4/24/2018 Presentation Order Improving Access to Depression - PDF document

4/24/2018 Presentation Order Improving Access to Depression • Late-life depression: Symptoms, DSM-5 criteria for major depressive disorder Treatment for Low-income Homebound • Etiology, stigma and misinformation, and Seniors Through Tele-delivered effects of untreated depression Counseling • Evidence-based psychotherapy and access barriers • Research Projects 1, 2, and 3 Principal Investigator: Namkee Choi, PhD • Challenges among low-income homebound Professor & Louis and Ann Wolens Centennial Chair in Gerontology older adults Community Partner: Meals on Wheels Central Texas • Telehealth / telemental health policies • Future of telemental health SOCIAL WORK LTSS RESEARCH AND POLICY NETWORK PRESENTATION 04/27/2018 Acknowledgment of Funding Sources for Research Projects 1-3 • Almost everyone— sometime in life • National Institute of Mental Health (R34 • Everyone knows someone MH083872) who suffers/suffered from • National Institute on Minority Health and depression. Health Disparities (1R01MD009675) • Even if you have never • AARP Foundation (national) been depressed, you can • St. David’s Foundation help someone if you have • Mitte Foundation a better understanding of depression. • Brain chemicals Body and Mind Connection • Health problems (physical, mental, and cognitive) • Genetics • Money worries • Loss and grief • Relationship issues / lack of support • Lack of activities / engagement, isolation, loneliness • Maladaptive coping strategies National Nursing Home Social Work Network - Webinar Series 1

4/24/2018 National Nursing Home Social Work Network - Webinar Series 2

4/24/2018 • Antidepressant medications are • Improved health (from needed for severe depression. improved self-care and more active daily • Medications alone have limited living) effect on late-life depression: • Improved cognitive It does NOT impart coping skills. health • May need to take them for life • More energy • Some people experience side effects (e.g., • Better at relationships dry mouth, headache, too much sleep…) • Improved quality of life especially with polypharmacy No digging up past issues (not • Higher rates of major depressive disorder (MDD): effective) 8.5% -13.5% among 65+ age group (Bruce et al ., Focus on “here and now” 2002; Ell et al ., 2005) Rational (vs. emotional) problem- solving / stress coping skills training • Higher rates of clinically significant depressive • Recognize and avoid depressive behaviors symptoms among 65+ group: 10% - 25% (Ell et al. , • Behavior activation (BA): Participation in meaningful 2005; Li & Conwell, 2007; Sirey et al ., 2008) activities • More structure in daily life by planning and engaging in activities that are meaningful in your chosen life areas • Significantly higher rates of MDD (16%) and • Engage in at least one pleasant activity everyday! depressive symptoms (33%) among homebound • Practice, practice, and practice your coping skills! adults age 50-60 than among 61+ (Choi et al ., 2010) 16 Research Project 1 (completed): • Lack of transportation to clinic-based therapy Telehealth Problem-Solving Therapy for • Lack of affordable, evidence-based, in-home Low-Income Homebound Older Adults psychotherapy programs National Institute of Mental Health (R34 MH083872; 2009-2013) • Lack of insurance/co-pay St. David’s Foundation & Mitte Foundation • Other competing life demands/stressors Principal Investigator • Stigma Namkee G. Choi, PhD With • Lack of depression-related knowledge – denial Meals on Wheels Central Texas of depression • Shortage of geriatric mental health work force First comparative efficacy trial of tele-PST versus in-person PST for in-person, in-home sessions 17 National Nursing Home Social Work Network - Webinar Series 3

4/24/2018 Treatment: Problem-Solving Therapy (PST) Telehealth problem-solving therapy: Effect on Depression PST : 7-step problem-solving coping skills training (more effective for late-life depression than cognitive behavioral therapy or CBT) Over 6-8 weeks, six sessions • via Skype (Tele-PST), or • in-home, in-person (In-person PST) Compared to 6 telephone support (care) calls Research Design: 3-arm randomized clinical trial (RCT) Effect sizes (dGMA-raw): Compared to Telehealth problem-solving therapy: Effect on Disability telephone care calls Effects on Death/Suicidal Ideation Hopelessness Scores and Mediation Effects Figure 4. Hopelessness Scores by Treatment Group Figure 3. Ideation Ratings by Treatment Group 1.8 1.4 1.6 1.2 1.4 1 1.2 0.8 1 Baseline Baseline 0.8 36 weeks 0.6 36 weeks 0.6 0.4 0.4 0.2 0.2 0 0 In-person PST Tele-PST Support calls In ‐ person PST Tele ‐ PST Support calls Effect sizes (compared to support call) at 36 weeks: All three mediation requirements were met for tele- 0.17 for in-person PST and 0.31 for tele-PST PST, but not for in-person PST. 23 24 National Nursing Home Social Work Network - Webinar Series 4

