IMPACTImproving Mood –

Promoting Access to Collaborative Treatment for Late-Life Depression

Funded by

John A. Hartford Foundation, California HealthCare Foundation, Robert Wood Johnson Foundation,

Hogg Foundation

What is Depression?

Depression is NOT…Having -a ‘bad day’, -a ‘bad attitude’, -or ‘normal sadness’-Part of ‘normal aging’

Major Depression

Common: 5-10 % in primary care

Pervasive depressed mood / sadness and loss of interest/ pleasure …Plus: lack of energy, Fatigue, poor sleep and appetite, physical slowing or agitation, poor concentration, physical symptoms (aches and pains), thoughts of guilt, irritability and thoughts of suicide

If untreated, depression can last for years.

Often complicated by: chronic medical disorders, chronic pain, anxiety, cognitive impairment, grief/ bereavement, substance abuse

In late-life, depression israrely the only health problem

Depression

NeurologicalDisordersGeriatric

Syndromes

Diabetes

20-40%

10-20%

10-20%

Heart Disease20-40%

Chronic Pain

40-60%10-20%Cancer

Depression is expensive:Annual Health Costs in 1995 $

0

10002000

30004000

50006000

7000

0 (n=859)

1-2(n=616)

3-5 (n=659)

6-16(n=423)

Nodepression

Milddepression

Moderate toseveredepression

Unützer et al, JAMA, 1997

Chronic disease score

$

Depression is deadlyOlder adults have the highest rate of suicide.

Few Older Adults receive Effective Treatment

Depression CAN be treated, BUT…

-Only half of depressed older adults are ‘recognized’

-Older men, African Americans and Latinos have particularly low rates of depression treatment

-Fewer than 10% seek care from a mental health specialist. Most prefer treatment by their primary care physician

-Only one in five older adults treated for depression in primary care improve

One-Year Service Use by Depressed Adults

3%4%Inpatient Mental Health (MH)

1%4%ER visit for MH

8%25%Outpatient Mental Health

65 + (N = 113)

18-64(N = 1,382)

AGE GROUP

Primary care visit addressing

Mental Health Needs49%45%

9,585 adults from 60 US communities. Klap, Tschantz, Unützer. AJGP, 2003

Barriers to Effective Depression Care

“I didn’t know what hit me …”

Stigma of mental illness: “I am not crazy”

“Isn’t depression just a part of ‘normal aging’?”

“Of course I am depressed. Wouldn’t you be?”The ‘fallacy of good reasons’

Knowledge and Attitudes

Limited time and competing priorities: Limited follow-up -> early treatment dropoutStaying on ineffective treatments for too long

“I thought this was as good as I was going to get”Limited access to mental health experts

Challenges in Primary Care

IMPACT Study

1998 – 2003

1,801 depressed older adults in primary care

18 primary care clinics - 8 health care organizations in 5 states

Diverse health care systems (FFS, HMO, VA)450 primary care providers Urban and semi-rural settings Capitated and fee-for-service

Funded byJohn A. Hartford Foundation; California HealthCare Foundation; Robert Wood Johnson Foundation; Hogg Foundation

IMPACT Study TeamNone of us is as smart as all of us.

Study coordinating center

Study sitesUniversity of Washington / Group Health CooperativeWayne Katon (PI), Elizabeth Lin (Co-PI), Paul CiechanowskiDuke University Linda Harpole (PI), Eugene Oddone (Co-PI), David SteffensKaiser Permanente, Southern CA (La Mesa, CA)Richard Della Penna (Co-PI), Lydia Grypma (Co-PI), Mark Zweifach, MD, Rita Haverkamp, RN, MSN, CNSIndiana UniversityChristopher Callahan (PI), Kurt. Kroenke, Hugh. Hendrie (Co-PI)UT Health Sciences Center at San AntonioJohn Williams (PI), Polly Hitchcock-Noel (Co-PI), Jason WorchelKaiser Permanente, Northern CAEnid Hunkeler (PI), Patricia Arean (Co-PI)Desert Medical GroupMarc Hoffing (PI); Stuart Levine (Co-PI)

Study Advisory BoardLisa Goodale (NDMDA), Rick Birkel (NAMI), Thomas Oxman, Kenneth Wells, Cathy Sherbourne, Lisa Rubenstein, Howard Goldman

Jürgen Unützer (PI), Sabine Oishi, Diane Powers, Michael Schoenbaum, Tom Belin, Linqui Tang, Ian Cook. PST-PC experts: Patricia Arean, Mark Hegel

IMPACT Study Methods

Randomized control trial. 1,801 depressed older adults with major depression and / or dysthymia randomly assigned to IMPACT or Care as Usual

Primary care or referral to specialty mental health as available

Collaborative / stepped care disease management program for depression in primary care offered for up to 12 months

Independent assessments of health outcomes and costs for 24 months. Intent to treat analyses.

Unützer et al, Med Care 2001; 39(8):785-99

Design

Usual Care

IMPACT Care

Analyses

IMPACT Study Participants

42 %Antidepressant use in 3 months prior to study

12 %African American

35 %Cognitive impairment at screening

3.2Mean chronic medical diseases (out of 10)

53 %Major depression + dysthymia3 %All others8 %Latino

23 %Non-white71.2 (7.5)Mean age (SD)

65 %Female

N = 1,801*

* No significant baseline differences between intervention and usual care.

