Q&A with Zvi Gellis
Currently in the United States, there are approximately 45 million people who are 65 years of age and older. By 2030, that number is expected to jump to nearly 75 million people.
But people aren’t just growing older in ever-increasing numbers—they’re also living longer. Today, there are about 54,000 people who are 100-plus years of age. In 2040, there will be approximately 600,000 people who are centenarians.
What’s crucial to Zvi Gellis, a professor in Penn’s School of Social Policy & Practice, is that people age well—that they have fulfilling, enriched lives after the age of 65 and continue to engage in the world after retirement.
Gellis is an expert in gerontology and geriatrics, and has long studied anxiety and depression in older populations. He is the director of the Penn Center for Mental Health & Aging, as well as the director of the Ann Nolan Reese Penn Aging Certificate, where students can specialize in geriatric social work.
“We’ve developed the Penn Aging concentration program to get students really excited about having the skills and knowledge to work with older people,” Gellis says. “The moment they start working with older people, they tell us, ‘We love it.’ This year we have 15 [students], the largest cohort ever. Usually, we get about 10 to 12 percent of the entire student body [at SP2] that is interested in geriatrics and older persons.”
Gellis’ interest in working with an older population was sparked early in his career. After receiving his M.S.W. from the University of Toronto, Gellis held a job as a social worker for adults in inpatient and outpatient psychiatry. He wasn’t specifically working with an older population, but became interested in the area as he noticed medical, social, and psychological services were lacking as his patients aged.
He made the transition to academia after completing a one-year certificate in research methods at the University of Toronto, and he was invited to apply to the Ph.D. program. With the support of his family—most notably, he says, his wife, who went back to work full-time while he was in school—Gellis earned his Ph.D. in 1999 from the University of Toronto’s School of Social Work. He was recruited to Penn in 2008.
Gellis conducts research through the Center for Mental Health & Aging, and has also led several projects ranging from teaching problem-solving therapy that he also developed, creating a gerontology curricula, and using technology to assist an aging population in the home as they communicate with nurses, doctors, geriatric social workers, and other health professionals.
At the core of his research is the belief in increasing the quality of life for an aging population so they are able to experience lives of quality, not just quantity.
“Social connectivity is such an important issue for older people—increasing behavioral activities, doing things that are pleasurable and fun to do. This is really important,” Gellis says. “An engagement in life is very important, not just extending your life, but engaging it and making something of it, because the key thing here is meaning and purpose in your life.”
The Current sat down with Gellis to discuss his research on aging and depression, how depression is often underdiagnosed in an older population, why there’s a shortage in geriatric social workers, and what it means to age successfully.
Q: What are some of the big issues associated with mental health and aging?
A: As people become older—over 65, over 75, over 85—they can develop chronic illnesses, ranging from cardiac disease and hypertension to cancer and arthritis, and these are very high-costing diseases and there are very rapid re-hospitalization rates, particularly for cardiovascular disease and chronic obstructive pulmonary disease, COPD. Specifically, it’s been found that these cardiac and COPD patients return to hospital within one month of being discharged, so it’s very high-costing. And with these chronic diseases, there are very high rates of depression or depressive symptoms. This is how I started as a gerontologist in this field—I was basically an inpatient-outpatient psychiatry social worker in an academic health setting. We noticed many of these people had depressive disorders. We developed a treatment program, using evidence-based practice interventions particularly for homebound older people who were discharged from hospitals back to home. We developed these interventions to be delivered in the home; a nurse, a social worker team would go into the home and provide what was needed—medical treatments and psychological treatments for depression for the older person with the goal of teaching the patient to control and manage their disease versus the disease managing them. For older people who are medically disabled, their weeks are filled with medical appointments, and so navigating the health system was very difficult for them, and understanding their symptoms and how to deal with it. What tended to happen is they would rush to their primary care physician or they would rush to the ER. We’ve been able to show in our research that we’ve been able to reduce depression significantly and also reduce hospitalizations and ER visits particularly for cardiac disease, and COPD patients, as well. Our research team was the first to design an RCT [randomized controlled trial] study with the home health care patient population and demonstrated significant reductions in depression outcomes. We’re now using telehealth technology with the depression care interventions. First we were doing face-to-face; we could come into people’s homes and offer face-to-face interventions, and we decided to try telehealth technology, particularly for older medically disabled patients who are living far away from a city center or where there may be a lack of available health care resources. They may be living in the suburbs or in rural areas. This has been very exciting research. This is the first telehealth effectiveness for depression care study of its kind.
