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Program to Encourage Active, 

Rewarding Lives for Seniors (PEARLS) 

Program Description

The Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) is an intervention for people 60 years 

and older who have minor depression or dysthymia and are receiving home-based social services from 

community services agencies. The program is designed to reduce symptoms of depression and improve healthrelated quality of life. PEARLS provides eight 50-minute sessions with a trained social service worker in the

client’s home over 19 weeks. Counselors use three depression management techniques: (1) problem-solving 

treatment, in which clients are taught to recognize depressive symptoms, define problems that may contribute 

to depression, and devise steps to solve these problems; (2) social and physical activity planning; and (3) 

planning to participate in pleasant events. Counselors encourage participants to use existing community services 

and attend local events.

Descriptive Information

Areas of Interest  Health and wellness

 Mental health promotion

Outcomes

Review Date: March 2007

 Symptoms of depression

 Health-related quality of life

Ages

 50–60 (Older adult)

 61–74 (Older adult)

 75–84 (Older adult)

 85+ (Older adult)

Genders  Female 

 Male 

Races/Ethnicities

 American Indian or Alaska Native

 Asian

 Black or African American

 Hispanic or Latino

 White

Settings Home

Geographic Locations  Urban

 Suburban

Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the 

developer.

Implementation History

PEARLS was first implemented in the Seattle, Washington, area through two local 

agencies: (1) Aging and Disability Services, Area Agency on Aging for Seattle and King 

County, and (2) Senior Services of Seattle/King County. Each agency implemented the 
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intervention as part of the first evaluation study of PEARLS, conducted by the 

developer in 2000. Since 2008, more than 40 PEARLS programs have been active 

throughout the United States, in Arizona, California, Colorado, Georgia, Illinois, Iowa, 

Massachusetts, Missouri, New York, North Carolina, Ohio, Vermont, Washington, and 

Wyoming. Agencies implementing PEARLS include area agencies on aging, 

community mental health centers, senior centers, and other community-based 

organizations. Approximately 1,900 clients have participated in PEARLS, and over 300 

providers have been trained to date. Technical assistance is provided by the 

University of Washington Health Promotion Research Center. PEARLS providers often 

conduct evaluations of their program for internal use or funding organizations. To 

date, none of these evaluations have been published in peer-reviewed literature.

Adaptations No population- or culture-specific adaptations were identified by the developer. 

Quality of Research

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., ... LoGerfo, J. (2004). 

Community-integrated home-based depression treatment in older adults: A randomized controlled trial. Journal 

of the American Medical Association, 291(13), 1569–1577. PubMed abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/15069044

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 at the 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. An evaluation of a self-report inventory. Archives of General Psychiatry, 35(10), 1189–1195. 

PubMed abstract available at http://www.ncbi.nlm.nih.gov/pubmed/697537

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(13), 1626–1628. PubMed abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/15069051
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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. PubMed abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/15242140

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

(0.0–4.0 scale) 3.6

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

(0.0–4.0 scale) 3.4
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Study Populations 

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

Study Age Gender Race/Ethnicity 

Study 1

 50–60 (Older adult)

 61–74 (Older adult)

 75–84 (Older adult)

 85+ (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) 

Criterion 

Ratings 

Outcome 1 Outcome 2 

Reliability of Measures 4.0 3.0

Validity of Measures 4.0 4.0

Intervention Fidelity 3.0 3.0

Missing Data and Attrition 4.0 4.0

Potential Confounding Variables 3.0 3.0

Appropriateness of Analysis 3.5 3.5

Overall Rating 3.6 3.4
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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 healthrelated 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: 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 program 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). 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.
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Readiness for Dissemination Ratings by Criteria (0.0–4.0 scale) 

Criterion Rating 

Implementation Materials 2.0

Training and Support 1.5 

Quality Assurance 1.8 

Overall Rating 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.
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Implementation Materials 

Item Description Cost 

Required by 

Developer 

PEARLS Toolkit (includes background on PEARLS; 

detailed instructions, guidance, and tips for 

implementing PEARLS within an organization and 

carrying out the components of the PEARLS sessions 

with clients; and forms for creating the organizational 

and data management infrastructure necessary for the 

implementation of PEARLS)

