Reaching Veterans at Risk of Social Isolation and Depression

1. Reaching Veterans at Risk of Social Isolation and Depression Maryland Living Well Center of Excellence (LWCE), A Division of MAC, Inc. – Maintaining Active Citizens Area Agency on Aging Sue Lachenmayr, State Program Coordinator

2. Who We are; What We Do CHRONIC DISEASE SELF-MANAGEMENT EDUCATION PROGRAMS

3. LWCE Services • Statewide Licenses for Chronic Disease Group Programs (English, Spanish, Worksite Programs), Diabetes(English, Spanish), Pain, Cancer, Building Better Caregivers; • Falls Prevention Group Programs: Stepping On, Enhance Fitness; • EnhanceWellness (individual chronic disease self-management); and • PEARLS (individual depression Intervention) • Centralized referral, workforce certification, fidelity monitoring, privacy compliant training and processes • Screening for Social Determinants of Health (SDoH) and referral to appropriate services and evidence-based programs • Statewide calendar for registration/referral to evidence-based program workshops • Participant satisfaction/engagement and quality assurance monitoring of leader fidelity and competency

5. Cost and Impact of Depression • According to the Centers for Disease Control and Prevention (CDC), “Depression is a treatable medical condition, not a normal part of aging, however, older adults are at increased risk for experiencing depression.”1 • More than two million of the 34 million Americans age 65 and older suffer from some form of depression.2 • Depressive Symptoms Are Associated With Higher Rates of Readmission or Mortality After Medical Hospitalization. 3 • Older patients with symptoms of depression have roughly 50% higher healthcare costs than non-depressed seniors.4 1. Healthy Aging: Depression is not a normal part of growing older, Centers for Disease Control and Prevention, accessed 3-9-2018, https://www.cdc.gov/aging/mentalhealth/depression.htm . 2. National Institute of Mental Health: “Older Adults: Depression and Suicide Fact Sheet.” Accessed August 1999. Netscape: http://www.nimh.nih.gov/publicat/elderlydepsuicide.cfm. 3. Jenelle L. Pederson, MSc1, Lindsey M. Warkentin, MSc2, Sumit R. Majumdar, MD, MPH1,3, Finlay A. McAlister, MD, MSc1,4, Journal of Hospital Medicine Vol 11 | No 5 | May 2016 4. Unutzer, J., “Depressive symptoms and the cost of health services in HMO patients aged 65 years and older,” JAMA 277;20 (1997).

6. The Link Between Social Isolation and Risk for Depression • A lack of social connections can increase the risk of death by at least 50%, and in some circumstances, by more than 90% [1] • Lonely individuals are more prone to depression [2] • Loneliness and low social interaction are predictive of suicide in older age [3] • Holt-Lunstad, Smith, Baker, Harris & Stephenson, 2015 • Cacioppo et al, 2006 and Green et all 1992, https//www.campaingtoendlonelinessorg/about-loneliness/ • O’Connell et al, 2004 http://wwwcampaingtoendloneliness.org/about-loneliness

7. Clinical Outcomes for Veterans are Similar to Outcomes for other Older Adults • Over 50% of clients had a significant reduction in level of depression, which was maintained for over 12 months.1 • 44% achieved remission of depression symptoms, maintained for at least 6 months.1 • Depression Screening and enrollment into PEARLS results in an average $1100 savings in health care costs per patient.2 1. Ciechanowski, JAMA, April 7, 2004—Vol 291, No. 13 1569) 2. Galea S, Tracy M, Hoggatt KJ, Dimaggio C, Karpati A. Am J Public Health 2011;101(8):1456–65.)

8. Veterans and Research About Depression • Successful recruitment included building trust, ensuring cultural appropriateness, meeting individuals where they are to cut across barriers to participation in PEARLS. • Stories of former clients helped illustrate what PEARLS is and communicate that the program is relevant. • It’s critical to meet clients where the client’s are; consider client’s motivation, readiness to change, beliefs about depression, and what else is going on in their lives. Lesley Steinman, Kristen Hammerback, and Mark Snowden (2013) The Gerontologist, 2015, Vol. 55, No. 4, 667–676doi:10.1093/geront/gnt137: “It Could Be a Pearl to You: Exploring Recruitment and Retention of the Program to Encourage Active, Rewarding Lives (PEARLS) With Hard-to-Reach Populations”.

