Depression Special Interest Project

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Prevention Research Centers (PRC)-Healthy Aging
Research Network (HAN) Webinar Series
Evidence-Based Depression Care Management
Program to Encourage Active, Rewarding Lives for
Seniors (PEARLS) Moderated by Sheryl Schwartz
Mark Snowden
Pamela Piering
Susy Favaro
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Sponsors Prevention Research Centers-Healthy
Aging Research Network http//www.prc-han.org/ R
etirement Research Foundation http//www.rrf.org/
National Council on Aging http//ncoa.org/index.c
fm
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Community-Integrated Home-Based Depression
Treatment for the ElderlyMark Snowden, MD,
MPHAssociate Professor Dept. of PsychiatryUW
Health Promotion Research Center

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Learning 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

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PEARLS 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

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Depression Care ManagementCore Components

• Active Screening to identify depressed patients
• Measurement-based care
• Depression care manager (MSW,Ph D, RN)
• Supervising Psychiatrist
• Evidence Based Treatment

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PEARLS 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

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PEARLS 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)

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Problem Solving Treatment

• Theory
• Overwhelming, unsolved problems increase
  depression
• Solving Problems decreases depression
• Patient Centered and Directed
• Skill building

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Problem Solving Treatment

• 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

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PEARLS Participant Criteria

• Inclusion
• 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

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Diagnostic and Statistical Manual Criteria 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
gt/ 2 wks
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Dysthymia

• Depressed more days than not at least 2yrs
• Two or more symptoms when depressed
• Never without symptoms more than 2 months

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Recruitment of Study Participants

• Agency referral
• 1,238 ? 105 eligible
• Self-referral
• 181 ? 45 eligible
• (marketing prospect)

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Study Participant Demographics
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Intervention Group

• Intervention participants received
• a mean of 6 in-person visits
• a mean of 3.5 follow-up phone contacts

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Outcome Measures

• Response rate
• 50 reduction in depression scores
• Remission rate
• no longer meets DSM criteria

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PEARLS Study Results6 month (N138)
JAMA 2004 2911569-1577
Plt.01
Plt.01
P.07
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PEARLS Study Results

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

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Antidepressant 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.

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Cost 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

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Conclusions

• 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.

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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/publica
tions/Monograph/
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PEARLS Policy and Management

• Pamela Piering, Director
• Aging and Disability Services
• Seattle Human Services Dept
• October 23, 2008

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Learning 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

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Moving From Research to Practice

• 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

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Research to Practice, Adaptations

• 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.

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Educating 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

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PEARLS 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

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Challenges 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

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Challenges 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

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• 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.

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PEARLS A Counselors Perspective

• Susy Favaro, MSW
• Social Worker, Northshore Senior Center

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PEARLS Website

• http//depts.washington.edu/pearlspr/

Questions Answers
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Future PRC-HAN Webinars All 300-430 pm EST

• More on Evidence-based Programs
• Wed., October 29 Healthy IDEAS
• Relevant to all Evidence-based Programs
• Thurs., November 13 Money Matters
• To Register
• http//ncoa.org/content.cfm?sectionID64