Team care
more cost-effective than usual care for depression
A team care model for treating depression in adults aged 60
years and older is more cost-effective than standard
treatment options, according to a University of Washington
study that appears in the Dec. 5 issue of the Archives of
General Psychiatry, one of the JAMA Archives journals.
Cost-effectiveness is defined as the health benefits
patients receive from medical care in relation to the cost
of that care.
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.
"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.
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.
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Background: IMPACT
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.jhartfound.org)
is dedicated to improving health care for older Americans.
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.impact.ucla.edu/