The team care model, which includes a case manager, primary care provider and consulting psychiatrist, results in better outcomes when treating clinical depression, which affects an estimated 3 million older adults in the United States.
Depression in late life is a major contributor to Medicare costs. It is associated with 50 to 70 percent higher health care expenses, mostly due to increased medical, not mental health, visits and treatment. As team care treatment for depression has proven to be more cost effective than usual treatment models, major health care organizations around the country are starting to implement the team treatment model.
The team care approach, called IMPACT (Improving Mood - Promoting Access to Collaborative Treatment for Late Life Depression), features a nurse, social worker or psychologist serving as a depression care manager who works with the primary care physician and a consulting psychiatrist to care for depressed patients in primary care clinics. Previous studies have shown the IMPACT program to provide powerful health benefits, including decreased depression and pain, improved physical functioning and better overall quality of life.
"For the same price as usual care, the IMPACT model provided an additional 107 depression-free days, a whole 'season of light,'" said Dr.Wayne Katon, professor and vice-chair of psychiatry and lead author of the cost effectiveness study. "We found that health benefits persist even a year after completion of the IMPACT program, and our cost data suggest that there is potential for long-term cost savings."
"The research also showed that in specific subgroups of patients, such as the nearly 25 percent of study participants with diabetes, there were even greater clinical benefits and more medical cost savings," said Dr. Jürgen Unützer, professor and vice chair of psychiatry at the UW and director of the IMPACT Coordinating Center.
Based on its cost-effectiveness, several major health organizations have already implemented the IMPACT model for depression care, including Kaiser Permanente of Southern California, which serves more than 3 million members in its 12 regional medical centers. The John A. Hartford Foundation is supporting the efforts of Unützer and Katon to help other health systems take up the IMPACT model.
"This could revolutionize the way depression is treated in medical settings," said Dr. Richard Della Penna, head of Kaiser Permanente's Aging Network (KPAN) and lead researcher from one of two Kaiser regions that took part in the original IMPACT trial. "The strong results of this important study and our experiences with the IMPACT program have clearly shown the value of the team care model for depression."
The cost of using the IMPACT model of depression care treatment is only about $580 per year for each patient - a modest investment compared to the total medical costs of about $8,000 per year for an older adult with depression. When the cost of the IMPACT model is spread out over an entire population of older adults, the cost amounts to less than $1 per month for each member.
According to the cost-effectiveness study, the costs of providing IMPACT care were offset by health care cost savings in the year following the program, suggesting potential long-term cost savings. The cost-effectiveness of the IMPACT model is better than the cost-effectiveness of several other commonly used medical treatments, such as hypertension screening and treatment, statin use, or coronary artery bypass surgery.
A more effective method of treating clinical depression in late life has become more important in recent years, as physicians have learned that the condition affects many older adults and helps drive up health care costs. Studies estimate that 5 to 10 percent of older adults seen in primary care suffer from clinical depression. The condition is associated with a bevy of other medical problems, including more suffering and physical pain, decreases in physical ability and self-care of chronic illnesses, and a high potential for suicide. It also can significantly increase medical costs.
Doctors and their patients often share the misconception that depression is a natural consequence of aging. Even when the condition is successfully diagnosed, patients often do not receive effective, evidence-based treatment with drugs, psychotherapy, or a combination of the two.
The IMPACT study, which began in 1999, randomly assigned 1,801 depressed older adults from 18 primary care clinics affiliated with eight diverse health care organizations in five states to usual depression care or to the IMPACT program. In IMPACT care, a depression care manager (a nurse or psychologist) with consultation from a psychiatrist and an expert primary care physician helped patients and their primary care doctors treat depression in the primary care setting. The care managers helped educate patients about depression, closely tracked depressive symptoms and side effects, helped make changes in treatment when necessary, supported patients on anti-depressant medications, and offered a brief course of psychotherapy to help patients make changes in their lives.
The IMPACT program did not replace the patient's regular primary care physician, but instead supported these physicians to help them provide higher quality depression care. An independent evaluation of the study outcome was done at baseline 3, 6, 12, and 24 months to compare IMPACT to usual care.
The 18 study sites that were part of the IMPACT Project are located at Duke University, South Texas Veterans Health Care System, Central Texas Veterans Health Care System, San Antonio Preventive and Diagnostic Medicine Clinic, Indiana University School of Medicine, Health and Hospital Corporation of Marion County in Indiana, Group Health Cooperative of Puget Sound in cooperation with the University of Washington, Kaiser Permanente of Northern California, Kaiser Permanente of Southern California, and Desert Medical Group in Palm Springs, California.
The IMPACT study was supported primarily by a grant from the John. A. Hartford Foundation with additional support from the California Healthcare Foundation, the Hogg Foundation, and the Robert Wood Johnson Foundation. The John A. Hartford Foundation (http://www.
The IMPACT Coordinating Center, where physicians and health care professionals can learn more about implementing the IMPACT model in their organizations, can be found at http://www.