Can a care management intervention improve treatment and outcomes for depressed elderly adults?

Older adults with depression were more likely to receive treatment and be satisfied with care and achieved better outcomes when assigned to a trained nurse or psychologist who collaborated with the patient and primary care physician to support medication management and/or provide brief psychotherapy, under supervision of a psychiatrist and primary care expert.

Why is this important?

Depressed older adults report poorer quality of life, are at increased risk of death because of medical illness or suicide, and use more medical services than non-depressed older adults (DHHS 2000). Yet depressed elderly adults are less likely than nonelderly adults to perceive that they need mental health care or to receive any specialty mental health care (Klap et al. 2003).

Efforts to improve the treatment of the depressed elderly through patient screening and practitioner education have fallen short of expectations, suggesting that a more comprehensive intervention strategy is needed (Callahan 2001). Experience suggests that interventions that support effective depression treatment through primary care may be more acceptable to elderly patients that those that seek to facilitate referral to specialty care (Bartels et al. 2004).

Interventions

Patients ages 60 and older who were treated at one of 18 primary care clinics affiliated with eight diverse organizations were randomly assigned to receive either usual care or a care intervention delivered by depression clinical specialists (specially trained nurses or psychologists) in collaboration with the patient's primary care physician. This intervention is known as the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) program.

Working under the supervision of a psychiatrist and primary care expert and guided by evidence-based protocols, depression care specialists conducted initial visits, devised treatment plans, and maintained weekly or biweekly contact (in person or by telephone) with patients for up to 12 months. Care included initiation of antidepressant medication and/or psychotherapy followed by regularly scheduled assessments to maintain or amend treatment (Unutzer et al. 2001).

Findings

One year after the study began, 21 percent more intervention patients were using antidepressant medication or psychotherapy, 29 percent more were satisfied with their depression care, and 26 percent more demonstrated at least a 50 percent improvement in depressive symptoms than those receiving usual care.

The self-reported functional impairment score was 21 percent lower and the quality of life score was 9 percent higher for the intervention group compared with usual care (Unutzer et al. 2002).

Implications

The IMPACT model offers a promising approach to improving depression care among elderly patients. Improvements were seen across all participating organizations, suggesting that this approach is feasible in diverse primary care settings.

• Treatment of late-life depression is challenging, reflected by the fact that less than 50 percent of patients receiving this intervention reported at least a 50 percent decrease in depressive symptoms.
• The investigators predict that the 12-month intervention cost of $553 per patient will likely offset health care costs otherwise incurred by this population, which are up to 50 percent higher than for older adults without depression (Unutzer et al. 2002).

Improvement Ideas and Resources

For more information and resources, see the IMPACT program Web site.

Measure:

The IMPACT (Improving Mood: Promoting Access to Collaborative Treatment) study was a randomized controlled trial that enrolled 1,801 depressed individuals ages 60 and older who were treated at one of 18 primary care facilities in five states. Research assistants blinded to the study conditions conducted an in-person baseline interview and follow-up telephone interviews with patients at three, six, and 12 months to collect information regarding the severity of depressive symptoms, health-related functional impairment, overall quality of life in the past month, satisfaction with depression care, and use of antidepressant medications, counseling, or psychotherapy within the past three months. All measured differences between the intervention and control groups were statistically significant in adjusted regression analysis at three-, six-, and 12-month follow-up. The intervention effect increased over time but varied by organization (Unutzer et al. 2002).

Limitations:

It is not known if improvement persisted after the intervention ended or whether primary care practices can implement such an intervention without outside resources.

Source:

The IMPACT program was based on patient interviews and conducted by researchers at the University of California, Los Angeles, Neuropsychiatric Institute; University of Washington, Seattle; Indiana University Center for Aging Research and the Regenstrief Institute, Indianapolis; and other collaborating institutions and investigators (Unutzer et al. 2002).

References:

* Indicates source of data used in the chart(s).Bartels, S. J., E. H. Coakley, C. Zubritsky et al. 2004. 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. The American Journal of Psychiatry 161 (8): 1455–62.

Callahan, C. M. 2001. Quality Improvement Research on Late Life Depression in Primary Care. Medical Care 39 (8): 772–84.

DHHS (Department of Health and Human Services). 2000. Older Adults and Mental Health. Mental Health: A Report of the Surgeon General.

Klap, R., K. T. Unroe, and J. Unutzer. 2003. Caring for Mental Illness in the United States: A Focus on Older Adults. The American Journal of Geriatric Psychiatry 11 (5): 517–24.

* Unutzer, J., W. Katon, C. M. Callahan et al. 2002. Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A Randomized Controlled Trial. Journal of the American Medical Association 288 (22): 2836–45.

Unutzer, J., W. Katon, J. W. Williams, Jr. et al. 2001. Improving Primary Care for Depression in Late Life: The Design of a Multicenter Randomized Trial. Medical Care 39 (8): 785–99.