ArticlesPsychotherapy for depression in older veterans via telemedicine: a randomised, open-label, non-inferiority trial
Introduction
Depression is a serious and debilitating psychological disorder, with a lifetime prevalence of about 10% in the USA for all age groups.1 Prevalence is slightly lower for older adults (defined as ages 60 years and older)2 in the USA (ages 45–64 years 10%; ages 65 years and older 7%); nonetheless, about 6·5 million people older than 65 years have the disorder in the USA.3, 4 Furthermore, 20% of older US adults have substantial symptoms of depression that do not meet DSM diagnostic criteria, but might still warrant treatment5, 6 because untreated minor depression is a risk factor for development of the full clinical disorder.7
Depression is particularly problematic for veterans, with substantial depressive symptoms 2–5 times more likely than in their civilian counterparts.8 Depression in old versus young adults seems to be represented by a somewhat different clinical presentation, characterised by increased physical complaints, fatigue, and apathy, and decreased attention and concentration, but fewer reported symptoms of sadness in older adults.9 Causes of these age-based differences might include neurological changes associated with ageing, effects of acute disease states, effects of chronic disease states such as atherosclerosis10, 11, 12, 13, 14 or cardiovascular complications,15, 16 and individual predisposition (ie, late onset of depression).17 Age-specific psychosocial factors include increasingly unstable psychosocial environments associated with old age, resulting from death or incapacitation of those giving social support (ie, friends and family die or become too ill to serve in social support roles), reduced financial freedom, and frequent bereavement.9, 18
Depression is common in suicidal individuals, and suicide rates in older adults are disproportionally high compared with the rest of the population,19 particularly with respect to older veterans.20 Despite its wide prevalence and potentially increasing lethality in old age, depression is generally poorly detected and hence undertreated.21, 22
Effective treatment of depression in older adults includes some specific forms of psychotherapy and pharmacotherapy (most notably the selective serotonin reuptake inhibitors).23 Cognitive behavioural therapies are the most recommended forms of psychotherapy for depression because of their simplicity and cost-effectiveness.24 If collaborative care (interprofessional intervention) models are used, reduced costs are often evident secondary to reduced doctor visits and generally improved functioning.25 However, because most geriatric depression is diagnosed and treated in the primary care setting by non-mental-health specialists, pharmacological treatment is the most widely used, although it is slightly less effective than psychotherapy.26, 27
Barriers to psychotherapy for elderly people include mobility issues, stigma concerns, and geographical isolation (eg, living in rural areas). Telemedicine service delivery strategies, such as videoteleconferencing, offer a medium to address these concerns and increase access to evidence-based care.28, 29, 30 Findings from studies testing use of telemedicine to deliver psychotherapy show that these methods are non-inferior to those obtained by traditional same-room care in treatment of post-traumatic stress disorder,31, 32, 33, 34, 35 and are cost efficient.36 Other disorders, including depression, have received substantially less attention. Thus, we designed this study to assess the efficacy of telemedicine in delivery of psychotherapy for depression to older adult veterans in their homes.
Section snippets
Study design and participants
In this randomised, controlled, open-label, non-inferiority trial, we recruited participants from the Ralph H Johnson Veterans Affairs Medical Center (Charleston, SC, USA) and four associated community outpatient-based clinics (Goose Creek, Beaufort, and Myrtle Beach, SC, and Savannah, GA, USA). Male and female veterans (aged 60 years or older) meeting DSM-IV37 criteria for major depressive disorder were eligible. However, after we started recruitment, veterans from the Vietnam War era already
Results
Between April 1, 2007, and July 31, 2011, 377 (48%) of the 780 patients who were screened consented to participate in the study (figure 1). Of these, we randomly allocated 241 (64%) to either the telemedicine (120 [50%]) or same-room (121 [50%]) treatment groups (intention-to-treat sample). In the telemedicine group, 100 (83%) returned for the final assessment and 104 (86%) of same-room participants returned (per-protocol sample).
All study therapists achieved a more than 90% protocol-specified
Discussion
To our knowledge, this is the first randomised controlled trial of manualised evidence-based psychotherapy for depression in older adults via telemedicine (panel). We have shown that this method is feasible and produces outcomes that are no worse than in-person delivery 12 months after treatment. Participants in both groups tolerated and clinically benefitted from behavioural activation for depression. The magnitude of treatment effect noted in this study is similar to what has been noted in
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