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- Title
Effect of Telehealth Treatment by Lay Counselors vs by Clinicians on Depressive Symptoms Among Older Adults Who Are Homebound: A Randomized Clinical Trial.
- Authors
Choi, Namkee G.; Marti, C. Nathan; Wilson, Nancy L.; Chen, Guoqing John; Sirrianni, Leslie; Hegel, Mark T.; Bruce, Martha L.; Kunik, Mark E.
- Abstract
Key Points: Question: Is tele-delivered behavioral activation (tele-BA) treatment by bachelor's-level lay counselors for older adults who are depressed and homebound with low income clinically effective? Findings: In this randomized clinical trial with 277 participants, tele-BA by lay counselors and tele-delivered problem-solving therapy by licensed clinicians were significantly more effective than telephone support calls in improving depressive symptoms, disability, social engagement and activities, and satisfaction with participation in social roles. Tele-BA was significantly less effective than tele-delivered problem-solving therapy in reducing depressive symptoms, but there were no differences in other outcomes. Meaning: These findings suggest that tele-BA by lay counselors for older adults with low income who are homebound was an effective depression treatment. This randomized clinical trial examines the effectiveness of depression treatment tele-delivered by lay counselors compared with by clinicians or an attention control among older adults who are homebound. 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.
- Subjects
BRIEF psychotherapy; MENTAL depression; PROBLEM solving; QUESTIONNAIRES; RESEARCH funding; TELEMEDICINE; VIDEOCONFERENCING; RANDOMIZED controlled trials; TREATMENT effectiveness; MIDDLE age; OLD age
- Publication
JAMA Network Open, 2020, Vol 3, Issue 8, pe2015648
- ISSN
2574-3805
- Publication type
Academic Journal
- DOI
10.1001/jamanetworkopen.2020.15648