Telehealth Depression Treatments for Older Adults

The long-term objective of the proposed study is to improve access to depression treatments
for low-income, racially diverse homebound seniors, a population experiencing significant
disparities in mental health care due to their homebound and low-income status. Specific aims
are to compare the acceptability, clinical effectiveness, treatment cost, and budget impact
of the two teledelivered treatment delivery models: problem-solving therapy (PST) by licensed
clinicians and self-care management (SCM) support by trained lay mental health
workers/advisors. The interventionists will be integrated into an aging-service agency;
hence, integrated tele-PST (IT-PST) ad integrated tele-SCM (IT-SCM). Although
tele-psychotherapy is likely to be an effective mental health service delivery model for the
target population, the current and projected shortage of such clinicians and the costs of
deploying highly trained professionals pose barriers to this model's widespread real-world
adoption and sustainability. A more plausible option may indeed have to utilize trained lay
mental health workers. The study participants will be 276 low-income, racially diverse
homebound seniors who are served by a home-delivered meal (HDM) program and other
aging-service agencies in Austin, Tex. In a 3-arm, pragmatic clinical trial with
randomization prior to consent (a preferred public health approach), the participants will
receive five sessions of IT-PST, five sessions of IT-SCM, or five telephone check-in calls
(for the usual care-UC-group). Our first hypothesis is that IT-PST and IT-SCM will be equally
acceptable to the participants. Our second hypothesis is that both IT-PST and IT-SCM will be
more effective than UC in reducing depressive symptoms, although IT-PST may be more effective
than IT-SCM. Symptoms will be assessed with the 24-item Hamilton Depression Rating Scale
(HAMD) at 12, 24, and 36 weeks after baseline. Additional outcomes will be depression-free
days (DFDs) and disability (WHODAS 2.0). Our third hypothesis is that IT-SCM will have a
lower delivery cost than IT-PST, but both IT-PST and IT-SCM will be more cost-effective than
usual care. The analyses include (a) comparisons of delivery costs between IT-PST and IT-SCM;
(b) assessment of cost-effectiveness (CEA) based on DFDs and health-related quality adjusted
life-year measured by EuroQol-5 (EQ-5D); and (3) budget impact (BIA) of IT-PST relative to
IT-SCM. Both CEA and BIA will employ a hybrid public program perspective of the AoA and the
Centers for Medicare and Medicaid. Public health significance of this study is that the data
will help aging-service providers and funders assess respective strengths and weaknesses of
each model as a sustainable approach to providing depression care for an underserved and
growing population group and improving their access to evidence-based mental health services.
(The terms older adults and seniors are used interchangeably because the latter term is
frequently used in aging services.)

Inclusion Criteria:

- (1) HAMD >14; (2) age > 49; (3) English or Spanish Speaking; and (4) Non-Hispanic
White, Black, or Hispanic

Exclusion Criteria:

- (1) antidepressant intake < 9 weeks; (2) high suicide risk; (3) probable dementia;( 4)
bipolar disorder; and (5) substance use