EffectiveCollaboration

Prepared, Pro-activePractice Team

Informed, ActivatedPatient

IMPACT Team Care Model

Practice Support

Collaborative Care

Primary care provider (PCP)Refers; prescribes

antidepressant medications

+ Depression Care Manager+ Consulting Psychiatrist

Unützer et al, Med Care 2001; 39(8):785-99

Chooses treatment in consultation with provider(s):

-Antidepressants and/or brief pyschotherapy

Patient

Evidence-based ‘team care’ for depression

- Consultation focused on patients not improving as expected

- Recommendations for additional treatment / referral according to evidence-based guidelines

- Support anti-depressant Rx by PCP

- Brief counseling (behavioral activation, PST-PC, CBT, IPT)

- Facilitate treatment change / referral to mental health

- Relapse prevention

2. Stepped Care

a) Change treatment according to evidence-based algorithm if patient is not improving

b) Relapse prevention once patient is improved

- Caseload consultation for care manager and PCP (population-based)

- Diagnostic consultation on difficult cases

-Patient education / self management support

-Close follow-up to make sure pts don’t ‘fall through the cracks’

1. Systematic diagnosis and outcomes tracking

e.g., PHQ-9 to facilitate diagnosis and track depression outcomes

Consulting Psychiatrist

Care Manager

TWO NEW ‘TEAM MEMBERS’Supporting the Primary Care Provider (PCP)TWO PROCESSES

Stepped Care

Insufficient responseChange treatment

• According to evidence-based algorithm• In consultation with team psychiatrist

Adjust treatment based on clinical outcomes

Systematic outcomes tracking

•Patient Health Questionnaire (PHQ-9)

Evidence-Based Depression Care Management

a.Case finding (screening, referral) -> confirm diagnosisb.Proactive follow-up & tracking (PHQ-9)

•Change treatment if patient not improving•Relapse prevention plan for patients in remission

a. Educationb. Brief Therapy: Behavioral Activation / Problem Solving

a. Primary Care (Antidepressant Medications)b. Specialty Mental Health Care / Psychotherapy

a. Caseload supervision / consultation for care managersb. Psychiatry consultation for treatment nonresponders

Identify and track depressed patients

Enhance patient self-management

Support additional treatment

Mental health consultation for difficult cases

Improved Satisfaction with Depression Care

020406080

100

0 3 12month

perc

ent

Usual Care Intervention

P<.0001 P<.0001

P=.2375

Unützer et al, JAMA 2002; 288:2836-2845

(% Excellent, Very Good)

Mean HSCL-20 Depression Severity Score

0.0

0.5

1.0

1.5

2.0

Baseline 3 6 12

Follow-up (Months)

P=.553

P<.0001P<.0001

Usual Care

Intervention

P<.0001

Unutzer, et al. JAMA 2002; 288:2836-2845

IMPACT: Doubles the Effectiveness of Usual Care for Depression

Findings Robust Across Diverse Health Care Organizations

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8

Usual Care IMPACT

%

Participating Organizations

TREATMENT RESPONSE50 % or greater improvement in depression at 12 months

Unutzer, et al. JAGS 2003; 51:505-514

Better Physical Function

38

38.5

39

39.5

40

40.5

41

41.5

Baseline 3 mos 6 mos 12 mos

Usual Care IMPACT

PCS-12

P<0.01

P<0.01P<0.01

P=0.35

Callahan et al, JAGS 2005; 53:367-373.

00.20.40.60.8

11.21.41.61.8

2

Baseline 3 6 12 18 * 24 *

months

Mea

n HS

CL-

20 D

epre

ssio

n Se

verit

y Sc

ore

IMPACT Usual Care

Effects persist even 1 year after the program ends

AFTER IMPACTIMPACT INTERVENTION

P=0.55

P<0.01P<0.01

P<0.01

Hunkeler et al, BMJ, 2006.

P<0.01 P<0.01

IMPACT

Usual Care

Additional Depression-Free Days

0

100

200

300

400

IMPACT in Diabetes116 more Depression-Free Days over 2 Years

381

265

116

Days

Katon et al, Diabetes Care; 2006

IMPACT in DiabetesLower Health Care Costs

Usual Care IMPACT

Savings$0

$2,500

$5,000

$7,500

$10,000

$12,500

$15,000

$17,500

$20,000

$896

Katon et al, Diabetes Care; 2006

$18,035$18,932

IMPACT Summary

Photo credit: J. Lott, Seattle Times

- Less depression(IMPACT doubles effectiveness of usual care)

- Less physical pain- Better functioning- Higher quality of life- Greater patient and

provider satisfaction- More cost-effective

“I got my life back”

Moving IMPACT from Research to PracticeJohn A. Hartford Foundation

Supported by a grant from the John A. Hartford Foundation.

IMPACT Disseminationhttp://impact-uw.org

IMPACT TrainingIn Person and on the Web

Trained over 1600 providers

The IMPACT Communityhttp://impact-uw.org