SOMERVILLE -- Harold Carr dragged himself out of bed. Raging against the blindness that had shuttered his world, the retired courier paced his small apartment. Across the room lay his razor-sharp Swiss Army knife, waiting on a shelf. To the right just a few steps stood the balcony door, and a six-story plunge that could end his misery.
As he agonized over his next move, help knocked at the front door. Regina Kelly, the therapist who had been visiting him for weeks, had sensed Carr's deepening depression and arrived, that day in February 2003, to escort him to Somerville Hospital's psychiatric unit. After a short stay and a medication change, Carr, then 65, was back home and able to begin the long struggle, with Kelly's help, to rebuild his life.
Kelly's house calls are part of a growing effort to bring counseling and psychiatric medicines to troubled seniors in their homes. Federal estimates suggest that one in every five seniors suffers from a mental disorder, often exacerbated by loneliness, death of a spouse, failing health, and loss of independence. Depression, in particular, strikes hard: Men age 65 and older commit suicide at a rate three times that of other Americans.
But seniors are often the least likely to seek help. Some, like Carr, are homebound by physical ailments. Others don't have transportation. And many more are put off from visiting a clinic or even talking with their doctor by the perceived stigma of a mental illness.
''If we're going to be successful, we have to go to them," said Elizabeth Childs, state commissioner of mental health.
Both the state and federal governments are backing expansion of programs that treat seniors in their homes as part of larger efforts to improve all mental health services to the nation's growing population of elders. The Cambridge Health Alliance, which runs the program that serves Carr, recently won a federal grant to expand home counseling to hundreds more seniors in Malden, Everett, and surrounding communities. And the Romney administration is finalizing plans to build on the home-based programs currently offered by some community health centers and home-care agencies.
''We want to expand the number of providers who are able to do this," said Perry Trilling, the state's assistant secretary of elder affairs. Trilling says improving mental health services for seniors is the agency's top priority, along with housing. Trilling is reviewing a proposal from Mass Home Care, the state's association of elder service providers, to add mental health care to the state-funded programs they already provide. The expansion ties in with other state efforts to help seniors live independently longer and stay out of hospitals and nursing homes.
A survey of seniors' mental health needs in northeastern Massachusetts, conducted recently for six home care agencies, found that more than one-third of seniors with depression were not getting the care they needed. Besides a need for home care, the survey found that state-funded crisis teams weren't properly serving seniors facing psychiatric emergencies, and that many mental health clinics had little experience serving seniors.
''We have a rapidly increasing number of older people experiencing loss and depression and anxiety that is affecting their ability to function in the community," said Paul Lanzikos, executive director of North Shore Elder Services. ''We need to address this."
The six agencies, including North Shore Elder Services, are developing their own project to provide in-home assessment and care to seniors, modeled on a pilot in Marblehead. Similar programs are already offered by BayPath Elder Services in communities west of Boston, Geiger-Gibson Community Health Center in Dorchester, and Jewish Family & Children's Service.
''There's a comfort level of being in their own home that makes it more acceptable" to seniors who resist the idea of therapy, said Marsha Frankel, director of mental health services for Jewish Family & Children's Service.
Funding for home care has been a stumbling block to quicker expansion. Medicare and most private insurers pay therapists the same fee for home visits as for office visits, although the travel required makes home visits much more costly. And Medicare requires patients to pay half the cost of any outpatient mental health care, compared with 20 percent for care of physical ailments. Most of the existing home-visit programs in Massachusetts draw on extra grants from the state or federal government or generous donors.
Identifying mental illness in elders can also be difficult, caregivers say, because many seniors are more likely to complain of pain or insomnia than sadness and to resist mental health treatment. So, many of the programs count on nurses and aides already providing physical care to make referrals. Because mental and physical illnesses are often linked in the elderly -- depression is common in patients with heart disease, for example -- the programs also try to coordinate all aspects of health care.
''The seniors may not even recognize that what they have is depression," said Meckle Elston, psychiatry manager of geriatric outpatient services for the Cambridge Health Alliance. ''But it can turn into a severe crisis -- leading to not eating, not getting out of bed."
Carr faced that kind of crisis when he awoke blind one September morning in 2002. Years earlier, he had lost vision in his left eye. But he'd been able to hold a job with
He took to his bed. He dropped 54 pounds from his 6-foot-2 frame.
''I just didn't care anymore," he said. ''I felt like I was dying."
Although the Massachusetts Commission for the Blind was trying to link him with needed services, he couldn't -- and wouldn't -- go for psychiatric help.
''I don't like to go to clinics," he said. His early experiences with psychiatrists had left him wary. At 17, after bouncing among several foster homes, he broke into a store and was sent to a state youth facility.
''It took him a while to trust me," said Kelly, a licensed clinical social worker who started visiting Carr in December 2002, along with a clinical nurse specialist who prescribed antidepressants. Kelly and Carr now meet weekly.
He has regained some peripheral vision and learned to live with his disability. Carr, now 68, gets out regularly, cooks for himself, and handles his bills.
''Regina helped me out a lot," he said.
Alice Dembner can be reached at Dembner@globe.com.