Free Yes

2-day, off-site training in Seattle, WA

$395 per participant 

(includes tuition, course 

materials, continental 

breakfast, and snacks)

No

On-site training

Varies depending on the 

number of participants

(minimum of 15–20 

persons), plus travel 

expenses

No

Online training modules Contact the developer No

Monthly technical assistance conference call Free No

Phone- or email-based technical assistance Free No

Tailored technical assistance

Varies depending on site 

needs and number of 

participants

No

PEARLS Fidelity Instrument (brief, 20-item multiplechoice survey) Free No

Other Citations

Chaytor, N., Ciechanowski, P., Miller, J. W., Fraser, R., Russo, J., Unutzer, J., & Gilliam, F. (2011). Long-term 

outcomes from the PEARLS randomized trial for the treatment of depression in patients with epilepsy. Epilepsy 

and Behavior, 20(3), 545–549. PubMed abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21333607

Ciechanowski, P., Chaytor, N., Miller, J., Fraser, R., Russo, J., Unutzer, J., & Gilliam, F. (2010). PEARLS depression 

treatment for individuals with epilepsy: A randomized controlled trial. Epilepsy and Behavior, 19(3), 225–231. 

PubMed abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20609631
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Community Preventive Services Task Force. (2012). Recommendation from the Community Preventive Services 

Task Force for use of collaborative care for the management of depressive disorders. American Journal of 

Preventive Medicine, 42(5), 521–524. PubMed Abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/22516494

Frederick, J. T., Steinman, L. E., Prohaska, T., Satariano, W. A., Bruce, M., Bryant, L., ... Late Life Depression 

Special Interest Project Panelists. (2007). Community-based treatment of late life depression: An expert panel–

informed literature review. American Journal of Preventive Medicine, 33(3), 222–249. PubMed abstract available 

at http://www.ncbi.nlm.nih.gov/pubmed/17826584

Jacob, V., Chattopadhyay, S. K., Sipe, T. A., Thota, A. B., Byard, G. J., Chapman, D. P., & Community Preventive 

Services Task Force. (2012). Economics of collaborative care for management of depressive disorders. A 

Community Guide systematic review. American Journal of Preventive Medicine, 42(5), 539–549. PubMed 

abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22516496

Thota, A. B., Sipe, T. A., Byard, G. J., Zometa, C. S., Hahn, R. A., McKnight-Eily, L. R., ... Community Preventive 

Services Task Force. (2012). Collaborative care to improve the management of depressive disorders: A 

Community Guide systematic review and meta-analysis. American Journal of Preventive Medicine, 42(5), 525–

538. PubMed abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22516495

Translational Work

PEARLS was developed as an in-home intervention for older adults with minor depression or dysthymia, and the 

program was evaluated in a randomized controlled trial in 2000–2003 through a partnership between the 

University of Washington Health Promotion Research Center and two local agencies: (1) Aging and Disability 

Services (ADS), Area Agency on Aging for Seattle and King County, and (2) Senior Services of Seattle/King County

(SSSKC). The program was designed to be delivered during home visits with clients from ADS, and 

implementation by ADS and SSSKC continues to date. After the first evaluation, PEARLS was evaluated in a 

randomized controlled trial with 80 adults with epilepsy and co-occurring depression. Partnerships with several 

community-based organizations have contributed to the expansion of PEARLS to reach other populations, such 

as clients who speak limited English and adults with major depression. In 2007, the PEARLS Toolkit 

(http://www.pearlsprogram.org/Training/PEARLS-Toolkit.aspx) was developed with the support of the 

Washington State Aging and Disability Services Administration to assist in the dissemination and implementation 

of PEARLS in community agencies. PEARLS providers and training participants from sites across 14 States 

participate in monthly technical assistance calls conducted by the PEARLS research team. These calls offer an 

opportunity to solve problems and provide strategies for overcoming organizational barriers to implementation 

within and outside the system. PEARLS has been included in the Substance Abuse and Mental Health Services 

Administration’s National Registry of Evidence-based Programs and Practices 

(http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=29) and in the Agency for Healthcare Research and 