Q: You’ve done research on problem-solving therapy in a depressed geriatric population. What is problem-solving therapy, exactly?
A: It’s a type of cognitive behavioral therapy, so it’s a way to re-learn and understand how you’re thinking about problems that you’re having in your life. As an example, an older person may have problems with transportation—how do I get somewhere, how do I go shopping, how do I find my benefits, how do I get my health insurance, how do I do my taxes, and also, am I having trouble with psychological problems, emotional problems like depression or anxiety? Am I having trouble with family relationships? Any problem in life that you might be experiencing can be worked on to obtain some rational solutions. The intervention is delivered by breaking down problems into manageable components to be worked on with the patient, the older person, and having them learn how to problem-solve. There are about five or six steps to problem-solving. In the therapy, we actually educate, practice, and review the steps to problem-solving and have the patient attempt weekly solutions by completing homework assignments. We also teach the patient how to look at life in a more optimistic and positive way, and this is very important because research shows that people that have an optimistic view of themselves are better equipped to face the challenges of life, of a medical disease, and are likely to have successful outcomes in therapy. Problem-solving therapy is an effective short-term therapy that ranges in duration from six- to eight-weeks long. It has been proven to be effective. The older person learns how to solve their problems in a very systemic and rational way, and thinking about understanding the irrational thoughts they may have about not being able to solve their problems in their life, not being able to deal with challenges, not being able to be optimistic about the future. These are really key issues for older people—having a purpose in their life, having meaning in their life is very important and without an aim or without a goal in their life, they will become very depressed and very anxious. The highest rate of suicide in the country is among persons 85 years and older, particularly older white men. Our research attempts to address these issues. Our goal is to reduce suicidal thoughts, suicidal actions, because depression will lead to serious potential threats for suicide.
Q: How has technology played a role in your research?
A: Telehealth technology has been a wonderful intervention for depression because it’s emerging as an effective and cost-effective modality, but there needs to be more research. It hasn’t quite met all the evidence-based criteria but it’s getting there because Medicaid is providing reimbursements and numerous large health insurers are providing reimbursements, particularly for rural areas, where it makes a lot of sense. This is where you could have a discussion or counseling face-to-face on a computer screen between the patient and the social work therapist or nurse therapist. You can provide remote monitoring of cardiac symptoms or COPD symptoms. The nurse can view if there are any red flags and this will prevent the person from having to rush to the ER because the nurse is taking care of them on a day-to-day basis by the remote monitoring. Then the social worker is providing counseling over the remote device, or using FaceTime or Skype.
Q: Is there any kind of barrier to technology or a learning curve associated with telehealth?
A: Older people are very savvy in using the equipment because they are trained on how to use the equipment. It’s very simple. There are a couple of buttons, you press ‘yes’ or ‘no,’ you press the ‘send’ button. They don’t need to connect anything, they just need to turn the ‘on’ button. The remote monitoring, the telehealth machine is about the size of [a laptop] or it could be an iPad. You can also put a heart monitor on yourself to monitor your heart, temperature, oxygen saturation; you can have a scale on the floor. This is all connected based on your needs and the symptoms. We were very surprised in our studies and we found very high satisfaction rates with using the equipment. The older patients stated that it was very easy to use because they received training for it. These are homebound older people. Now, if you ask older people where would they rather live, in an assisted living facility or in a retirement community or in their own home, the majority of people will say they want to live at home, they want to pass away at home, they don’t want to live in an institution of any kind, if at all possible. This is why we’ve targeted the homebound older person, because most older people live in the community, they don’t live in nursing homes. Less than 3 percent of older people live in a nursing home or an institution. We have 97 percent of all older people in this country living at home or in the community.
Q: You’ve written that there’s a shortage in geriatric social workers. What accounts for the shortage?
A: When you think about professional psychology, nursing, social work, and medical students, do they really want to go into geriatrics? No. There is a major negative bias toward older people, toward aging. You’ll hear people say, ‘He’s just cranky, he’s old. He’s old so of course he’s depressed.’ I hear this frequently. At the same time, a lot of our graduate students don’t even think about working with the older population unless they’ve had a very positive experience with their grandparents or they may have been a volunteer at a nursing home.
