Case Management and Problem Solving Therapy for Depressed Older Adults

描述（由申请人提供）：这是一个新的和早期研究者的建议，将评估病例管理-问题解决疗法（CM-PST）和自我指导问题解决疗法（SG-PST）对生活在农村社区的抑郁症老年人的有效性。PST是一种治疗晚期抑郁症的行为疗法，在城市环境中对流动和患病的老年人有效；有执行功能障碍的老年人；通过CARE-D项目（PI: Arean; MH075900）与临床病例管理（CM-PST）相结合的低收入残疾老年人。此外，PST和CM-PST已被证明可以改善功能，并可能提高抑郁老年人的自我效能和弹性，从而降低他们的机构化风险。PST和CM-PST均未在农村地区的老年抑郁症患者中进行过研究。在农村社区实施CM-PST可能会受到缺乏精神卫生临床医生和农村精神卫生保健系统分散状态的挑战。克服这些障碍的一种潜在的低成本方法是使用高级同伴咨询师来支持参与者使用自我引导的PST （SG-PST）。主要目的是检查CM-PST在减轻农村社区老年人抑郁症状和改善功能能力方面的临床效果；比较农村社区与城市社区的结果（来自拟议项目和CARE-D项目的数据）；检查CM-PST和SG-PST干预措施在农村社区的相对有效性；通过过程评价，探索CM-PST和SG-PST在农村社区实施的可行性。地理临床目标（农村vs.城市）：评价CM-PST对农村老年抑郁症患者抑郁症状（HDRS）的影响。2. 评价CM-PST对农村老年重度抑郁症患者功能能力（WHODAS）的影响。3. 确定农村环境中的抑郁和功能影响（拟议项目的第五年结果）是否优于城市环境中的影响（CARE-D项目）。3 .转化临床目标（CM-PST vs. SG-PST）：在农村居住的老年人中，确定SG-PST干预的抑郁和功能结局是否不低于CM-PST干预的结局。翻译实施目标（CM-PST vs. SG-PST）：评估在农村环境中实施CM-PST和SG-PST的可接受性（拒绝率、辍学率、满意度）、障碍（从参与者退出调查和实施过程访谈中收集）、对干预模型（CM-PSTAS、CMAS）的保真度和成本（每位参与者的直接服务预算）。

DESCRIPTION (provided by applicant): This is a proposal from a new and early stage investigator that will evaluate the effectiveness of Case Management-Problem Solving Therapy (CM-PST) and Self-Guided Problem Solving Therapy (SG-PST) for depressed older adults living in a rural community. PST is a behavioral treatment for late life depression proven effective in urban settings with ambulatory and medically ill older adults; older adults with executive dysfunctions; and low-income older adults with a disability when combined with clinical case management (CM-PST) through the CARE-D project (PI: Arean; MH075900). Furthermore, PST and CM-PST have been shown to improve functioning, and may improve self-efficacy and resiliency in depressed older adults, thereby decreasing their risk of institutionalization. Neither PST nor CM-PST has been studied in depressed older adults living in rural settings. Implementing CM-PST in a rural community will likely be challenged by a lack of mental health clinicians, and the fragmented state of rural mental health care systems. A potentially low-cost way to overcome these barriers is to use Senior Peer Counselors to support participant's use of self- guided PST (SG-PST). The main objectives are to examine the clinical effectiveness of CM-PST in reducing depressive symptoms and improving functional ability of older adults in a rural community; compare outcomes in a rural community to those in an urban community (data from the proposed and CARE-D projects); examine the relative effectiveness of CM-PST and SG-PST interventions in a rural community; and explore the feasibility of implementing CM-PST and SG-PST in a rural community through a process evaluation. Geographic Clinical Aims (rural vs. urban): 1. Evaluate effect of CM-PST on depressive symptoms (HDRS) in rural older adults suffering from major depression. 2. Evaluate effect of CM-PST on functional ability (WHODAS) in rural older adults suffering from major depression. 3. Determine if depression and functional effects in rural settings (year 5 outcomes from proposed project) are non-inferior to effects in urban settings (CARE-D project). Translational Clinical Aims (CM-PST vs. SG-PST): 4. Among rural-dwelling older adults, determine if depression and functional outcomes of the SG-PST intervention are non-inferior to outcomes of the CM-PST intervention. Translational Implementation Aims (CM-PST vs. SG-PST): 5. Evaluate acceptability (refusal rate, dropout rate, satisfaction), barriers (collected from participant exit surveys and implementation process interviews), fidelity to the intervention models (CM-PSTAS, CMAS), and cost (direct services budget per participant) of implementing CM-PST and SG-PST in a rural setting.