where patients' presenting problems, therapists' theoretical orientations, and related practices, including homework assignments, vary considerably. They also may not be applicable to more socially, ethnically, and clinically diverse groups of depressed older adults. Also, the study is correlational and does not rule out the possibility that a pretreatment individual-difference variable (e.g., perceived reasons for depression) is responsible for both homework compliance and improvement.33 Similarly, the study cannot rule out the possibility that patients who improved were more likely to do their homework, rather than the premise that homework compliance actually led to improvement in patient outcomes. More specifically, the results are based on patients who enrolled in a randomized clinical trial comparing C/B, medication, and pharmacotherapy, rather than a trial comparing "homework" and "no-homework" control conditions. Thus, the study's positive results, along with those of other "naturalistic" homework studies,10 must be interpreted judiciously. However, a recent study,10 using nonrecursive structural-equation modeling techniques in two groups of depressed adult outpatients, supported the hypothesis that homework compliance has a causal effect on depression and showed that the magnitude of the effect was large. Research that attempts to replicate these results using samples of older adults is needed.

Authors of a recent meta-analysis of 27 studies examining homework assignments in therapy13 propose several additional future directions in homework studies applicable to geriatric psychiatry research. Additional research on the use of homework in psychotherapy is necessary in order to 1) determine whether homework is more useful for particular patient problems; 2) examine the relative effectiveness of different types of homework assignments and which types of assignments facilitate improvement for which problems; and 3) identify therapist behaviors that enhance homework effects. Indeed, recent work25 found that homework compliance, combined with acceptance of treatment rationale, accounted for only 20% of the variance in treatment outcome in C/B treatment for depression, suggesting that other variables moderated treatment outcomes. Studies of homework compliance with racially and ethnically diverse older adults are warranted to help ensure the generalizability of psychotherapy and pharmacotherapy findings.34,35 Research on homework compliance with depressed older adults needs to examine other outcomes (e.g., quality-of-life components, social and occupational functioning, interpersonal relationship factors, and coping skills) that extend beyond depressive symptoms alone. Additional work investigating the relationship between homework compliance and the maintenance of gains among older adults is also needed.15

Finally, this discussion of homework completion and compliance is framed within a C/B individual-therapy model. However, our experience with time-limited group therapy for late-life depression, as well as time-limited C/B-based psychoeducational classes to reduce distress among depressed older adults and family caregivers, suggests that similar points and principles apply.5,15,36,37 Reviews and discussions of homework compliance in the literature tend to focus on C/B therapies. No doubt this is due, at least in part, to C/B's theoretical assumptions regarding the usefulness of homework and the importance of practice. Yet, other approaches, including systemic and family approaches, as well as solution-focused therapy, have begun to endorse its use.13 These endorsements lay encouraging groundwork for other approaches to consider its integration in the future and to examine more systematically its relationship to therapeutic outcomes.


   ACKNOWLEDGMENTS
 
This work was supported principally by Grant #MH 37196 from the National Institute of Mental Health.

The desipramine was provided by Merrill-Dow Chemical.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Beck AT, Rush AJ, Shaw BF, et al: Cognitive Therapy of Depression. New York, Guilford, 1979
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  18. Spitzer RL, Endicott J, Robins E: Research Diagnostic Criteria: rationale and reliability. Arch Gen Psychiatry 1978; 35:773-782[CrossRef][Medline]
  19. Thompson LW, Gantz F, Florsheim M, et al: Cognitive-behavioral therapy for affective disorders in the elderly, in New Techniques in Psychotherapy of Older Patients. Edited by Myers WA. Washington, DC, American Psychiatric Press, 1991, pp 3-20
  20. Endicott J, Spitzer RL: A diagnostic interview for affective disorders and schizophrenia. Arch Gen Psychiatry 1978; 35:837-844[CrossRef][Medline]
  21. Hamilton M: Development of a rating scale for primary depressive illness. British Journal of Social and Clinical Psychology 1967; 6:278-296
  22. Beck AT, Ward CH, Mendelson M, et al: An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:561-571
  23. Folstein MF, Folstein SE, McHugh PR: Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189-198[CrossRef][Medline]
  24. Spitzer RL, Endicott J: SADS-Change Interview. New York, New York State Psychiatric Institute, 1977
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  27. Kornblith SJ, Rehm LP, O'Hara MW, et al: The contribution of self-reinforcement training and behavioral assignments in the efficacy of self-control therapies for depression. Cognitive Therapy and Research 1983; 7:499-528
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  29. Rybarczyk B, Gallagher-Thompson D, Rodman J, et al: Applying cognitive-behavioral psychotherapy to the chronically ill elderly: treatment issues and case illustration. Int Psychogeriatr 1992; 4:127-140[CrossRef][Medline]
  30. Bryant MJ, Simons AD, Thase ME: Therapist skill and patient variables in homework compliance: controlling an uncontrolled variable in cognitive therapy outcome research. Cognitive Therapy and Research 1999; 23:381-399[CrossRef]
  31. Coon DW, Rider K, Gallagher-Thompson D, et al: Cognitive-behavioral therapy for the treatment of late-life distress, in Handbook of Counseling and Psychotherapy With Older Adults. Edited by Duffy M. New York, Wiley, 1999, pp 487-510
  32. Organista KC, Muñoz RF: Cognitive-behavioral therapy with Latinos. Cognitive and Behavior Practice 1996; 3:255-270
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  37. Thompson L, Powers D, Coon D, et al: Older adults, in Cognitive-Behavioral Group Therapy for Specific Problems and Populations. Edited by White JR, Freeman AS. Washington, DC, American Psychological Association, 2000, pp 235-261



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