Thanks to a grant from the John A. Hartford Foundation, a group of
psychiatrists and primary care physicians came together in 1999 to develop a
new model for treating depressed older Americans. They named the model"
IMPACT" ("Improving Mood Promoting Access to Collaborative
In essence, IMPACT would place a depression care manager (usually a nurse)
in a primary care clinic to assist primary care physicians in the care of
older depressed patients. The manager would work with the physicians to
establish depression treatment plans for the patients. In addition, the
manager would contact the patients every other week to see how they were
doing. If they recovered from depression, a relapse-prevention plan would be
put into effect, and the manager would follow them over the next few months to
determine how well the plan was working. If they did not recover from
depression, the manager would discuss their case with a consulting
psychiatrist, and treatment would be adjusted accordingly.
Also in 1999, with funding from the John A. Hartford Foundation, California
Healthcare Foundation, Hogg Foundation, and Robert Wood Johnson Foundation, a
large clinical trial to assess the clinical effectiveness of the IMPACT model
was launched. It included some 1,800 depressed adults aged 60 and over and
took place in 18 primary care clinics in five states. Subjects were then
randomized to receive either IMPACT care or "care as usual."
One-year treatment results from the trial, which became available in late
2002 and early 2003, were quite positive (Psychiatric News, January
17 and April 4, 2003). Forty-five percent of the IMPACT subjects had a 50
percent or greater reduction in depressive symptoms by the end of the study,
compared with only 19 percent of the usual-care subjects—a highly
significant difference. IMPACT subjects also reported more satisfaction with
depression care, less functional impairment, and greater quality of life than
Two-year follow-up results from the trial, which appeared in the February 4
British Medical Journal, are even more encouraging. Subjects who had
received IMPACT treatment for a year were found to fare significantly better
two years after treatment ended than subjects who had gotten usual care for a
Specifically, the IMPACT group did better concerning continuation of
antidepressant treatment, depression remission, physical functioning, quality
of life, and satisfaction with depression care. Even more impressive, these
positive results applied to both men and women subjects, to subjects from
various ethnic backgrounds, to subjects of various ages, and to subjects who
had medical conditions as well as depression.
Thus, "tailored collaborative care actively engages people [aged 60
and over] in depression treatment and delivers important benefits that persist
at least one year after the completion of the intervention program," the
researchers concluded in their study report.
Two of the principal investigators were Jurgen Unutzer, M.D., and Wayne
Katon, M.D., both vice chairs of psychiatry at the University of Washington.
In fact, it was Unutzer who oversaw efforts to develop the IMPACT model back
Moreover, Unutzer and Katon are working hard to get the IMPACT model
established in real-world health care settings, they told Psychiatric
News. During the past two years, they have trained more than 500
clinicians from some 50 organizations in the model. During the past year,
Kaiser Permanente of Southern California has made the model available to its 3
million members. Indeed, along with Sutter Health and Duke University, Kaiser
Permanente is using the model to treat depressed patients of all ages.
Getting the model incorporated into various health care settings isn't
easy, Katon and Unutzer concurred. As they wrote in the December 2005
Psychiatric Clinics of North America, "It is not clear whose
job it is in the medico-academic industrial complex to disseminate
evidence-based practices and whose job it is in the real world of health care
delivery to adopt proven innovations...."
Katon told Psychiatric News, "The biggest hurdles are
organizational barriers and economic barriers to change." Nonetheless,
he continued, "Some of the proposed changes like pay-for-performance
insurance that pays for improving patient outcomes may help." Also,
Unutzer stressed, "We are only in the second year of a five-year grant
from the John A. Hartford Foundation to get the model implemented in
Thus, the model will undoubtedly be disseminated further during the next
five to 10 years, he anticipates—say, in major health care organizations
like Kaiser Permanente.
An abstract of "Long-Term Outcomes From the IMPACT Randomized
Trial for Depressed Elderly Patients in Primary Care" is posted at<http://bmj.bmjjournals.com/cgi/content/abstract/332/7536/259?>.
More information about the IMPACT model is posted at<www.impact.ucla.edu>.▪