Steve Hicks School of Social Work, University of Texas at Austin, Austin.
Baylor College of Medicine, Houston, Texas.
JAMA Netw Open. 2020 Aug 3;3(8):e2015648. doi: 10.1001/jamanetworkopen.2020.15648.
Older adults who are homebound and have low income have limited access to psychosocial treatments because of their homebound state and geriatric mental health workforce shortages.
To evaluate clinical effectiveness of a brief, aging service-integrated, videoconferenced behavioral activation (tele-BA) treatment delivered by lay counselors compared with videoconferenced problem-solving therapy (tele-PST) delivered by licensed clinicians and attention control (AC; telephone support calls).
DESIGN, SETTING, AND PARTICIPANTS: This 3-group randomized clinical trial using a randomization prior to consent approach included individuals aged 50 years or older who were homebound and had 24-item Hamilton Depression Rating Scale (HAMD) scores of 15 or greater between February 15, 2016, and April 15, 2019. Tele-BA and tele-PST participants received 5 weekly treatment sessions. Assessments were performed at baseline and 12, 24, and 36 weeks after baseline. Intention-to-treat statistical analyses were performed from January 1, 2020, to February 15, 2020.
Tele-BA participants were taught 5 steps for reinforcing healthy behaviors to improve mood, physical functioning, and social engagement. Tele-PST participants were taught a 7-step approach for problem solving coping skills.
The primary outcome was the 24-item HAMD scores. Response (ie, ≥50% reduction in HAMD) and remission (ie, HAMD <10) rates and effect sizes for clinically meaningful differences were examined. Secondary outcomes were disability, social engagement and activity frequency, and satisfaction with participation in social roles.
A total of 277 participants were enrolled, including 193 (69.7%) women, 83 (30.0%) who were Black, 81 (29.2%) who were Hispanic, and 255 (92.1%) with income of $35 000 or less. The mean (SD) age was 67.5 (8.9) years. Among these, 90 participants were randomized to tele-BA, 93 participants were randomized to tele-PST, and 94 participants were randomized to the AC. Compared with participants in the AC group, participants in the tele-BA and tele-PST groups had significantly higher response and remission rates and medium to large effect sizes (tele-BA: raw growth modeling analysis d = 0.62 [95% CI, 0.35 to 0.89]; P < .001; tele-PST: raw growth modeling analysis d = 1.00 [95% CI, 0.73 to 1.26]; P < .001) for HAMD scores. While tele-PST was significantly more effective than tele-BA for reducing HAMD scores (t258 = -2.79; P = .006), there was no difference between tele-BA and tele-PST on secondary outcomes.
In this randomized clinical trial, participants who received tele-BA by lay counselors achieved statistically and clinically meaningful changes in depressive symptoms. Given shortages of licensed mental health clinicians, tele- and lay counselor-delivered services may help improve access to evidence-based depression treatment for large numbers of underserved older adults.
ClinicalTrials.gov Identifier: NCT02600754.
由于行动不便和老年心理健康劳动力短缺，经济困难的老年居家者获得心理社会治疗的机会有限。
评估由非专业顾问提供的简短、老龄化服务整合、视频会议行为激活（远程 BA）治疗与由持照临床医生提供的视频会议问题解决治疗（远程 PST）和对照（电话支持电话）在临床效果方面的差异。
设计、地点和参与者：本项采用随机分组前知情同意的 3 组随机临床试验纳入了年龄在 50 岁或以上、汉密尔顿抑郁量表（HAMD）得分为 15 或更高且行动不便的个体，研究时间为 2016 年 2 月 15 日至 2019 年 4 月 15 日。远程 BA 和远程 PST 参与者每周接受 5 次治疗。基线和基线后 12、24 和 36 周进行评估。从 2020 年 1 月 1 日至 2020 年 2 月 15 日进行意向治疗统计分析。
远程 BA 参与者接受了 5 个强化健康行为的步骤，以改善情绪、身体功能和社会参与度。远程 PST 参与者接受了 7 步问题解决应对技能的培训。
主要结果是 24 项 HAMD 评分。评估了反应（即 HAMD 评分降低≥50%）和缓解（即 HAMD<10）率以及有临床意义差异的效应大小。次要结果是残疾、社会参与和活动频率以及对参与社会角色的满意度。
共有 277 名参与者入组，包括 193 名（69.7%）女性、83 名（30.0%）黑人、81 名（29.2%）西班牙裔和 255 名（92.1%）收入在 35000 美元或以下。平均（SD）年龄为 67.5（8.9）岁。其中，90 名参与者被随机分配到远程 BA 组，93 名参与者被随机分配到远程 PST 组，94 名参与者被随机分配到对照（AC）组。与 AC 组的参与者相比，远程 BA 和远程 PST 组的参与者在 HAMD 评分方面的反应和缓解率更高，且效应大小为中到大（远程 BA：原始增长模型分析 d=0.62[95%CI，0.35 至 0.89]；P<0.001；远程 PST：原始增长模型分析 d=1.00[95%CI，0.73 至 1.26]；P<0.001）。虽然远程 PST 在降低 HAMD 评分方面明显优于远程 BA（t258=-2.79；P=0.006），但远程 BA 和远程 PST 在次要结局上没有差异。
在这项随机临床试验中，接受由非专业顾问提供的远程 BA 的参与者在抑郁症状方面取得了具有统计学和临床意义的改善。鉴于持照心理健康临床医生的短缺，远程和非专业顾问提供的服务可能有助于改善大量服务不足的老年患者获得基于证据的抑郁治疗的机会。
ClinicalTrials.gov 标识符：NCT02600754。
