Evidence-based Programs
CDC's Healthy Aging Program is seeking to increase awareness that depression is a public health issue and can be effectively addressed through community-based programs. The three programs presented here are all evidence-based and have been successfully replicated in other communities. They were also featured as part of the Effective Programs to Treat Depression in Older Adults conference held in May 2008, sponsored by the CDC Prevention Research Centers Healthy Aging Research Network and the Rosalynn Carter Georgia Mental Health Forum. They do not represent all available evidence-based programs, but rather a sample of what can be done.
The Selected Programs
IMPACT (Improving Mood-Promoting Access to Collaborative Treatment)
PEARLS (Program to Encourage Active Rewarding Lives for Seniors)
Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors)
IMPACT is a program for older adults who have major depression or dysthymic disorder.
The intervention is a stepped, collaborative care approach in which a nurse, social worker, or psychologist works with the participants' regular primary care provider to develop a course of treatment.
Target population: Older adults.
Setting: Primary care settings. (The program has also been implemented in other settings, including home health care and chronic disease management).
Description of activity: Potential participants are either referred by the primary care provider or identified via routine screening of all clients. During the initial visit, the Depression Care Manager (DCM) completes an assessment, provides education about depression and available treatments, and asks the participant about his or her preference for depression treatment. All participants are encouraged to engage in some form of behavioral activation, such as engaging in physical activity or scheduling of pleasant events. For participants already taking antidepressant medications who are still depressed, the recommendation typically is to increase the dose, augment the antidepressant with a trial of problem-solving treatment (PST), or switch to a different medication or PST.
Intensity and duration: Once participants have started treatment, the DCM follows up in person or by telephone approximately every two weeks during the intensive phase and approximately monthly thereafter until the patient's symptoms are stable enough to move to the maintenance phase. Patients stay in the maintenance phase for several months to insure that symptoms are stable before completing the relapse prevention plan and ending treatment. Participants electing to take the PST course receive six to eight sessions of brief structured psychotherapy delivered by a DCM in the primary care setting.
Partners: A partnership is needed with a psychiatrist who can provide regular caseload-based consultation and supervision. If the DCM is not able to offer evidence-based counseling/psychotherapy as a treatment option, the program should partner with a mental health professional within the organization or an external organization. If the program is being initiated in a mental health setting, a partnership is needed with the participant's primary care provider.
Staff requirements, training, and supervisory issues: The DCM role can be filled by a variety of professionals, including nurses, social workers, and psychologists. Two training options are available: a 2-3 day in-person course or free on-line training. Training is also available in the brief, evidence-based psychotherapy. There is no official certification in IMPACT care, but trainees can receive certification in PST after completing training. The DCM works with the primary care physician and receives additional support from a consulting psychiatrist, who focuses on difficult cases and individuals not responding as expected.
Evidence base: Patients receiving IMPACT care were twice as likely as usual care patients to experience a 50% or greater reduction in depression symptoms. IMPACT patients also experienced greater rates of depression treatment, greater satisfaction with their depression care, less functional impairment and better quality of life (1). These benefits were sustained 12 months after IMPACT care ended (2). To date, over 50 peer-reviewed articles documenting the extensive evidence base for IMPACT, including evaluations of adaptations and implementations that took place after the conclusion of the original randomized controlled trial, have been published.
Costs: The estimated cost per participant is $750 per year in 2008 dollars. Start-up costs vary significantly depending on how the organization chooses to implement the program. All the program materials are available free of charge via the IMPACT Implementation Center website. In-person training comprises the primary start-up cost; however, free online training is available. If an organization chooses in-person training for DCMs, the average cost is $250 per trainee. Case-based training in the PST technique costs approximately $1,000-$1,500 per trainee.
IMPACT has been found to reduce total health care costs by about $3,300 per person over a four-year period compared to persons receiving usual care (3).
Resources: Program materials address clinical, administrative, financial, and participant issues related to the delivery of this intervention and are all available at no cost on an easy-to-use website. In-person, webcast, and free interactive web-based trainings are available to implementers. The program developer is available for telephone consultation and support throughout implementation.
Contact information:
PEARLS is a brief, time-limited, and participant-driven program that teaches depression management techniques to older adults with depression. It is offered to people who are receiving home-based services from community services agencies. The program consists of in-home counseling sessions followed by a series of maintenance session contacts conducted over the telephone.
Target population: Community-dwelling older adults (60+ years).
Setting: Participant's place of residence in the community.
Description of activity: PEARLS is an intervention for older adults who have minor depression or dysthymia and are receiving home-based social services from community services agencies. The program is designed to reduce symptoms of depression and improve health-related quality of life. PEARLS requires its depression care managers (DCM) to use three depression management techniques: (1) problem-solving treatment, in which participants are taught to recognize depressive symptoms, define problems that may contribute to depression, and devise steps to solve these problems; (2) social and physical activity planning; and (3) pleasant event planning and scheduling.
Intensity and duration: The intervention comprises eight 50-minute sessions with a trained social service worker over a 19-week period with 3-6 subsequent telephone contacts.
