Effect of Telehealth Treatment by Lay Counselors vs by Clinicians on Depressive Symptoms Among Older Adults Who Are Homebound: A Randomized Clinical Trial.

Importance: Older adults who are homebound and have low income have limited access to psychosocial treatments because of their homebound state and geriatric mental health workforce shortages. Objective: To evaluate clinical effectiveness of a brief, aging service-integrated, videoconferenced behavioral activation (tele-BA) treatment delivered by lay counselors compared with videoconferenced problem-solving therapy (tele-PST) delivered by licensed clinicians and attention control (AC; telephone support calls). Design, Setting, and Participants: This 3-group randomized clinical trial using a randomization prior to consent approach included individuals aged 50 years or older who were homebound and had 24-item Hamilton Depression Rating Scale (HAMD) scores of 15 or greater between February 15, 2016, and April 15, 2019. Tele-BA and tele-PST participants received 5 weekly treatment sessions. Assessments were performed at baseline and 12, 24, and 36 weeks after baseline. Intention-to-treat statistical analyses were performed from January 1, 2020, to February 15, 2020. Interventions: Tele-BA participants were taught 5 steps for reinforcing healthy behaviors to improve mood, physical functioning, and social engagement. Tele-PST participants were taught a 7-step approach for problem solving coping skills. Main Outcomes and Measures: The primary outcome was the 24-item HAMD scores. Response (ie, ≥50% reduction in HAMD) and remission (ie, HAMD <10) rates and effect sizes for clinically meaningful differences were examined. Secondary outcomes were disability, social engagement and activity frequency, and satisfaction with participation in social roles. Results: A total of 277 participants were enrolled, including 193 (69.7%) women, 83 (30.0%) who were Black, 81 (29.2%) who were Hispanic, and 255 (92.1%) with income of $35 000 or less. The mean (SD) age was 67.5 (8.9) years. Among these, 90 participants were randomized to tele-BA, 93 participants were randomized to tele-PST, and 94 participants were randomized to the AC. Compared with participants in the AC group, participants in the tele-BA and tele-PST groups had significantly higher response and remission rates and medium to large effect sizes (tele-BA: raw growth modeling analysis d = 0.62 [95% CI, 0.35 to 0.89]; P < .001; tele-PST: raw growth modeling analysis d = 1.00 [95% CI, 0.73 to 1.26]; P < .001) for HAMD scores. While tele-PST was significantly more effective than tele-BA for reducing HAMD scores (t258 = -2.79; P = .006), there was no difference between tele-BA and tele-PST on secondary outcomes. Conclusions and Relevance: In this randomized clinical trial, participants who received tele-BA by lay counselors achieved statistically and clinically meaningful changes in depressive symptoms. Given shortages of licensed mental health clinicians, tele- and lay counselor-delivered services may help improve access to evidence-based depression treatment for large numbers of underserved older adults. Trial Registration: ClinicalTrials.gov Identifier: NCT02600754.

Telehealth problem-solving therapy for depressed low-income homebound older adults.

OBJECTIVE: To evaluate the acceptance and preliminary efficacy of in-home telehealth delivery of problem-solving therapy (tele-PST) among depressed low-income homebound older adults in a pilot randomized control trial designed to test its feasibility and preliminary efficacy. METHODS: A total of 121 homebound individuals who were age 50+ and scored 15+ on the 24-item Hamilton Rating Scale for Depression (HAMD) participated in the three-arm randomized control trial, comparing tele-PST with in-person PST and telephone support calls. Six sessions of the PST-primary care were conducted for the PST participants. For tele-PST, sessions 2-6 were conducted via Skype video call. Acceptance of tele-PST or in-person PST was measured with the 11-item, 7-point scale modified Treatment Evaluation Inventory (TEI). A mixed-effect regression analysis was used to examine the effects of treatment group, time, and the interaction term between treatment group and time on the HAMD scores. RESULTS: The TEI score was slightly higher among tele-PST participants than among in-person PST participants. The HAMD scores of tele-PST participants and in-person PST participants at a 12-week follow-up were significantly lower than those of telephone support call participants, and the treatment effects were maintained at a 24-week follow-up. The HAMD scores of tele-PST participants did not differ from those of in-person PST participants. CONCLUSIONS: Despite their initial skepticism, almost all participants had extremely positive attitudes toward tele-PST at the 12-week followup. Tele-PST also appears to be an efficacious treatment modality for depressed homebound older adults and to have significant potential to facilitate their access to treatment.

