A Home-Based Intervention to Reduce Depressive Symptoms and Improve Quality of Life in Older African Americans: A Randomized Trial

Depression is a common, major mental health problem with debilitating consequences for older adults. Although primary care is the principal setting for depression detection and treatment, symptoms are often underrecognized and undertreated in this setting, particularly for older African Americans (1–3). Compared with white persons, older African Americans are at greater risk for not receiving standard depression care (4–6) or participating in psychotherapy or other guideline treatments because of system-level (lack of access or minimal time spent on mental health) and patient-level (stigma or lack of symptom recognition) factors (7). Furthermore, prevalence rates of depressive symptoms among older African Americans, particularly those with chronic illnesses, may be as high as 30%, double the rates previously reported (8–11). Improving access to depression care for this group remains a public health concern. Depression has profound harmful health and psychosocial consequences, including increased risk for dementia (12), prolonged inflammatory responses after infection (13), functional decline (3, 14), poor quality of life, and death (3, 15). Even mild to moderate symptoms, if not successfully treated, are associated with poor health outcomes, erode quality of life, and increase health care utilization and costs (13, 14). Limitations of previous depression trials (psychosocial or medication) include an almost exclusive focus on primary care patients, lack of attention to approaches addressing barriers to accessing depression care, and lack of inclusion of older African Americans (16–27). Community- and home-based nonpharmacologic depression treatment approaches are promising, but few are tailored to or specifically tested in older African Americans (18, 25, 28–30). Building on previous trials (18, 27, 28), we designed the BTB (Beat the Blues) trial to address depressive symptoms in older African Americans. The trial represents a partnership between a university research center and senior center, with each contributing to intervention design, study plan, and execution. Senior centers are overlooked and underused settings providing disease prevention, health education, and social services to more than 1 million older adults daily, many of whom are vulnerable and underserved (20, 31). Yet, few senior centers offer depression care. Involving senior centers in depression care may reduce barriers to mental health services for older adults who may view clinical treatment as stigmatizing. The BTB trial was tailored to older African Americans. Recruitment strategies were spearheaded by the senior center, the program name reflected the language of the targeted group, behavioral activation was included as a treatment approach because activity is a preferred coping strategy of the targeted group, and stress reduction was tailored to participants’ personal preferences (32). We hypothesized that BTB participants would have reduced depressive symptoms (primary end point) and, secondarily, improvements in depression knowledge and efficacy, quality of life, physical function, anxiety, and behavioral activation at 4 months compared with wait-list control participants. We also considered whether control group participants showed similar benefits after receiving BTB and whether the initial BTB group maintained benefits at 8 months. Finally, we examined proportions of participants in remission, with clinically meaningful score reductions and improvement in diagnostic category.