A team approach to treating depression in older adults, already shown to improve health, can also cut total health-care costs, according to a new study led by the University of Washington. The study appears in the February issue of the American Journal of Managed Care.

Clinical depression affects about 3 million older adults in the United States and is associated with 50 to 70 percent higher health-care expenses, mostly due to an increased use of medical, not mental health, services. In this study, researchers found that adults over 60 who received a year of team care for depression had lower average costs for all of their health care over a four-year period - about $3,300 less than patients receiving traditional care, even when the cost of the team care treatment is included.

Over the past several years, a multi-center research team has been studying a team care approach called IMPACT (Improving Mood – Promoting Access to Collaborative Treatment for Late Life Depression). The treatment model features a nurse, social worker or psychologist serving as a depression-care manager. This depression-care manager works with the primary care physician and a consulting psychiatrist to care for depressed patients in their primary care clinic.

Previous studies have shown that the IMPACT program provides powerful health benefits, including significantly decreased depression and chronic physical pain, improved physical functioning and better overall quality of life. In this cost evaluation study, 551 IMPACT participants from two large health-care organizations, Group Health Cooperative of Puget Sound and Kaiser Permanente of Southern California, were followed for four years to examine long-term effects of team care on medical costs.

“Study participants assigned to the IMPACT program saw significantly lower total health care costs over four years than patients receiving standard care, and our research shows that this difference was almost certainly due to the IMPACT team-care model,” said Dr. Jurgen Unutzer, professor and vice-chair of psychiatry and director of the IMPACT Implementation Center at the UW. “This research, combined with our other work showing how team care for depression has significant health benefits for older adults, illustrates how important it is for health organizations to consider implementing evidence-based collaborative models of depression care, such as IMPACT.”

The cost of using the IMPACT model of depression care treatment is only about $500 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 spread out over an entire population of older adults, the cost of offering IMPACT as a health care benefit amounts to about $1 per person per month.

Based on its high effectiveness and 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 people in its 12 regional medical centers. In the Seattle area, Virginia Mason Medical Center will begin rolling out IMPACT to patients in their primary care clinics over the next few months. The John A. Hartford Foundation is supporting the efforts of Unutzer and his colleagues to help these and other health-care systems around the country adapt and implement IMPACT.

A cheaper, more effective method of treating clinical depression in older adults has become more important in recent years, as physicians have learned that the condition affects not only the mental health but also the physical health of millions of patients 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.

Unfortunately, many older adults don’t seek treatment for depression, and when they do, physicians can sometimes inadvertently delay diagnosis or misdiagnose the condition. Doctors and their patients often share the misconception that depression is a natural consequence of aging. When the condition is successfully diagnosed, patients often do not receive effective, evidence-based treatment with medication, psychotherapy, or a combination of the two. With a team-care program, like IMPACT, may of these barriers can be overcome.

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Background: IMPACT

The IMPACT study, which began in 2001, randomly assigned 1,801 depressed older adults from 18 diverse primary care clinics in eight cities in the United 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, CA.

The IMPACT study was supported primarily by a grant from the John. A. Hartford Foundation with support from the California Healthcare Foundation, Hogg Foundation, and the Robert Wood Johnson Foundation.

Contact: Justin Reedy
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University of Washington