Intended for healthcare professionals


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

BMJ 2006; 332 doi: (Published 02 February 2006) Cite this as: BMJ 2006;332:259
  1. Enid M Hunkeler, senior research scientist (emh{at},
  2. Wayne Katon, professor of psychiatry2,
  3. Lingqi Tang, statistician3,
  4. John W Williams Jr, professor of medicine4,
  5. Kurt Kroenke, professor of medicine5,
  6. Elizabeth H B Lin, scientific investigator6,
  7. Linda H Harpole, head, global health outcomes7,
  8. Patricia Arean, associate professor8,
  9. Stuart Levine, medical director9,
  10. Lydia M Grypma, internist10,
  11. William A Hargreaves, professor emeritus of psychology11,
  12. Jürgen Unützer, professor of psychiatry12
  1. 1 Kaiser Permanente, Division of Research, 2000 Broadway, 2nd Floor, Oakland, CA 94612, USA
  2. 2 Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-6560, USA
  3. 3 Health Services Research Center, Neuropsychiatric Institute, University of California at Los Angeles, Los Angeles, CA 90024-6505, USA
  4. 4 Health Services Research and Development, Duke University Medical Center, Hock Plaza, 2424 Erwin Rd, Suite 1105, Durham, NC 27705, USA
  5. 5 Regenstrief Institute, 1050 Wishard Blvd, RG6, Indianapolis, IN 46202, USA
  6. 6 Center for Health Studies, Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101, USA
  7. 7 GlaxoSmithKline, 3030 Cornwallis Rd, MAI.B.530, RTP, NC 27709, USA
  8. 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. 9 SCAN Health Plan, 3800 Kilroy Airport Way, Long Beach, CA 90801, USA
  10. 10 Kaiser Permanente, Primary Care, 8080 Parkway Drive, La Mesa, CA 91942, USA
  11. 11 University of California, San Francisco and Kaiser Permanente Division of Research, 2000 Broadway, 2nd Floor, Oakland, CA 94612, USA
  12. 12 University of Washington, Department of Psychiatry, Box 356560, Seattle, WA 98195, USA
  1. Correspondence to: E M Hunkeler
  • Accepted 8 November 2005


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.


  • We thank the patients, primary care providers, and staff at the coordinating centre, and at all of the participating study sites for their contributions and support We would like to thank the investigators and the IMPACT study advisory board for their scientific and other contributions. We thank Christopher Langston, senior programme officer from the John A Hartford Foundation for all of his contributions and support throughout the entire study period. We thank Sabine Oishi for her project coordination efforts. We acknowledge Diane Fraser for editorial assistance. We thank Bruce Fireman and Joe Selby for review and comments on the manuscript. We acknowledge Carla Tillman for preparation of the manuscript. We also thank Claudia Cruz and Yolanda Yarbough for their help with preparation of the manuscript.

  • Contributors JU and WJK conceived the study and were the primary designers, although all authors contributed to the design. JU coordinated the study. EMH, WJK, JWW, KK, EHBL, LHH, PA, SL, LMG, and JU each conducted the study at a different participating site. This included provision of the intervention, data collection and extraction. LT, EMH, JU, WJK, and WAH developed the analysis plan, and LT conducted the analyses. EMH and LT wrote the original draft of the article. JU, WJK, KK, WAH, EHBL, PA, JWW, and LHH made substantial contributions to the manuscript. SL and LMG made more minor revisions to the manuscript. All coauthors contributed to and approved the final version of the manuscript. EMH and JU are the guarantors.

  • Funding This study is supported by grants from the John A. Hartford Foundation, the California Healthcare Foundation, the Hogg Foundation, and the Robert Wood Johnson Foundation.

  • Competing interests EMH has received research funding from Eli Lilly and Company, Merck, Wyeth-Ayerst, Pfizer, Solvay, and GlaxoSmithKline. EMH received a consulting fee regarding women's health from Eli Lilly. JWW has received consulting fees from Wyeth-Ayerst, Pfizer, and GlaxoSmithKline for participating in advisory boards that address depression care. LH has served as a consultant to Wyeth-Ayerst and is currently employed by GlaxoSmithKline. KK has received research funding and consulting fees from Pfizer, Eli Lilly, and Wyeth-Ayerst.

  • Ethical approval The study protocol was formulated independently by the investigators and approved by institutional review boards at all participating study sites and the UCLA study coordinating centre.

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