Stage One: Develop an Issue Statement
Depression can strike anyone regardless of age, ethnic background, socioeconomic background, or gender (NIMH, 2011). An estimated 7 million of the nation’s 39 million adults aged 65 years and older are stricken by depression, which is a persistent sad, anxious, or empty feeling, or a feeling of hopelessness and pessimism (Aldrich, 2010). When the elderly population experiences depression, it may be overlooked because seniors, like children and adolescents may experience different and less obvious symptoms and signs of depression and may be unable or unwilling to acknowledge feelings of sadness or grief (NIMH, 2011).
It is important to note that depression is not a normal part of aging. While older adults may face widowhood, loss of function, or loss of independence, persistent bereavement or serious depression is not normal and should be treated (Aldrich, 2010). Living with untreated depression presents a serious public health problem (Aldrich, 2010; CDC, 2010; NIMH, 2011). Depression complicates chronic conditions such as heart disease, diabetes, and stroke; increases health care costs; and often accompanies functional impairment and disability (Aldrich, 2010; CDC, 2010; CDC & NACDD, ND). Depression is also linked to higher health care costs and tied to higher mortality from suicide and cardiac disease (Aldrich, 2010; MHA, 2012). Depression in older adults is often not recognized or treated and yet, it is fairly easy to detect, highly treatable, and a candidate for prevention efforts—making it an excellent focus for public health activities (NIMH, 2011). Because depression is a highly treatable but currently undertreated condition among community-based older adults, all disease prevention programs for older adults should include a depression treatment component (CDC & NACDD, ND).
Stage Two: Use Data to Describe the Issue
Depression is the leading cause of disability as measured by Years Lived with Disability (YLDs) and the 4th leading contributor to the global burden of disease in 2000 (WHO, 2012). By the year 2020, depression is projected to reach 2nd place of the ranking of Disability Adjusted Life Years (DALYs) calculated for all ages, both sexes (WHO, 2012). Using the Behavioral Risk Factor Surveillance System (BFSS), the CDC found that lifetime indicators for depression in California for ages 50-64 are up to 17% and for those ages 65 and up, almost at 10% (CDC, 2006). Risk factors for late-onset depression included widowhood, physical illness, low educational attainment (less than high school), impaired functional status, and heavy alcohol consumption (CDC, 2006).
Depression is a significant predictor of suicide in elderly Americans. Comprising only 13% of the U.S. population, individuals aged 65 and older account for 20% of all suicide deaths, with white males being particularly vulnerable (MHA, 2012). Suicide among white males aged 85 and older (65.3 deaths per 100,000 persons) is nearly six times the suicide rate (10.8 per 100,000) in the United States (MHA, 2012).
In regards to treatment, more than 55% of older persons treated for mental health services received care from primary care physicians and less than 3% aged 65 and older received treatment from mental health professional (MHA, 2012). Primary care physicians accurately recognize less than one half of patients with depression, resulting in potentially decreased function and increased length of hospitalization (MHA, 2012).
Stage Three: Search and Organize Information
Over the last decade, depression and other mental health problems have gained increased attention from the public health community. Mental health, including treatment of depression, is one of the Healthy People 2020 Leading Health Indicators requiring action (U.S. Department of Health and Human Services, 2012). The World Health Organization has launched an initiative focused on depression in public health (WHO, 2012). The Guide to Community Preventive Services (The Community Guide), developed by the non-federal Task Force on Community Preventive Services, has given the rating of “Recommended” to interventions involving collaborative care for treatment of adults 18 years of age or older who have major depression, as well as to home- and clinic-based depression care management interventions for older adults (Community Guide, 2011).
Using one of the leading EBPH resources, The Community Guide, as a tool for intervention recommendations, this resource recommends several strategies to manage depressive disorders. Each recommendation is based on evidence from a systematic review of the published scientific literature examining the effectiveness of the strategy (The Community Guide, 2011). The Community Guide’s evidence table on the recommendation of depression care management for older adults can be found in Appendix 1.
