Treating Depression at Home

Summarized by Robert W. Griffith, MD
July 16, 2004

Introduction

Depression is a very real illness, striking 15% to 20% of elderly people in the USA. The only good aspect of this is that depression in the elderly is less likely to be 'major depression', with its attendant risk of self-harm or suicide. More likely, older folk have minor depression, or dysthymia, as it's called when the symptoms persist for at least 2 years. Even so, minor depression can lead to significant disability, although it's often unrecognized and/or untreated.

Minor depression responds to medication and non-drug therapies, but little is known about how these remedies can be used in community settings. Patients are often homebound, isolated socially, relatively poor, and not functioning well. Providing adequate treatment, therefore, presents challenges.

A group of researchers from Seattle have studied the effectiveness of a home-based program for detecting and managing minor depression in older people. Their findings are reported in the Journal of the American Medical Association, and are summarized here.

What was done

Volunteers were recruited through community senior service agencies in the Seattle area. A total of 138 patients over 60 were selected; roughly half had minor depression and half had dysthymia. They were randomly assigned to receive either an active treatment program - the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) - or what was called 'usual care'.

PEARLS therapy consists of problem-solving treatment (identifying and addressing problems of daily life), social and physical activities, and recommendations to the patients' physicians regarding antidepressant medications. Eight 1-hour therapy visits to the patients were scheduled within a 19-week period.

Each session with the PEARLS therapist included having the patient select from a list of 250 pleasant activities to engage in before the next session. Physical activities were chosen to achieve at least 30 minutes' exercise on at least 5 days a week.

The subjects were followed for 12 months. At the end of this time, assessments of depression and quality of life were compared with the results obtained at baseline.

What was found

The average of the people in the study was 73 years; 79% of them were women. They had, on average, more than 4 chronic medical conditions each; ¾ of them lived alone, and 1 in 3 were on antidepressant medications at the start of the study.

At the 12-month evaluation, the PEARLS patients were about 5 times more likely than the usual-care patients to have a 50% response or a complete remission of their depressive symptoms. They had improved quality-of-life and emotional well-being scores, and they were less likely to require hospitalization.

What this means

The PEARLS treatment offers an effective home-based care program that's clearly suited to these single elderly people with minor depression. The study authors estimate the cost at an average of $630 per patient, which is not excessive, considering the good results achieved. Indeed, it's likely that the costs would be covered by the savings in hospitalization and other disease-burden expenses. We can only hope that resources are made available for a wider introduction of the PEARLS approach in looking after elderly depressed people.

Source

• Community-integrated home-based depression treatment in older adults. A randomized controlled trial. P. Ciechanowski, E. Wagner, K. Schmaling,  et al., JAMA, 2004, vol. 291, pp. 1569--1577

Related Links
An Even Simpler Depression Screening Test
'Beating the Senior Blues'
Walk away from depression?

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