Passive coping response to depressive symptoms among low-income homebound older adults: Does it affect depression severity and treatment outcome?
ABSTRACT Due to their homebound state, lack of financial resources, and/or other life demands, a significant proportion of depressed, low-income homebound older adults experience depression. Because of their limited access to psychotherapy, most of these older adults self-manage their depressive symptoms. The purposes of this study were to examine (1) the relationship between homebound older adults' coping responses to depressed mood and the severity of their depressive symptoms at baseline (n = 121), and (2) the moderating effect of passive coping responses on the relationship between participation in problem-solving therapy (PST: in-person or telehealth delivery) and depressive symptoms at 12- and 24-week follow-ups. Controlling for the effects of demographic and disability characteristics, cognitive passive coping was significantly associated with baseline depressive symptoms, while behavioral passive coping was not. The main effect of baseline cognitive passive coping response was also significant in mixed-effects regression analysis, but the interaction between coping pattern and group was not significant. The results point to a possibility that cognitive passive copers may have benefited as much from PST as the rest of the PST participants. Further research needs to examine the moderating effect of coping responses to depressive symptoms on treatment efficacy of PST and other psychosocial interventions for late-life depression.
- SourceAvailable from: Namkee Choi[Show abstract] [Hide abstract]
ABSTRACT: Despite their high rates of depression, homebound older adults have limited access to evidence-based psychotherapy. The purpose of this paper was to report both depression and disability outcomes of telehealth problem-solving therapy (tele-PST via Skype video call) for low-income homebound older adults over 6 months postintervention. A 3-arm randomized controlled trial compared the efficacy of tele-PST to in-person PST and telephone care calls with 158 homebound individuals who were aged 50+ and scored 15+ on the 24-item Hamilton Rating Scale for Depression (HAMD). Treatment effects on depression severity (HAMD score) and disability (score on the WHO Disability Assessment Schedule [WHODAS]) were analyzed using mixed-effects regression with random intercept models. Possible reciprocal relationships between depression and disability were examined with a parallel-process latent growth curve model. Both tele-PST and in-person PST were efficacious treatments for low-income homebound older adults; however the effects of tele-PST on both depression and disability outcomes were sustained significantly longer than those of in-person PST. Effect sizes (dGMA-raw ) for HAMD score changes at 36 weeks were 0.68 for tele-PST and 0.20 for in-person PST. Effect sizes for WHODAS score changes at 36 weeks were 0.47 for tele-PST and 0.25 for in-person PST. The results also supported reciprocal and indirect effects between depression and disability outcomes. The efficacy and potential low cost of tele-delivered psychotherapy show its potential for easy replication and sustainability to reach a large number of underserved older adults and improve their access to mental health services.Depression and Anxiety 02/2014; 31(8). · 4.29 Impact Factor
Passive coping response to depressive symptoms among low-income homebound
older adults: Does it affect depression severity and treatment outcome?
Namkee G. Choia,*, Mark T. Hegelb, Leslie Sirriannia, Mary Lynn Marinuccia, Martha L. Brucec
aSchool of Social Work, University of Texas at Austin, 1 University Station, D3500, Austin, TX 78712-0358, USA
bDartmouth Medical School, Lebanon, NH, USA
cWeill Cornell Medical College, White Plains, NY, USA
a r t i c l e i n f o
Received 13 June 2011
Received in revised form
15 July 2012
Accepted 23 July 2012
Homebound older adults
a b s t r a c t
Due to their homebound state, lack of financial resources, and/or other life demands, a significant
proportion of depressed, low-income homebound older adults experience depression. Because of their
limited access to psychotherapy, most of these older adults self-manage their depressive symptoms. The
purposes of this study were to examine (1) the relationship between homebound older adults’ coping
responses to depressed mood and the severity of their depressive symptoms at baseline (n ¼ 121), and
(2) the moderating effect of passive coping responses on the relationship between participation in
problem-solving therapy (PST: in-person or telehealth delivery) and depressive symptoms at 12- and 24-
week follow-ups. Controlling for the effects of demographic and disability characteristics, cognitive
passive coping was significantly associated with baseline depressive symptoms, while behavioral passive
coping was not. The main effect of baseline cognitive passive coping response was also significant in
mixed-effects regression analysis, but the interaction between coping pattern and group was not
significant. The results point to a possibility that cognitive passive copers may have benefited as much
from PST as the rest of the PST participants. Further research needs to examine the moderating effect of
coping responses to depressive symptoms on treatment efficacy of PST and other psychosocial inter-
ventions for late-life depression.
