Evidence-Based Reviews

Making an IMPACT on late-life depression

Current Psychiatry. 2006 September;5(9):85-92

References

1. Lyness JM, Caine ED, King DA, et al. Psychiatric disorders in older primary care patients. J Gen Intern Med 1999;14(4):249-54.

2. Klap R, Unroe KT, Unützer J. Caring for mental illness in the United States: a focus on older adults. Am J Geriatr Psychiatry 2003;11(5):517-24.

3. Callahan CM, Hendrie HC, Dittus RS, et al. Improving treatment of late life depression in primary care: a randomized clinical trial. J Am Geriatr Soc 1994;42(8):839-46.

4. Bartels SJ, Coakley EH, Zubritsky C, et al. Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. Am J Psychiatry 2004;161(8):1455-62.

5. Crystal S, Sambamoorthi U, Walkup JT, et al. Diagnosis and treatment of depression in the elderly medicare population: predictors, disparities, and trends. J Am Geriatr Soc 2003;51(12):1718-28.

6. Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry 2003;54(3):216-26.

7. Lin EH, Katon W, Von Korff M, et al. Relationship of depression and diabetes self-care, medication adherence, and preventive care. Diabetes Care 2004;27(9):2154-60.

8. Unützer J, Patrick DL, Simon G, et al. Depressive symptoms and the cost of health services in HMO patients aged 65 years and older. A 4-year prospective study. JAMA 1997;277(20):1618-23.

9. Oxman TE, Dietrich AJ, Schulberg HC. Evidence-based models of integrated management of depression in primary care. Psychiatr Clin North Am 2005;28(4):1061-77.

10. Hegel MT, Dietrich AJ, Seville JL, et al. Training residents in problem-solving treatment of depression: a pilot feasibility and impact study. Fam Med 2004;36(3):204-8.

11. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16(9):606-13.

12. Unützer J, Katon WJ, Williams JW, et al. Improving primary care for depression in late life: the design of a multi-center randomized trial. Medical Care 2001;39:785.-

13. Bachman J, Pincus HA, Houtsinger JK, Unützer J. Funding mechanisms for depression care management: opportunities and challenges. Gen Hosp Psychiatry 2006;28(4):278-88.

14. Unützer J, Katon W, Williams JW, Jr, et al. Improving primary care for depression in late life: the design of a multicenter randomized trial. Med Care 2001;39(8):785-99.

15. Unützer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002;288(22):2836-45.

16. Unützer J, Powers D, Katon W, et al. From establishing an evidence-based practice to implementation in real-world settings: IMPACT as a case study. Psychiatr Clin North Am 2005;28(4):1079-92.

17. Katon WJ, Schoenbaum M, Fan MY, et al. Cost-effectiveness of improving primary care treatment of late-life depression. Arch Gen Psychiatry 2005;62(12):1313-20.

18. Hunkeler EM, Katon W, Tang L, et al. Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. BMJ 2006;332(7536):259-63.

19. Lin EH, Katon W, Von Korff M, et al. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. JAMA 2003;290(18):2428-9.

20. Bruce ML, Ten Have TR, Reynolds CF, 3rd, et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA 2004;291(9):1081-91.

21. Grypma L, Haverkamp R, Little S, et al. Taking an evidence-based model of depression care from research to practice: making lemonade out of depression. Gen Hosp Psychiatry 2006;28(2):101-7.

Consulting psychiatrist’s role. If a patient is not sufficiently improved after 8 to 10 weeks, the care manager works with the PCP and psychiatrist to change treatment according to an evidence-based algorithm (Figure).¹² In large health care systems, the psychiatrist meets weekly with the care manager to review treatment plans for approximately 100 depressed older adults, with particular attention to those who are not improving. Psychiatrists may see patients in person or facilitate other specialty mental health treatment, as indicated.

Patients are encouraged to choose an antidepressant prescribed by their PCP, psychotherapy provided by the care manager in the primary care setting, or both. The patient and PCP make treatment decisions with support from the care manager and psychiatrist.

After depressive symptoms remit, the care manager completes a relapse prevention plan with the patient. This includes:

steps the patient can take to prevent a relapse
identifying relapse warning signs
an action plan if depressive symptoms recur.

Training for clinicians in the IMPACT model is available at workshops and on the Internet (see Related resources). Successful implementation requires addressing operational and financing issues, and potential funding sources for primary care-based management have been described.¹³

Figure 3-step IMPACT intervention for a typical older patient with depression

PST-PC: Problem Solving Treatment in Primary Care

ECT: Electroconvulsive therapy

Source: Adapted and reprinted with permission from Unützer J, Katon WJ, Williams JW, et al. Improving primary care for depression in late life: the design of a multi-center randomized trial. Medical Care 2001;39:785.

How impact was tested

The IMPACT team care model has been tested in a randomized trial with 1,801 depressed older adults from 18 primary care clinics in 8 U.S. health care organizations. These included feefor-service plans, health maintenance organizations, and Veterans Affairs clinics with more than 450 PCPs in rural and urban settings.

Patients were randomly assigned to receive IMPACT care for 12 months or care as usual (in usual care, the patient and provider were informed that the patient met diagnostic criteria for major depression or dysthymia). Patients assigned to usual care could engage in any depression treatment the provider normally used, including referral to specialty mental health services.¹⁴

Result: Better outcomes. IMPACT was more effective than usual care for late-life depression in all 8 organizations over 2 years.^15,16 Overall, IMPACT doubled the effect of usual care. IMPACT patients:

experienced >100 additional depression-free days¹⁷
showed substantial improvements in physical and social functioning^15,17 and quality of life,¹⁵ even 12 months after IMPACT resources were withdrawn¹⁸
experienced less pain and pain-related functional impairment¹⁹
had significantly less suicidal ideation.²⁰

IMPACT care also was more cost-effective than usual care for depression in older adults with and without comorbid medical illnesses.¹⁷

From research to practice

Based on the robust study outcomes, researchers received a grant from the John A. Hartford Foundation to provide materials, training, and technical assistance to organizations interested in adopting IMPACT. More than 20 health care organizations have used IMPACT, and several have completed program evaluations showing outcomes matching the original IMPACT trial’s.

Kaiser Permanente of Southern California serves 3 million members. Before adopting collaborative care for depression, Kaiser conducted a pilot study of the project IMPACT model modified to fit its health care system. Adaptations included:

expanding the program to serve depressed adults of all ages
adding medical assistants to the care team to help with patient follow-up
adding a “depression class” to offer group-based patient education
providing psychiatric consultation to the care manager and primary care providers by telephone.

Kaiser investigators compared the outcomes of 300 patients who experienced the adapted program with outcomes in 140 usual-care patients and 140 intervention patients in the original IMPACT study. The effects on depression symptoms were equal to those achieved in the original IMPACT study, with 68% of depressed older adults showing substantial improvement (at least a 50% reduction in depression symptoms) at 6 months.²¹

Related resources

Project IMPACT. www.impact-uw.org.
American Association of Geriatric Psychiatry. www.aagpgpa.org.
Positive Aging Resource Center. http://positiveaging.org.

Acknowledgment

This paper is based on a presentation by Dr. Unützer for the Distinguished Scientist Award at the American Association of Geriatric Psychiatry annual meeting in Puerto Rico, March 10, 2006.