Effect of Telehealth Treatment by Lay Counselors vs by Clinicians on Depressive Symptoms Among Older Adults Who Are Homebound
Authors: Namkee G. Choi, C. Nathan Marti, Nancy L. Wilson, Guoqing John Chen, Leslie Sirrianni, Mark T. Hegel, Martha L. Bruce, Mark E. Kunik
Journal: JAMA Network Open (2020)

<h3>Importance</h3> 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. <h3>Objective</h3> 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). <h3>Design, Setting, and Participants</h3> 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. <h3>Interventions</h3> 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. <h3>Main Outcomes and Measures</h3> The primary outcome was the 24-item HAMD scores. Response (ie, ≥50% reduction in HAMD) and remission (ie, HAMD &lt;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. <h3>Results</h3> 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<i>d</i> = 0.62 [95% CI, 0.35 to 0.89];<i>P</i> &lt; .001; tele-PST: raw growth modeling analysis<i>d</i> = 1.00 [95% CI, 0.73 to 1.26];<i>P</i> &lt; .001) for HAMD scores. While tele-PST was significantly more effective than tele-BA for reducing HAMD scores (<i>t</i><sub>258</sub> = −2.79;<i>P</i> = .006), there was no difference between tele-BA and tele-PST on secondary outcomes. <h3>Conclusions and Relevance</h3> 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. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT02600754.