? 2012 Elsevier Ltd. All rights reserved.
A significant proportion of disabled, homebound older adults
experience depression, as chronic medical illness, disability, and
social isolation tend to be highly correlated with depression
(Bruce et al., 2002; Choi, Teeters, Perez, Farar, & Thompson, 2010;
Ell, Unützer, Aranda, Sanchez, & Lee, 2005; Sirey et al., 2008).
Financial worries and other life stressors (e.g., family conflict,
housing instability) related to limited financial resources are also
highly correlated with depression among low-income home-
bound older adults (Choi, Hegel, Marinucci, Sirrianni, & Bruce,
of depression, however, low-income homebound older adults
tend to underutilize depression treatment services other than
antidepressant medication prescribed mostly by their primary
carephysicians. Their homebound
resources, and/or other life demands create a barrier to accessing
psychotherapy that may help them learn coping skills for
stressors and depressed mood itself.
Previous research on coping strategies and styles largely
examined their moderating effects on the relationship between
outcomes (Blalock & Joiner, 2000; Lazarus, 1999; Lazarus &
Folkman, 1984; Thoits, 1995). However, little research has been
conducted regarding the nature of cognitive and behavioral
coping responses to their depressive symptoms among older
adults in general and homebound older adults in particular.
Although coping responses to depressive mood may be an
extension of an individual’s general coping style, they represent
the specific ways in which the individual reacts to depression per
se and reveal the kind of help-seeking behaviors, or lack thereof,
that he or she employs to self-manage and cope with depressed
mood. The purposes of the present study were to examine the
type of coping responses to depressed mood and the effect of
passive coping responses on depression severity and treatment
outcomes among low-income homebound older adults who
participated in a pilot randomized controlled trial of problem-
solving therapy (PST).
* Corresponding author. Tel.: þ1 512 232 9590; fax: þ1 512 471 9600.
E-mail address: email@example.com (N.G. Choi).
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Behaviour Research and Therapy 50 (2012) 668e674
Active versus passive coping responses to depression and
Our literature search did not yield any study that examined
depressed older adults’ efforts to cope with their depressed mood;
however, previous research on response styles among individuals
with depression/dysthymia suggests that the ways in which indi-
viduals respond todepressed moodinfluenceboththedurationand
severity of their depression (Nolen-Hoeksema, 1991). Ruminative
responses, inwhich individuals focus intentlyon their symptoms of
depression without taking action to relieve them, were often found
to exacerbate and prolong depression (Just & Alloy,1997; Morrow &
Nolen-Hoeksema, 1990; Nolen-Hoeksema, Morrow, & Fredrickson,
1993). Another study found that both pretreatment rumination
and distractiondthoughts and behaviors that individuals engage to
distract themselves from depressed mooddwere associated with
more depressive symptoms at the conclusion of treatment (PST,
paroxetine, or placebo) among primary care patients aged 18 to 59
(Schmaling, Dimidjian, Katon, & Sullivan, 2002).
Active versus passive coping responses represent the approach
versus avoidance dimensions of coping method (Billings & Moos,
1981; Suls & Fletcher, 1985). Active coping refers to cognitive and
behavioral attempts to deal directly with problems and their
effects, while passive/avoidant coping refers to cognitive attempts
to avoid actively confronting problems and/or behaviors to indi-
rectly reduce emotional tension by such behaviors as eating or
smoking more (Billings & Moos, 1981, p. 141). Passive coping
responses are often used when individuals decide that the basic
circumstances cannot be altered and, thus, they need to accept
a situation as it is (Blalock & Joiner, 2000).