Quality’s Innovations Exchange (http://www.innovations.ahrq.gov/content.aspx?id=2613). PEARLS received the 

Title III-D Highest Tier Evidence-Based Health Promotion/Disease Prevention Programs rating by the 

Administration on Aging and was awarded the 2011 Archstone Award for Excellence in Program Innovation.
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The implementation of PEARLS by ADS is documented in a qualitative study conducted in 2008. Focus group 

interviews with PEARLS providers and their clients were analyzed to identify facilitators and barriers to 

implementation. PEARLS clients reported that in addition to treating depression, PEARLS provided other 

benefits, such as increasing physical and pleasurable activities, social support, quality of life, and ability to live 

independently. Program administrators reported that the implementation of PEARLS was innovative for ADS 

because area agencies on aging had not typically provided mental health services. ADS gained evidence-based 

program experience, a partnership with the University of Washington Health Promotion Research Center, and 

new funding opportunities. PEARLS counselors were viewed as a support for case managers as well as an 

integral part of a comprehensive program to help meet clients’ mental health needs. Some barriers to 

implementations were identified, such as client ineligibility because of program exclusion criteria, beliefs about 

the depression screening instruments, and the added workload to case managers. 

The partnership between the University of Washington Health Promotion Research Center and three 

community-based organizations implementing PEARLS in Seattle–King County has been documented by PEARLS 

researchers through a series of semistructured interviews conducted with PEARLS counselors, PEARLS referrers, 

and PEARLS participants from January to March 2011. Informants provided insight on three major areas: 

populations that are hard to reach with PEARLS, barriers to reaching these populations, and suggestions for 

improving recruitment and retention. Veterans, men and women who are ethnic minorities, immigrants, people 

who speak limited English, adults over age 75, adults with low incomes, and people residing in rural 

communities were identified as being hard to reach. Some of the challenges in reaching these populations 

revolved around stigma; client mistrust and negative perceptions about research; isolation created by the 

client’s geographic location; and socioeconomic barriers (e.g., transportation, poverty, low levels of education). 

Suggested strategies for reaching these populations included recruiting clients through word of mouth by 

PEARLS program completers, recruiting clients through a variety of media outlets, and using positive language to 

describe the program. Strategies for improving retention included ensuring that PEARLS counselors are caring 

and helpful to the clients they serve, establishing rapport to keep clients engaged, and being flexible with each 

client’s needs. Another suggested strategy to improve client retention was to taper PEARLS sessions gradually, 

specifically early in the program. Informants also noted that booster sessions and follow-up phone calls should 

be provided to the clients. 

Site With 

Translational 

Work 

Articles Describing Site’s Translational Work, by Category 

Planning/ 

Partners Adoption 

Reach/ 

Recruitment Implementation Effectiveness Maintenance 

Aging and 

Disability 

Services

Article 1 Article 1 — Article 1 Article 1 Article 1

3 communitybased 

organizations 

in Seattle–King 

County

Article 2 — Article 2 — — —
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Article 

Number Article Reference 

1 

Steinman, L., Cristofalo, M., & Snowden, M. (2012). Implementation of an evidence-based 

depression care management program (PEARLS): Perspectives from staff and former clients. 

Preventing Chronic Disease, 9, E91. PubMed abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/22537909

2 

Steinman, L., Hammerback, K., & Snowden, M. (2011). It could be a pearl to you: Exploring Program 

to Encourage Active and Rewarding Lives for Seniors (PEARLS) with hard-to-reach populations.

Unpublished manuscript.

Contacts

To learn more about implementation or research, contact:

Lesley Steinman, M.S.W., M.P.H.

University of Washington Health Promotion Research Center

(206) 543-9837

mailto:mlesles@uw.edu

Additional program information can be obtained through the following Web sites: 

http://www.pearlsprogram.org

http://depts.washington.edu/hprc/depression

This intervention summary was developed through funding from the Administration for Community Living (ACL), 

Administration on Aging (AoA). The summary contains information from the Quality of Research and Readiness 

for Dissemination reviews that were completed in March 2007 for the intervention summary developed by the 

National Registry of Evidence-based Programs and Practices (NREPP), which is funded by the Substance Abuse 

and Mental Health Services Administration (SAMHSA).