CAPSTONE PART 3

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Capstone Part II: Literature Review

Introduction

The purpose of this literature review is to evaluate whether the Cognitive Behavioral

Therapy (CBT), which is prescribed by computer-assisted and telemedicine-based systems, is

equally effective to improve depressive symptoms of Long-term care (LTC) patients or residents.

This review will enable an in-depth insight into the recent changes made in terms of the

outcomes, feasibility, cost-effectiveness, and ethical questions of using CBT to treat depression

in this population. The proposed PICOT question is supported by the review: Among Older

Adults aged 65 and older living in long-terminal care facilities (P), does Cognitive Behavioral

Therapy (CBT) (I) compared to usual care or doing nothing (C) reduce symptoms of depression

(O)?

Literature review

Effectiveness of CBT in Reducing Depression Among Older Adults

CBT has been proven by various studies to be an effective psychotherapeutic

management of depression in the elderly. CBT interventions delivered in the residential setting

reported that participants receiving CBT in LTC facilities achieved a clinically significant

reduction of more than 58% in depressive symptoms in older adults. CBT interventions for

depression and anxiety are acceptable to Residential Aged Care Facilities (RACFs) residents and

judged positively by staff members. The review was performed that included randomized

controlled trials (RCTs) and concluded that CBT, depending on the cognitive and physical

abilities of older adults, led to better mood, less negative thinking styles, and more coping

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strategies. More recent evidence from SupportiveCare (2025) supports these findings, reporting

that 58% of participants receiving CBT in LTC facilities achieved a clinically significant

reduction in depressive symptoms compared with 27% in the usual-care group. According to

SupportiveCare (2025), “In a long-term study spanning 10 years, participants who received CBT

exhibited notably higher remission rates compared to control groups. Specifically, 58% of

individuals in the CBT group achieved remission across all diagnoses, with remission rates for

depression reaching 88% and anxiety at 63%. In contrast, the control group showed remission

rates of 27% for all diagnoses, 54% for depression, and 35% for anxiety”.

Equally similar, Morgado et al. (2024) conducted a meta-analysis type of studies focusing

on psychotherapeutic interventions to treatment of depressive signs and symptoms in aging

adults living under community care and concluded CBT showed roughly 15-30 percent

superiority in lowering depressive symptoms over usual care and the probability of being more

effective than control groups is at 73-83 percent among treatment recipients. Morgado et al.

(2024) found that, “Group and individual psychotherapeutic interventions reduce depressive

symptoms in community-dwelling older adults, with group psychotherapeutic interventions

being more effective”.

The structured and goal-oriented features of CBT are interestingly beneficial to the

elderly patient because they have practical suggestions to adopt in cognitive and emotional

requirements. Dafsari et al. (2024) compared CBT and supportive psychotherapy randomized

clinical trials studies in adults with late-life depression. It has been discovered that patients in

CBT received more improvement in depressive symptoms and perception of physical health as

compared to patients in supportive therapy. The authors state that “patients with high PPH at

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baseline showed 12–14% greater reductions in depressive symptoms compared to SUI across

week 5, end of treatment, and 6-month follow-up”. These findings support the hypothesis that

CBT reduces depressive symptoms.

Synthesis and Relevance to the PICOT Question

Studies find that CBT, and internet-delivered CBT or embedded in collaborative care, can

decrease depression by large amounts at a minimal incremental cost, typically 2-5 dollars per

depression-free day or <5,100 per QALY with some models gaining net healthcare savings over

time. This implies that there is high potential of cost-effectiveness when implemented in the

setting of long-term care (Morgado et al. 2024). The evidence indicates that traditional and

telehealth-based CBT interventions demonstrate a great degree of improvement in the symptoms

of depression, preserve physical wellbeing, and can be economically sustainable. Such findings

are near those of the PICOT question.

