Prevention Research Centers (PRC)-Healthy Aging Research Prevention Research Centers (PRC)-Healthy Aging Research Network (HAN) Webinar SeriesNetwork (HAN) Webinar Series

Evidence-Based Depression Care Evidence-Based Depression Care Management: Program to Encourage Management: Program to Encourage Active, Rewarding Lives for Seniors Active, Rewarding Lives for Seniors

(PEARLS)(PEARLS)Moderated by: Sheryl SchwartzModerated by: Sheryl Schwartz

Mark Snowden Pamela Piering Susy Favaro

Sponsors:Sponsors:

Prevention Research Centers-Prevention Research Centers-Healthy Aging Research NetworkHealthy Aging Research Network

http://www.prc-han.org/

Retirement Research FoundationRetirement Research Foundationhttp://www.rrf.org/

National Council National Council on Agingon Aginghttp://ncoa.org/index.cfm

Community-Integrated Home-Community-Integrated Home-Based Depression Treatment for Based Depression Treatment for

the Elderlythe Elderly

Mark Snowden, MD, MPHAssociate Professor Dept. of PsychiatryUW Health Promotion Research Center

Learning ObjectivesLearning Objectives• The clinical components of PEARLS

• The personnel involved in delivering PEARLS

• The target population of older adults most suitable for PEARLS

• Outcomes that have been demonstrated in research trials of PEARLS

• Challenges and strategies for overcoming the challenges related to funding, client treatment and program management

PEARLS Study GoalsPEARLS Study Goals

• To develop a case-finding system for frail elderly individuals with or at high risk for depression

• To develop a community-based depression treatment program for physically impaired and socially isolated older adults

• To use this system to recruit and randomize participants comparing the treatment program with usual care

Depression Care ManagementDepression Care ManagementCore ComponentsCore Components

• Active Screening to identify depressed patients

• Measurement-based care

• Depression care manager (MSW,Ph D, RN)

• Supervising Psychiatrist

• Evidence Based Treatment

PEARLS InterventionPEARLS Intervention

Conducted in the home of participants, in 8 sessions over 19 wks

• Active screening for depression– PHQ-2 initially, now use CES-D-11

• Measurement-based outcomes– PHQ-9

• Trained depression care manager– Recruited from Agency Case managers– Problem Solving Treatment– Physical Activation (30 mins moderate activity 5D/wk)– Social Activation– Pleasant Events

PEARLS InterventionPEARLS Intervention

• A supervising psychiatrist – Eligibility questions– PST supervision– If necessary, recommendations for medication

management– Management Suicidal Ideation

• Follow-up phone calls (1/month, for 3- 6 months)

Problem Solving Problem Solving TreatmentTreatment

• Theory:– Overwhelming, unsolved problems increase

depression– Solving Problems decreases depression

• Patient Centered and Directed

• Skill building

Problem Solving Problem Solving TreatmentTreatment

• 7 Steps– Clarify and define the problem– Set realistic goals– Generate multiple solutions– Evaluate and compare solutions– Select a feasible solution– Implement the solution– Evaluate the outcome

PEARLS Participant CriteriaPEARLS Participant CriteriaInclusion:• Age 60+• Diagnosis of minor depression or dysthymic disorder• Recipient of services from Senior Services or Aging &

Disability Services, or resident of public housing

Exclusion:• Major depression and other psychiatric disorders (e.g.,

bipolar disorder and psychotic disorder)• Substance abuse• Cognitive disorder

Diagnostic and Statistical Manual Diagnostic and Statistical Manual Criteria: Minor DepressionCriteria: Minor Depression

1) Depressed Mood And/Or 2) Anhedonia

3) Anorexia/wt loss or Weight Gain

4) Insomnia or Hypersomnia

5) Psychomotor Agitation or Retardation

6) Fatigue

7) Feelings of Worthlessness/Guilt

8) Indecisiveness/Trouble Concentrating

9) Recurrent Thoughts of Death/Suicide

***2-4 of 9 symptoms >/= 2 wks***

DysthymiaDysthymia

• Depressed more days than not at least 2yrs

• Two or more symptoms when depressed

• Never without symptoms more than 2 months

Recruitment of Study Recruitment of Study ParticipantsParticipants

• Agency referral– 1,238 105 eligible

• Self-referral– 181 45 eligible– (marketing prospect)

Usual Care (n=66)

Intervention (n=77)

Total (n=138)

Female 50 (76%) 59 (82%) 109 (79%)

Average age 73.5 72.6 73.0

Living Alone 43 (65%) 56 (78%) 99 (72%)

Ethnic Minority 28 (43%) 30 (42%) 58 (42%)

No. of Chronic Conditions 4.6 4.5 4.6

Annual Household income <$10,000

33 (51%) 45 (64%) 78 (58%)