Previous studies found that individuals under duress typically
use multiple tactics to deal with the stressors, especially when they
appraise the stressors as severe threats/harm/loss (Blalock & Joiner,
2000; Folkman & Lazarus,1980; Thoits,1995). Furthermore, certain
coping strategies have both active and passive components. For
example, ruminative and distracting responses to depression,
largely passive coping styles as they tend to aggravate depressive
symptoms, may also be considered active, as even ruminative
individuals focus on their symptoms of depression to try to assess
and remedy their depressed state (Morrow & Nolen-Hoeksema,
1990). Nevertheless, a high level of passive coping responses to
depressive symptoms, with or without active coping, may amplify
a depressed mood among homebound older adults in the following
ways: First, given that the cognitive symptoms of the feelings of
hopelessness, helplessness, and worthlessness tend to be more
sensitive to depression in older than younger adults (Moberg et al.,
2001), passive coping may prolong the course of depression by
reinforcing these feelings. Second, as late-life depression is also
characterized by anhedonia and a depletion syndrome manifested
by withdrawal, apathy, and a lack of vigor (Blazer, 2009), passive
coping can aggravate these tendencies. Rather than engaging in
pleasurable activities and/or seeking help from social support
networks to alleviate depressed mood, those with passive coping
responses may choose to further withdraw from activities and
interactions with others, resulting in increased social isolation and
worsening depressed mood. A 10-year prospective study found that
baseline avoidant coping among late-middle-aged persons was
associated with both more chronic and more acute stressors 4 years
later, and these life stressors linked baseline avoidance coping and
depressive symptoms 10 years later (Holahan, Moos, Holahan,
Brennan, & Schutte, 2005).
Passive coping responses to depressive symptoms can also
interfere with treatment outcomes, since the feelings and behav-
iors associated with learned helplessness can contribute to wors-
ening cognitive distortions about the level of threats from a minor
adverse event and negatively affect one’s sense of control over life
stressors and self-efficacy related to the outcomes of treatment.
One previous study that examined PST-PC (primary care) and
coping styles (related to the general life stress) among primary care
patients (average age of 55.2 ? 16.0; 64% employed at least part
time) with minor depression found that those who were high in
avoidant coping, but not those low in avoidant coping, showed
greater improvement with PST-PC than those who received usual
care consisting of routine physician practice (Oxman, Hegel, Hull, &
Dietrich, 2008). The authors credited PST’s compensatory effect on
those with avoidant coping style. The compensatory effect of PST-
PC may be lower for depressed, low-income homebound older
adults with limited personal and social resources than for younger,
mostly employed primary care patients.
Both personal and social coping resources are inversely
distributed by social status (Thoits, 1995). Personal coping
resources, or a sense of control/mastery over life, have been
presumed to influence the choice and/or the efficacy of the coping
strategies that people use in response to stressors (Folkman, 1984;
Rosenbaum,1990). By the same token, social coping resources that
include social support and willingness and comfort with help-
seeking from others (Billings & Moos, 1981; Nadler, 1990) are also
likely to influence an individual’s coping responses. Some low-
income homebound older adults with limited personal and social
coping resources may adopt passive coping responses to their
depressive symptoms, perceiving that they have limited control
over life circumstances that led to their depression and over the
symptoms of depression.
In the absence of any empirical study of the association between
coping responses todepressive mood and the severity of depressive
mood and treatment outcome among low-income homebound
older adults, the present study provides the first test of such
association. The specific hypotheses were: (H1) Controlling for
demographic characteristics and level of disability, passive coping
responses would be associated with higherdepressive symptoms at
baseline and (H2) passive coping responses at baseline would
moderate the relationship between participation in PST (in-person
or telehealth delivery) and depressive symptoms at the 12-week
and 24-week follow-ups by diminishing the treatment effect.
Recruitment process and participants
Depressed homebound adults aged 50 years and older who
were non-Hispanic White, Black, or Hispanic and spoke English
were referred to the project by case managers at a large Meals on
Wheels (MOW) program and other agencies serving low-income
homebound older adults in central Texas. Referred individuals
either scored 10 or higher on the PHQ-9 screener or appeared to
have depressive symptoms. Following referral, they were admin-
istered the 24-item Hamilton Rating Scale for Depression (HAMD).
Those whose HAMD scores were 15 or higher were included in the
randomized controlled trial (RCT) testing the feasibility and
preliminary evidence of efficacy of 6 weekly sessions of telehealth
PST (tele-PST: PST delivered via Skype video call), compared to 6
weekly sessions of in-person PST and attention control.