9. What is PEARLS? • Community-based program designed to reduce depression and social isolation in older adults ages 50 and older. • Concrete, easy-to-learn and empowering approach to solving problems and reducing depression. • Delivered One-on-one in home or at a community location by a certified & trained PEARLS counselor.

10. PEARLS Principles • Participants experiencing symptoms due to depression • Link between unsolved problems and depression • Participation in social, physical and other pleasant activities leads to a decrease in depressive symptoms

11. PEARLS Principles Symptoms of depression but do not meet DSM criteria for major depression or PDD Ongoing, low-grade depression of 2 or more years in which depressive symptoms are present more days than not Enough symptoms over past 2 weeks to meet the criteria for a major depressive episode

12. Conducting The PEARLS Program • Session Structure: • 6-8 one-on-one sessions over a 6 month period • Each session is one hour in length Clinical Supervision: Psychiatrist, or equivalent, reviews all cases during regular case supervision meetings with the PEARLS counselor.

13. Conducting PEARLS Session • Every month for up to 3 months after program • 15-minute conversations

14. SCREENING FOR ELIGIBILITY • In person or telephone assessment to determine whether a client could benefit and if they are eligible. • Screen out if: • History of schizophrenia or bi-polar disorder * There may be some flexibility to serve client if bi-polar disorder is well-controlled • Current substance abuse problems * Veterans can participate as long substance abuse does not interfere with their ability to do PEARLS (keep appointments, not be intoxicated during appointments, do follow-up homework in between sessions • Cognitive impairment • In-person meetings build rapport and trust between client and counselor • Need strategies in place if person is ineligible • Referral to other home and community-based services, evidence-based programs (if appropriate)

15. Tips for Recruiting Veterans • Where possible, utilize a peer-driven engagement model to recruit older veterans into PEARLS as veterans respond well to being viewed as an expert, sharing what got them to enroll in PEARLS in the first place, and what worked for them during and after the program. • Older veterans are more receptive to the program when it is described as “skills training”. • Use terms such as “sad” or “blue” rather than talking about “depression” or “mental illness.” • Focus on symptoms (such as being more tired than usual, losing interest in things you once enjoyed) versus the label of depression. • Take the time to slowly build relationship and introduce PEARLS. • Recruit through the local center where people feel comfortable vs knocking on doors.   • Emphasize that the focus of PEARLS is on the ‘Here and Now’, not the past. • Be flexible when considering session content, timing, and location. Miruna Petrescu-Prahova, Lesley Steinman, Anna Dronen, Sluggo Rigor & Mark Snowden (2017) The Development and Evaluation of a Peer-Driven Engagement Intervention to Reach Older Veterans with Depression, Military Behavioral Health, 5:3, 274-283,DOI: 10.1080/21635781.2017.1316805

16. PEARLS Depression Screening and Behavioral 6-month One-on-One Intervention Aug 1 2018 – May 13 2019 • 50 Active Clients • An additional 17 have completed 6 or more sessions to date • Of those completing the program • 60% had remission of depressive symptoms • 33% had reduced depression • Average age 70-79 • 33% African American • 41% with an income below $15,000/year

17. 47 New PEARLS and EnhanceWellness Coaches Trained November 2018/March 2019 • AAA capacity to deliver PEARLS: Baltimore City, Anne Arundel, Baltimore, Carroll, Dorchester, Frederick, Prince Georges, Somerset, Talbot, Washington, Wicomico, and Worcester Counties • AAA capacity to deliver Enhance Wellness (One-on-One Self-Management): Baltimore City, Baltimore, Montgomery, Prince Georges, Somerset, Talbot, Washington, and Wicomico Counties

18. Story From the Field: Veteran Residing in Low Income Housing Mr. G • Treated during military career for depression • Current mood low, unhappy, isolated • Requires wheelchair for mobility, so limited in where he can go/what he can do • Feels guilty about limited interaction with son and daughter, unable to find people with common interests • Felt hopeless and frustrated • More positive about his general situation • Celebrated anniversary and his wife's birthday • More positive about his daughter and acknowledges her concern about him • Found new friends to play games with on I-phone • Attended holiday lunch at apartment complex • PHQ-9 results: reduced from 15 to 9 over 8 sessions

19. Opportunities for Collaboration • Sue Lachenmayr, State Program Director Phone: 908-797-5650 E-mail: bslach@earthlink.net