Partners: Mental health specialty care providers, including a professional (typically a psychiatrist) to serve as a PEARLS supervisor, are essential partners. Staff requirements, training, and supervisory issues: The DCM is typically a trained social worker or mental health counselor who has also undergone training in delivering the problem-solving treatment, as well as techniques that encourage physical and social activation. The DCM works closely with a supervising psychiatrist, who helps with eligibility questions, supervision of the problem-solving treatment process, medication management, and more. A PEARLS team member should be familiar with psychiatric resources so that participants who are not progressing as expected can be referred for alternative or more intensive services. A manual is used to support the DCM in delivering the program.
Evidence base: Participants who received the PEARLS intervention were three times more likely than those receiving usual care to significantly reduce their depressive symptoms (43% vs. 15%) or completely eliminate their depression (36% vs. 12%). Participants were more likely to report greater health-related quality of life improvements in functional and emotional well being, as well as reduced use of health care services, including hospitalizations, compared to those receiving usual care. (4).
Costs: The cost to implement PEARLS is about $630 per patient. This estimate is based on mean costs for the services provided to PEARLS participants in the 2002-2003 study, which included problem-solving treatment sessions ($422), follow-up and psychiatric telephone calls ($40), psychotherapy quality assurance ($87), and depression management team sessions ($81) (4).
Resources: Resources include a free user-friendly implementation toolkit and a training program (with a $500 registration fee), held in Seattle on a twice-yearly basis. Technical assistance by phone or email is available on an ongoing basis; a charge may be incurred for intensive technical assistance. Guidance and suggestions for program adaptation are available for certain populations and settings. Quality assurance forms are provided to assist supervisors in monitoring implementation fidelity.
Contact information:
Healthy IDEAS is a community depression program designed to detect and reduce the severity of depressive symptoms in older adults with chronic health conditions and functional limitations through existing community-based case management services. Healthy IDEAS integrates depression awareness and management into existing case management services provided to older adults (such as those that offer assistance with home-based care). The program also seeks to improve the linkage between community aging service providers (for example, area agencies on aging) and health care professionals through appropriate referrals, better communication, and effective partnerships.
Target population: Community-dwelling, underserved, frail, high-risk, older adults (60+ years) receiving case management services.
Setting: Participant's place of residence in the community.
Description of activity: Potential participants are identified via routine screening of case management clients for symptoms of depression using a standardized depression scale. Participants and their caregivers, if appropriate, receive education about depression treatment and self-care, and participants receive active assistance in obtaining further treatment from primary care and mental health providers. They receive coaching and support as they engage in behavioral activation to manage their depression and pursue personal, meaningful activities.
Intensity and duration: Typically, the program involves at least three face-to-face visits and three to six telephone contacts over a three to six month period. Participants with more severe symptoms of depression may require more contacts over a longer time period.
Partners: Behavioral health experts are essential to help with training and ongoing consultation around services and outcome assessment activities. It is also important to have mental health professionals who can act as consultants to staff and who are available for outside referral when needed.
Staff requirements, training, and supervisory issues: On-site training is available. A manual outlines the steps of the intervention and includes written worksheets, client handouts, and forms to support and document the process and client outcomes. Program implementers are not required to have professional licensure in any particular field.
Evidence base: Participants showed reductions in depression severity and self-reported pain, increased knowledge of how to get help for depression, increased activity levels, and knowledge of how to manage depressive symptoms (5).
Costs: A free consultation is available to assess the organization's readiness to implement Healthy IDEAS. For agencies that decide to pursue the program, an implementation package, including consultation with the local leadership team, ongoing technical assistance, and all the Healthy IDEAS materials, including a program manual, a staff manual, and a training DVD and facilitator's training guide, are available for a one time fee of $3,000 plus travel expenses from Houston, TX. Per patient costs have not yet been determined.
Resources: The basic replication toolkit includes a program manual with sections for agency leaders and direct providers, client handouts, sample assessment and reporting forms, a training DVD, and a training curriculum. Self-Assessing Readiness for Implementing Healthy IDEAS is a tool to assist a community aging service provider and other partnering organizations in determining their capacity to implement Healthy IDEAS. It is designed to help organizations identify what additional commitments, capabilities, resources and partners might be needed to progress with plans to implement this program.
Contact information:
- For more information on the basic replication toolkit, contact Healthy IDEAS Program Developer Nancy Wilson: nwilson@bcm.edu; (713) 798-3850.
- The organizational readiness self-assessment tool, as well as replication guidance, case studies, and technical assistance, are available at the Care for Elders website http://www.careforelders.org/healthyideas
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References
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(1)
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Unützer J, et al. Collaborative care management of late-life depression in the primary care setting. JAMA 2002;288:2836-45.
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(2)
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Hunkeler E, et al. Long term outcomes from the IMPACT randomised trial for depressed older primary care patients. British Medical Journal 2006;332: 259-263.
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(3)
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Unützer J, Katon WJ, Fan MY, Schoenbaum M, Lin EHB, Della Penna R, Powers D. Long-term cost effects of collaborative care for late-life depression. American Journal of Managed Care 2008;14:95-100.
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(4)
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Ciechanowski O, Wagner E, Schmaling K, Schwartz S, Williams B, Diehr P, et al. Community-integrated home-based depression treatment in older adults: A randomized controlled trial. JAMA 2004;291:1569-1577.
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(5)
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Quijano LM, Stanley MA, Petersen NJ, Casado BL, Steinberg EH, Cully JA, Wilson NL. Healthy IDEAS: A depression intervention delivered by community-based case managers serving older adults. Journal of Applied Gerontology 2007;26:139-156.
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