The research by SupportiveCare, (2025), Morgado et al. (2024) and Dafsari et al. (2024)

combines high-quality empirical evidence of the usefulness of CBT in obtaining substantial

improvements in depression across the older adult population. In parallel, Ali et al. (2024) and

Witlox et al. (2022) indicate that the relatively cost-effective implementation of such

interventions is achievable, in particular through the application of telemedicine services. The

literature also reported that a 6-month implementation window suffices in detecting quantifiable

changes in depressive symptoms and therefore concurs with the duration in the PICOT. Besides

this, the articles studied herein provide an urgent need for proper screening along with ethical

service delivery and further discuss how the usage of CBT should be made in a conscientious,

competent, and continuous assessment type.

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Evidence for my Practice Change

In their study, Witlox et al. (2022) compared Acceptance and Commitment Therapy

(ACT) and Cognitive Behavioral Therapy (CBT). Although the Unified Protocol (UP) was

effective, evidence showed that the more cost-effective and applicable was CBT to be studied.

Notably, the study indicated the effectiveness of the telehealth-based ACT on the one hand and

CBT on the other, which implies the adaptability of distance-delivered therapies to geriatric

groups. This will promote the use of CBT through digital medium in LTC facilities, particularly

for persons with mobility or transport access obstructions. In their study, Ali et al. (2024) found

that computer-assisted modality substantiated the assumption that it ensures equal and even

better outcomes than are achieved by in-patient therapy, and costs are substantially lower.

Similarly, Shahsavar, & Choudhury, (2025), observed that CCBT can be a potentially

effective intervention that can be used in LTC facilities. The study's relevance lies in its strong

support for digital mental health interventions, which can be adapted for use in LTC facilities

with minimal investment in infrastructure. With many LTC facilities set up short on staffing and

physical capacity, telemedicine and computer-aided CBT (CCBT) appear to be potential

solutions to providing effective mental care.

Bell et al. (2023) conducted a systematic review and meta-analysis to assess the

effectiveness of CBT based on telemedicine on the depression and anxiety of older adults. The

researchers found out that the telehealth approaches (videoconferencing and using the phone)

reduced the symptoms of depression similarly to face-to-face interventions.

Objectives for my Practice Change

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Objective 1: Implement CBT to reduce depression in older adults residing in LTC

In order to achieve this, I will start by choosing a CBT protocol that is specifically

tailored to older adults and use age-appropriate language, examples, and pace. Depending on

residents and their needs, the intervention will either be provided in individual or small-group

sessions. I shall involve the mental health professionals to make sure that the therapy fits into the

clinical best practice and is operable within an LTC setting. There will be regular meetings to

facilitate compliance, and the progress will be observed utilizing the standardized depression

rating tools, which will enable timely changes to treatment plans.

Objective 2: Integrate telehealth and computer-assisted delivery models to expand access

I will leverage both telehealth platforms and computer-assisted CBT (CCBT) programs to

increase accessibility for residents with varying mobility and cognitive capacities. Tele-CBT will

encompass the deployment of licensed therapists to give moment-by-moment sessions through

stable video-conferencing, whereas CCBT modules will permit residents to access structured

therapeutic material at their convenience. A satisfactory technological infrastructure in the form

of tablets, headsets, and uninterrupted internet connectivity within the facility will back this dual

delivery method. Employees will help residents orient themselves with technology in order to

enjoy equal participation irrespective of their previous digital literacy.

Objective 3: Train LTC staff in basic CBT principles to support therapy efforts.

In order to maintain the practice change, I will create and implement the training of LTC

staff on the principles of CBT underlying practice, active listening techniques, and methods of

strengthening therapeutic principles in regular interactions. This will enable the employees to

detect issues regarding mood early, motivate residents to implement the techniques taught in

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CBT, and act as an intermediary to formal therapy sessions. Refresher training and regular

check-ins at the supervising level would help maintain staff skills and confidence in mental

health support.

