Clinically significant depression affects 15 to 20 percent of elderly individuals in the United States, according to background information in the article. Older adults with social isolation, multiple illnesses, 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.
Paul Ciechanowski, M.D., M.P.H., of the University of Washington School of Medicine, Seattle, and colleagues conducted a randomized controlled trial comparing a program for treating minor depression and dysthymia (a chronic depressive syndrome persisting for at least 2 years), the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS), with usual care in medically ill, low-income, mostly homebound older adults. The study included 138 participants (51.4 percent with minor depression, and 48.6 percent with dysthymia) aged 60 years or older, recruited through community senior service agencies in metropolitan Seattle from January 2000 to May 2003. Seventy-two percent of the participants lived alone, 58 percent had an annual income of less than $10,000, and 69 percent received a form of home assistance.
Patients were randomly assigned to the PEARLS intervention (n = 72) or usual care (n = 66). The PEARLS intervention consisted of visits and phone calls from a therapist and the patients received a form of brief psychotherapy known as problem-solving treatment, modified to emphasize physical activity and increased socialization. There were also potential recommendations regarding antidepressant medications.
The researchers found that at 12 months, compared with the usual care group, patients receiving the PEARLS intervention were about 5 times more likely to have at least a 50 percent reduction in depressive symptoms (43 percent vs. 15 percent), nearly 5 times more likely to achieve complete remission from depression (36 percent vs. 12 percent), and to have greater health-related quality-of-life improvements in functional well-being and emotional well-being.
"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."
(JAMA. 2004;291:1569-1577. Available post-embargo at JAMA.com)
Editor's Note: The authors acknowledge the funding of the Prevention Research Centers Program of the Centers for Disease Control and Prevention and the University of Washington Health Promotion Research Center.
EDITORIAL: TREATMENT OF DEPRESSIVE CONDITIONS IN LATER LIFE
In an accompanying editorial, Jeffrey M. Lyness, M.D., of the University of Rochester Medical Center, Rochester, N.Y., writes that the findings by Ciechanowski et al provide evidence-based hope for the millions of elderly persons living in the "dark tunnel" of major depression or the only slightly less "dim tunnels" of lesser depressions.
"Unfortunately, there are numerous barriers to the delivery of mental health care for older adults, even for traditional services, let alone for innovative methods such as on-site care managers or home-based programs. Among these barriers are disparities in Medicare reimbursement for depression and other mental illnesses compared with 'physical' disorders," he writes.
"The current system can only be described as discriminatory and, in many cases, results in prohibitive costs for elders. 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."
(JAMA. 2004;291:1626-1628. Available post-embargo at JAMA.com)
Editor's Note: Dr. Lyness is supported by a grant from the National Institute of Mental Health.