Xiang Xiaoling, Kayser Jay, Turner Skyla, Ash Samson, Himle Joseph A
School of Social Work, University of Michigan, Ann Arbor, MI, United States.
J Med Internet Res. 2024 Mar 4;26:e53001. doi: 10.2196/53001.
Depression is the most prevalent mental health condition in older adults. However, not all evidence-based treatments are easily accessible. Web-delivered cognitive behavioral therapy (wCBT) facilitated by laypersons is a viable treatment alternative.
This randomized controlled trial aims to evaluate the efficacy of a novel wCBT program, Empower@Home, supported by trained lay coaches, against a waitlist attention control. Empower@Home is among the very few existing wCBT programs specifically designed for older adults. The primary objective was to assess the efficacy of the intervention compared with attention control. The secondary objective was to evaluate the program's impact on secondary psychosocial outcomes and explore potential change mechanisms.
Older adults (N=70) were recruited via web-based research registries, social media advertisements, and community agency referrals and randomly assigned to either the intervention or control group in a 1:1 allocation ratio. The intervention group received access to Empower@Home, which included 9 web-delivered self-help lessons and weekly telephone coaching sessions by a trained layperson over 10 weeks. The control group received weekly friendly phone calls and depressive symptom monitoring. The primary clinical outcome was the severity of depressive symptoms assessed using the Patient Health Questionnaire-9. The secondary clinical outcomes included anxiety, anger, social isolation, insomnia, pain intensity, and quality of life. Linear mixed modeling was used to determine the treatment effects on depression, and 2-tailed t tests were used to assess within-group changes and between-group differences.
Most participants in the intervention group completed all 9 sessions (31/35, 89%). The usability and acceptability ratings were excellent. The intervention group had a large within-group change in depressive symptoms (Cohen d=1.22; P<.001), whereas the attention control group experienced a medium change (Cohen d=0.57; P<.001). The between-group effect size was significant, favoring the intervention group over the control group (Cohen d=0.72; P<.001). In the linear mixed model, the group-by-time interaction was statistically significant (b=-0.68, 95% CI -1.00 to -0.35; P<.001). The treatment effects were mediated by improvements in cognitive behavioral therapy skills acquisition; behavioral activation; and satisfaction with the basic psychological needs of autonomy, competence, and relatedness. Furthermore, the intervention group showed significant within-group improvements in secondary psychosocial outcomes, including anxiety (P=.001), anger (P<.001), social isolation (P=.02), insomnia (P=.007), and pain (P=.03). By contrast, the control group did not experience significant changes in these outcome domains. However, the between-group differences in secondary outcomes were not statistically significant, owing to the small sample size.
Empower@Home, a wCBT program supported by lay coaches, was more efficacious in reducing depressive symptoms than friendly telephone calls and depression symptom monitoring. Future studies should examine the effectiveness of the intervention in community and practice settings using nonclinician staff already present in these real-world settings as coaches.
ClinicalTrials.gov NCT05593276; https://clinicaltrials.gov/ct2/show/NCT05593276.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/44210.
抑郁症是老年人中最普遍的心理健康问题。然而，并非所有循证治疗都易于获得。由非专业人员提供的网络认知行为疗法（wCBT）是一种可行的治疗选择。
这项随机对照试验旨在评估一种由训练有素的非专业指导者支持的新型wCBT项目“在家赋权”（Empower@Home）相对于等待名单注意力控制组的疗效。“在家赋权”是极少数专门为老年人设计的现有wCBT项目之一。主要目的是评估干预措施与注意力控制相比的疗效。次要目的是评估该项目对次要心理社会结果的影响，并探索潜在的变化机制。
通过基于网络的研究登记处、社交媒体广告和社区机构推荐招募老年人（N = 70），并以1:1的分配比例随机分配到干预组或对照组。干预组可以使用“在家赋权”项目，该项目包括9节网络自助课程以及由一名训练有素的非专业人员在10周内进行的每周电话指导。对照组接受每周一次的友好电话和抑郁症状监测。主要临床结局是使用患者健康问卷-9评估的抑郁症状严重程度。次要临床结局包括焦虑、愤怒、社交隔离、失眠、疼痛强度和生活质量。采用线性混合模型确定对抑郁症的治疗效果，使用双尾t检验评估组内变化和组间差异。
干预组的大多数参与者完成了所有9节课程（31/35，89%）。可用性和可接受性评分很高。干预组在抑郁症状方面有较大的组内变化（科恩d = 1.22；P <.001），而注意力控制组有中等程度的变化（科恩d = 0.57；P <.001）。组间效应大小显著，干预组优于对照组（科恩d = 0.72；P <.001）。在线性混合模型中，组×时间交互作用具有统计学意义（b = -0.68，95%置信区间 -1.00至 -0.35；P <.001）。治疗效果通过认知行为疗法技能习得、行为激活以及对自主性、能力和关联性等基本心理需求的满意度的改善而介导。此外，干预组在次要心理社会结局方面有显著的组内改善，包括焦虑（P =.001）、愤怒（P <.001）、社交隔离（P =.02）、失眠（P =.007）和疼痛（P =.03）。相比之下，对照组在这些结局领域没有显著变化。然而，由于样本量小，次要结局的组间差异没有统计学意义。
由非专业指导者支持的wCBT项目“在家赋权”在减轻抑郁症状方面比友好电话和抑郁症状监测更有效。未来的研究应该使用这些现实环境中已有的非临床工作人员作为指导者，来检验该干预措施在社区和实践环境中的有效性。
ClinicalTrials.gov NCT05593276；https://clinicaltrials.gov/ct2/show/NCT05593276。
国际注册报告标识符（IRRID）：RR2-10.2196/44210。