4/24/2018 Reciprocal Effects of Depression & Disability Impact on ED visit (latent growth curve model-LGC-for mediation) • During 6 months prior to treatment participation: 22.3% reported 1 visit, 12.4% reported 2 visits, and 21.4% reported 3–9 visits. • During 6 months post-treatment, 16.5% reported 1 visit, 5.8% reported 2 visits, and 7.5% reported 3–8 visits. • ED visit frequencies at both times were significantly positively associated with depressive symptom scores . Tele-PST Participants’ Feedback • “I preferred in-person therapy and had some discomfort with BUT: Is Tele-PST Sustainable / Scalable??? tele-PST on the first day, but think it was effective and recognize that this works.” • “I enjoyed it. I looked forward to it. I loved the computer part. … I was skeptical at first, but found it worked great.” • “It was great. Didn’t have to go anywhere, and could do it at home in my nightgown. A lot of people that don’t know about this that need help could really use this help.” • “It is much better than going to a clinic where everyone can see you.” • “I didn’t even think about it being any different [from in-person sessions]. • “I got as much out of it because it was like she [therapist] was here in person. Much better than telephone.” 27 28 Population Aging and Unmet Calls to Mental Health Needs • test effectiveness of lay MH workers for older adults and other underserved groups – Imperative to develop alternative geriatric MH • Shortage of licensed workforce: Articles in Lancet, JAMA geriatric MH clinicians Psychiatry, New England J of Medicine… (current and projected) • integrate evidence-based, short-term MH • Service fragmentation treatment into aging-service agencies and • Success of lay MH use technology in service delivery to facilitate access to treatment: Administration on Aging providers in other Issue Briefs , with funding from the Older countries Americans Act: National Nursing Home Social Work Network - Webinar Series 5

4/24/2018 Research Project 2 (ongoing): Specific Aims To improve access to Telehealth Treatments for Depression with Low- depression treatment for low- Income Homebound Seniors income homebound persons aged 50+ through • Collocated MH providers at National Institute on Minority Health and Health Disparities MOWCTX for care ( 1R01MD009675; 2015-2019) coordination St. David’s Foundation • Tele-delivery for cost savings Principal Investigator • Evaluation of acceptability, Namkee G. Choi, PhD clinical & cost effectiveness of Tele-SCM and Tele-PST With compared to support calls Meals on Wheels Central Texas (MOWCTX) (waitlist control condition) Short-term Evidence-based Behavior Activation (BA) and Coping Skills Training • Tele-SCM by trained lay providers: 5-step BA: Manual (Choi et al., 2004) adapted and validated for • https://www.mealsonwheelscentraltexas.or homebound older adults from the original BA g/programs/telehealth-treatment-for- manual (Lejuez, et al, 2011) • Tele-PST by licensed MH clinicians: 7-Step BA: depression PST-PC manual ( Hegel, 2001, 2016) • In-home baseline assessment, 5 tele-treatment sessions, 2 monthly booster calls, & 3 follow-up (F/U) assessments over 6 months • Waitlist control condition: Telephone support calls (to account for interaction effect); after 36-w F/U, offered Tele-SCM or Tele-PST Recruitment Flier Equipment Secure Video platform for tele-sessions (HIPAA compliant) L aptops, LTE 4G wireless cards, and headphones loaned to clients More practical than telephone sessions 35 36 National Nursing Home Social Work Network - Webinar Series 6

4/24/2018 Motivational Talking Points • Accept treatment (give it a try; nothing to lose) • “I can do it by myself.”—Working with a professional is always a better option • It is just one hour a week for five weeks: You can do it and deserve a healthier, more peaceful, and happier life. • Understand how behavior activation can change brain (focus on “Here and Now”) National Nursing Home Social Work Network - Webinar Series 7

4/24/2018 47 48 National Nursing Home Social Work Network - Webinar Series 8

4/24/2018 Progress to date Participant Characteristics Enrollment: 200 (Enrollment goal: 300 by 6/30/2019) Few intervention dropout • High acceptance rating Positive outcomes Many grateful participants 50 Preliminary Outcomes: HAMD Score Changes Baseline to 36-week Follow-up 51 52 53 54 National Nursing Home Social Work Network - Webinar Series 9