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Intervention Summary

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Program to Encourage Active, Rewarding Lives (PEARLS)

The Program to Encourage Active, Rewarding Lives (PEARLS), an intervention for individuals with a depression or dysthymia diagnosis, aims to reduce symptoms of depression and suicidal ideation and improve quality of life. Designed to empower clients through behavioral techniques, PEARLS consists of these primary components:

  • Problem-solving treatment: Participants learn to understand the link between unsolved problems and depression and to apply a seven-step approach to solving their problems.
  • Social and physical activation: Participants are encouraged to engage in social and physical activities that most interest them.
  • Pleasant activity scheduling: Participants identify and participate in activities they find pleasurable.

PEARLS is delivered in six to eight 50-minute sessions by a trained health or social service professional (e.g., social worker, nurse, case manager) in the client's home or other community-based setting. Sessions are initially held weekly and become less frequent over a 4- to 5-month period. During sessions, clients choose the problems they would like to discuss, and the counselor guides, teaches, and supports the client in developing action plans that are to be implemented between sessions to address these problems.

PEARLS has been implemented with adults and older adults with chronic conditions and with veterans and the spouses of veterans. In the studies reviewed for this summary, PEARLS was implemented with the following populations:

  • Older adults (ages 60 years and older) with minor depression or dysthymia who were receiving home-based social services from community services agencies
  • Outpatients with epilepsy and clinically significant acute or chronic depression.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: January 2014
1: Symptoms of depression
2: Health-related quality of life
3: Suicidal ideation

Review Date: March 2007
1: Symptoms of depression
2: Health-related quality of life
Outcome Categories Mental health
Quality of life
Ages 26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Settings Home
Other community settings
Geographic Locations Urban
Suburban
Implementation History The intervention, previously known as Program to Encourage Active, Rewarding Lives for Seniors, was originally developed for older adults with depression. It was first implemented as part of an evaluation conducted between 2000 and 2003. Since then, PEARLS has been implemented in 18 States (Arizona, California, Colorado, Georgia, Illinois, Indiana, Iowa, Massachusetts, Missouri, Nebraska, New York, North Carolina, Ohio, Oregon, Vermont, Washington, Wisconsin, Wyoming) in approximately 50 sites including Area Agencies on Aging, senior centers, community centers, community mental health agencies, epilepsy foundations, and other community-based and home settings. Over 2,000 participants, mainly older adults, have participated in the intervention.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: No
Adaptations PEARLS forms and handouts have been translated into Mandarin, Russian, Somali, and Spanish.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: January 2014

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Chaytor, N., Ciechanowski, P., Miller, J. W., Fraser, R., Russo, J., Unützer, J., et al. (2011). Long-term outcomes from the PEARLS randomized trial for the treatment of depression in patients with epilepsy. Epilepsy & Behavior, 20(3), 545-549.  Pub Med icon

Ciechanowski, P., Chaytor, N., Miller, J., Fraser, R., Russo, J., Unützer, J., et al. (2010). PEARLS depression treatment for individuals with epilepsy: A randomized controlled trial. Epilepsy & Behavior, 19(3), 225-231.  Pub Med icon

Supplementary Materials

Cramer, J. A., Perrine, K., Devinsky, O., Bryant-Comstock, L., Meador, K., & Hermann, B. (1998). Development and cross-cultural translations of a 31-item Quality of Life in Epilepsy inventory. Epilepsia, 39(1), 81-88.  Pub Med icon

Farren, L., Snowden, M., Steinman, L., & Monroe-DeVita, M. (2013). PEARLS fidelity instrument: Development and evaluation. Manuscript submitted for publication.

Glass, R. M., Allan, A. T., Uhlenhuth, E. H., Kimball, C. P., & Borinstein, D. I. (1978). Psychiatric screening in a medical clinic: An evaluation of a self-report inventory. Archives of General Psychiatry, 35(10), 1189-1195.  Pub Med icon

University of Washington. (2012). PEARLS fidelity instrument. Seattle, WA: Author.

