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Telepsychology-Service Delivery for Depressed Elderly Veterans

Summary 
  • Need: To provide evidence-based psychotherapy for depression in elderly veterans who are unable to seek mental health treatment due to distance or stigma.
  • Intervention: Telepsychology-Service Delivery for Depressed Elderly Veterans compared providing behavioral activation therapy via home-based telehealth and the same treatment delivered in a traditional office-based format.
  • Results: A 2015 study and two 2016 studies show that providing treatment via home-based telehealth to elderly veterans in South Carolina resulted in the same improved health outcomes, quality of life, satisfaction with care, and cost of healthcare compared to those receiving face-to-face treatment.

Evidence-level

Evidence-Based (About evidence-level criteria)

Description

According to a 2016 U.S. Department of Veterans Affairs (VA) document, veterans are 2 to 5 times more likely to experience depressive symptoms than their civilian counterparts. 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.

Work continues to expand the use of home-based telehealth for treatment of major depressive disorder and post-traumatic stress disorder (PTSD) in the VA, including discussions to expand to rural areas throughout South Carolina, Georgia, and Alabama, as well as projects to test expansion to Latino/a veterans in the VA Caribbean Healthcare System. In addition, researchers are working with Connected Health (formerly the National Center for Telehealth & Technology) to provide similar services to those currently serving in the military.

Services offered

Patients receive 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 are 60 minutes long and occur 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 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.

Contact Information

Ron Acierno, PhD, Senior Clinical Research Scientist
Ralph H. Johnson Veterans Affairs Medical Center
843.792.2949
ronald.acierno@uth.tmc.edu

Topics
Depression
Elderly population
Telehealth
Veterans

States served
South Carolina

Date added
December 19, 2016

Date updated or reviewed
December 5, 2019


Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.