The exclusion criteria were (1) high suicide risk; (2) dementia
(assessed with the Mini-Cog that is a composite 3-item recall and
clock drawing test; Borson, Scanlan, Brush, Vitaliano, & Dokmak,
2000); (3) bipolar disorder; (4) current (12-month) or lifetime
psychotic symptoms or disorder; (5) presence of co-occurring
alcohol or other addictive substance abuse; and (6) current
involvement in psychotherapy. Those who had been on antide-
pressant medication for more than two months but still showed
N.G. Choi et al. / Behaviour Research and Therapy 50 (2012) 668e674
significant depressive symptoms were not excluded from the study.
Of 186 referrals received during the 24-month recruitment and
enrollment period, 124 met the inclusion criteria and 121 who
agreed to participation in the study were randomly assigned into
three groupsdtele-PST (n ¼ 43, 35%); in-person PST (n ¼ 42, 35%),
and telephone support calls (n ¼ 36, 30%). Written informed
consent, approved by the first author’s university institutional
review board, from each participant was obtained after the study
procedures had been fully explained. Fourteen participants drop-
ped out from the study before completing 6 sessions of in-person
PST (n ¼ 7), tele-PST (n ¼ 5), and telephone care calls (n ¼ 2),
and 5 (2 tele-PST participant; and 3 telephone care call partici-
pants) who completed all 6 sessions of intervention dropped out
before 24-week follow-up. Attrition was due mostly to deterio-
rating health problems that resulted in hospitalization, nursing
home placement, and death; however, the baseline demographic
and clinical characteristics of the dropouts did not significantly
differ from those who continued in the study.
Therapist training, supervision, and fidelity monitoring
The second author (MTH) trained two licensed master’s-level
social workers (LS & MLM) in PST-PC (Catalan et al., 1991; Mynors-
Wallis, Gath, Lloyd-Thomas, & Tomlinson, 1995) and has provided
ongoing clinical supervision and fidelity monitoring for them. The
(first and one random selection between the second and fifth
sessions) from 20% of all participants throughout the study. Each
therapistprovidedbothtele-PSTandin-person PST.The meanglobal
adherence and competence rating score on the PST-PC Therapist
Adherence and Competence Scale (Hegel, Dietrich, Seville, & Jordan,
2004) was 4.4 on a 6-point scale (0 ¼ very poor to 5 ¼ very good),
with no significant difference between the two therapists.
Conduct of PST sessions and attention control
In each 60-min PST session, the therapist and participant used
a worksheet to progress through the 7-steps of PST (Hegel & Areán,
2002)d(1) identifying and clarifying a problem area; (2) estab-
lishing clear, realistic, and achievable goals for problem resolution;
(3) generating multiple solution alternatives or appropriate solu-
tion possibilitiesthrough brainstorming;
decision-making guidelines through identifying pros and cons of
each potential solution (e.g., advantages and disadvantages, feasi-
bility and obstacles, and other benefits and challenges); (5) evalu-
ating and choosing solutions by comparing and contrasting them;
(6) developing an action plan detailing steps the client would take
to implement the preferred solutions; and (7) evaluating the
outcome and reinforcement of success and continued effort.
Those assigned to tele-PST were loaned a laptop computer with
Skype and engaged in PST sessions with a therapist via videocon-
ferencing, and those assigned to in-person PST engaged in face-to-
face PST sessions with a therapist in their own residence. The
participants in the attention control group received six weekly, 30-
min telephone support calls from two research associates. The
purpose of the calls was to provide support and empathy and to
monitor the participants’ depressive symptoms to ensure their
safety. The detailed intervention procedures were described else-
where (Choi et al., 2012, in press).
The 24-item HAMD consists of the GRID-HAMD-21 structured
interview guide augmented with 3 additional items assessing
feelings of hopelessness, helplessness, and worthlessness with
specific probes and follow-up questions developed by Moberg et al.
(2001). The scoring format of the 3 additional questions was
slightly modified so that both frequency and intensity of these
feelings can be factored in their ratings as in the case with other
comparable items (e.g., depressed mood, anxiety) in the GRID-
HAMD-21. The HAMD was administered at baseline and at 12-
and 24-week follow-ups.
