Telehealth Problem-Solving Therapy for Depressed Low-Income Homebound Older Adults

Abstract

Previous randomized controlled trials (RCTs) showed the efficacy of in-home, short-term problem-solving therapy (PST) for reducing depressive symptoms among medically ill, homebound older adults.1,2 Despite its efficacy with depressed homebound older adults, in-home, in-person PST or other psychotherapy for them is likely to be cost prohibitive. Most mental health and aging-service agencies lack sufficient professional staff to deliver in-person depression interventions at older adults' homes. Travel expenses for in-person delivery are likely to create an undue burden on these providers. Moreover, one study that tested the effectiveness of providing a home delivered, therapeutic psychosocial intervention for rural older adults found that it was not unusual for interventionists to travel an hour to a participant's home for a scheduled appointment only to discover that no one was there, or that the older adult was not feeling well enough to participate in a treatment session.3 Previous studies of telepsychiatry in general, compared to face-to-face modalities, have reported overall favorable findings about reliability of clinical assessment, equivalent clinical outcomes and client satisfaction, and long-term cost effectiveness.4-8 Despite the rapid growth in telepsychiatry over the past decade, however, our literature search yielded only two studies focusing on the practice using videoconferencing link and its effectiveness with frail and disabled older adults: one on psychogeriatric assessment in Hong Kong and the other on dementia assessment in Australia.9,10 In these past practices of telepsychiatry, however, clients had to be at a site where videoconferencing equipment was set up for use by many others. Internet-based, guided self-help PST for depression has been tested with younger age persons with depression.11,12 However, we found no studies that evaluated delivery of psychosocial intervention via an interactive videoconferencing link between a therapist's office and homebound older adults' residences. Telephone-administered psychotherapy for depression or other mental disorders has also been found to be effective and to result in lower attrition rates than in-person psychotherapy.13-16 However, videoconferencing therapy has advantages over telephone delivery of psychotherapy, as it enables therapist and client to maintain visual contact and see nonverbal behavior. Videoconferencing also allows therapist and client to show each other worksheets and other therapy aids. For isolated homebound older adults, the visual contact and interactive nature of videoconferencing are likely to be especially beneficial as they allow most of the benefits of in-person sessions. Considering the resource constraints and high costs of in-person PST delivery and the advantages of videoconferencing over telephone delivery, home-based telehealth PST (tele-PST) may have potential to facilitate homebound older adults' access to depression treatment. With the availability of low-cost videoconferencing tools, real-time, interactive tele-PST, which allows therapists and clients most benefits of in-person sessions, holds promise as the most practical, accessible depression treatment for homebound older adults and disabled persons. The purpose of this study was to evaluate the acceptance and preliminary efficacy of in-home tele-PST (via Skype video call) among low-income homebound older-adults who participated in a pilot RCT designed to test its feasibility and preliminary signal of efficacy, compared to in-person PST and telephone support calls. We examined tele-PST acceptance among these older adults and the changes in depressive symptoms over 24 weeks.