Q: What specifically does the Penn Aging Certificate program teach students?
A: When you think about older people, what do you think about? Medicare, nursing homes, and so on, but only 3 percent of the older population resides in a nursing home, and students start to figure it out when they see themselves working with older people. We’ve developed a program with several courses, clinical practice courses. We offer standardized clinical patient training at the School of Medicine and we take all of our geriatric social work fellows there and they actually prepare to meet with two older patients: One is a depressed case, the other is an end-of-life treatment case. They have to talk with the person about end-of-life because they just received bad news that they have cancer and it’s terminal. They get a chance to experience these things under pressure and they get videotaped and then they get immediate feedback after the session. We’re talking about 30-minute counseling sessions with the patients. They say this is the best experience they’ve had in graduate school.
Q: Is depression in the older population underdiagnosed?
A: It is underdiagnosed. It could be for many reasons. One reason is the older person tends to mask it or tends not to say anything about it because they don’t want to talk about their emotions or it’s stigmatizing for them. They will come to the doctor’s office and say, ‘I’ve got a neckache, I’ve got a backache, I’ve got a headache.’ They’ll somatize it in a physical form because that’s what they understand when they go to the doctor’s office. But the talk about psychiatry, or about emotional problems—they will not talk about that. The other thing is that health professionals are not well-trained in diagnosing for depression unless you’re in specialty care. Also, it’s a cohort effect. The older generation, when you think about what they think about psychiatry—they know about Freud, they know about psychoanalysis on the couch, and they know about asylums, nervous breakdowns. For them, it’s very stigmatizing.
Q: Since depression can lead to all kinds of other health issues, can it also exacerbate health problems in older adults?
A: Yes, and that’s what I was telling you about the co-morbidity prevalences of depression with other chronic diseases. It’ll exacerbate it, yes. It’ll make it worse and they’ll end up back in the ER or hospital or they’ll take more medications and so on. The idea is to help people enrich their lives in their home and be able to manage their chronic diseases and understand symptoms so they don’t have to rush to the ER.
Q: At the Center for Mental Health & Aging, you manage research and several national projects. Can you talk about one of these projects?
A: The AGE-SAFETY at home toolkit, the safety scale that we’ve developed, is still in development. We’ve sent it out to occupational therapists across the country and we’re going to be sending it out to more home health care workers around the country. There are 10,000 agencies in this country that are home health care-based, which means that nurses and social workers and PT [physical therapy], OT [occupational therapy] go to people’s homes post-surgery or post-hospitalization to make sure that they’re doing well and they don’t run back to the hospital. We said we really need a toolkit to help these workers who, when they go into the home, can make sure that the older person is completely safe, physically and also mentally. The AGE-SAFETY scale covers all kinds of safety issues in the home—carpets, stairs, even coming from the outside, are there stairs when you go in the house? How difficult is it to pull the door open or closed? Indoor issues—lighting, is the person able to cook? Do they leave the burners on? Do they have access to a car, are they able to drive? These are all kinds of extra issues that other safety toolkits have not looked at. Has there been a depression assessment recently? Has there been an anxiety assessment? Has there been a financial assessment? Is there a place where all important information is kept and is known where it’s kept? Also, home wandering, the community itself that they live in, transportation, assistive devices, and communication. We’re really concerned with the social connectedness for older people and this is where our problem-solving therapy interventions come into play. It’s a life problem: ‘I’m isolated, I don’t have much of a network, my friends have died, nobody’s coming to visit me.’ This is a problem that a social work therapist would work on to help increase social connectivity. For older people, if they don’t have meaning and purpose in life, it starts to go down the slippery slope to depression, to suicide. If you’re having chronic conditions or you’re wheelchair-bound or isolated, it leads to negative outcomes.
Q: As the older population increases in size, it seems like the need for more geriatric social work professionals is only going to get larger.