Coping responses to depressive symptoms
In the absence of a validated scale measuring coping responses
to depressed mood among homebound older adults, a 22-item
checklist of coping responses to depression was compiled based
on the findings of a previous study of depressed, low-income older
adults’ help-seeking behaviors (Choi & McDougall, 2007; see also
Biegel, Farkas, & Song, 1997). The items were: just waited and
hoped the problem goes away; brooded and continued worrying;
withdrew from others; slept a lot; ate more than usual; drank beer,
wine, or liquor more than usual; talked to spouse/family member;
talked to a close friend; talked to a clergyman; consulted a regular
family physician; talked to a psychiatrist/psychologist; talked to
a social worker; visited a faith healer; called the crisis line; bought
over-the-counter drugs to sooth the nerves; prayed frequently;
watched religious program on TV; listened to music or watched
entertainment programs on TV; exercised/took a walk/did house-
work; had crying spells; and other (specify). At baseline assess-
ment, each individual was asked to check (yes ¼ 1; no ¼ 0) the
coping responses that he or she had used in the preceding three
months to help him or her get out of the depressed, sad, or down-
in-the dumps mood.
Cognitive passive coping was defined as the endorsement of all
three of the following statements: just waiting and hoping the
problem goes away, brooding and continuing worrying, and with-
drawing from others. The data showed that 91.7% of the sample
endorsed at least one of the three cognitive passive coping
responses, 77.7% endorsed at least two of them, and 33.9% endorsed
all three items. Given the high prevalence of at least one or two
passive coping responses, we focused on endorsement of all three
items to represent a high level of cognitive passive coping. For
behavioral passive coping, 45.5% of the sample endorsed “sleeping
a lot,” 41.3% endorsed “eating more than usual,” and 7.4% (n ¼ 9)
endorsed “drank beer, wine, or liquor more than usual” as their
coping responses, and 67.8% endorsed at least one of these three.
Again to represent a high level of behavioral passive coping, we
defined it as the endorsement of both sleeping and eating and/or
drinking. This showed that 28.1% of the sample who had engaged in
behavioral passive coping.
We used separate codings for cognitive and behavioral passive
coping to explore if these two types of passive coping may be
different in their associations with depressive symptoms and in
their moderating effect on the relationship between participation
in PST and depressive symptoms. We suspected that, compared to
cognitive passive coping, behavioral passive coping including
sleeping and eating patterns among some chronically ill, disabled
older adults might have been affected by the medications that they
were taking and, thus, may be less likely to represent their true
Controls: demographic and disability
ethnicity, and family income. Disability status at baseline was
assessed using the short form (12-item, 5-point scale) WorldHealth
Organization Disability Assessment Schedule (WHODAS-II; WHO,
2000). The WHODAS-II assesses disabilities without asking
respondents to identify whether the problem was caused by
N.G. Choi et al. / Behaviour Research and Therapy 50 (2012) 668e674
medical or mental health conditions. In consideration of the
homebound state of the participants, the last item “Your day to day
work” was reworded to “Your day to day work in and around the
house.” The number of diagnosed medical conditions (arthritis;
high blood pressure; stroke; diabetes; emphysema; heart disease;
cancer; kidney disease; and liver disease) that still caused problems
was also counted.
All analyses wereperformed using SPSS v.19 (IBM Corp, Armonk,
NY), and all tests of significance were two tailed with set at 0.05.
Between-group one-way ANOVA (with Bonferroni-corrected post-
hoc tests),c2tests, and t-testswereused toassess group differences
in baseline participant characteristics. To test H1 (association
between passive coping and depressive symptoms at baseline),
independent samples t-tests of the HAMD scores between those
who employed passive coping (passive coper) and those who did
not (nonpassive coper) were followed by ordinary least squares
(OLS) regression analysis. To test H2 (moderating effect of passive
coping on the relationship between PST and depressive symptoms
at follow-ups), we employed an intent-to-treat approach using
piecewise mixed-effects regression with random intercept model
(Raudenbush & Byrk, 2001). Treatment group (tele-PST or in-
person PST vs. telephone care call), cognitive passive coping (vs.
no cognitive passive coping), time, and the interaction term
between treatment group and coping pattern and that between
treatment group and time were included in the model, with group
and coping pattern as between-subject effects and time as a two-
piece (piece 1 [time 1] ¼ baseline to 12 weeks; piece 2 [time
2] ¼ 12 weeks to 24 weeks) continuous within-subject variable.
