This study proposes to compare the efficacy of Case Management combined with Problem Solving Therapy (CM-PST) to that of Case Management alone (CM) in low-income elderly recipients of Home-Delivered Meals Services with major depression, disability and problem solving difficulties. We focus on meals recipients because they are often afflicted by depression and because the complexity of their clinical state coupled with their financial limitations creates a formidable challenge for care. Clinical logic and emerging empirical data suggest that integrating CM with PST may have a synergistic effect in depressed low-income elders as CM can help them with their socioeconomic needs and PST can improve their ability to cope with chronic stressors and utilize their new resources. The participants will be 200 (100 from each Center) elderly (>64 years) non-psychotic, non-demented Home-Delivered Meals recipients with unipolar major depression who will be randomly assigned to receive 12 sessions of CM-PST or CM. The study is designed to test the hypotheses that CM-PST is more effective than CM in reducing depressive symptoms and disability;both treatments will be delivered at the clients'homes by trained case workers of the Home-Delivered Meals Services. Furthermore, we hypothesize that these effects are mediated by improvement in generation of alternative solutions, and decision-making. While we are aware of the methodological problems and confounds posed by studying a """"""""sick, disabled, and old population"""""""", we bring to this project two groups with a history of a successful collaboration in a two-center psychotherapy study, complementary expertise in treatment studies and psychotherapy research, and experience in directing multicenter studies. Moreover, the project will be supported by the structures of the Cornell Advanced Center for Interventions and Services Research (ACISR), whose principal objective is to develop treatment interventions targeting depressed elders with specific clinical and biological characteristics. Accordingly, we are well positioned to meet the challenges inherent in this difficult but important area of research. If CM-PST were found efficacious, it may be offered by trained case-workers of social services to large numbers of depressed, homebound, low-income elders.
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