April 6, 2004 --- The Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) significantly reduces depressive symptoms and improves health status in chronically ill older adults, according to the results of a randomized trial published in the April 7 issue of The Journal of the American Medical Association.

"Clinically significant depression affects 15% to 20% of elderly individuals in the US," write Paul Ciechanowski, MD, MPH, from the University of Washington School of Medicine in Seattle, and colleagues. "Older adults with social isolation, medical comorbidity, and physical impairment are more likely to be depressed but may be less able to seek appropriate care for depression compared with older adults without these characteristics."

From January 2000 to May 2003, 138 chronically ill, mostly homebound participants aged 60 years or older, including 51.4% with minor depression and 48.6% with dysthymia, were recruited through community senior service agencies in metropolitan Seattle. Annual income was less than $10,000 in 58% of participants; 72% lived alone; 69% received home assistance; and 42% belonged to a racial or ethnic minority.

Of the 138 participants, 66 received usual care and 72 received the PEARLS intervention, which consisted of visits and phone calls from a therapist for problem-solving treatment, modified to emphasize physical activity and increased socialization. There were also potential recommendations regarding antidepressant medications.

At 12 months, reduction in depressive symptoms by 50% or more occurred in 43% of the PEARLS group and in 15% of the usual care group (odds ratio [OR], 5.21; 95% confidence interval [CI], 2.01 - 13.49). The PEARLS group also fared better in terms of achieving complete remission from depression (36% vs. 12%; OR, 4.96; 95% CI, 1.79 - 13.72), greater health-related quality-of-life improvements in functional well-being (P = .001) and emotional well-being (P = .048).

Study limitations include moderate sample size limited to one urban geographical area, reliance on self-reports, and a greater proportion of dysthymia at baseline in the PEARLS group.

"This is one of the first studies to show that by partnering with community agencies, it is possible to target and effectively treat depressed, frail, elderly adults using primarily nonpharmacological treatments such as psychotherapy," the authors write. "Dissemination of PEARLS within existing community social service programs has the potential to significantly improve the well-being and function of depressed older adults served by these programs."

The Prevention Research Centers Program of the Centers for Disease Control and Prevention and the University of Washington Health Promotion Research Center funded this study.

In an accompanying editorial, Jeffrey M. Lyness, MD, from the University of Rochester Medical Center in New York, notes that there are numerous barriers to the delivery of mental health care for older adults, especially for innovative methods such as on-site care managers or home-based programs.

"The current system can only be described as discriminatory and, in many cases, results in prohibitive costs for elders," Dr. Lyness writes. "To turn the implications of studies such as [PEARLS] into reality for older adults will require the application of their results, and concomitant demonstrations of favorable cost-benefit analyses, to the changing of social policy and health care payment and delivery systems. The well-being of an aging society demands meeting these challenges."

Dr. Lyness is supported by the National Institutes of Mental Health.

JAMA. 2004;286(6):1284-1289

Clinical Context

Study Highlights

• 138 participants aged 60 years or older receiving services from senior service agencies were recruited either by community social workers or self-referred.
• Exclusion criteria were absence of depression, major depression, bipolar disorder, psychosis, substance abuse, and Mini Mental Status Examination (MMSE) score less than 3 of 6 points.
• Participants were randomized to receive either the PEARLS intervention or usual care, and they were followed for 12 months.
• Outcomes at 6 and 12 months, assessed by blinded interviewers, were depressive symptoms using the Hopkins Symptom Checklist (HSCL-20), use of antidepressant medication, health-related quality of life using the Functional Assessment of Cancer-Therapy Scale (FACT-G), and healthcare utilization compared with baseline using the Cornell Services Index (use of emergency departments, hospitalizations, and at least 5 outpatient visits).
• Usual care participants received no additional services and had a letter sent to their regular physicians reporting their diagnosis of depression and recommendation to continue usual care.
• The PEARLS intervention consisted of stepped care offered by a team of trained social worker/therapists and psychiatrists. Case management meetings occurred weekly or biweekly. The regular physician was not directly or actively involved.
• Problem-solving treatment sessions were offered to PEARL participants 8 times at home over 19 weeks and each session lasted for 50 minutes. Physical activation was offered to include moderate activity of at least 30 minutes at least 5 times a week. Social activation was offered in the third or fourth session and consisted of suggested activities to increase patient interactions outside the home using a resource list. After 19 weeks, monthly brief telephone contact was maintained with participants for the next 33 weeks.
• Patients with Patient Health Questionnaire scores higher than 50% of baseline and continuing or recurring dysphoria or dysthymia at 4 to 5 weeks were discussed with a psychiatrist who then contacted their regular physician to recommend initiating or adjusting antidepressant medication dose.
• 51.4% of participants had minor depression, 48.6% had dysthymia. Mean age was 72 years (SD, 8.5 years). They had a mean of 4.6 (SD, 2.1) chronic medical conditions. 72% lived alone, 58% had an annual income less than $10,000, and 69% received home assistance.
• Intervention participants received a mean of 6.6 home visits (SD, 2.5). During the 33-week follow-up, there was a mean of 3.5 telephone contacts (SD, 2.7) per participant. No patient was seen by the psychiatrist.
• At baseline 36% of participants were taking antidepressants, and there were no significant between-group differences in antidepressant use at 6 and 12 months. 9.7% of patients in the intervention group and 6.1% of those in the usual care group who were not on an antidepressant at the beginning of the study started an antidepressant during the study.
• One third of the intervention group and 12% of the usual care group experienced remission of depression.
• Participants in the PEARLS group were more likely, at 12 months, to have at least a 50% reduction in depressive symptoms (43% vs. 15%; OR, 5.21; 95% CI, 2.01 - 13.49) and to achieve complete remission from depression (36% vs. 12%; OR, 4.96; 95% CI, 1.79 - 13.72).
• The PEARLS group had greater improvement in health-related quality of life, such as acceptance of illness and enjoyment of recreation ( P = .001), and emotional well-being, such as increased satisfaction with coping ( P = .048) at 12 months.
• There were no significant differences in healthcare utilization between the groups.

Pearls for Practice

• The PEARLS intervention results in lower severity and greater remission of minor depression and dysthymia and significant improvements in functional and emotional well-being at 12 months compared with usual care.
• Healthcare utilization and use of antidepressants is not affected by the PEARLS intervention.

CME Test