Tele-PST and in-person PST groups were combined as one group
based on the lack of significant difference in baseline and follow-up
HAMD scores between two PST delivery modalities (for further
details, Choi et al., in press). Only cognitive coping pattern was
included as a covariate in the model because there was no rela-
tionship between behavioral coping pattern and HAMD scores at
baseline and follow-ups. Variance explained in the residual was
estimated using a formula from Raudenbush & Byrk.
Sample characteristics at baseline
Table 1 shows that the sample was diverse in age (31% 50e59
years; 40% 60e69 years; and 29% 70þ years) and racial/ethnic
distributions (with 59% either Black or Hispanic), and a majority of
them had family income at or less than $25,000. As expected, the
participants on average had 3.19 ? 0.54 chronic medical conditions.
No differencewasfoundinbaselinedepressive symptomseverity by
age, gender, race/ethnicity, income, and by intervention group
assignment, but depressive symptom severity was positively but
weakly associated with disability score (r ¼ 0.27, p ¼ 0.003). As
in cognitive passive coping and behavioral passive coping, respec-
cognitive nor behavioral passive copers. Further analysis found no
difference in coping pattern by age, gender, race/ethnicity, income,
disability score, and by intervention group assignment. The most
frequently resorted coping responses among these low-income,
depressed homebound older adults were listening to music or
watching entertainment programs on TV (91.7%) and frequent
praying (81.8%). For formal help seeking, 70.2% reported that they
(mostly their case manager); 15.7% had talked to a clergyman; 13.2%
had consulted a psychiatrist or psychologist; and 3.3% each had
visited a faith/folk healer and called a crisis hotline. In these coping
responses, however, passive copers, either cognitive or behavioral,
did not significantly differ from nonpassive copers, showing that
passive copers also resorted to active coping responses.
Association between passive coping and baseline depression severity
Despite the finding that both passive and nonpassive copers did
not differ with respect to the rest of the coping responses, Table 2
Sample characteristics at baseline (N ¼ 121).
Age, mean (SD) (range: 50e89)
Gender (n, %)
Race/ethnicity (n, %)
Family income (n, %)
SCID diagnosis (n, %)
Major depressive disorder
Depressive disorder, NOS
Disability (WHODAS-II) score,amean (SD)
Depression severity (HAMD score), mean (SD)
Coping pattern (n, %)
Cognitive passive copingb(with or without
behavioral passive coping)
Behavioral passive copingc(with or without
cognitive passive coping
Cognitive passive coping only
Behavioral passive coping only
Both cognitive and behavioral passive coping
Neither type of passive coping
RCT group (n, %)
Telephone support call
aThe possible ranges of the score are 12e60.
bJust waited and hoped the problem goes away, brooded and continued
worrying, and withdrew from others.
cSlept a lot and ate more than usual and/or drank beer/wine/liquor more than
Baseline HAMD scores by coping pattern.
Coping patternHAMD score
Cognitive passive coping with/without
behavioral passive coping vs. no
cognitive passive coping
Behavioral passive coping with/without
cognitive passive coping vs. no
behavioral passive coping
Cognitive passive coping only
Behavioral passive coping only
Both cognitive and behavioral
Neither cognitive or behavioral
2.82 117 0.042
(): Standard deviation.
a,b: Denote a significantly different pair based on Bonferronni-corrected post-hoc
N.G. Choi et al. / Behaviour Research and Therapy 50 (2012) 668e674
shows that cognitive passive copers had significantly higher base-
line HAMD scores than the rest (26.66 ? 6.88 vs. 23.46 ? 6.26,
t ¼ 2.57, df ¼ 119, p ¼ 0.011). However, behavioral passive copers
were not significantly different from the rest in their HAMD scores
(23.65 ? 6.69 vs. 24.90 ? 6.60, t ¼ 0.93, df ¼ 119, p ¼ 0.353). Data
also show that those who engaged in cognitive passive coping only
(i.e., without behavioral passive coping) had significantly higher
baseline HAMD scores than those who engaged in behavioral
passive coping only (i.e., without cognitive passive coping)
(HAMD ¼ 27.08 ? 6.42 vs. 21.84 ? 5.19, p ¼ 0.042). Further analysis
found that thosewho reported at least two cognitive passive coping
responses also had higher HAMD scores than the rest (25.70 ? 6.73
vs. 20.52 ? 4.34, t ¼ 3.78, df ¼ 119, p < 0.001), and the same was
true for those who reported at least one cognitive passive coping
response (25.05 ? 6.58 vs.19.0 ? 4.40, t ¼ 2.84, df ¼ 119, p ¼ 0.005).
