Telehealth Problem-Solving Therapy for Depressed Homebound Older Adults

描述（由申请人提供）：这是一个R34探索/发展补助金申请的重新提交。拟议的试点研究的目的是评估的可行性和初步疗效的远程医疗解决问题的治疗（远程PST）的居家老年人患有临床显着的中度至重度抑郁症状。设备包括宽带电缆或DSL调制解调器和无线视频会议设备，该设备安全地连接到老年人的家庭电视机和治疗师的工作站，当治疗师呼叫老年人客户时，会议开始。实时，交互式视频会议可能会让治疗师和客户获得面对面会议的大部分好处。为了实现研究目标，我们选择了两个阶段的研究设计。在第一阶段，我们将实施一项不受控制的可行性研究，每周6次远程PST，其中10名受试者是从德克萨斯州中部的“车轮上的饭菜”计划和家庭支持服务计划中招募的，并评估受试者对干预的接受程度以及实施过程中可能出现的程序和后勤问题。在为期2周的一次性随访中，还将评估受试者的抑郁、残疾和足智多谋。在II期，我们将实施一项小规模的三组RCT，每组30例受试者。第一组将接受每周最多六次的远程PST会议。第二组将接受每周最多六次面对面的PST会议。在PST会议之后，这两个小组还将收到他们的治疗师每月六次的维护电话。第一阶段的调查结果将指导第二阶段使用的远程PST和面对面PST程序的任何修改和调整。面对面PST作为基准或金标准的比较，用于检测信号，表明远程PST的有效性。第三组是注意力控制组，每周接受六次电话，每月接受六次电话。所有这三个组别的人士将继续获得由机构个案经理提供的送饭上门或家居支援服务及个案管理的惯常服务。将使用两名医学社会工作者级别的治疗师，每人将进行远程PST和面对面PST课程。这一阶段的具体目标是：（1）评估招募、登记和保留战略的适当性，特别关注种族/民族少数群体，以及研究工具的适当性;（2）比较远程PST和面对面PST的依从率和服务提供成本;以及（3）估计初步效应量并检测关于抑郁、残疾、其它健康状况在6次每周一次的PST课程结束后的2周、12周和24周，将远程PST与亲自PST和注意力控制条件的结果进行比较。研究结果预计将提供必要的数据，设计一个未来的随机对照试验，以测试的可复制性，治疗效果和成本效益的远程PST与更大的样本残疾人在家。这项研究的公共卫生意义在于，远程保健PST（远程PST）可能有潜力显着减少访问障碍，不仅在居家老年人，但在其他残疾人。鉴于目前和预计的精神卫生工作人员短缺，远程PST有望成为居家老年人和其他残疾人最实用和最容易获得的抑郁症治疗方法。

DESCRIPTION (provided by applicant): This is a resubmission of an R34 exploratory/developmental grant application. The proposed pilot study is designed to evaluate the feasibility and preliminary efficacy of telehealth problem-solving therapy (tele-PST) for homebound older adults suffering from clinically significant moderate-to-severe depressive symptoms. Equipment includes a broadband cable or DSL modem and a wireless videoconferencing device that is securely connected to an older adult's home television set and to the therapist's workstation, with the conferencing beginning when the therapist calls the older-adult client. The real-time, interactive videoconferencing is likely to allow the therapist and the client most of the benefits of in-person sessions. In order to pursue the study aims, we have chosen a two-phase research design. In Phase I, we will implement an uncontrolled feasibility study of six weekly sessions of tele-PST with 10 subjects recruited from a Meals on Wheels program and an in-home support services program in central Texas and evaluate the subjects' acceptance of the intervention and procedural and logistical issues that may arise during its implementation. At a 2-week, one-time follow-up, the subjects' depression, disability, and resourcefulness will also be assessed. In Phase II, we will implement a small-scale, three-group RCT with 30 subjects in each group. The first group will receive up to six weekly tele-PST sessions. The second group will receive up to six weekly in- person PST sessions. Both groups will also receive six monthly maintenance calls from their therapists following the PST sessions. The Phase I findings will guide any modifications and adaptations in tele-PST and in-person PST procedures to be used in Phase II. In-person PST serves as the benchmark or gold standard of comparison for detecting signals that are suggestive of efficaciousness of tele-PST. The third group, an attention control group, will receive six weekly telephone calls and six monthly calls. All three groups will continue to receive their usual services of home-delivered meals or in-home support services and case management from their agency case managers. Two MSW-level therapists will be used, each of whom will conduct both tele-PST and in-person PST sessions. Specific aims in this phase are to (1) assess adequacy of recruitment, enrollment, and retention strategies with special attention to racial/ethnic minorities, and of research instruments; (2) compare compliance rates and service delivery cost between tele-PST and in- person PST; and (3) estimate preliminary effect size and detect clinically significant signals with regard to depression, disability, other health status, and resourcefulness outcomes of tele-PST compared to those of in- person PST and attention control condition at 2 weeks, 12 weeks, and 24 weeks following the conclusion of the 6 weekly PST sessions. The findings are expected to provide data necessary for designing a future RCT to test the replicability, therapeutic efficacy, and cost effectiveness of tele-PST with a larger sample of disabled homebound persons. The public health significance of this study lies in the fact that telehealth PST (tele-PST) may have potential to significantly reduce access barriers not only among homebound older adults but among other disabled persons. Given the current and projected shortage in the mental health workforce, tele-PST holds promise as the most practical and accessible depression treatment for homebound older adults and other disabled persons.