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IIR 04-421 – HSR&D Study

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IIR 04-421
Telepsychology-Service Delivery for Depressed Elderly Veterans
Leonard E. Egede MD MS
Ralph H. Johnson VA Medical Center, Charleston, SC
Charleston, SC
Funding Period: August 2006 - July 2012

BACKGROUND/RATIONALE:
Depression affects a significant proportion of elderly veterans and is associated with increased morbidity, increased health utilization, and increased health care costs. A large number of veterans, especially the elderly, low income, and ethnic minority veterans live in rural areas, and may have limited access to mental health services. Telehealth is a viable method to provide optimal care for rural dwelling veterans with mental illness. The VA has made telehealth a priority strategy for bringing quality services to veterans in rural areas. However, telehealth for mental illness is underdeveloped. Therefore, research that addresses the efficacy of this mode of service delivery is acutely needed. Findings from this study will allow for improved mental health service delivery and access to elderly depressed veterans.

OBJECTIVE(S):
The immediate objective is to test the hypothesis that a novel mode of geriatric mental health service delivery, using in-home videoconferencing technology ("Telepsychology"), will be as effective as the traditional mode of service delivery ("Same-Room") for treating older adult veterans suffering from major depressive disorder (MDD). The ultimate objective is to help the VA develop and evaluate strategies for providing mental health care to elderly veterans who live in rural areas, many of whom are minorities.

METHODS:
Research Design: This project is a 4-year prospective, randomized between-groups study comparing the efficacy of an intervention for geriatric depression delivered via two different modes (Telepsychology, Same-Room). Participants in the Telepsychology condition will receive care in their own home via videophone contact with a therapist at the Charleston VA Medical Center; participants in the Same-room condition will receive their care via traditional face-to-face therapy sessions held at the Charleston VA Medical Center. Two-hundred and twenty-four (224) participants will be recruited from primary care and mental health clinics within the Charleston VA Medical Center catchment area. Treatment will be administered over an 8-week period (active treatment phase); and participants will be followed for an additional 12-months (follow-up phase) to ascertain longer-term effects of treatment on three outcome domains: (1) clinical outcomes: symptom severity and social functioning; (2) process outcomes: patient satisfaction and acceptance, treatment credibility, session attendance, treatment adherence, and treatment dropout; and (3) cost-effectiveness.

Population and Sample: Participants will be elderly veterans (N = 224), age 60 and above, with diagnoses of major depressive disorder (MDD). Based on our previous research and local demographics, we expect approximately 40% of our sample will be African-American.

Types of Data: To assess outcome, we will use measures that have been widely validated in the clinical evaluation of older adults with MDD. Measures will be collected at pre-treatment (baseline), post-treatment (8 weeks), 3-month, and 12-month follow-up.

Data Analyses Plan: The primary clinical response variable is proportion (%) of patients who respond to treatment, where treatment response is defined as at least a 50% improvement on the Geriatric Depression Scale (GDS) from baseline to post-treatment. Two approaches to estimation of the primary response variable will be taken. The first approach will estimate proportion of responders (% responders) at the end of the 8-week active treatment course based on the total number randomized to each treatment. This is equivalent to a "worst case" analysis in which all premature exits (for whom response status is missing) will be treated as non-responders. We will also estimate proportion of responders for each treatment based on only those who complete the 8-week treatment course (completer analysis). The second approach will use multivariable logistic regression to estimate adjusted % responders. Finally, we will conduct a range of analyses between African-American and White subjects to look at differential efficacy, patient preferences and satisfaction, and adherence across racial groups.

FINDINGS/RESULTS:
The initial recruitment goal was to recruit 224 eligible veterans. 377 subjects were screened and 247 subjects were randomized (telepsychology - 123; same room - 125), 22 subjects dropped out before receiving any treatment (telepsychology - 9; same room - 13) and 225 subjects completed at least one treatment session (telepsychology - 114; same room - 113). The primary analysis was based on the intent-to-treat (ITT) sample (n=247). In this sample, mean age was 63.9 years, 97.5% were men, 59.6% were white, 39.2% were African American and 1.3% were other, 69% were married, mean years of education was 13.7 years, 20.6% reported income <$15,000, 20.7% were current smokers, 66.8% were dual users, 45.1% were service connected, 69.6% reported a disability, mean years as a VA patient was 16.2 years, and mean Charlson comorbidity index was 4.2. There were no statistically significant differences at baseline between the two groups for key socio-demographic variables. Primary treatment response was defined as at least a 50% improvement from baseline to post-treatment (8 weeks) level on the GDS [percent change from baseline: (baseline-post)/baseline 50%]. Preliminary analyses showed that 8 week treatment response on the GDS was 17.6% (95% CI 11.6-23.6) in the telepsychology arm and 22.4% (95% CI 15.8-29.1) in the Same room arm, with an absolute difference of -4.8 (95% CI -13.8-4.1) and 12 month treatment response on the GDS was 22.0% (95% CI 15.2-28.8) in the telepsychology arm and 20.2% (95% CI 13.7-26.7) in the Same room arm, with an absolute difference of 1.8 (95% CI -7.6-11.2). Treatment response on the SCID at 12 months was 50% (95% CI 41.8-58.2) in the telepsychology arm and 44.2% (95% CI 36.2-52.2) in the Same room arm, with an absolute difference of 5.8 (95% CI -5.7-17.3). Results from these preliminary analyses suggest that treatment response was moderate at 8 weeks and 12 months on the GDS and high on the SCID at 12 months, and was not statistically different between the two treatment arms.