On the other hand, the number of behavioral coping responses was
not associated with HAMD scores.
The OLS regression results in Table 3 confirm significant asso-
ciation between cognitive passive coping (endorsement of all three
cognitive passive coping responses) and depression severity and no
such association between behavioral passive coping and depression
severity at baseline, controlling for demographic and disability
variables. Cognitive passive copers had, on average, a 3.0-point
higher HAMD score than nonpassive copers. Sensitivity analysis
found that endorsement of any two or one of the three cognitive
coping responses was also significantly associated with higher
HAMD scores (B ¼ 5.04, SE ¼ 1.32, t ¼ 3.80, p < 0.001 for
endorsement of two responses and B ¼ 5.05, SE ¼ 2.07, t ¼ 2.44,
p ¼ 0.016 for endorsement of one response).
Moderating effect of cognitive passive coping on treatment outcome
Table 4 shows the results of the mixed-effects regression anal-
ysis. The main effect of cognitive passive coping, as compared to
non-cognitive passive coping, was significant (t ¼ 3.26, df ¼ 111;
p ¼ 0.001), as was the effect of PST, as compared to telephone
support call (t ¼ ?2.36, df ¼ 208; p ¼ 0.019). The main effect of time
1 (baseline to 12 weeks) was also significant (t ¼ ?4.63, df ¼ 206;
p < 0.001), but the main effectof time 2 (12 weeks to24 weeks) was
not significant (t ¼ ?1.42, df ¼ 207; p ¼ 0.158). Intervention group
by time 1 interaction effect was also significant (t ¼ ?2.91, df ¼ 207;
p ¼ 0.004), but intervention group by time 2 interaction effect was
nonsignificant (t ¼ 1.13, df ¼ 206; p ¼ 0.260). Intervention group by
cognitive passive coping interaction effect was not significant,
either (t ¼ ?1.50, df ¼ 113; p ¼ 0.127). The model pseudo-R2,
calculated from comparing the full model’s residual estimate to
that of the intercept only model, was 0.68.
This study examined low-income homebound older adults’ self-
reported coping responses to their depressive symptoms, associa-
tion between passive coping responses and depressive symptom
severity, and the moderating effect of passive coping on PST. The
findings show that most of these older adults resorted to both
active and passive coping responses to their depressive symptoms.
However, the findings show that those who resorted to any
cognitive passive coping response, compared to those who did not,
had significantly higher depressive symptoms, while those who
resorted to any behavioral passive coping did not differ in their
depressive symptom severity from those who did not. Those who
had resorted to behavioral passive coping without engaging in
cognitive passive coping had significantly lower HAMD scores than
thosewho resorted to cognitive passive coping without engaging in
behavioral passive coping.
In support of H1, multivariate linear regression analysis
confirmed that controlling for individual demographic character-
istics and disability scores, cognitive passive coping was signifi-
cantly associated with baseline depressive symptom severity, while
behavioral passive coding was not. Given the cross-sectional data, it
was not clear if cognitive passive coping responses to depression
resulted from severe depression or vice versa.
The baseline cognitive passive coping response also had
a significant main effect on depressive symptoms at 12- and 24-
week follow-ups. However, contrary to H2 that predicted that
passive coping would diminish the PST’s treatment effect, the
results point to a null moderating effect. Given the significant main
effect of PST on reducing depressive symptoms, the good news is
that everyone, regardless of his or her coping pattern benefited
from the psychotherapy, although cognitive passive copers who
had higher depressive symptoms at baseline still had higher
depressive symptoms at follow-ups. PST is based on the social
problem-solving theory of depression which posits that depression
Association between passive coping and HAMD score at baseline (N ¼ 121).
Cognitive passive coping
Behavioral passive coping
Treatment effects by group, time, and coping pattern: mixed-effects regression results.
