Telepsychology-Service Delivery for Depressed Elderly Veterans

Evidence-level

Evidence-Based (About evidence-level criteria)

Description

Many rural veterans struggle to receive treatment for depression due to distance from the nearest VA health facility, difficulty with transportation, or mobility issues. Some veterans avoid mental health treatment because of the stigma associated with such care.

Researchers and clinicians at the Ralph H. Johnson VA Medical Center in Charleston, South Carolina, developed a home-based telepsychology program that tested delivery of behavioral activation therapy to elderly veterans with major depressive disorder. The VA Health Services Research and Development Office funded the four-year study.

Services offered

Patients received a type of therapy called behavioral activation, in which therapists work with patients to identify value-based activities, obstacles to performing these activities, and strategies to overcome these obstacles. Patients then proactively schedule these specific values-based behaviors and keep track of their successful completion using daily planners, valued activity lists, and lists of strategies to help overcome obstacles.

Sessions were 60 minutes long and occurred weekly for 8 weeks. This evidence-based psychotherapy technique was delivered to half of the participants via home-based telehealth and half via face-to-face visits at the VA hospital in Charleston.

Telehealth patients used in-home videoconferencing technology to receive care, typically on a tablet but also on their home computer if they preferred.

Results

A study was conducted in South Carolina from April 2007 to July 2011, with 241 veterans aged 58 years old or older. Of these 241 veterans:

• 71% are rural residents
• 40% are African American
• 21% have an income less than $15,000
• 70% have a disability
• 67% are dual users of Medicaid and Medicare

One group received telehealth treatment via tablet or analogue videophone (to account for any veterans without broadband internet access), while the other group received face-to-face treatment. Researchers found that:

• There was no significant difference in the two groups' response to treatment.
• 90% of the telehealth patients saw at least a 50% reduction in symptom severity.
• There were no significant differences in quality of life, patient satisfaction, or treatment credibility.
• Cost trajectories over time for inpatient, outpatient, and pharmacy were not different between the two groups.

Researchers concluded that evidence-based behavioral activation via telehealth is an effective way for elderly veterans to overcome barriers to care and receive psychotherapy in their homes. The use of telehealth did not adversely influence patients' quality of life, satisfaction with care, or cost of care over time, suggesting that home-based telehealth is an effective way to address the mental health needs of rural patients.

For more information on program results:

Egede, L.E., Gebregziabher, M., Walker, R.J., Payne, E.H., Acierno, R., & Frueh, B.C. (2017). Trajectory of Cost Overtime after Psychotherapy for Depression in Older Veterans via Telemedicine. Journal of Affective Disorders, 207, 157-162. Article Abstract

Egede, L.E., Acierno, R., Knapp, R.G., Walker, R.J., Payne, E.H., & Frueh, B.C. (2016). Psychotherapy for Depression in Older Veterans via Telemedicine: Effect on Quality of Life, Satisfaction, Treatment Credibility, and Service Delivery Perception. Journal of Clinical Psychiatry, 77(12), 1704-1711. Article Abstract

Egede, L.E., Acierno, R., Knapp, R.G., Lejuez, C., Hernandez-Tejada, M., Payne, E.H., & Frueh, B.C. (2015). Psychotherapy for Depression in Older Veterans via Telemedicine: a Randomised, Open-Label, Non-Inferiority Trial. The Lancet Psychiatry, 2(8), 693-701. Article Abstract

Replication

The therapists in the study were masters-level with at least 5 years of clinical experience. They attended a two-day workshop before treating patients using behavioral activation and were overseen by a clinical psychologist.

Patients with the following active or present conditions were excluded from the study and are recommended to seek face-to-face treatment to allow comprehensive treatment of additional symptoms:

• Dementia
• Psychosis
• Suicidal ideation and clear intent
• Substance dependence

To assess patients' depression, researchers used the Beck Depression Inventory (BDI) and Geriatric Depression Scale (GDS), in addition to the Structured Clinical Interview for DSM-IV.

The researchers have completed another study investigating PTSD and found similar results suggesting telehealth is an effective way to provide mental health treatment. The researchers hope to see additional studies on the effectiveness of telepsychology, especially using other forms of technology such as cell phones.