Elsevier

The Lancet Psychiatry

Volume 2, Issue 8, August 2015, Pages 693-701
The Lancet Psychiatry

Articles
Psychotherapy for depression in older veterans via telemedicine: a randomised, open-label, non-inferiority trial

https://doi.org/10.1016/S2215-0366(15)00122-4Get rights and content

Summary

Background

Many older adults with major depression, particularly veterans, do not have access to evidence-based psychotherapy. Telemedicine could increase access to best-practice care for older adults facing barriers of mobility, stigma, and geographical isolation. We aimed to establish non-inferiority of behavioural activation therapy for major depression delivered via telemedicine to same-room care in largely male, older adult veterans.

Methods

In this randomised, controlled, open-label, non-inferiority trial, we recruited veterans (aged ≥58 years) meeting DSM-IV criteria for major depressive disorder from the Ralph H Johnson Veterans Affairs Medical Center and four associated community outpatient-based clinics in the USA. We excluded actively psychotic or demented people, those with both suicidal ideation and clear intent, and those with substance dependence. The study coordinator randomly assigned participants (1:1; block size 2–6; stratified by race; computer-generated randomisation sequence by RGK) to eight sessions of behavioural activation for depression either via telemedicine or in the same room. The primary outcome was treatment response according to the Geriatric Depression Scale (GDS) and Beck Depression Inventory (BDI; defined as a 50% reduction in symptoms from baseline at 12 months), and Structured Clinical Interview for DSM-IV, clinician version (defined as no longer being diagnosed with major depressive disorder at 12 months follow-up), in the per-protocol population (those who completed at least four treatment sessions and for whom all outcome measurements were done). Those assessing outcomes were masked. The non-inferiority margin was 15%. This trial is registered with ClinicalTrials.gov, number NCT00324701.

Findings

Between April 1, 2007, and July 31, 2011, we screened 780 patients, and the study coordinator randomly assigned participants to either telemedicine (120 [50%]) or same-room treatment (121 [50%]). We included 100 (83%) patients in the per-protocol analysis in the telemedicine group and 104 (86%) in the same-room group. Treatment response according to GDS did not differ significantly between the telemedicine (22 [22·45%, 90% CI 15·52–29·38] patients) and same-room (21 [20·39%, 90% CI 13·86–26·92]) groups, with an absolute difference of 2·06% (90% CI −7·46 to 11·58). Response according to BDI also did not differ significantly (telemedicine 19 [24·05%, 90% CI 16·14–31·96] patients; same room 19 [23·17%, 90% CI 15·51–30·83]), with an absolute difference of 0·88% (90% CI −10·13 to 11·89). Response on the Structured Clinical Interview for DSM-IV, clinician version, also did not differ significantly (39 [43·33%, 90% CI 34·74–51·93] patients in the telemedicine group and 46 [48·42%, 90% CI 39·99–56·85] in the same-room group), with a difference of −5·09% (−17·13 to 6·95; p=0·487). Results from the intention-to-treat population were similar. MEM analyses showed that no significant differences existed between treatment trajectories over time for BDI and GDS. The criteria for non-inferiority were met. We did not note any adverse events.

Interpretation

Telemedicine-delivered psychotherapy for older adults with major depression is not inferior to same-room treatment. This finding shows that evidence-based psychotherapy can be delivered, without modification, via home-based telemedicine, and that this method can be used to overcome barriers to care associated with distance from and difficulty with attendance at in-person sessions in older adults.

Funding

US Department of Veterans Affairs.

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

References (53)

  • DC Steffens et al.

    Prevalence of depression and its treatment in an elderly population: the Cache County study

    Arch Gen Psychiatry

    (2000)
  • Depression in older persons

  • D Blazer et al.

    The epidemiology of depression in an elderly community population

    Gerontologist

    (1987)
  • C Bottino et al.

    Treatment of depression in older adults

    Curr Psychiatry Rep

    (2012)
  • CS Hankin et al.

    Mental disorders and mental health treatment among US Department of Veterans Affairs outpatients: the Veterans Health Study

    Am J Psychiatry

    (1999)
  • A Fiske et al.

    Depression in older adults

    Ann Rev Clin Psychol

    (2009)
  • G Meneilly et al.

    Diabetes in elderly adults

    J Gerontol A Biol Sci Med Sci

    (2001)
  • L Egede

    Diabetes, major depression, and functional disability among U.S. Adults

    Diabetes Care

    (2004)
  • L Egede et al.

    Effect of comorbid depression on quality of life in adults with type 2 diabetes

    Expert Rev Pharmacoecon Outcomes Res

    (2013)
  • R Schulz et al.

    Association between depression and mortality in older adults: the Cardiovascular Health Study

    Arch Intern Med

    (2000)
  • K Van der Kooy et al.

    Depression and the risk for cardiovascular diseases: systematic review and meta-analysis

    Int J Geriatr Psychiatry

    (2007)
  • R Bolland et al.

    Course and outcome of depression

  • Suicide. Facts at a glance

  • K Zivin et al.

    Suicide mortality among individuals receiving treatment for depression in the Veterans Affairs health system: associations with patient and treatment setting characteristics

    Am J Public Health

    (2007)
  • DL Gerritsen et al.

    Act in case of depression: the evaluation of a care program to improve the detection and treatment of depression in nursing homes. Study protocol

    BMC Psychiatry

    (2011)
  • J Unutzer et al.

    Older adults with severe, treatment-resistant depression

    JAMA

    (2012)
  • Cited by (137)

    • Telehealth in Geriatrics

      2022, Primary Care - Clinics in Office Practice
    View all citing articles on Scopus
    View full text