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、不同种族的返乡老年人获得抑郁症治疗的机会，这些老年人因其居家和低收入状况而在心理健康护理方面存在显著差异。具体目的是比较两种远程交付治疗模式的可接受性、临床有效性、治疗成本和预算影响：由有执照的临床医生进行的问题解决治疗(PST)和由训练有素的非专业精神卫生工作者/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化服务机构；因此，综合远程PST(IT-PST)和综合远程供应链管理(IT-SCM)。虽然远程心理治疗很可能是目标人群的一种有效的心理健康服务提供模式，但目前和预计此类临床医生的短缺以及部署训练有素的专业人员的成本对这一模式在现实世界中的广泛采用和可持续性构成了障碍。一个更合理的选择可能确实必须使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、不同种族的返乡老年人，他们由德克萨斯州奥斯汀的家庭送餐计划(HDM)和其他老龄服务机构提供服务。在一项三臂、务实的临床试验中，参与者将收到五次IT-PST、五次IT-SCM或五个电话登记电话(用于常规护理-UC组)，并在征得同意之前进行随机抽样(首选公共卫生方法)。我们的第一个假设是，IT-PST和IT-SCM将同样被参与者接受。我们的第二个假设是，IT-PST和IT-SCM在减少抑郁症状方面都将比UC更有效，尽管IT-PST可能比IT-SCM更有效。在基线后12、24、36周用24项汉密尔顿抑郁量表(HAMD)评定症状。其他结果将是无抑郁天数(DFDS)和残疾(WHODAS 2.0)。我们的第三个假设是，IT-SCM的交付成本将低于IT-PST，但IT-PST和IT-SCM都将比通常的护理更具成本效益。这些分析包括：(A)IT-PST和IT-SCM交付成本的比较；(B)基于DFDS的成本效益(CEA)评估和EUROQOL-5(EQ-5D)衡量的健康相关质量调整寿命年；以及(3)IT-PST相对于IT-SCM的预算影响(BIA)。CEA和BIA都将采用AOA以及医疗保险和医疗补助中心的混合公共计划视角。这项研究的公共卫生意义在于，这些数据将帮助老龄服务提供者和资助者评估每种模式的各自优势和劣势，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。(我们交替使用老年人和老年人，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.)