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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
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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
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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
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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
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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
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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
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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
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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)
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Problem Solving Problem Solving TreatmentTreatment
• Theory:– Overwhelming, unsolved problems increase
depression– Solving Problems decreases depression
• Patient Centered and Directed
• Skill building
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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
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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
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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***
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DysthymiaDysthymia
• 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 Recruitment of Study ParticipantsParticipants
• Agency referral– 1,238 105 eligible
• Self-referral– 181 45 eligible– (marketing prospect)
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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
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Intervention GroupIntervention 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 MeasuresOutcome Measures
• Response rate– 50% reduction in depression scores
• Remission rate– no longer meets DSM criteria
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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
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PEARLS Study ResultsPEARLS Study Results
• Quality of Life– Improved Emotional Well-being– Improved Functional Well-being
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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.
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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
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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.
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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/publications/Monograph/
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PEARLS: Policy and PEARLS: Policy and ManagementManagement
Pamela Piering, Director
Aging and Disability Services
Seattle Human Services Dept
October 23, 2008
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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
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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
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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.
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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
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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
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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
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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
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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: PEARLS: A Counselor’s Perspective A Counselor’s Perspective
Susy Favaro, MSW
Social Worker, Northshore Senior Center
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PEARLS WebsitePEARLS Website
http://depts.washington.edu/pearlspr/
Questions & AnswersQuestions & Answers
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Future PRC-HAN WebinarsFuture PRC-HAN Webinars All 3:00-4:30 pm EST All 3:00-4:30 pm EST
More on Evidence-based ProgramsMore on Evidence-based ProgramsWed., October 29: Healthy IDEAS
Relevant to all Evidence-basedRelevant to all Evidence-based ProgramsPrograms
Thurs., November 13: Money Matters
To Register:To Register: http://ncoa.org/content.cfm?sectionID=64