Stage Four: Prioritize Options
Collaborative care for the management of depressive disorders, also referred to as Depression Care Management (DCM) is a multicomponent, healthcare system-level intervention that uses case managers to link primary care providers, patients, and mental health specialists (The Community Guide, 2011). It is designed to: (1) improve the routine screening and diagnosis of depressive disorders; (2) increase provider use of evidence-based protocols for the proactive management of diagnosed depressive disorders; and (3) improve clinical and community support for active patient engagement in treatment goal setting and self-management (The Community Guide, 2011). This is a multi-component, healthcare system-level intervention that uses case managers to link primary care providers, patients, and mental health specialists and this type of intervention improves depression outcomes and is applicable to adult populations in most settings (The Community Guide, 2011).
The Task Force on Community Preventive Services “recommends collaborative care for the management of depressive disorders based on strong evidence of effectiveness in improving depression symptoms, adherence to treatment, response to treatment, and remission and recovery from depression” (The Community Guide, 2011). The Task Force also “finds that collaborative care models provide good economic value based on the weight of evidence from studies that assessed both costs and benefits” (The Community Guide, 2011).
Stage Five: Develop and Implement an Intervention
The DCM model is a systematic team approach to treating depression in older adults, which is based on the model for treating chronic diseases (Aldrich, 2010; The Community Guide, 2011). Common elements of DCM include diagnosing depression through a validated screening instrument and providing psychotherapy or antidepressants according to evidence-based guidelines (Snowden, Steinman, & Frederick, 2008). Treatment is reexamined periodically through a validated severity measurement to determine how well patients are responding and to adjust treatment as needed (Snowden, Steinman, & Frederick, 2008). A trained social worker, nurse, or other practitioner (sometimes called a “depression care manager” or “care manager”) educates patients, tracks outcomes, assists with psychotherapy, and monitors anti-depressants prescribed by a primary care provider (Aldrich, 2010; Snowden, Steinman, & Frederick, 2008). The care manager works in consultation with a psychiatrist who supervises care, but typically does not see the patients (The Community Guide, 2011). The goal is to improve rates of faithfulness to treatment and to improve recognition and treatment for patients not responsive to their initial treatment (Snowden, Steinman, & Frederick, 2008).
In clinics, the depression care manager works with the patient’s primary care provider, a consulting psychiatrist, and other health care personnel to deliver the intervention (The Community Guide, 2011). Managing depression in primary care clinics is effective: elderly people already visit these facilities regularly, and one study of depressed older adults found that DCM was delivered at a mean cost of $580 per patient, compared with total health care cost per patient of about $8000 (Snowden, Steinman, & Frederick, 2008). In the home-based intervention, the depression care manager makes home visits and coordinates with other members of the collaborative care team outside of the participant’s home (Aldrich, 2010; Snowden, Steinman, & Frederick, 2008). One study of home-based management of depression found that costs averaged $630 per patient for an average of six visits (Snowden, Steinman, & Frederick, 2008).
Stage Six: Evaluate the Program
One program that follows the DCM model is the Program to Encourage Active and Rewarding Lives for Seniors (PEARLS) (Aldrich, 2010). PEARLS is a brief, time-limited, and participant-driven program that teaches depression management techniques to older adults with depression (Aldrich, 2010; Snowden, Steinman, & Frederick, 2008; University of Washington School of Public Health, 2009). It is offered to people who are receiving home-based services from community services agencies and the program consists of in-home counseling sessions followed by a series of maintenance session contacts conducted over the telephone (University of Washington School of Public Health, 2009). The PEARLS intervention is comprised of eight 50-minute sessions with a trained social service worker over a 19-week period including 3-6 subsequent telephone contacts (University of Washington School of Public Health, 2009).
The objectives of the PEARLS program include: (1) empowering participants and helping them develop the skills to define and solve their problems, (2) enabling participants to become more socially and physically active, and to experience more pleasant activities, and (3) to decrease participants’ symptoms of depression and improve their health-related quality-of-life and emotional well-being (Aldrich, 2010).
