At-home therapy helps seniors beat the blues

By Marsha King
Seattle Times staff reporter

	GREG GILBERT / THE SEATTLE TIMES Chuck Lazenby, 72, right, chats with butcher Ellery Heer at the Pike Place Market, which he walks to from his Capitol Hill home.
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After a year, study participants were far more likely than nonparticipants to have cut their depressive symptoms in half — symptoms like poor appetite, trouble falling asleep and feelings of hopelessness. Many participants managed to get rid of their depression completely.

As a result, their health status and emotional well being improved and they tended to be hospitalized less, says the study that appears in today's edition of the Journal of the American Medical Association.

"It was a lifesaver for me," says Chuck Lazenby, 72, who fell into despair and drinking after his partner of 50 years died suddenly of a heart attack.

Late-life depression affects 15 to 20 percent of older Americans, says Dr. Paul Ciechanowski, a co-investigator and psychiatrist on the study called PEARLS — Program to Encourage Active Rewarding Lives for Seniors. Yet, doctors and their older patients often wrongly assume depression is an unavoidable consequence of aging.

Patients also may be too proud to ask for help. For whatever reason, only about half of depressed older adults receive treatment and, of those, many don't receive adequate treatment, Ciechanowski says.

This psychological suffering, the costly health-care ramifications and the large numbers of aging baby boomers on the horizon are driving a national search for solutions.

PEARLS was conducted by the University of Washington's Health Promotion Research Center in collaboration with Aging and Disability Services, a city of Seattle division, and Senior Services.

The Health Promotion Research Center is leading a nationwide research initiative on healthy aging for the U.S. Centers for Disease Control and Prevention, which paid for the UW study.

The goal is to create programs that can be scientifically shown to improve the health of older adults and replicated at low cost in communities nationwide.

"This is an attempt to reach the most vulnerable population in our society," says Dr. Jim LoGerfo, the UW center's director.

	THOMAS JAMES HURST / THE SEATTLE TIMES Montana Smith, 84, has suffered some setbacks this year, but strategies from a UW study program are helping her learn how to cope.

PEARLS cost $630 per participant per year, which includes eight in-home sessions with a social worker over 19 weeks and after that monthly follow-up phone calls.

The plan now is to seek Medicaid funding for a broader study in this state.

"The reduction in hospitalization is so tantalizing it might be a good investment on their part to look at it," LoGerfo says.

Efforts also are under way to make the antidepression program available to a broader range of older people across the state, through senior centers as well as in-home settings. Older refugees and immigrants likely will be a focus.

Life's losses are trigger

The UW study replicates and extends the 2002 findings of a national study called IMPACT — Improving Mood: Promoting Access to Collaborative Treatment for Late Life Depression — the largest study on depression in the United States.

Seattle was one of seven cities in the IMPACT study, which found that depressed patients being seen at clinics improved through problem-solving therapy, increased social activity and targeted medication management.

The UW study takes that approach out of the primary-care setting and into the community and people's homes. It also relies on the assistance of partner agencies in the community.

A JAMA editorial says depression studies such as the UW's "provide evidence-based hope for millions of elderly persons living in the dark tunnel of major depression or the only slightly less dim tunnels of 'lesser' depressions."

Life's losses are frequently the trigger: careers end; family and dear friends die; the body starts to give out; and independence is tough to maintain.

Seniors with chronic conditions or physical limitations stay inside, feeling isolated and useless. Adults over age 65 represent 13 percent of the U.S. population yet accounted for 18 percent of all suicides in 2000.

The 2½-year study sent social workers from Aging and Disability Services into the homes of 138 low-income seniors, age 60 and older, most of whom were single and had serious disabilities.

The social workers primarily focused on a therapy that emphasized exercise and increased socialization.

PEARLS patients learned to identify what was bothering them and to write down practical step-by-step solutions.

"It's like breaking the bundle one stick at a time," Ciechanowski says.

A social worker followed up with encouraging visits and phone calls to keep patients on track. But ultimately, patients were expected to solve their own problems, which helped them regain a sense of control over their lives.

If a participant didn't improve in the first few weeks, the study's care-management team recommended that a primary-care doctor evaluate the person for antidepressant medication.

Regaining control after partner dies

Participant Lazenby spiraled down after his partner died.

	THOMAS JAMES HURST / THE SEATTLE TIMES Montana Smith and social worker Carl Kaiser fill out a problem-solving worksheet as part of a program to help older people manage depression. Smith meets regularly with Kaiser, who is monitoring her symptoms of depression and helping her identify solutions to problems.

"It was such a shock. After 50 years, I was alone and making decisions for myself. I had no close friends," says Lazenby, a retired office manager from Seattle.

He disguised his despair by drinking heavily, frequenting bars and spending too much money. He stopped managing his diabetes and, at the lowest point, considered suicide.

"I was vulnerable and I didn't really care."

Many people tried to help him, but he never could shake the despondency.

Luckily, an observant senior-center worker recognized his symptoms and suggested he contact the PEARLS research project.

For starters, Lazenby was helped to see that financial difficulties were making him a nervous wreck. As a result, he managed on his own to find a cheaper apartment that he loves.

Life's been mostly positive since. "I'm back doing the things I like to do," he says.

He volunteers at church and in the community and walks from his home on Seattle's Capitol Hill down to Pike Place Market to buy flowers and eggs.

He attends the theater and, on his doctor's recommendation, is learning to cook again. Recently, he entertained several friends and said "it felt good." His diabetes is under control. So is his bank account.

And he's no longer consumed with grief over his partner.

"I do admit I talk to him. But nobody's around, so they can't lock me up. I feel he's with me."

Money needed to expand

Aging and Disability Services now uses the PEARLS approach with its low-income, homebound clients throughout King County.

The dream is to find funding to make it widely available in all kinds of settings and in a culturally relevant way to older people who have limited English-speaking ability, says the agency's director, Pam Piering.

Montana Smith, 84, has just started using the PEARLS strategy to try to overcome three major setbacks in the past year.

The small, normally active woman underwent knee-replacement surgery, learned an adult son has cancer, and had to move out of her home in Seattle's Rainier Valley for a year, because of Sound Transit's light-rail construction.

The move has been especially difficult, even though her 88-year-old cousin gave her a front bedroom in his house.

Smith doesn't have her own comfortable mattress, and the front stairs are so steep it hurts her new knee to go up and down. Her car needs repair, so she has to depend on her family to take her places.

"It bothered me," she says. "Sometimes I felt like I was cranky and cross. Then at night, I'd go to bed and cry, and I wouldn't know why."

Now she meets regularly in her cousin's home with social worker Carl Kaiser, who's monitoring her symptoms of depression and helping her identify step-by-step solutions to problems.

Smith dearly wants to see and help care for her sick son more often. But he lives in Tukwila, and she's never been one to take the bus.

So she resolves to ask her cousin to drive her there and another family member to pick her up. She also commits to try to find a way to get her car fixed.

One of her early successes at problem solving was taking the easier back way out of her cousin's house, instead of taking the steep front stairs.

"I even ventured over to a granddaughter's and I left my cane at home," says Smith, who held onto someone's arm instead.

"I made it over and back, and I was proud of myself."

Marsha King: 206-464-2232 or mking@seattletimes.com

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