Objective 4: Establish standardized depression screening and referral protocols

In cooperation with the leadership at the facility, I plan to integrate depression screening

instruments that are evidence-based, and in this case, these are the Geriatric Depression Scale, to

be implemented periodically across the facility to all residents. The screening outcome will be

used to determine timely referrals to competent mental health professionals and proper enrolment

into CBT programs. Documentation processes and channels of communication will be clearly

defined, ensuring that all care team members are informed about mental health conditions and

the progress of residents.

Objective 5: Improve residents’ quality of life through evidence-based mental health care

The utmost goal is to ensure the enhancement of the emotional health status, social

interaction, and sense of purpose of the residents due to regular high-quality mental health

services. Incorporating CBT with the available delivery models, trained staff, and screening

patterns, the program will establish a positive therapeutic setting where caring about mental

health in LTC would be normal. The intervention should be responsive to the changing needs by

regularly assessing the performance outcomes of residents and through resident and staff input,

so that the intervention can attain a more favorable and fulfilling experience of living

environment on the part of older adults.

Where the Problem Exists, Why It Exists, and the Proposition for Change

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Barriers and Facilitators to CBT in Long-Term Care

Although CBT proved to be a worthwhile measure in various environments, there are

certain issues with applying it to an LTC facility. The Atchison et al. (2023) study investigated

both the barriers and facilitators to anxiety management among LTC residents and revealed that

the following structural and systemic factors hindered the application of psychotherapeutic

measures among the majority of residents: staff workload, absence of mental health-specific

training, and stigma attached to mental health. Nonetheless, support factors including employee

education, family engagement, and flexible delivery models of therapy (e.g., group CBT or tele-

CBT) enhanced engagement and response.

Furthermore, Sen (2024) addressed the issue of organizational social work (OSW)

practices and defined a number of obstacles hindering the use of CBT, among which it is possible

to distinguish the lack of funds, available staff trained in CBT, and organizational predisposition

to rejecting any possible changes. Nonetheless, the study pointed out that the awareness activities

and institutional support to evidence-based practices were instrumental in raising the adoption

levels. These results are relevant in terms of approaching the question of how CBT could be

implemented in LTC institutions where the organizational culture and limited funding may

hamper innovations. Gerhards et al. (2025) took one step further and examined the extent to

which educational level in older adults determined the impacts of CBT. According to the authors,

the execution of CBT should be adapted to people who have different levels of health literacy

and cognitive abilities in LTC residents.

Current State of the Problem: Pros vs. Cons

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The existing mental health care is a moderately prone and reactive system as compared to

an active one in LTC facilities. Among the advantages of using CBT, one may note high clinical

effectiveness, the possibility of digital treatment practice, and good patient compliance. As

demonstrated in the research by Bell et al. (2023) and Ali et al. (2024), telehealth CBT is

versatile and cost-effective, and this factor may play a critical role in an LTC facility.

Relevance, Feasibility, and Ethical Considerations

Cost-Effectiveness and Feasibility

Cost-effectiveness measures in healthcare are one of the principal factors to be

considered when planning interventions, especially in a poorly funded medical system like that

in LTC. According to Ali et al. (2024), CCBT combined with clinician support was proven to

enhance quality-adjusted life years (QALYs) at a modest incremental cost with an incremental

cost-effectiveness ratio (ICER) of approximately US $37,300 per QALY, and of roughly US

$3,623 per successful case of treatment-a cost-effective intervention with a willingness-to-pay of

US $50,000 per QALY. Its cost-effectiveness was also especially prominent among the older

adult population that normally takes significantly longer sessions of therapy because of comorbid

disorders and cognitive decline.

Witlox et al. (2022) used a randomized controlled trial, which compared the treatments of

CBT with ACT for older adults and measured their cost-utility ratios. CBT turned out to be the

less expensive treatment offering larger symptom decreases at the dollar cost. The authors came

to the conclusion that CBT should become a priority in environments where money is limited,

i.e., LTC facilities.

