This is a proposal from a new and early stage investigator that will evaluate the effectiveness of Case Management-Problem Solving Therapy (CM-PST) and Self-Guided Problem Solving Therapy (SG-PST) for depressed older adults living in a rural community. PST is a behavioral treatment for late life depression proven effective in urban settings with ambulatory and medically ill older adults; older adults with executive dysfunctions; and low-income older adults with a disability when combined with clinical case management (CM-PST) through the CARE-D project (PI: Arean; MH075900). Furthermore, PST and CM-PST have been shown to improve functioning, and may improve self-efficacy and resiliency in depressed older adults, thereby decreasing their risk of institutionalization. Neither PST nor CM-PST has been studied in depressed older adults living in rural settings. Implementing CM-PST in a rural community will likely be challenged by a lack of mental health clinicians, and the fragmented state of rural mental health care systems. A potentially low-cost way to overcome these barriers is to use Senior Peer Counselors to support participant's use of self- guided PST (SG-PST). The main objectives are to examine the clinical effectiveness of CM-PST in reducing depressive symptoms and improving functional ability of older adults in a rural community; compare outcomes in a rural community to those in an urban community (data from the proposed and CARE-D projects); examine the relative effectiveness of CM-PST and SG-PST interventions in a rural community; and explore the feasibility of implementing CM-PST and SG-PST in a rural community through a process evaluation. Geographic Clinical Aims (rural vs. urban): 1. Evaluate effect of CM-PST on depressive symptoms (HDRS) in rural older adults suffering from major depression. 2. Evaluate effect of CM-PST on functional ability (WHODAS) in rural older adults suffering from major depression. 3. Determine if depression and functional effects in rural settings (year 5 outcomes from proposed project) are non-inferior to effects in urban settings (CARE-D project). Translational Clinical Aims (CM-PST vs. SG-PST): 4. Among rural-dwelling older adults, determine if depression and functional outcomes of the SG-PST intervention are non-inferior to outcomes of the CM-PST intervention. Translational Implementation Aims (CM-PST vs. SG-PST): 5. Evaluate acceptability (refusal rate, dropout rate, satisfaction), barriers (collected from participant exit surveys and implementation process interviews), fidelity to the intervention models (CM-PSTAS, CMAS), and cost (direct services budget per participant) of implementing CM-PST and SG-PST in a rural setting.
Almost one-fifth of older adults live in non-metropolitan areas, and compared to older adults in urban communities, rural older adults have higher rates of isolation and depression; experience greater difficulty accessing transportation services and medical services; and are subject to minimal service infrastructure, and inadequate and unsafe housing. Depression tends to go untreated even after diagnosis, increasing risk of hospitalization, institutionalization, disability, and mortality. Studying the effectiveness of CM-PST (an evidence based intervention for depression in older adults) and SG-PST in treating depression among rural older adults is an important public health endeavor and may decrease unnecessary institutionalization resulting from untreated or undertreated late life depression.
