Long-term outcomes from the PEARLS randomized trial for the treatment of depression in patients with epilepsy

Abstract

Depression is associated with higher rates of suicide and lower quality of life in individuals with epilepsy. We previously published the 12-month outcome from our randomized clinical trial of PEARLS (Ciechanowski P, Chaytor N, Miller J, et al. Epilepsy Behav. Epub 5 July 2010). The purpose of this study was to determine the long-term effectiveness of PEARLS, a home-based collaborative care intervention consisting of problem-solving treatment, behavioral activation, and psychiatric consultation, in individuals with epilepsy. Patients were randomly assigned to PEARLS (N = 40) or usual care (N = 40), and assessed at baseline and 6, 12, and 18 months. Patients assigned to PEARLS achieved lower depression severity (P < 0.05) (Hopkins Symptoms Checklist-20), lower suicidal ideation (P < 0.02), and better emotional well being (QOLIE-31) (P < 0.02) over 18 months, compared with patients given the usual care. The PEARLS program significantly reduces depressive symptoms in adults with epilepsy, and this effect is maintained for 18 months after baseline and for more than 1 year after completion of home visits.

Introduction

Depression affects 30–50% of individuals with epilepsy [1], [2], [3] and contributes to functional impairment [4], [5], [6], unemployment [7], lower quality of life (QOL), and suicide rates 5–25 times higher than those in the general population [2], [4]. Epilepsy leads to unique challenges that contribute to depression, including driving restrictions [8], physical inactivity [9], social isolation, and unemployment [10]. Depression is suboptimally treated in epilepsy [4], [11], [12], and there are few clinical trials of psychotherapeutic or pharmacological depression treatment in this population. We adapted PEARLS [13] to treat adults with epilepsy through collaboration between public health, psychiatric, and epilepsy professionals. We conducted a randomized controlled trial of PEARLS for treatment of clinically significant depression in people with epilepsy. In 2010, we published the short-term findings from this study showing that PEARLS reduced depression and suicidal ideation and increased emotional well-being compared with usual care over 1 year [14]. Because depression is chronic and recurrent, it is important to explore the long-term impact of this intervention. The current study extends our previous findings to include the 18-month outcome of the PEARLS intervention (i.e., 13 months after services were withdrawn). The PEARLS intervention focuses on teaching participants problem-solving skills and encouraging more active and pleasurable lives, as well as initiation of psychotropic medication when appropriate. It was expected that these skills and behaviors would be maintained after the intervention was withdrawn and result in long-lasting benefits. Specifically, we hypothesized that the benefits of the PEARLS intervention would be maintained over 18 months despite the withdrawal of in-home treatment sessions at 5 months.