Reasons for refusing referrals and challenges to effectual engagement in tele-treatment for depression among low-income homebound older adults

Abstract

Objectives: To describe reasons for refusal to be referred to or enroll in a depression treatment study and post-enrollment challenges to treatment engagement and technology-related problems among low-income homebound individuals aged 50+ years with depression.

Methods: Data came from a 3-arm randomized clinical trial that evaluated real-world effectiveness of lay counselor-delivered behavioral activation (BA) versus clinician-delivered problem-solving therapy (PST). Interventionists were embedded in a large home-delivered meals program and treatment sessions were videoconferenced; hence Tele-BA and Tele-PST. We described refusal reasons of those who refused initial case manager referrals (n = 279), telephone screening (n = 64), enrollment (n = 47), or post-enrollment baseline assessments (n = 18). We used inductive thematic analysis to explore challenges to effectual treatment engagement and tele-delivery-related problems among Tele-PST or Tele-BA participants (n = 183) from the interventionists’ tele-session process recordings.

Results: More than a third of potentially eligible older adults refused their case managers’ referral, and a quarter of those who accepted referral refused further screening or enrollment. Three quarters of those who refused reported no interest or need or declined to talk about depression. Others refused given their busy schedule with medical appointments and caregiving. Nearly 80% of Tele-BA or Tele-PST participants had some challenges to effectual engagement in treatment sessions due to environmental and health-related conditions and other life stressors including financial distress. Though many tele-sessions had connectivity and other technology-related problems, these did not affect depression outcomes.

Conclusion: Mental health service providers for low-income older adults need to be aware of these challenges when adopting best practice strategies for them.

Keywords:

• Homebound older adults
• depression
• referral
• tele-delivery
• treatment engagement

Acknowledgements

Authors express their gratitude toward community partners, especially Meals on Wheels Central Texas, their case managers and all participants in the study, Channing Spears, and Jessica Lim.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the National Institute on Minority Health and Health Disparities (under grant 1R01MD009675; PI: N. Choi). St. David’s Foundation also provided supplemental grant.