A collaborative care management program for late-life depression produces
long-term health care improvement at a steadily declining price, according to
a study of the Improving Mood Promoting Access to Collaborative Treatment
The study, published in the December 2005 Archives of General
Psychiatry, assessed over two years the costs and benefits of the IMPACT
approach on 1,801 patients over 60 years old with major depression and/or
The IMPACT one-year intervention featured either a nurse or psychologist
care manager working in each participant's primary care clinic to support the
patient's regular primary care physician. The care manager helped the primary
care physician follow the patient's medication adherence, symptoms, and
progress or lack thereof. Decisions about medication and therapy followed the
The study's lead author, Wayne Katon, M.D., said it differs from many
previous depression care cost-effectiveness studies, which followed patients
for only one year. This research found most of the health care costs for this
type of care occur in the first year, while the benefits of reduced overall
health care costs continue into the second year. Katon is a professor in the
Department of Psychiatry and Behavioral Sciences at the University of
Washington School of Medicine.
"What this study shows is that you continue to accrue benefits in the
second year, so health care organizations investing in this may see some
increased costs in the first year, but those are largely made up for in the
cost savings in the second year," Katon said.
The study found that total mental health care costs per patient were about
$921 higher for IMPACT participants over the two years; however, other
medication costs dropped $126 on average, and other outpatient costs were cut
by $501. It also found average per-patient outpatient costs were $383 higher
in the first year, but became an $88 cost savings in the second year, when
intervention services ceased. When all medication costs were excluded, there
was a net cost of $180 associated with intervention in the first year and a
net cost savings of $175 in the second year.
The benefit of the services seemed to hold throughout the study period,
despite treatment ending at one year. The study found a mean of 52
depression-free days attributed to the intervention in the first year, while
the mean number of depression-free days in the second year rose to 54
Katon said the findings indicate that the benefit in reduced depression
symptoms continues into the third year and perhaps beyond, with the medical
care costs savings also continuing.
"Researchers are planning studies to confirm that," he noted."
It takes some investment up front to develop these kinds of programs.
What is holding back the movement to provide chronic care are incentives for
the health care systems to try this approach."
Although the study followed a collaborative care model first described in
1995, it was modified to include some unique features, which Katon said
appeared to improve outcomes.
One change was that patients were given a choice to start treatment with
either psychotherapy or medication. Additionally, patients were allowed to
augment their medication with therapy if they were not improving, and they
could augment their therapy with medication if therapy alone did not appear to
improve their condition.
"Disease-management programs that provide a choice can treat a wider
group of patients because some patients have a strong feeling about what kind
of treatment they want to start with," Katon said.
Predispositions for or against medications or psychotherapy can affect
patient adherence to treatment, he said. So giving the patients choice can
improve their compliance. The additional step is especially important in
patients over age 60, Katon said, because research has found they are much
more reluctant to seek mental health services than are younger patients.
The researchers hope their study will change the current system in which
only 10 percent of elderly patients with depression are ever seen by a
psychiatrist or mental health professional. So for most elderly who have
depression, a primary care physician is the source of care.
Many elderly are reticent to go for specialized mental health care because
of stigma, ambulation problems, or priority assignment to other medical
"The only place that we can improve care would be in the primary care
system for these patients," Katon said.
Previous studies have tried to improve mental health screening in primary
care settings and then refer elderly patients to specialized care. However,
those studies have found that 50 percent of elderly patients who are referred
to mental health professionals never make an appointment, and half of those
who do make an appointment go only once or twice, he said. Studies that ask
patients where they would like to get their mental health care overwhelmingly
report it to be in primary care settings.