Telehealth Problem-Solving Therapy for Depressed Homebound Older Adults

描述(由申请人提供)：这是一份R34试探性/开发性资助申请的重新提交。这项拟议的试点研究旨在评估远程健康问题解决疗法(Tele-PST)对患有临床上显著的中到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，当治疗师呼叫老年人客户时，会议开始。实时、互动的视频会议很可能会让治疗师和客户享受到面对面会谈的大部分好处。为了追求研究目标，我们选择了两阶段的研究设计。在第一阶段，我们将对每周六次的Tele-PST会议进行不受控的可行性研究，从德克萨斯州中部的Meals on Wheels计划和家庭支持服务计划招募10名受试者，并评估受试者对干预措施的接受程度，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、残疾和足智多谋也将得到评估。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。第一组将接受每周最多六次的太平洋司令部电话会议。第二组每周将接受最多六次面对面的PST会议。在PST会议之后，这两组人还将每月收到六个来自他们的治疗师的维护电话。第一阶段的调查结果将指导第二阶段中使用的远程PST和面对面PST程序的任何修改和调整。面对面PST是检测暗示远程PST有效性的信号的基准或黄金标准。第三组是注意力控制组，每周会接到6个电话，每月会接到6个电话。所有三个小组都将继续从其机构病例经理那里获得其惯常的上门送餐或居家支助服务和病例管理服务。将使用两名MSW级别的治疗师，每人将进行电话PST和面对面PST会议。这一阶段的具体目标是：(1)评估招募、招生和保留战略的充分性，特别关注种族/少数民族，以及研究工具的充分性；(2)比较电话PST和面对面PST之间的遵从率和服务提供成本；以及(3)在每周6次PST会议结束后的2周、12周和24周，与面对面PST相比，估计TELE-PST的初步效应大小，并检测与抑郁、残疾、其他健康状况和足智多谋的结果有关的临床显著信号。这些发现有望为设计未来的随机对照试验提供必要的数据，以测试TELE-PST在更大样本中的可复制性、治疗效果和成本效益。这项研究的公共卫生意义在于，远程保健PST(Tele-PST)可能不仅有可能显著减少居家老年人和其他残疾人的获得障碍。鉴于目前和预计的精神卫生劳动力短缺，Tele-PST有望成为待在家里的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.