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December 10, 2002

Team approach doubles effectiveness of depression care for seniors

Study shows older adults benefit from model primary-care program

Seattle—A new study conducted at Group Health Center for Health Studies and seven other healthcare organizations shows that a team-care approach more than doubles the effectiveness of depression treatment for older adults in general medical settings. The findings appear in the December 11 edition of the Journal of the American Medical Association (JAMA).

Over 270 Group Health seniors at Northgate Medical Center and Eastside Primary Care were among 1,801 depressed older adults who participated in the study. Half were assigned to care as usual and the other half were assigned to a new model of team care that was originally developed by researchers at Group Health Center for Health Studies and by Wayne Katon, MD, professor of psychiatry at the University of Washington.

The model program, called "Improving Mood—Promoting Access to Collaborative Treatment" or "IMPACT," assigned patients aged 60 and older to a depression care manager in their usual primary care clinic. These specially trained nurses or psychologists worked in close collaboration with the patients’ regular physicians for up to 12 months to educate and support patients, track symptoms and side effects, assist with changes in antidepressant treatment, and provide counseling. At each site, a team psychiatrist consulted on the care of all IMPACT patients and saw about 10 percent for consultations.

The study found that the IMPACT care model was significantly more effective than usual care for depression at each of the eight participating study sites. About half of the participants assigned to the IMPACT program reported a 50 percent or greater reduction in depression symptoms at 12 months, compared with 19 percent of those in usual care.

"Most of the patients in usual care received prescriptions for antidepressant medications from their primary care physicians, but it may not be enough for physicians to diagnose depression and write a prescription," said Jürgen Unützer, MD, an associate professor of psychiatry at the David Geffen School of Medicine at UCLA who directed the study coordinating center at the UCLA Neuropsychiatric Institute. "We found that, with the added support and the close follow-up provided by the IMPACT team, patients felt better, functioned better, and enjoyed life more fully than patients treated in usual care."

Elizabeth Lin, MD, a Group Health family physician and co-principal investigator on the study agrees. "Most of these older patients with depression also have other chronic health problems. This active follow-up by the primary care team works because it helps to ensure that patients get appropriate treatment for depression as well as their other chronic conditions."

Other findings include the following:

• IMPACT patients at each study site reported less depression, less impairment in day-to-day functioning and greater improvements in quality of life at 3-, 6-, and 12-month evaluations.
• IMPACT patients had closer follow-up and more frequent adjustments in medications.
• IMPACT patients were more likely to receive desired counseling or psychotherapy.
• The average cost of providing IMPACT services totaled $550 per person for 12 months. This compares with $ 6,000 per year per person that Medicare reports spending for the care of depressed older adults. An upcoming report will examine the effect of IMPACT on patients’ overall heath care costs over two years.

Lin, who led the Group Health part of the study in her role as an affiliate investigator at Group Health Center for Health Studies, is now working on ways Group Health can use the IMPACT approach in routine care for depressed patients throughout the Cooperative.

"The IMPACT model may be too resource-intensive for implementation at Group Health right now," Lin said. "But there may be ways we can easily adopt elements of this model using the resources we already have." To find out, Lin is conducting a pilot study in two teams at Capitol Hill Family Heath Center (FHC) that involves primary care team nurses as care managers for their depressed population, and closer coordination between primary care nurses and FHC’s behavioral health specialist. In addition, behavioral health specialists are trained in problem solving treatment, a structured and brief psychotherapy adapted for primary care, offered by the IMPACT model.

The John A. Hartford Foundation of New York City, the California HealthCare Foundation, the Hogg Foundation, and the Robert Wood Johnson Foundation funded the $11 million national study.

The study was coordinated at the UCLA Neuropsychiatric Institute. Participating study sites include Group Health Cooperative in cooperation with the University of Washington; Duke University, Durham, N.C.; The South Texas Veterans Health Care System, The Central Texas Veterans Health Care System, and The San Antonio Preventive and Diagnostic Medicine Clinic; Indiana University School of Medicine and Health and Hospital Corporation of Marion County, Indianapolis; Kaiser Permanente of Northern California, Oakland and Hayward, Calif.; Kaiser Permanente of Southern California, San Diego; and Desert Medical Group, Palm Springs, Calif.

About Group Health Center for Health Studies
Group Health Center for Health Studies conducts epidemiologic, health-services, and clinical research related to prevention, diagnosis, and treatment of major health problems. Funded primarily through government and private research grants, the Center is located in Seattle, Washington.

Group Health Cooperative is the nation’s largest consumer governed health care system, serving nearly 600,000 people in Washington and Idaho.

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