Multidisciplinary Model Delivers Improved Depression Care to Elderly

The investigation sample consisted of some 1,800 depressed older adults—17 percent with major depression, 30 percent with dysthymic disorder, and 53 percent with both. It was, in fact, “the largest study of the treatment of depression ever done of any age group,” Wayne Katon, M.D., a professor of psychiatry at the University of Washington in Seattle and one of the study investigators, told Psychiatric News. What’s more, 12 percent of study subjects were African Americans and 8 percent Latinos, providing a robust sample of these minorities.

The subjects were treated at 18 primary care clinics in five states—California, Indiana, North Carolina, Texas, and Washington. Nine of the facilities were HMO clinics, five were academic group practice clinics, three were Veterans Affairs clinics, and one was a private group practice clinic. Half the subjects received “care as usual” from primary care physicians. This means that, in most instances, they were prescribed antidepressant medications; however, a small number received specialty mental health care such as visits to a psychiatrist, psychologist, or other counselor.

“We had no limitations on such use,” Unützer explained in an interview. “The usual care group was encouraged to use whatever services they might normally use if they weren’t in a study.”

The other half of the subjects received IMPACT (Improving Mood—Promoting Access to Collaborative Treatment) care. This means that they received a 20-minute educational videotape and a book about late-life depression and were encouraged to have a visit with a nurse or psychologist trained for the study as a depression clinical specialist. The specialists then worked with the subjects and their primary care physicians to establish a treatment plan. Here, the specialists used a recommended treatment algorithm.

The algorithm suggested an initial choice of an antidepressant medication or six to eight sessions of a brief, structured psychotherapy for depression delivered by a depression clinical specialist. For patients who were already on antidepressant medications but who were still depressed, the recommendation was to increase the dose or to augment the antidepressant with the brief psychotherapy for depression or to switch to a different medication.

The depression clinical specialists then contacted subjects every other week during the acute treatment phase to see how they were doing. If they recovered from depression, a relapse prevention plan was spelled out, and the specialists followed them over the next few months. If they had not responded to the initial treatment, the specialists discussed their cases with the psychiatrists heading up IMPACT care at their clinics, and a “step two” treatment plan was developed, which perhaps included a psychiatric consultation. If subjects still did not get better, then further medication changes, psychotherapy, hospitalization, or electroconvulsive therapy was considered.

The investigators also assessed subjects in the IMPACT group, as well as in the usual care group, for depression not just at the start of the study, but at three, six, and 12 months later. This way, treatment outcomes for subjects in each group could be assessed, and treatment outcomes between the two groups could be compared.

At 12 months, 45 percent of the IMPACT subjects had a 50 percent or greater reduction in depressive symptoms compared with at the start of the study, whereas only 19 percent of the usual care subjects did—a highly significant difference statistically. IMPACT subjects also experienced significantly greater rates of depression treatment, more satisfaction with depression care, lower depression severity, less functional impairment, and greater quality of life.

The IMPACT model thus appears to be “feasible and significantly more effective than usual care for depression in a wide range of primary care practices,” the researchers concluded in their study report.

The investigators also assessed the cost of providing IMPACT services. They found that the one-year cost per subject averaged $553. This amount is small compared with what Medicare spends for an average enrollee’s annual medical costs ($5,506 according to 1998 figures), and what Medicare spends for an average enrollee who is depressed—50 percent more.

As Thomas Oxman, M.D., director of geriatric psychiatry at Dartmouth Medical School and a member of the study’s expert advisory panel, told Psychiatric News: “I think this is a very impressive study that has applied key elements of chronic disease management to the treatment of depression in primary care and shown that it works very well. It has demonstrated that an efficient role for psychiatrists is to supervise other providers. It is important that insurers and other payers take note of these results and begin paying for services like care management and supervision by psychiatrists.”

Meanwhile, “a number of our study sites have adopted this model and now offer IMPACT-like care with a depression clinical specialist,” Unützer said.

The study was supported by grants from the John A. Hartford Foundation, California Healthcare Foundation, Hogg Foundation, and Robert Wood Johnson Foundation.