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Bell et al. (2023) pointed out the economic and logistical viability of the telemedicine-

based CBT, as the mentioned model demands fewer resources in terms of staff and infrastructure

to implement compared to conventional models. It is especially beneficial to LTC facilities with

constant shortages of staff and patient-to-caregiver ratios that are too high. Therefore, even the

prerequisite of introducing CBT via telemedicine platforms can sound not only possible but also

rather sustainable over the long run.

Ethical Considerations and Screening Protocols

Ethical considerations need to be applied before any mental healthcare intervention, more

so when the population in question is vulnerable or in need, such as those staying in LTC.

Among them is the employment of appropriate screening instruments to select residents who are

good candidates for CBT.

Sen (2024) noted, the presence of organizational barriers might undermine the ethical

standards of using mental health interventions in case such practices are introduced without

training and support. The research advocated policies that would require the creation of

guidelines to be used by the institution regarding therapy that will incorporate regular screenings,

frequent reviews, and culturally relevant practices. This suggestion is consistent with the best

practice in mental health care and with the ethical practice of CBT in LTC facilities (Dafsari et

al. 2024).

Conclusion

The current literature review has supported that CBT is an effective, feasible, and

ethically correct intervention in the reduction of depressive symptoms among older adults living

in LTC facilities. The treatment, both on clinical and through a telehealth delivery and computer-

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assisted interventions formats, has displayed similar success in various high-quality studies. The

implementation of CBT in LTC is both clinically supported and defensible with regard to the

notion of cost-effectiveness and ethical positioning point of view. The use of CBT can therefore

be taken very seriously as a mental health intervention in practice in long-term care settings in

line with the project's aims and scopes of the PICOT question.

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References

Ali, S., Alemu, F. W., Owen, J., Eells, T. D., Antle, B., Lee, J. T., & Wright, J. H. (2024). Cost-

Effectiveness of Computer-Assisted Cognitive Behavioral Therapy for Depression

Among Adults in Primary Care. JAMA Network Open, 7(11), e2444599–e2444599.

https://doi.org/10.1001/jamanetworkopen.2024.44599

Atchison, K., Toohey, A. M., Ismail, Z., & Goodarzi, Z. (2023). Understanding the Barriers to

and Facilitators of Anxiety Management in Residents of Long-Term Care. Canadian

Journal on Aging =, 1–18. https://doi.org/10.1017/s0714980823000417

Bell, P., Thayane Martins Dornelles, Natan Pereira Gosmann, & de, C. (2023). Efficacy of

telemedicine interventions for depression and anxiety in older people: A systematic

review and meta-analysis. International Journal of Geriatric Psychiatry, 38(5). https://

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Dafsari, F. S., Bewernick, B., Böhringer, S., Domschke, K., Elsaesser, M., Margrit Löbner,

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Müller, Wagner, M., Peters, O., Lutz Frölich, Steffi Riedel-Heller, Schramm, E.,

Hautzinger, M., & Jessen, F. (2024). Perceived Physical Health and Cognitive Behavioral

Therapy vs Supportive Psychotherapy Outcomes in Adults With Late-Life Depression.

JAMA Network Open, 7(4), e245841–e245841. https://doi.org/10.1001/

jamanetworkopen.2024.5841

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Gerhards, S. K., Luppa, M., Zülke, A. E., Pabst, A., Claus, M., Bewernick, B., Elsaesser, M.,

Zehender, N., Wagner, M., Peters, O., Frölich, L., Schramm, E., Hautzinger, M., Jessen,

F., Dafsari, F. S., & Riedel-Heller, S. G. (2025). Educational attainment and cognitive

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Witlox, M., Kraaij, V., Garnefski, N., Bohlmeijer, E., Smit, F., & Spinhoven, P. (2022). Cost-

effectiveness and cost-utility of an Acceptance and Commitment Therapy intervention vs.

a Cognitive Behavioral Therapy intervention for older adults with anxiety symptoms: A

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