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Rapid Responses: Rapid Responses published:
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Long term outcomes from the IMPACT randomized trail for depressed elderly patients in primary care: information on cost effectiveness will be helpful
- Samuel Y Wong (9 February 2006)
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What do we mean by collaborative care?
- Susan M Smith (14 February 2006)
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Persistence of therapeutic benefit from attention in older people with depression
- Marion E T McMurdo, Ian C. Reid (27 February 2006)
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Samuel Y Wong, Assistant Professor in Family Medicine Department of Community and Family Medicine, Chinese University of Hong Kong, PWH, Shatin, Hong Kong
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I would like to congratulate Hunkeler et al (2006) on their efforts in conducting such a well designed randomized trial for depressed elderly patients in primary care. The results from this trial touched on an important issue: compliance with medication and continuity of care are important in the treatment of depression in primary care. It would be even more interesting to evaluate the cost effectiveness for the IMPACT program such that health care policy makers can consider the feasibility and financial implications of implementing similar collaborative management program in primary care. Reference: Hunkeler EM, Katon W, Tang L, Williams J, Kroenke K, Lin E et al. Long term outcomes from the IMPACT randomized trial for depressed elderly patients in primary care. BMJ2006; 332: 259-263. Competing interests: None declared |
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Susan M Smith, Senior Lecturer in Primary Care Department of Public Health and Primary Care, Trinity College Dublin
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This is an important paper and it raises questions about the nature of collaborative care for chronic conditions. (1) As the authors acknowledge, the intervention is complex and it remains unclear which intervention components led to the improved outcomes in the IMPACT group of patients. They suggest that the relationship with the depression case manager may explain the study’s success. The intervention is described as collaborative care and was delivered by a team including both primary care and specialists. However, only 10% of patients were seen by a psychiatrist. The majority of patients received the benefit of a specialist psychiatrist’s input into the care protocol but is that the same as receiving specialist care? Starfield has described a ‘strong imperative’ for a shared model of relationship between primary care and specialty care physicians in managing common chronic conditions. (2) The potential benefit of collaborative or shared care is the provision of a combination of specialist care expertise and primary care with its emphasis on continuity of care and management of all existing co- morbidities. This type of more extensive collaborative care where individual patients with a chronic disease get the benefit of both specialist and primary care input has significant cost implications and could only be justified if it were found to be more effective than interventions involving consulting specialists and/or case managers alone. We need to be clear about what we mean when we use terms such as collaborative care and we need to test different models of collaborative care against each other if we are to be able to provide cost effective services for people with chronic diseases such as depression. 1. Hunkeler EM, Katon W, Tang L, Williams JW, Jr., Kroenke K, Lin EHB, et al. Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. BMJ. 2006 February 4, 2006;332(7536):259-63. 2. Starfield B. Primary and specialty care interfaces: the imperative of disease continuity. Br J Gen Pract. 2003 September 2003;53:723-9. Competing interests: None declared |
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Marion E T McMurdo, Professor of Ageing and Health Ninewells Hospital, Dundee DD1 9SY, Ian C. Reid
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Sir, Hunkeler and colleagues report the results of the IMPACT trial in which older adults with depression randomised to collaborative care enjoyed sustained benefits 12 months after the end of the intervention1. While this may be the result of the targeted intervention, the possibility that it is simply the effect of attention should not be dismissed. In our trial of the effects of exercise in older people with poorly responsive depressive disorder, participants (mean age 64 years) were randomised to either group exercise twice weekly for 10 weeks or to group health education sessions for the same period 2. Both interventions were matched for frequency and duration to allow us to disentangle the diversional and social effects of coming together as a group from the effects of exercise itself. Participants were assessed at baseline, 10 and 34 weeks by a psychiatrist blind to group allocation. Whilst a significantly higher proportion of the exercise group (55% v. 33%) experienced a greater than 30% decline in depression at 10 weeks according to the Hamilton Rating Scale for Depression (HRSD), both groups showed statistically significant differences from baseline in both HRSD and Geriatric Depression Scale which persisted to 34 weeks, despite the cessation of the interventions 6 months previously. Whilst this may reflect regression to the mean, or simply be a consequence of participation in a research trial as our study lacked a usual care group, the potential therapeutic effect of an intervention which involves frequent social contact should not be underestimated in a population for whom loneliness and isolation may be common. The persistent benefits reported by the IMPACT authors 12 months after the cessation of their collaborative care intervention may therefore simply represent the therapeutic effect of the attention received by those in the intervention arm, in comparison to those in the usual care arm of the study. To allow investigators to unpick the effects of social contact from the effects of other interventions, we believe it is essential that studies of depression in older people include an appropriate attentional control. Marion E T McMurdo Ian C Reid Reference List 1. Hunkeler EM, Katon W, Tang L, Williams JW, Jr., Kroenke K, Lin EH et al. Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. BMJ 2006;332:259-63. 2. Mather AS, Rodriguez C, Guthrie MF, McHarg AM, Reid IC, McMurdo ME. Effects of exercise on depressive symptoms in older adults with poorly responsive depressive disorder: randomised controlled trial. Br.J.Psychiatry 2002;180:411-5. Competing interests: None declared |
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