Effects of Cognitive Behavioral Therapy and Cash Transfers on Older Persons Living Alone in India
Madeline McKelway, Abhijit Banerjee, Erin Grela, Frank Schilbach, Miriam Sequeira, Garima Sharma, Girija Vaidyanathan, Esther Duflo
Abstract
BACKGROUND: A growing number of older persons in developing countries live entirely alone and are physically, mentally, and financially vulnerable. OBJECTIVE: To determine whether phone-based cognitive behavioral therapy (CBT) or a cash transfer reduce functional impairment, depression, or food insecurity in this population. DESIGN: Randomized controlled trial. (ClinicalTrials.gov: NCT04225845; American Economic Association RCT Registry: AEARCTR-0007582). SETTING: Tamil Nadu, India, 2021. PARTICIPANTS: 1120 people aged 55 years and older and living alone. INTERVENTIONS: A 6-week, phone-based CBT and a 1-time cash transfer of 1000 rupees (U.S. $12 at market exchange rates) were evaluated in a factorial design. MEASUREMENTS: The World Health Organization Disability Assessment Schedule (WHODAS), the Geriatric Depression Scale, and food security, all measured 3 weeks after CBT for 977 people and 3 months after for 932. Surveyors were blind to treatment assignment. RESULTS: The WHODAS score (scale 0 to 48, greater values representing more impairment) decreased between baseline and the 3-week follow-up by 2.92 more (95% CI, -5.60 to -0.23) in the group assigned cash only than in the control group, and the depression score (ranging from 0 to 15, higher score indicating more depressive symptoms) decreased by 1.01 more (CI, -2.07 to 0.06). These effects did not persist to the 3-month follow-up, and CBT alone and the 2 together had no significant effects. There were no effects on food security. LIMITATIONS: The study cannot say whether more sustained or in-person therapy would have been effective, how results would translate outside of the COVID-19 period, or whether results in the consented sample differ from those in a larger population. Primary outcomes were self-reported. CONCLUSION: Among older people living alone, a small cash transfer was effective in alleviating short-term (3 weeks) functional impairment, produced a small but not clinically or statistically significant reduction in depression, and had no effect on food security. There were no short-term effects from CBT or the 2 interventions together. None of the interventions showed any effect at 3 months. PRIMARY FUNDING SOURCE: National Institute on Aging (NIA).