Study Participant DemographicsStudy Participant Demographics

Intervention GroupIntervention Group

Intervention participants received:

• a mean of 6 in-person visits

• a mean of 3.5 follow-up phone contacts

Outcome MeasuresOutcome Measures

• Response rate– 50% reduction in depression scores

• Remission rate– no longer meets DSM criteria

PEARLS Study ResultsPEARLS Study Results6 month6 month (N=138)(N=138)

JAMA 2004; 291:1569-1577

8 10

34

54

44

22

0

10

20

30

40

50

60

≥50% drop on HSCL-20 % Achieving Remission % Reporting AnyHospitalizations

Pe

rce

nt

Usual Care Intervention

P<.01 P<.01P=.07

PEARLS Study ResultsPEARLS Study Results

• Quality of Life– Improved Emotional Well-being– Improved Functional Well-being

Antidepressant UsageAntidepressant Usage

• 35% of all participants were on antidepressants at the beginning of study.

• 7 (9.7%) intervention participants started an antidepressant medication during the study period vs. 4 (6.1%) participants in the usual care group.

• 5 (6.7%) participants in each group stopped using an antidepressant during study.

Cost AssessmentCost Assessment

Mean costs of providing the PEARLS program per participant:

• $422 for PST intervention • $28 for follow-up phone calls• $12 in psychiatric follow-up phone calls• $87 for psychotherapy quality assurance• $81 for depression management team sessions• Total mean cost per participant = $630

ConclusionsConclusions

Dissemination of the PEARLS program within existing community social service organizations has the potential to significantly improve the well-being and function of depressed older adults served by these organizations.

From Fixsen DL, Naoom SF, Blasé KA, Friedman RM, Wallce F. Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231), 2005. Available at URL: http://nirn.fmhi.usf.edu/resources/publications/Monograph/

PEARLS: Policy and PEARLS: Policy and ManagementManagement

Pamela Piering, Director

Aging and Disability Services

Seattle Human Services Dept

October 23, 2008

Learning ObjectivesLearning Objectives

• The elements of the PEARLS intervention in a community setting

• Understand the steps required to bring this new program from research to practice

• Identify and explore opportunities to attract funding from new partners

Moving From Research to Moving From Research to PracticePractice

• Find funding to implement PEARLS• AAA Advisory Council

– .5 FTE discretionary funding 2004, now 1.0 (Older Americans Act)

• Adjust present psychiatrist role to provide PEARLS consultation

• Advocate for State resources: new AAA pilot, Spokane WA

Research to Practice, Research to Practice, AdaptationsAdaptations

• Now serving age 50+ with new funding• Phone follow up calls completed in 3 months• Initiated food voucher/food card • Sessions may run from 4 – 6 in number• Initiated 30 day in-home visits when team

Supervisor determines client meets PEARLS criteria

• Multiple referral sources instead of a primary screener.

Educating PolicymakersEducating Policymakers

• JAMA article, April 2004

• ADSA funded “PEARLS Toolkit” now downloadable from UW web site

• Bring information, results to ADS Advisory Council and Sponsors, Seattle, United Way and King County

• Education of local funder: King County Veterans and Human Services Levy

PEARLS ExpansionPEARLS Expansion

• CDC new research study with University of Washington brings .5 FTE Implementation Manager to study best referral flow

• King County Veterans and Human Services Levy brings $220,000 in 2008, renewable six years. Two new subcontractors:– African American Elders Project– IDIC Filipino elders “drop-in” center

• New ADS internal pilot: Chinese elders– Three clients currently enrolled. Learning pros/cons of

using this approach work for this community

Challenges and OpportunitiesChallenges and Opportunities

• Training now through new UW center: CHAMMP– Recently offered: September 24-26 2008, Seattle

• Consider adding new mental health provider for PEARLS through Medicaid funding

• Document results from expansion projects, seek to extend funding statewide

• Link to overall health promotion work in the community

Challenges and OpportunitiesChallenges and Opportunities

• Identifying appropriate clients, and flow• Referral process• Encouraging Medicaid LTC clients with wellness

focus• Use of incentives• New easy-to-use data system needed, show

outcomes, fidelity to original• PEARLS counselors have many expectations in

addition to client services: training, education, “championing”, handling inquiries, etc

“Prior to participating in the PEARLS program I lacked motivation, was severely depressed, and suffering from chronic pain. Having completed the program, I am happy to say that I have successfully overcome these difficulties, thanks to my counselor and the tools and exercises he presented.”

PEARLS: PEARLS: A Counselor’s Perspective A Counselor’s Perspective

Susy Favaro, MSW

Social Worker, Northshore Senior Center

PEARLS WebsitePEARLS Website

http://depts.washington.edu/pearlspr/

Questions & AnswersQuestions & Answers

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