The PEARLS counselor is the individual who works directly with clients to implement the program. In most settings, the counselor will be responsible for some or most of the recruiting of clients for PEARLS (University of Washington School of Public Health, 2009). Many PEARLS counselors will also be case managers; however, it is recommended that a counselor does not deliver PEARLS to the same client(s) he or she case manages (University of Washington School of Public Health, 2009).
The three basic components of the PEARLS Program include:
• Problem-Solving Treatment–A seven-step, participant-driven approach in which the individual is supported by a counselor to identify and solve problems that the participant wants to address (University of Washington School of Public Health, 2009).
• Social and Physical Activation–Counselors work with participants to increase their engagement in social, physical and recreational activities, in both their homes and in their community (University of Washington School of Public Health, 2009).
• Pleasant Activity Scheduling–Participants are encouraged to select an activity they would enjoy doing on their own or in the company of others (a pleasant activity they can do as “homework”); over 200 diverse activities are offered in the PEARLS Toolkit as possible options for participants to consider (University of Washington School of Public Health, 2009).
Within the 19 week PEARLS program, at least 40% of participants in the program will have a reduction or elimination of depressive symptoms, greater reported health-related quality of life, and improvements in functional and emotional well-being. The participants depression will be diagnosed through the Patient Health Questionnaire (PHQ-9) (a nine-item, validated instrument for screening and diagnosing depression) (Appendix 2), a score of 10.9 indicates an intermediate level of depression (Snowden, Steinman, & Frederick, 2008; University of Washington School of Public Health, 2009). The PHQ-9 is completed early in each PEARLS session. In addition, this set of questions sets the context for identifying a problem. According to Snowden et al., after using the PEARLS treatment in a study, the average PHQ-9 score had decreased to 4.8 and 30 (87%) of the 35 participants were in remission (Snowden, Steinman, & Frederick, 2008).
Outcome data in the PEARLS toolkit from the University of Washington School of Public Health include the following:
• PHQ-9 scores (from the PEARLS Tracking Chart, Baseline and Final Questionnaires)
• General Health (from the Baseline and Final Questionnaires)
• Social Activity (from the Baseline and Final Questionnaires)
• Physical Activity (from the Baseline and Final Questionnaires)
• Pleasant Activity (from the Baseline and Final Questionnaires)
Aldrich, N. (2010). CDC promotes public health approach to address depression among older adults. Retrieved from http://www.cdc.gov/aging/pdf/CIB_mental_health.pdf.
Centers for Disease Control and Prevention (CDC). (2010). Mental health and aging. Retrieved from http://www.cdc.gov/aging/mentalhealth/depression.htm.
Centers for Disease Control and Prevention (CDC). (2006). Indicator: Lifetime diagnosis of depression. Retrieved from http://apps.nccd.cdc.gov/MAHA/IndicatorDetails.aspx?IndId=23.
Centers for Disease Control and Prevention (CDC) and National Association for Chronic Disease Directors (NACDD). (ND). The state of mental health and aging in America. Retrieved from
The Guide to Community Preventive Services. (2011). Interventions to reduce depression among older adults. Retrieved from http://www.thecommunityguide.org/mentalhealth/depression-home.html.
Mental Health America (MHA). (2012). Depression in older adults. Retrieved from
National Institute for Mental Health. (2011). Mental Health Topics. Retrieved from
Snowden, M., Steinman, L., & Frederick, J. (2007). Treating depression in older adults: Challenges to implementing the recommendations of an expert panel. Prevention of Chronic Disease. 5 (1): 26.
University of Washington School of Public Health. (2009). Depression care management: Evidence-based programs, PEARLS. Retrieved from http://www.prc-han.org/docs/PEARLS_feb09.pdf.
U.S. Department of Health and Human Services. (2012). Mental health and mental disorders. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=28.
World Health Organization (WHO). (2012). Disorders Management. Retrieved from
World Health Organization (WHO). (2012). WHO initiative on depression in public health.
Retrieved from http://www.who.int/mental_health/management/depression/depressioninph/en/.