BMJ  2006;332:259-263 (4 February), doi:10.1136/bmj.38683.710255.BE (published 20 January 2006)

Research

Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care

Enid M Hunkeler, senior research scientist1, Wayne Katon, professor of psychiatry2, Lingqi Tang, statistician3, John W Williams, Jr, professor of medicine4, Kurt Kroenke, professor of medicine5, Elizabeth H B Lin, scientific investigator6, Linda H Harpole, head, global health outcomes7, Patricia Arean, associate professor8, Stuart Levine, medical director9, Lydia M Grypma, internist10, William A Hargreaves, professor emeritus of psychology11, Jürgen Unützer, professor of psychiatry12

1 Kaiser Permanente, Division of Research, 2000 Broadway, 2nd Floor, Oakland, CA 94612, USA emh{at}dor.kaiser.org, 2 Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-6560, USA, 3 Health Services Research Center, Neuropsychiatric Institute, University of California at Los Angeles, Los Angeles, CA 90024-6505, USA, 4 Health Services Research and Development, Duke University Medical Center, Hock Plaza, 2424 Erwin Rd, Suite 1105, Durham, NC 27705, USA, 5 Regenstrief Institute, 1050 Wishard Blvd, RG6, Indianapolis, IN 46202, USA, 6 Center for Health Studies, Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101, USA, 7 GlaxoSmithKline, 3030 Cornwallis Rd, MAI.B.530, RTP, NC 27709, USA, 8 Department of Psychiatry, Langley Porter Psychiatric Institute, University of California, San Francisco, 401 Parnassus Avenue, Box ADM-0984, San Francisco, CA 94143-0984, USA, 9 SCAN Health Plan, 3800 Kilroy Airport Way, Long Beach, CA 90801, USA, 10 Kaiser Permanente, Primary Care, 8080 Parkway Drive, La Mesa, CA 91942, USA, 11 University of California, San Francisco and Kaiser Permanente Division of Research, 2000 Broadway, 2nd Floor, Oakland, CA 94612, USA, 12 University of Washington, Department of Psychiatry, Box 356560, Seattle, WA 98195, USA

Correspondence to: E M Hunkeler emh{at}dor.kaiser.org

Abstract

Objective To determine the long term effectiveness of collaborative care management for depression in late life.

Design Two arm, randomised, clinical trial; intervention one year and follow-up two years.

Setting 18 primary care clinics in eight US healthcare organisations.

Patients 1801 primary care patients aged 60 and older with major depression, dysthymia, or both.

Intervention Patients were randomly assigned to a 12 month collaborative care intervention (IMPACT) or usual care for depression. Teams including a depression care manager, primary care doctor, and psychiatrist offered education, behavioural activation, antidepressants, a brief, behaviour based psychotherapy (problem solving treatment), and relapse prevention geared to each patient's needs and preferences.

Main outcome measures Interviewers, blinded to treatment assignment, conducted interviews in person at baseline and by telephone at each subsequent follow up. They measured depression (SCL-20), overall functional impairment and quality of life (SF-12), physical functioning (PCS-12), depression treatment, and satisfaction with care.

Results IMPACT patients fared significantly (P < 0.05) better than controls regarding continuation of antidepressant treatment, depressive symptoms, remission of depression, physical functioning, quality of life, self efficacy, and satisfaction with care at 18 and 24 months. One year after IMPACT resources were withdrawn, a significant difference in SCL-20 scores (0.23, P < 0.0001) favouring IMPACT patients remained.

Conclusions Tailored collaborative care actively engages older adults in treatment for depression and delivers substantial and persistent long term benefits. Benefits include less depression, better physical functioning, and an enhanced quality of life. The IMPACT model may show the way to less depression and healthier lives for older adults.


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