Caring for Late-Life Depression: Collaboration Is Best
Abstract & Commentary
Synopsis: Depressed seniors fared better when treated by a team of primary care practitioners and psychiatrists.
Source: Unützer J, et al. JAMA. 2002;288:2836-2845.
Building on their previous work that demonstrated that the combination of collaboration between primary care physicians (PCPs) and psychiatrists, patient education, and surveillance of antidepressant medication refills improved satisfaction with care and resulted in better depressive outcomes, Unützer and colleagues turned their attention to depressed elderly.1,2
The Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program enrolled patients from 18 primary care clinics in 5 states. The clinics were a mix of rural and urban; the PCPs were general internists, family physicians, nurse practitioners, and physician assistants. The patients could enter the study through 2 routes: referral from their PCP, other clinic staff, or themselves, or identification by a systematic depression screening of older adults who used the clinics. Accordingly, 2190 patients were referred to the study and 32,908 patients were approached for screening. These approximately 35,000 patients were pared to 1801 (average age, 71.2 years, 65% female, 23% ethnic minorities). Inclusion criteria were age 60 years or older, plans to use the clinic for usual care for the next year, and a current diagnosis of depression or dysthymia.
Patients were excluded if they refused to participate in the screening or eligibility interview, had an incomplete screen, or did not meet the criteria for depression or dysthymia (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). Others were excluded if they had an active drinking problem, were bipolar, were currently under the care of a psychiatrist, were severely cognitively impaired, or were acutely suicidal. The 1801 remaining patients were randomly assigned to either "usual care" or the IMPACT intervention.
Briefly, IMPACT involved receiving an educational videotape and a booklet on late-life depression and encouragement to attend a visit with a depression care manager (a specially trained nurse or psychologist). After discussing the case with the supervising team psychiatrist, the care manager and the patient’s PCP developed a treatment plan, following a treatment algorithm. The algorithm advised either a course of an antidepressant or a short course of structured psychotherapy. The care manager delivered the psychotherapy in the primary care office. Further treatment could include larger doses of the antidepressant, a different antidepressant, or adding the psychotherapy if the patient was not currently receiving it. Patients were followed for 12 months and evaluated at 0, 3, 6, and 12 months. All participants completed the study.
Analyses were by intention to treat. Not surprisingly, at 12 months IMPACT patients were more likely to use either antidepressants or psychotherapy than usual care patients (82% vs 61%). They were also more satisfied with the care of their depression (76% vs 47%), had lower depression severity (1.0 vs 1.4 on a 4-point scale), higher rates of treatment response (45% vs 19%), and higher rates of complete remission (25% vs 8%). The usual care patients had worse overall functional impairment (4.5 vs 3.6 on a 10-point scale) and worse quality of life (6.0 vs 6.7 on a 10-point scale) than the intervention patients. All of these results were statistically significant. Unützer et al estimated the cost of providing the IMPACT intervention for 12 months to be $533 per patient.
Comment by Allan J. Wilke, MD
Studies of depression have been appearing with consistent regularity in the medical literature. A brief sampling includes managing depression as a chronic illness,3 identifying patients with severe depressive symptoms,4 and the US Preventive Services Task Force’s recommendation for screening for depression in primary care settings.5
There was not much to quibble about in this study. The intervention lasted only 12 months; I would like to know what happens to these folks in the longer term. The measurements of health-related functional impairment and quality of life were self-reports. Given these limitations, is the juice worth the squeeze? At $533 per patient per year, I should think so!
Upward of 7% of people older than age 60 are depressed.6 Depression in the elderly is attended by considerable morbidity and mortality. We have the tools to identify them,7 the drugs to treat them (selective serotonin reuptake inhibitors are first line), and the colleagues (psychiatrists, psychologists) to refer them to for counseling if we are too busy to do it ourselves. Why aren’t we doing this?
References
1. Katon W, et al. JAMA. 1995;273:1026-1031.
2. Katon W, et al. Arch Gen Psychiatry. 1999;56: 1109-1115.
3. Rost K, et al. BMJ. 2002;325:934-937.
4. Culpepper L. J Fam Pract. 2002;51:769-776.
5. Pignone MP, et al. Ann Intern Med. 2002;136:765-776.
6. Lyness JM, et al. J Gen Intern Med. 1999;14:249-254.
7. Valenstein M, et al. J Am Geriatr Soc. 1998;46: 1499-1505.
Dr. Wilke is Assistant Professor of Family Medicine at the Medical College of Ohio in Toledo.
Depressed seniors fared better when treated by a team of primary care practitioners and psychiatrists.
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