Outcomes

Outcome 1: Symptoms of depression
Description of Measures Symptoms of depression were measured using the Hopkins Symptom Checklist--20 (HSCL-20), a 20-item self-administered instrument used for the diagnosis of major depression in adult primary care patients. Respondents indicate how much they were distressed by various symptoms (e.g., feeling low in energy or slowed down, poor appetite, feeling blue) during the past 2 weeks using a scale ranging from 0 (not at all) to 4 (extremely). Scores were averaged across items, yielding a total score ranging from 0 to 4, with higher scores indicating greater depression symptoms.
Key Findings Patients with epilepsy were assessed for acute or chronic depression. Those with clinically significant depression were randomly assigned to the intervention group or a usual care control group. Physicians of control group patients received a letter that reported the depression diagnosis and encouraged clinically appropriate depression treatment. Participants were assessed at home at baseline and by phone 6, 12, and 18 months later. Intervention group participants had a greater reduction in depression symptoms than control group participants from baseline to 12 months (p < .005). Across the follow-up assessments, intervention group participants had fewer depression symptoms than control group participants (p = .046).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)
Outcome 2: Health-related quality of life
Description of Measures Health-related quality of life was assessed using the 31-item self-administered Quality of Life in Epilepsy--31(QOLIE-31). The instrument consists of the following subscales: overall quality of life, emotional well-being, cognition, medication effects, energy, social functioning, and seizure worry. Sample items include the following: "Overall, how would you rate your quality of life?" (with response options ranging from 10 [best quality of life] to 0 [worse quality of life]); "How much of the time during the past 4 weeks have you felt downhearted and blue?" (with response options ranging from 1 [all of the time] to 6 [none of the time]); and "How worried are you that medications you are taking will be bad for you if taken for a long time?" (with response options ranging from 1 [very worried] to 4 [not at all worried]). For each subscale, scores were summed and converted to scores ranging from 0 to 100, with higher scores reflecting better quality of life.
Key Findings Patients with epilepsy were assessed for acute or chronic depression. Those with clinically significant depression were randomly assigned to the intervention group or a usual care control group. Physicians of control group patients received a letter that reported the depression diagnosis and encouraged clinically appropriate depression treatment. Participants were assessed at home at baseline and by phone 6, 12, and 18 months later. Intervention group participants had a significant improvement on the emotional well-being subscale compared with control group participants from baseline to 12 months (p = .01). Across the follow-up assessments, intervention group participants had greater emotional well-being than control group participants (p = .02). No other significant differences were found between groups on QOLIE-31 subscales.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)
Outcome 3: Suicidal ideation
Description of Measures Suicidal ideation was measured using two items from the Hopkins Symptom Checklist--20 (HSCL-20), a 20-item self-administered instrument used for the diagnosis of major depression in adult primary care patients. These items asked respondents how much they were distressed by "thoughts of ending your life" and "thoughts of death or dying" during the past 2 weeks. Responses were given on a scale ranging from 0 (not at all) to 4 (extremely). The scores were summed, yielding a total score ranging from 0 to 8, with higher scores indicating greater suicidal ideation.
Key Findings Patients with epilepsy were assessed for acute or chronic depression. Those with clinically significant depression were randomly assigned to the intervention group or a usual care control group. Physicians of control group patients received a letter that reported the depression diagnosis and encouraged clinically appropriate depression treatment. Participants were assessed at home at baseline and by phone 6, 12, and 18 months later. From baseline to 12 months, the proportion of participants endorsing suicidal ideation decreased in the intervention group and increased in the control group (p = .025). Across the follow-up assessments, intervention group participants had less suicidal ideation than control group participants (p = .02).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult) 52.5% Female
47.5% Male
72% White
8% American Indian or Alaska Native
8% Hispanic or Latino
6% Black or African American
3% Asian
3% Native Hawaiian or other Pacific Islander

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Symptoms of depression 4.0 4.0 3.5 3.0 3.0 3.8 3.5
2: Health-related quality of life 4.0 4.0 3.5 3.0 3.0 3.8 3.5
3: Suicidal ideation 4.0 4.0 3.5 3.0 3.0 3.8 3.5

Study Strengths

The instruments used in the study are well researched and have acceptable reliability and validity. To measure implementation fidelity, a fidelity instrument was developed, validated, and used to assess adherence to the protocol for a third of therapeutic sessions, which were audiotaped. In addition, therapists participated in standardized training that included review of the manual, demonstrations, and role-playing, and cases were reviewed during weekly or biweekly depression management team sessions. Attrition was moderate. The study used random assignment. Appropriate analytical methods were used, including intent-to-treat analyses and inclusion of covariates.