A: I’m calling the new chapter of life, in terms of post-retirement, the adult wave. Life extension without life enrichment is a pathway to negative outcomes. As a matter of fact, there is a trend in this country to stop building nursing homes and start building or buying a home and bringing maybe eight to 10 people into a home. It’s called a greenhouse model. It’s really like you’re living on your own block, but it’s a home without stairs, it’s a one-level home. The rooms are on the periphery of the home and you come out to the living room, the hearth, the TV, the kitchen, and all the activity happens right there. Even if you’re in a wheelchair, it doesn’t matter. It’s certainly not the life of a nursing home. You are interacting with the staff. There are about three or four staff there, a cook, a couple of nurse assistants, a nurse, and so on. They’re interacting with you. Whatever you want to do today, we’re going to do—playing games, watching television, helping to cook, or even talking to us while cooking. It’s a very different model and non-institutionalizing at all. It very much feels like you’re at home. And you’re communicating with other residents because you sit around a very long dining room table.
Q: What are your goals for the Aging Certificate program and the Center?
A: The Aging Certificate program will continue into perpetuity after I retire because it’s so needed and the students who come into the program know what the future looks like, where the jobs are. They are also looking for an experience of a small cohort. They get to know each other really well. These are students who keep in touch with each other. For the Center for Mental Health & Aging, we have done more of the work on telehealth and depression; we were the pioneers in this area. It’s very difficult work to do because it’s randomized control trials and it’s working with home health care agencies across the country. We would like to do a larger study on integrated telehealth care for chronic illness and depression. This would be a national study, with six or seven sites, that would be our ideal. To undertake that costs a lot of money. Our current project now is on successful and productive aging; it’s a national project that we started here in Philly.
Q: What is that project about?
A: We were invited by the Osher Foundation’s Lifelong Learning Institute, [which offers] university-level courses to semi-retired or retired older persons without the course requirement of having to do assignments. You just come to class and enjoy and learn. Name something and they have it—film studies, art history, languages, yoga, trips, history, politics, art. They said, ‘We want you to do research with us. We’re not sure what, but we want to be involved in aging research.’ I suggested to them a study and survey on what is successful and productive aging. So, we’re calling it the National Successful Aging Project. We had such a wonderful recruitment. People were so excited about getting involved. It’s basically a survey and we decided we’re going to do this across the country. There are 116 of these Lifelong Learning Institutes across the country. We’re going to choose one or two in each census region; there are nine census regions in the country, so we might have nine sites. With our research team, particularly one of my doctoral students who is going to be graduating at the end of this year, we developed a survey and are looking at several important issues: meaning and purpose in life, satisfaction in life, optimism, resiliency, problem-solving, psychological health, socialization, and positive spirituality. We know in terms of definitions of successful aging, one piece of it is physical health, but there’s been so much research in that area. We know if you have a chronic disease it’s going to be really hard to have successful aging. Nobody’s looked at resiliency, nobody’s really looked at problem-solving and positive spirituality. This may reduce the sense of loss of control and helplessness that accompanies illness. Positive spiritual beliefs can increase the purpose and meaning of life even in the face of medical problems. We’re really excited to see what people who think of themselves as well—older people 65 years of age and older who are taking courses and so on—think about successful aging. One of my colleagues suggested we compare them to people living in retirement communities. I’m recruiting some of my colleagues around the country to disseminate the survey and they’ll be involved in our team, there will be publications. But I’m so excited about it because those areas—meaning and purpose in life, resiliency, optimism, satisfaction with life, and positive spirituality—let’s see how they predict successful aging in those populations.
Q: This project seems so different than so many other aging projects, which seem to focus on mortality and health risks.
A: Just because people look old doesn’t mean that they’re negative or unhappy. If you came to these courses, you’d say, ‘Wow, look at all the vibrancy and happiness and optimism. People are so excited to be here. That’s what aging is all about.’ Yes, people have serious illnesses [with] negative outcomes, but they can still have some happiness. I believe in that. It’s also the way individuals cope with life challenges. The old saying, is the glass half-full or half-empty—how do you view yourself and view the world? Do you view it in a positive way? Is it a challenge to you and you’re going to be as resilient as you can and still have a positive meaning in your life with your family in the days that you have left or is it going to be an all-downhill terrible drudge? I can tell you from our research with problem-solving, if you have an optimistic view of the world, you are more likely to have a very positive outcome in terms of solving your problems in general. Obviously you can’t stop cancer, but if you have a better outlook, you’ll have a better health outcome in general than people who are very negative. Stress will increase their anxiety and depression and so on and reduce their brain cells. The outlook that you have will determine what the outcomes are. And that’s what problem-solving is all about.