Namkee Choi noticed a recurring problem while working as a Meals on Wheels volunteer in three states over 15 years.
A number of the older adults to whom she delivered meals suffered from depression and were unable to get help for their illness. They couldn't afford treatment or didn't have transportation to get to a clinic regularly.
Choi, a professor in the Center for Social Work Research in the School of Social Work at The University of Texas at Austin, was not only in a position to recognize depression in the clients. She could do something about it.
Her idea: Use the Internet to connect homebound clients and psychotherapists.
Nationally, depression affects more than 6.5 million of the 35 million people aged 65 years or older, according to the National Alliance on Mental Illness. Rates are higher among those who are homebound or ill.
Those affected desperately want treatment, Choi said.
"When you are in that situation a terrible, terrible depressed mood you want help. You really look for help," she said. "They are very honest in admitting their depression.
"When they're depressed, they don't have energy," Choi said. "Their house is cluttered, and they can't take care of their business (paying bills and the like)." Other problems clients reported included physical limitations, other mental health problems, family conflict and social isolation.
Choi, whose research has focused on aging issues, won a $450,000 grant from the National Institutes of Health and received supplemental grants from the Roy F. and Joann Cole Mitte Foundation and the St. David's Foundation, both based in Austin, and set up a pilot study to test her idea.
Choi worked with Meals on Wheels and More in Austin to recruit participants for the study. Choi has been a Meals on Wheels and More volunteer and is currently an advisory board member.
During periodic in-home visits and assessments with Meals on Wheels and More clients, case managers identified prospective participants by administering a widely used depression screening scale, said Linda Perez, the agency's assistant vice president of client services.
For clients whose score indicated at least a moderate level of depression, the case managers provided a description of Choi's project and asked them if they would be willing to participate. Those who consented were put in touch with Choi.
In the pilot study that began in late 2009, Choi has provided Dell laptop computers to 54 homebound older adults. The computers were loaded with Skype, a free videoconferencing program, and equipped with a cellular network card to provide an Internet connection.
Mary Lynn Marinucci and Leslie Sirrianni, who graduated from the School of Social Work with master's degrees, provided the clients with an evidence-based, short-term and structured therapy called Problem Solving Treatment (PST).
PST has been found effective in dealing with depression for all age groups. The therapy was provided in six weekly sessions followed by six monthly telephone booster sessions.
A few minutes before a Skype therapy session, the social worker gave the client a reminder call. All the client had to do was press the computer's "on" button to bring up Skype.
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Then for the next hour the client and the therapist engaged in a tele-PST session.
In the project, another group of 43 homebound older adults received one-on-one, in-person PST from the same social workers-therapists in their homes. A third group of 34 homebound older adults received six weekly telephone support calls from two social workers who were not trained in PST. The in-person PST group and telephone support group served as controls to the tele-PST group.
Following six weeks of PST or telephone support, follow-up interviews were done with each participant at two, 12 and 24 weeks.
The depression outcomes for the tele-PST group and the in-person PST group were not significantly different from each other, but the participants in both groups scored significantly lower on depressive symptoms than those who received telephone support calls, Choi said.
The sample size for the study was not big enough to draw definitive conclusions, Choi said, "but we really can see tele-PST's potential as an effective depression treatment approach among depressed homebound older adults."
Choi also said that the participants accepted the technology. Some were enthusiastic about it. Even technical glitches didn't seem to bother them, Choi said. When a computer screen would freeze or a connection would drop during tele-PST sessions, the clients took it in stride. However, some participants were annoyed when an advertisement popped up on the screen.
Perez said Meals on Wheels and More clients who participated in the therapy love it. "They really see improvement, and we see it really has helped them."
She said some clients have been able to discontinue Meals on Wheels and More services after the therapy.
"That's a good thing," Perez said. "They were receiving meals because they were unable to prepare their own meals and get out and do things for themselves due to depression and/or disability."
After the therapy, she said, some of the clients went out to senior centers and other places they had shied away from.
Perez said that Meals on Wheels and More staffers were surprised that the clients responded so well to using technology.
"Let's say they didn't have a good day and they just didn't want to have somebody come into their home because they didn't get to clean up," she said. "This is a way to still be able to work through their issues because they're able to engage in a therapy session via videoconferencing."
Choi is pursuing a bigger test of the concept with a research project that would run in Austin and New York City. She is applying for a grant from the National Institutes of Health.
Choi continues to investigate technology for the project. Game devices, iPads and other tablets, and smartphones could be used. Devices that connect to a television would provide a bigger image.
Who knows? When it comes to treating depression, Choi might have an app for that.