Study Weaknesses

No data were provided on the ratings of audiotaped sessions or the completion of sessions. The sample size was small, and a relatively large percentage of participants did not complete all follow-up assessments. One confounding variable of concern is that a greater proportion of intervention than control group participants (25.7% vs. 3.4%) added or changed their antidepressant medications between baseline and 12-month follow-up, which may have affected the findings on suicidal ideation.

Review Date: March 2007

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Ciechanowski, P., Wagner, E., Schmaling, K., Schwartz, S., Williams, B., Diehr, P., et al. (2004). Community-integrated home-based depression treatment in older adults: A randomized controlled trial. Journal of the American Medical Association, 291(13), 1569-1577.  Pub Med icon

Schwartz, S. J., Wagner, E. H., Ciechanowski, P. S., Schmaling, K., Collier, C., Kulzer, J., et al. (2002, February). Case-finding strategies in a community-based depression treatment program for older adults: PEARLS [Roundtable presentation]. 16th National Conference on Chronic Disease Prevention and Control, Atlanta, GA.

Supplementary Materials

Glass, R. M., Allan, A. T., Uhlenhuth, E. H., Kimball, C. P., & Borinstein, D. I. (1978). Psychiatric screening in a medical clinic. Archives of General Psychiatry, 35, 1189-1194.

Health Promotion Research Center. (n.d.). Progress report: June 2002-September 2003. Report submitted to the Centers for Disease Control and Prevention Research Center Program.

Lyness, J. M. (2004). Treatment of depressive conditions in later life: Real-world light for dark (or dim) tunnels. Journal of the American Medical Association, 291, 1626-1628.

Schwartz, S. J. (2000, November). The PEARLS study: Program to Encourage Active, Rewarding Lives for Seniors. Report presented at the 15th National Conference on Chronic Disease Prevention and Control, Washington, DC.

Williams, J. W., Jr., Stellato, C. P., Cornell, J., & Barrett, J. E. (2004). The 13- and 20-item Hopkins Symptom Checklist Depression Scale: Psychometric properties in primary care patients with minor depression or dysthymia. International Journal of Psychiatry in Medicine, 34(1), 37-50.  Pub Med icon

Outcomes

Outcome 1: Symptoms of depression
Description of Measures Symptoms of depression were measured using the Hopkins Symptoms Checklist 20 (HSCL-20), a self-report instrument used for the diagnosis of major depression in adult primary care patients.
Key Findings At 12 months, compared with the usual care group, patients receiving the PEARLS intervention were more likely to have at least a 50% reduction in symptoms of depression (43% vs. 15%; p < .001) and to achieve complete remission from depression (36% vs. 12%; p = .002).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)
Outcome 2: Health-related quality of life
Description of Measures Health-related quality of life in functional, physical, social, and emotional well-being domains was assessed using the self-report Functional Assessment of Cancer Therapy Scale--General (FACT-G). The FACT-G is a generic core questionnaire with 27 items targeted to management of chronic illness. It has been used and validated with individuals diagnosed with cancer and other chronic conditions and with the general population.
Key Findings At 12 months, compared with the usual care group, patients receiving the PEARLS intervention were more likely to report greater health-related quality of life improvements in functional well-being (p = .001) and emotional well-being (p = .048).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.4 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 55+ (Older adult) 79% Female
21% Male
58% White
36% Black or African American
4% Asian
1% American Indian or Alaska Native
1% Hispanic or Latino

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Symptoms of depression 4.0 4.0 3.0 4.0 3.0 3.5 3.6
2: Health-related quality of life 3.0 4.0 3.0 4.0 3.0 3.5 3.4

Study Strengths

The investigators employed commonly used measures with sound psychometric properties. No differential attrition was evident across groups. Attrition and missing data were minimal and were handled appropriately with good statistical analyses. The intervention was implemented with the use of a manual, therapists underwent training consistent with the standard in the field, and weekly meetings were held to review cases. The investigators adequately attempt to account for variables found to differ significantly among groups. The use of a randomized controlled trial design minimized potential confounding variables.

