The Q&A: Namkee Choi

With each issue, Trib+Health brings you an interview with experts on issues related to health care. Here is this week's subject:

Namkee Choi is a professor at the University of Texas at Austin's School of Social Work. Choi got a master's degree in social work in Korea and worked at Planned Parenthood of Korea before she moved in 1981 to the United States, where she got a master's degree from the University of Minnesota and a Ph.D. in social welfare from the University of California-Berkeley. Choi researches the effectiveness of online teletherapy on older adults' depression, as opposed to in-home therapy or clinic-based therapy. One of her recent studies showed online teletherapy could be an effective and low-cost method that would help low-income older adults access mental health care.

Editor's note: This interview has been edited for length and clarity.

Trib+Health: Why do you think problem-solving therapy is more effective than antidepressants?

Namkee Choi: Well, antidepressants do not solve people’s stressors or train them how to cope with daily stressors. Low-income homebound older adults have a lot of daily stressors because of their disabilities and low income, so I don’t think antidepressant medications are that effective, and it doesn’t have a long term effect. You stop taking medication, and the effects are just gone.

So we chose problem-solving therapy because it’s short-term, very structured psychotherapy focused on teaching people the coping skills, specifically problem-solving coping skills so that they can use it in the future. And once you learn how to cope and you learn the seven steps of problem solving, you can practice and you can get better and better, and that’s what our outcomes actually show. People who learned how to actually use problem solving skills, six months later, they were actually doing much better than in the beginning.

Trib+Health: Your study looked at low-income adults who are 50 and over, and you point out they face a lot of barriers to access mental health care. Could you describe those barriers?

Choi: There are personal barriers as well as system barriers. First on system barriers, these are homebound older adults, and they are also disabled, and their medical situations are really serious, too. They already have many medical appointments, and they really need to go to a clinic for psychotherapy if they want to use the existing mental health system. That means they have to arrange their transportation, and they have to actually make room to continue with these appointments at the clinic, and sometimes it might conflict with their primary care appointment or specialist appointment.

So transportation is a cost, and time is a cost. And there are few places in town that provide in-home psychotherapy. … However, they all require co-pays. Some of my clients told me $10 a week is too much for them. Also, there’s a lack of psychotherapists for older adults themselves. They’re not abundant in town. A lot of people don’t want to work with older adults, and they don’t have experience in working with older adults. Those are system level barriers.

Personal level barriers are, of course, that the stigma is still rampant, and they really don't want to tell even their family members that they have depression and need to work with psychosocial providers. And they simply do not know, they really do not know that what they’re experiencing is depression. So it’s lack of knowledge and denial of depression. They just believe that what they’re going through is part of their medical problems or part of the aging process itself. We try to provide psychoeducation for these older adults, and that’s actually the first session of any problem-solving treatments that we provide.

Trib+Health: You had studied teletherapy and its impact in the past. How did this study build on that and what did you find?

Choi: The Veterans Administration is the largest provider of teletherapy. And telepsychotherapy, telepsychiatry, tele mental health, whatever name you call it, that's been around a long time. But before my testing, the older adults still had to show up in a clinic setting where they have all the equipment in front of them and they connect with remote providers. And that’s the same as really going to a clinic for psychotherapy face-to-face with a provider. That’s not going to really help older adults who are homebound.

So that’s why I tested in-home, that is, home-based telepsychotherapy. That’s the difference from previous ones. I think that a lot of providers are thinking of expanding home-based psychotherapy, and there actually are a lot private for-profit entities that provide exactly that, but they are so expensive. Some charge $200 or $150 a session. Older adults cannot afford that.

Trib+Health: Your study found that the effects on depression of teletherapy lasted longer that in-person home therapy. Why might that be?

Choi: We think it’s the self-efficacy strengths of this telepsychotherapy. Initially, most older adults said, “I don't want to do that over computer. I wish somebody would come out and talk to me in person.” But once they finished their first teletherapy session, they were hooked. They think this is really wonderful. Older adults thought this was really cool, that they joined the technical age. That’s one reason, self-efficacy. The second one is the convenience of it. A lot of people said, “I love it because I don't have to get up and clean my house, and I can do it in my pajamas. And still, it’s just like a therapist was next to me.”

The third one that our therapists told me is the older adults are more attentive when they are in psychotherapy sessions that are videoconferences because homebound older adults, [when they do] the in-person therapy sessions in their own home, in their own couch, I think they consider these psychotherapists as another person who visits them. So really the professionalism is sort of devalued when you go and sit on older adults’ couch and say, “Let's do psychotherapy.” They really don't think it’s that professional, and that’s empirically supported. We collected data about session lengths, and actually, the teletherapy was 11 minutes shorter than in-person therapy on average. That doesn't include the first ten minutes when the psychotherapist showed up in person. There's greetings, and older adults offer a glass of water and they sit down and they try to engage in psychotherapy. And then when there is a telephone ringing, older adults usually answer, and then they have to go to the bathroom in the in-person sessions. Those things rarely occurred when they were doing teletherapy.

Trib+Health: What are the implications this might have later on for cost and access? Is this a model that providers can use?

Choi: Well, of course. First of all, the rationale behind my new study that’s going to start this September is, first of all, we don’t have — and we will not have — enough geriatric mental health providers. The Institute of Medicine has a really wonderful book and found out that the problem is not going to be solved in the future. So there’s a lack of geriatric mental health workforce. You cannot really imagine sending psychotherapists in person to older adults’ homes. That’s going to cost you a lot. First of all, they don’t have enough psychotherapists to go do the in-person therapy. Second of all, it’s going to cost more time and effort, and there’s costs for transportation. Teletherapy enables fewer therapists providing sessions for more older adults, and the technology costs [of HIPAA compliant video conferencing platforms] will go down.

Trib+Health: Your new study is also trying to compare the difference between licensed clinicians and non-licensed workers. What do you expect to find?

Choi: We found that teletherapy with licensed clinical social workers is wonderful. It works. However, we go back to the same issue. Do we really have enough licensed clinical social workers or licensed mental health providers for these older adults, whose numbers is exploding? How can we meet the mental health needs of the exploding number of homebound older adults? That means that we have to train other people who will be able to provide treatments for depression. So I looked at examples from other countries, and we also were recommended by the Institute of Medicine to really train lay providers. We also looked at the example of community health workers, CHWs. By looking at that, we found out that actually there are very, very few studies or examples in the U.S. that used lay mental health workers. That’s why I wanted to examine the clinical effectiveness, as well as cost effectiveness.

These lay providers and these specialist-level people also are prohibited by state licensing laws from providing psychotherapy. Psychotherapy is really reserved turf for licensed clinicians. So we set to find something that these bachelor’s level people can provide, which is not psychotherapy or it's not considered psychotherapy, but still is effective for treating depression. That, we found out, is self care management (SCM) based on behavioral activation. The behavior activation manual is widely available so I developed it and adapted it to the needs of homebound older adults. And we tested it out in the community, and really, I was blown away by the older adults’ embrace of that.

We actually chose the older adults who were critical of tele problem-solving therapy (PST), and I wanted to get their honest opinions of how this tele SCM program would work. One of the participants in the preliminary validation study said, “This is really wonderful because when I was participating in PST, I was too depressed to solve any problems. But this one at least makes me get up in the morning and do something." So I think we see that tele SCM would be as effective as tele PST, clinically speaking, for depression symptoms. And cost-wise, we really expect it will be saving a lot of money because we do not have to fund and hire licensed clinicians. This can be implemented by specialist level people, with about 40 to 50 hours of training.