Acceptance of home-based telehealth problem-solving therapy for depressed, low-income homebound older adults: qualitative interviews with the participants and aging-service case managers.

PURPOSE: To report low-income homebound older adults' experience of telehealth problem-solving therapy (tele-PST) and aging-service case managers' (CMs') experience/perception of client-level personal barriers to accessing psychotherapy in general and PST specifically. DESIGN AND METHODS: The study sample consisted of 42 homebound older adults who participated in the feasibility and efficacy trial of tele-PST and completed 36-week follow-up assessments and 12 CMs of a large home-delivered meals program who referred their clients to the tele-PST trial. In-depth interviews with the older adults and written feedback and focus group discussions with the CMs provided the data. RESULTS: Older adults reported a high rate of approval of PST procedures and acknowledged its positive treatment effect. Tele-PST participants were satisfied with videoconferenced sessions because they were convenient and allowed them to see their therapist. However, CMs reported that only about 10%-20% of potentially eligible older adults gave oral consent for PST. Significant treatment engagement barriers were the older adults' lack of motivation, denial of depression, perceived stigma, and other personal attitudinal factors. IMPLICATIONS: The real-world implementation of tele-PST or other psychotherapies needs to include educating and motivating depressed homebound elders to recognize their depression and accept treatment.

Passive coping response to depressive symptoms among low-income homebound older adults: does it affect depression severity and treatment outcome?

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.

Self-reported antidepressant use among depressed, low-income homebound older adults: class, type, correlates, and perceived effectiveness.

Little research has been done on the use of antidepressants among homebound older adults, especially low-income homebound older adults, and their perceptions of the effectiveness of their medication. The purposes of this study were to examine self-reported use of antidepressants among depressed homebound older adults, class and type of antidepressants used, individual-level correlates of antidepressant use, and users' perceptions of the effectiveness of antidepressants. Data on self-reported use of antidepressants were obtained as part of a feasibility study of short-term telehealth problem-solving therapy for depressed low-income homebound adults (n = 162) aged 50 or older. The 24-item Hamilton Rating Scale for Depression (HAMD) was used to assess depression severity. The findings show that about half of the study participants were taking antidepressants, with 26.6% of those on antidepressants rating their medications very effective and 21.5% rating them effective. Female gender was positively, but older age and being Black/African American were negatively associated with the likelihood of antidepressant use. Perceived effectiveness of antidepressants was negatively associated with older age and the HAMD score. The findings suggest that personalized approaches to depression management may be needed in subgroups of depressed older adults, including culturally tailored medication counseling in Black/African-American older adults.

Association between participant-identified problems and depression severity in problem-solving therapy for low-income homebound older adults.

OBJECTIVES: The purpose of this study was to examine the relationship between the severity of baseline depressive symptoms and the problems that low-income homebound older adults (n = 66) identified in their problem-solving therapy (PST) sessions. METHODS: Depressive symptoms were measured with the 24-item Hamilton Rating Scale for Depression (HAMD). Participant-identified problems recorded in the therapists' worksheets were coded into seven categories: living arrangement/housing issues, financial/health care expense issues, family or other relationship issues, hygiene/task issues, social isolation issues, physical/functional health issues, and mental/emotional health issues. T-tests and ordinary least squares regression analyses were used to examine differences in HAMD scores between those who identified any problem in each category and those who did not. RESULTS: Participants who had living arrangement/housing and family or other relationship issues had higher baseline HAMD scores than the rest of the participants. At 2-week posttest, those with living arrangement/housing issues continued to have higher HAMD scores than the others, whereas those with family or other relationship issues did not. CONCLUSION: The study findings provide insights into the problems that low-income, depressed homebound individuals bring to their PST sessions. It was not clear if family conflict or other relationship issues contributed to their depression or vice versa, but it appears that PST may have contributed to alleviating depressive symptoms associated with these issues. Precarious living/housing situations appeared to have had a serious depressogenic effect and could not be easily resolved within a short time frame of the PST process, as these issues required formal support.