Study Weaknesses

The articles did not mention any development or use of a fidelity instrument. The FACT-G (used to measure health-related quality of life in the study) appears to be used in research with cancer patients. However, consistent support for the use of this measure for a wider population (i.e., adults over the age of 60) is lacking. The study sample was small and drawn from a single geographic area.

Readiness for Dissemination
Review Date: January 2014

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Farren, L., Snowden, M., Steinman, L., & Monroe-DeVita, M. (2013). PEARLS fidelity instrument: Development and evaluation. Manuscript submitted for publication.

Program Web site, http://www.pearlsprogram.org

Steinman, L. (2012). Lessons learned from implementation: Older Americans Behavioral Health Technical Assistance Center Police Academy Regional Meeting. [PowerPoint slides]. Seattle, WA: Author.

University of Washington. (2012). PEARLS community-based depression treatment: September 27-28, 2012. Seattle, WA [training brochure]. Seattle, WA: Author.

University of Washington. (2012). PEARLS fidelity instrument. Seattle, WA: Author.

University of Washington. (2013). Considering a PEARLS training? Seattle, WA: Author.

University of Washington. (2013). Training and implementation services. Seattle, WA: Author.

University of Washington Health Promotion Research Center. (2012). PEARLS implementation toolkit: Community-based depression treatment. Seattle, WA: Author.

University of Washington Health Promotion Research Center. (2012). PEARLS training workbook and forms: Community-based depression treatment. Seattle, WA: Author.

University of Washington Health Promotion Research Center. (n.d.). PEARLS: Program to Encourage Active, Rewarding Lives [brochure]. Seattle, WA: Author.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
4.0 4.0 4.0 4.0

Dissemination Strengths

Program materials are logically organized and easy to follow and access, and they include clear information on the program and its implementation. Although implementation is straightforward, training is offered. In addition, monthly technical assistance calls are available to all implementation sites and provide a forum for sharing program concerns and ideas. Quality assurance materials include a monitoring instrument to measure both short- and long-term fidelity and a depression screening instrument to support outcome monitoring.

Dissemination Weaknesses

No weaknesses were identified by the reviewers.

Review Date: March 2007

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Ciechanowski, P. (n.d.). The PEARLS study: Community-integrated home-based depression treatment for the elderly [PowerPoint slides].

Ciechanowski, P., & Schwartz, S. (2004, February 19). PEARLS: Program to Encourage Active, Rewarding Lives for Seniors. Presented at the 18th National Conference on Chronic Disease Prevention and Control, Washington, DC.

Kaiser, C. (n.d.). PEARLS: A practitioner's perspective [PowerPoint slides].

Ludman, E. (2004, July). PEARLS dissemination training: Problem solving treatment [PowerPoint slides].

Schwartz, S. (n.d.). PEARLS: Background [PowerPoint slides].

Schwartz, S. (n.d.). PEARLS: Quality monitoring and program evaluation [PowerPoint slides].

University of Washington Health Promotion Research Center. (2005, September). PEARLS counselor training manual. Seattle, WA: Author.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
2.0 1.5 1.8 1.8

Dissemination Strengths

The program materials offer detailed information on problem-solving treatment and some information on organizational implementation. In-person training is available on an as-needed basis, and limited guidance and suggestions for program adaptation are available for problem-solving treatment. Quality assurance forms are provided to assist supervisors in monitoring implementation fidelity.

Dissemination Weaknesses

A step-by-step program implementation manual is not yet available. Supervisory guidance is not provided. The manual appears complicated enough to require in-depth training and support, yet implementers are not required by the developer to undergo formal, in-person training. No procedures are specified for collecting and analyzing program data to support quality assurance.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
PEARLS Implementation Toolkit (including forms and materials) Free Yes
2-day, on- or off-site implementation training $450 per person, plus travel expenses if on site No
Online implementation training (didactic portion of in-person implementation training) $95 per person No
Monthly technical assistance calls Free No
Phone and email support Free No
PEARLS Fidelity Instrument Free No
Counselor self-assessment Free No
Replications

No replications were identified by the developer.

Contact Information

To learn more about implementation or research, contact:
Lesley Steinman, M.S.W., M.P.H.
(206) 543-9837
lesles@uw.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):