Therapeutics

IMPACT collaborative care improves depression in elderly patients in primary care in the longer term

Hunkeler EM, Katon W, Tang LQ, et al. Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. BMJ 2006;332:259–62.[Abstract/Free Full Text]

Q Is collaborative care more effective in the long term then usual care for elderly people in primary care who have depression?

Key Words: collaborative care • depression • elderly patients

Design: Randomised controlled trial.

Allocation: Concealed.

Blinding: Single blind (outcome assessors blinded).

Follow up period: Two years.

Setting: 18 primary care clinics from eight healthcare organisations, USA; 1999–2001.

Patients: 1801 people aged 60 years or over in primary care with DSM-IV major depression and/or dysthymia. Exclusions: current drinking problems; current psychiatric treatment; psychosis; bipolar disorder; high suicidal risk; severe cognitive impairment.

Intervention: 12 month collaborative care intervention (Improving Mood Promoting Access to Collaborative Treatment (IMPACT)) or usual care for depression. Collaborative care intervention: care was delivered by a team consisting of a depression care manager, a psychiatrist, and the participant’s primary care doctor. Treatment options included education, behavioural activation, problem solving treatment, antidepressants, and relapse prevention (including coping strategies). Usual care: participants and their primary care doctor received notification that they met the study criteria for depression, and were allowed access to antidepressants, counselling by the doctor, and referral to mental healthcare specialists.

Outcomes: Depressive symptoms (Hopkins Symptom Check List 20 (SCL-20) score, score range 0–4, higher scores indicate greater severity), response (50% reduction in SCL-20 from baseline), remission (SCL-20 score <0.5), continuing depression treatment (medication or psychotherapy).

Patient follow up: Not stated.

At two years, collaborative care reduced depressive symptoms and increased the proportion of people who responded and were in remission compared with usual care (p<0.0001, see http://www.ebmentalhealth.com/supplemental for table). People who had received collaborative care were also more likely to be continuing to receive treatment for depression (medication or psychotherapy; p<0.001).

Collaborative primary care management appears to be more effective than usual care in the long term for elderly people with depression.

One limitation of the study was that it relied on self-report of continuing depression treatment.

For correspondence: Enid M Hunkeler, Senior Research Scientist, Kaiser Permanente, Division of Research, 2000 Broadway, 2nd Floor, Oakland, CA 94612, USA; emh{at}dor.kaiser.org

Sources of funding: John A Hartford Foundation, Californian Healthcare Foundation, Hogg Foundation, and Robert Wood Johnson Foundation.

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Commentary

Jochen Gensichen, MD, MScEduc, MPH

Institute for General Practice, Chronic Care and Health Services Research
Center, Johann Wolfgang Goethe University Hospital, Frankfurt,
Germany

The 24 month follow up data build upon the results of the 12 month intervention trial "Improving Mood Promoting Access to Collaborative Care Treatment" (IMPACT). After 12 months this collaborative, stepped care management intervention was more effective than traditional care in a range of patients and in different medical organisations.¹ Reviews suggest disease management, compared with traditional care, has positive effects on outcomes in depression—but long term data are still rare.² Hunkeler et al focused on older patients, an increasing population in primary health care and with a high risk of comorbidity for major depression or dysthymia. The results indicate an enormous challenge for management of depression in primary care.

As screening for depression in isolation has only a minimal impact on outcomes,³ the quality of care can be improved by following it up with systematic care management. Depending on the resources of a primary care clinic/practice, some of the components of this intervention can be implemented. However, the study design does not provide strong evidence on which component led to the most enduring effect. The authors discuss two possible "mechanisms of action" for their programme: an ongoing, therapeutic relationship and relapse prevention. Both accord with the major principle of high quality: "continuity of care" for primary care services.⁴ A systematic review emphasised this by finding moderate patient outcomes for primary care based case management for major depression.⁵

Primary care clinicians will embrace new ways of enhancing care for their patients by improving communication skills and thus building a stronger long term relationship between patient and proactive care team. Integrating the roles of the specialist and the practice team efficiently will provide a sustainable service for people with mood disorder.

REFERENCES

1. Unutzer 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;288:2836–45.[Abstract/Free Full Text]
2. Badamgarav E, Weingarten RS, Henning JM. et al. Effectiveness of disease management programs in depression: a systematic review. Am J Psychiatry 2003;160:2080–90.[Abstract/Free Full Text]
3. Gilbody S, Whitty P, Grimshaw J. et al. Educational and organizational interventions to improve the management of depression in primary care. A systematic review. JAMA 2004;329:602–5.
4. Starfield B. Primary Care. Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998.
5. Gensichen J, Beyer M, Muth C. et al. Case management to improve major depression in primary health care: a systematic review. Psychol Med 2006;36:7–14.[CrossRef][Medline]

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