SE 95% CI
Cognitive passive coping (not cognitive passive coping)
PST (telephone support call)
Time 1: baseline to 12 weeks
Time 2: 12 weekse24 weeks
Group by coping pattern
PST ? cognitive passive coping (all others)
Group by time
PST ? time 1 (telephone support ? time 1)
PST ? time 2 (telephone support ? time 2)
?3.65 2.44(?8.49, 1.18)
N.G. Choi et al. / Behaviour Research and Therapy 50 (2012) 668e674
is mediated by the availability of problem solving skills and atti-
tudes for coping with daily hassles and major life problems
(D’Zurilla, 1986; Nezu, Nezu, & Perri, 1989). Since PST not only
teaches participants systematic problem solving skills but it also
encourages them to carry out daily pleasurable activities, it
promotes both cognitive and behavioral activation. Problem solving
and activity may have had significant impact on both passive and
nonpassive copers to become more active and proactive copers.
This is in line with the claim by Oxman et al. (2008) of PST’s
In summary, the findings show that cognitive and behavioral
passive coping responses to depressive symptoms, although both of
them may represent avoidant coping styles, have different effects
on baseline and post-treatment depression severity. Cognitive
passive coping responses to depressive symptoms, but not behav-
ioral passive coping response, are significantly correlated with
symptom severity both at baseline and post-treatment. However,
even cognitive passive coping does not interfere with PST’s treat-
ment outcomes among low-income homebound older adults.
Regardless of individual coping patterns, short-term PST, both in-
person and via videoconferencing delivery, had positive effect on
low-income homebound older adults’ depressive symptoms.
Although only 24-week follow-up effect was evaluated in the
present study, other studies have shown long-term (12e24
months) treatment effect of PST (Areán, Hegel, Vannoy, Fan, &
Unützer, 2008; Areán et al., 2010). More importantly, the results
of the study suggest that PST, due to its focus on teaching
systematic problem-solving skills and engaging in pleasant activi-
ties, may be beneficial for homebound older adults who have been
resorting to cognitive passive coping responses to their depressive
symptoms. Hence, clinical implications for the findings are that (1)
low-income, depressed homebound older adults, regardless of
their coping responses to their symptoms of depression, benefit
from a short-term, structured, evidence-based psychotherapy, and
(2) for enhanced treatment effect, their coping responses to
depressive symptoms need to be examined prior to treatment and
specific attention may need to be paid to cognitive passive coping
responses during treatment process.
The study had a few limitations. First, due to the small sample
size, caution is required to interpret the exploratory findings of
this study. Second, the validity and reliability of the self-reported
coping responses are not confirmed by any other means of
triangulation and the psychometrics of the checklist remain
unknown. Third, without data on the frequency and extent of
active coping, we had no way of knowing if the extent of active
coping reported by passive copers was more or less than that of
their passive coping. Thus the question of whether the passive
copers were fundamentally similar or dissimilar to nonpassive
copers could not be answered and calls for further research.
Despite these limitations, the study contributes to the knowledge
base regarding psychosocial interventions for late-life depression,
especially among low-income homebound older adults who have
been underexposed in research on depression, coping, and
The National Institute of Mental Health’s strategic research
priorities emphasize the development of new and better inter-
ventions that incorporate the diverse needs and circumstances of
people with mental illness and the expansion and deepening of the
focus to personalize intervention research (NIMH, 2011). Under-
standing predictors and potential moderators of treatment
outcomes is an important step forward to developing more effec-
tive, personalized intervention research. Some previous studies
have examined the effect of such moderators as baseline depres-
sion severity, demographic characteristics, age at depression onset,
total numberof previous depressiveepisodes,cognitive
impairment, disability, and personality characteristics on PST’s
treatment outcomes (Areán et al., 2010; Kiosses, Leon, & Areán,
2011). The present study suggests that coping responses to
depressive symptoms also need to be further examined as
a moderator in the future research of treatment efficacy of PST and
other psychosocial interventions for late-life depression.
N. Choi and M. Bruce designed and implemented the study, and
all authors contributed to producing this paper and agree to
Conflict of interest
No conflicts of interest exist for any of the authors. The funding
sources were not involved in the production of this paper in any
NIMH (R34 MH083872; PI: Choi NG and Co-I: Bruce ML) and the
St. David’s Foundation (PI: Choi NG).
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