IMPACT:
The telepsychology literature is undeveloped. The preliminary results of this project indicates that effective mental health therapy for major depressive disorder in an elderly population can be delivered just as effectively by in-home video teleconference as by face to face therapy sessions, and that the results are sustained at 12 months of follow up. Cost-effectiveness analysis is ongoing and if cost-effectiveness is demonstrated for telepsychology, then future research and program development will bring specialized mental health services to the homes of elderly rural dwelling veterans, of whom a large proportion are ethnic minority veterans, as well as VA community based outpatient clinics. Further, if Telepsychology effectiveness can be empirically established, then we can proceed with research that examines a range of important system issues, such as the optimal in-home telehealth delivery modality that is preferred by Veterans (e.g. smartphone, tablets, Skype etc) and maximizes outcomes. Thus, this project represents a major advancement in mental health service delivery for elderly and rural and underserved populations.

PUBLICATIONS:

Journal Articles

  1. Egede LE, Gebregziabher M, Walker RJ, Payne EH, Acierno R, Frueh BC. Trajectory of cost overtime after psychotherapy for depression in older Veterans via telemedicine. Journal of affective disorders. 2017 Jan 1; 207:157-162.
  2. Egede LE, Acierno R, Knapp RG, Lejuez C, Hernandez-Tejada M, Payne EH, Frueh BC. Psychotherapy for depression in older veterans via telemedicine: a randomised, open-label, non-inferiority trial. The lancet. Psychiatry. 2015 Aug 1; 2(8):693-701.
  3. Acierno R, Gros DF, Morland L, Greene C, Strachan MK, Egede LE, Tuerk PW, Frueh BC, Myrick H. Delivery of evidence-based psychotherapy via video telehealth. Journal of psychopathology and behavioral assessment. 2013 Dec 1; 35(4):506-521.
  4. Osborn CY, Egede LE. The relationship between depressive symptoms and medication nonadherence in type 2 diabetes: the role of social support. General hospital psychiatry. 2012 May 1; 34(3):249-53.
  5. Richardson LK, Frueh BC, Grubaugh AL, Egede L, Elhai JD. Current Directions in Videoconferencing Tele-Mental Health Research. Clinical psychology : a publication of the Division of Clinical Psychology of the American Psychological Association. 2009 Sep 1; 16(3):323-338.
  6. Egede LE, Frueh CB, Richardson LK, Acierno R, Mauldin PD, Knapp RG, Lejuez C. Rationale and design: telepsychology service delivery for depressed elderly veterans. Trials. 2009 Apr 20; 10:22.
  7. Cluver JS, Schuyler D, Frueh BC, Brescia F, Arana GW. Remote psychotherapy for terminally ill cancer patients. Journal of telemedicine and telecare. 2005 Mar 1; 11(3):157-9.
Conference Presentations

  1. Egede LE. Technology-Assisted Case Management (TACM) in Low Income, Rural Adults with Type 2 Diabetes. Paper presented at: Diabetes Annual Fall Symposium for Primary Health Care Professionals; 2016 Sep 22; Charleston, SC.
  2. Egede LE. Effect of Psychotherapy for Depression via Telemedicine on Glycemic Control in Adults with Type 2 Diabetes: Subgroup Analysis of a Randomized Clinical Trial. Paper presented at: Diabetes Annual Fall Symposium for Primary Health Care Professionals; 2016 Sep 22; Charleston, SC.
  3. Egede LE. Effect of Psychotherapy for Depression via Telemedicine on Glycemic Control in Adults with Type 2 Diabetes: Subgroup Analysis of a Randomized Clinical Trial. Paper presented at: American Diabetes Association Annual Scientific Session; 2016 Jun 10; New Orleans, LA.
  4. Egede LE. Technology-Assisted Case Management (TACM) in Low-Income, Rural Adults with Type 2 Diabetes. Paper presented at: American Diabetes Association Annual Scientific Session; 2016 Jun 10; New Orleans, LA.
  5. Egede LE. Pathways for the Relationship Between Diabetes Distress, Depression, Fatalism and Glycemic Control in Adults with Type 2 Diabetes. Poster session presented at: Medical University of South Carolina Perry V. Halushka Student Research Day Annual Symposium; 2015 Nov 12; Charleston, SC.


DRA: Mental, Cognitive and Behavioral Disorders, Aging, Older Veterans' Health and Care, Health Systems
DRE: Treatment - Observational, Technology Development and Assessment, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Telemedicine, Telemedicine/Telehealth, Rural, Depression, Ethnicity/Race, Frail elderly, Outcomes - Patient
MeSH Terms: none