The global, health care, and social value of community-based late-life depression care

Abstract

Despite its impact on health, health care, and costs of care, depression remains under-recognized and treated among older adults, in particular those underserved due to poverty, racism, and other social disadvantages. Traditional clinic-based mental health care is inadequate for addressing social determinants of mental health (e.g. economic deprivation, discrimination). One model for improving equity in access to late-life depression care is the Program to Encourage Active, Rewarding Lives (PEARLS). PEARLS aligns with global mental health recommendations to integrate quality care into accessible community-based organizations via trusted providers that reach underserved populations. Though PEARLS was developed with and by such organizations and has shown clinical effectiveness, it has not been widely adopted. The field of implementation science aims to close research-to-practice gaps so that evidence-based programs (EBPs) like PEARLS have the greatest public health impact. Research is needed to move beyond effectiveness in reducing depression to evaluate what matters to multiple partners - older persons, providers, organizations, and policymakers. What we know about barriers to EBP uptake offers clues for closing this research-to-practice gap. First, EBPs need to be adapted to local resource-constrained contexts in and outside the U.S. to reduce rather than exacerbate health inequities. For PEARLS, this means adapting the model for resource-constrained older persons and the community-based organizations that serve them. Second, EBPs need to show potential cost savings (e.g., through lower health care utilization), as improvement in health alone is often insufficient for PEARLS adoption or sustainability. Third, EBPs must address what matters now for both EBP participants and providers; for PEARLS and in COVID-19 context, what matter now is social isolation and loneliness (“social connectedness”). This dissertation brings together three studies to better understand PEARLS’ value by evaluating its global, health care, and social impact to promote older-adult health equity. Aim 1 uses a concurrent mixed-methods design to evaluate whether and how PEARLS improves social connectedness among older social service recipients living with depression and in poverty in five U.S. areas. Aim 2 applies quasi-experimental methods to existing administrative data on older social service recipients to assess PEARLS potential cost savings from reduced health care utilization (hospitalizations and nursing home stays). Aim 3 uses a multiple-case study design to evaluate PEARLS implementation with two resource-constrained cultural contexts: community health workers to support older U.S. Latinos, and newly trained social workers to support Cambodians living with diabetes. This dissertation integrates health services research, implementation science, global mental health, and health equity frameworks and methods to demonstrate the value of evidence-based depression care to improve the lives of underserved older populations.