Telehealth Problem-Solving Therapy for Depressed Homebound Older Adults

描述（由申请人提供）：这是一份R34探索性/发展性拨款申请的重新提交。提出的试点研究旨在评估远程医疗问题解决疗法（远程- pst）对患有临床显著的中度至重度抑郁症状的居家老年人的可行性和初步疗效。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，当治疗师打电话给老年人客户时，会议开始。实时、互动的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。为了实现研究目的，我们选择了两阶段的研究设计。在第一阶段，我们将实施一项不受控制的可行性研究，对从德克萨斯州中部的上门送餐计划和家庭支持服务计划中招募的10名受试者进行为期六周的远程pst治疗，并评估受试者对干预的接受程度以及在实施过程中可能出现的程序和后勤问题。在为期两周的一次性随访中，受试者的抑郁、残疾和应变能力也将被评估。在第二阶段，我们将实施一项小规模的三组随机对照试验，每组30名受试者。第一组每周将接受最多六次远程pst会议。第二组每周将接受六次面对面的PST课程。在PST疗程结束后，两组的治疗师每个月都会给他们打六个维护电话。第一阶段的研究结果将指导在第二阶段使用的远程PST和现场PST程序的任何修改和调整。现场PST作为检测暗示远程PST有效性的信号的基准或比较金标准。第三组是注意力控制组，他们将每周接到6次电话，每月接到6次电话。所有三个小组都将继续接受其通常的服务，即家庭送餐或家庭支助服务，并由其机构的病例管理人员进行病例管理。将使用两名msw级别的治疗师，他们每个人都将进行远程PST和面对面的PST会议。这一阶段的具体目标是(1)评估招聘、招生和留校战略的适当性，特别注意种族/少数民族和研究工具；(2)比较远程邮电服务和现场邮电服务的合规率和服务交付成本；(3)在6周PST课程结束后的第2周、第12周和第24周，与现场PST和注意控制条件相比，远程PST在抑郁、残疾、其他健康状况和机智方面的初步效应大小和检测临床显著信号。研究结果有望为设计未来的RCT提供必要的数据，以测试远程pst的可重复性、治疗效果和成本效益，并在更大的残疾居家人员样本中进行测试。本研究的公共卫生意义在于，远程医疗PST（远程-PST）不仅有可能显著减少居家老年人以及其他残疾人的就医障碍。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.