Telehealth Treatments for Depression with Low-Income Homebound Seniors

 描述（由申请人提供）：拟议研究的长期目标是改善低收入，种族多样化的居家老年人获得抑郁症治疗的机会，由于他们的居家和低收入状态，他们在心理健康护理方面存在显着差异。具体目标是比较两种远程治疗模式的可接受性、临床有效性、治疗成本和预算影响：由持牌临床医生进行的问题解决疗法（PST）和由训练有素的非专业心理健康工作者/顾问提供的自我护理管理（SCM）支持。干预者将被整合到一个老龄服务机构;因此，集成远程PST（IT-PST）和集成远程SCM（IT-SCM）。虽然远程心理治疗可能是一种有效的心理健康服务提供模式的目标人群，目前和预计短缺的临床医生和部署训练有素的专业人员的成本构成的障碍，这种模式的广泛真实的世界的采用和可持续性。一个更合理的选择可能确实必须利用训练有素的非专业精神卫生工作者。这项研究的参与者将是276名低收入，种族多样化的居家老年人，他们由德克萨斯州奥斯汀的家庭送餐（HDM）计划和其他老龄服务机构提供服务。在知情同意前随机化的3组实用临床试验（首选公共卫生方法）中，受试者将接受5次IT-PST、5次IT-SCM或5次电话登记（常规护理-UC组）。我们的第一个假设是，IT-PST和IT-SCM将同样可以接受的参与者。我们的第二个假设是IT-PST和IT-SCM在减少抑郁症状方面都比UC更有效，尽管IT-PST可能比IT-SCM更有效。将在基线后12、24和36周使用24项汉密尔顿抑郁评定量表（HAMD）评估症状。其他结果将是无抑郁日（DFD）和残疾（WHODAS 2.0）。我们的第三个假设是，IT-SCM将有一个较低的交付成本比IT-PST，但IT-PST和IT-SCM将比通常的护理更具成本效益。分析包括：（a）IT-PST和IT-SCM之间的交付成本比较;（B）基于DFD和由EuroQol-5（EQ- 5D）测量的健康相关质量调整生命年的成本效益评估（CEA）;以及（3）IT-PST相对于IT-SCM的预算影响（BIA）。CEA和BIA都将采用AoA和医疗保险和医疗补助中心的混合公共项目视角。这项研究的公共卫生意义在于，这些数据将帮助老年服务提供者和资助者评估每个模式各自的优势和劣势，作为一种可持续的方法，为服务不足和不断增长的人口群体提供抑郁症护理，并改善他们获得循证心理健康服务的机会。(We老年人和老年人可以互换使用，因为后者经常用于老龄服务。

 DESCRIPTION (provided by applicant): 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. (We use the terms older adults and seniors interchangeably because the latter term is frequently used in aging services.)