University of Washington’s PEARLS Model Reduces Depression Among Older Adults

July 05, 2018|4:01 p.m.| Community Health and Prevention Team

Depression is the most common mental health problem affecting older adults and the University of Washington Health Promotion Research Center (HPRC) developed and implemented one of the most effective evidence-based programs for older adult depression. The Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) is a home- and community-based program that has been shown to reduce depression symptoms by over 50 percent when delivered by trained professionals over the course of six to eight one-hour sessions. Currently, over 50 agencies offer PEARLS across 18 states and HPRC provides ongoing training and technical support as part of a network of 26 funded CDC academic research centers. ASTHO spoke with HPRC’s research scientist, Lesley Steinman, and the center’s principal investigator, Mark Snowden, to learn more about PEARLS and how the program is being used to confront the stigma associated with depression and mental health.

What differentiates PEARLS from other public health and mental health programs?

PEARLS is unique because it is not delivered by traditional behavioral health providers, but rather by trained community and social services professionals who provide home- and community-based support services. The model trains community providers already working with older adults who may otherwise have limited access to clinic-based services.

Because PEARLS uses an objective scale, the PHQ-9, to measure depression, HPRC can quantify the proportion of older adults reporting significant improvement in their depression. The program continues to show positive results, reinforcing the value of PEARLS both among the people delivering it and the agencies providing financial support for the program. The PHQ-9 also provides an opportunity to educate older adults about their depressive symptoms so they can better manage them. “We don’t just have anecdotal stories about people getting better,” says Snowden. “We can measure and see the improvements people have made. I think it's a testament to how well the model can work in different settings.”

What role does PEARLS play in integrating mental health and public health?

In Washington state and around the country, there are Accountable Communities for Health forming that are meant to integrate the work happening within clinical healthcare settings with health promotion. Many of these initiatives focus on better management of chronic conditions and integrating mental health, behavioral health, and primary care. There has been a shift from patient-level care to population care, requiring these organizations to work more effectively together to integrate not just mental and public health, but social services within the healthcare system as well.

PEARLS integrates mental and public health by simultaneously addressing depression and connecting older adults to other services in order to improve their quality of life. These services can include other evidence-based programs for caregiving support, falls prevention, chronic disease self-management, or physical activity, as well as linkages to primary care and support to address the social determinants of health, like housing assistance and food security. Some clients learn about the symptoms of hypertension and diabetes and get connected with public health and healthcare services to better monitor and treat their conditions.

An important aspect of integrating mental and public health is reimbursement for these services. In Washington, PEARLS is reimbursed through the Medicaid waiver program as a client education intervention and through a local property tax levy to fill gaps in services for veterans, racial and ethnic minorities, and other underserved communities.

How does the recruitment process for the PEARLS programs, and the program itself, address mental health stigma?

With depression often comes stigma, particularly in older communities where some believe depression is synonymous with more severe mental illnesses. On the other hand, some providers and clients think it is normal to feel tired and lethargic as people age. As a result, depression is underrecognized and undertreated in older adults. PEARLS tackles the stigma around mental health and normalizes mental health treatment. During the initial outreach, trained professionals will often use the language older adults use to describe their life rather than the term depression. “I think the use of the PHQ-9 can help people with [overcoming] stigma because it provides an objective measure of what depression is and helps to normalize it,” says Steinman.

In addition, many PEARLS providers share clients’ stories in their newsletters and websites. Providing examples helps normalize depression and highlights the impact an evidence-based program like PEARLS can have on improving quality of life. PEARLS can also help people become more accepting of other treatments for mental health problems, such as psychotherapy or antidepressants. For some clients, PEARLS has helped reduce the stigma associated with mental health illness allowing older adults to get connected to long-term psychotherapy.

How can state health departments work with the PEARLS program to address mental health and behavioral health issues?

Traditionally, PEARLS has been offered through social service providers who participate in the state’s aging network. However, several public health departments have implemented PEARLS and there are opportunities for public health professionals to promote the program. State health departments may consider funding PEARLS as part of their chronic disease programs, such as self-management, falls prevention, and physical activity promotion for older adults. Another potential strategy for states to explore is partnering with community health workers to train them to deliver PEARLS or connect older adults to the program as part of their regular outreach. For example, HPRC is currently part of a project in southern California led by the university’s Advancing Integrated Mental Health Solutions Center that is successfully training community health workers to deliver PEARLS to reduce depression in older, socially isolated Latino communities.