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A Randomized Controlled Trial

Jürgen Unützer, MD, MPH; Wayne Katon, MD; Christopher M. Callahan, MD; John W. Williams, Jr, MD, MHS; Enid Hunkeler, MA; Linda Harpole, MD, MPH; Marc Hoffing, MD, MPH; Richard D. Della Penna, MD; Polly Hitchcock Noël, PhD; Elizabeth H. B. Lin, MD, MPH; Patricia A. Areán, PhD; Mark T. Hegel, PhD; Lingqi Tang, PhD; Thomas R. Belin, PhD; Sabine Oishi, MSPH; Christopher Langston, PhD; for the IMPACT Investigators

JAMA. 2002;288:2836-2845.

Context  Few depressed older adults receive effective treatment in primary care settings.

Objective  To determine the effectiveness of the Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression.

Design  Randomized controlled trial with recruitment from July 1999 to August 2001.

Setting  Eighteen primary care clinics from 8 health care organizations in 5 states.

Participants  A total of 1801 patients aged 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%).

Intervention  Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual care (n = 895). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert and who offered education, care management, and support of antidepressant management by the patient's primary care physician or a brief psychotherapy for depresssion, Problem Solving Treatment in Primary Care.

Main Outcome Measures  Assessments at baseline and at 3, 6, and 12 months for depression, depression treatments, satisfaction with care, functional impairment, and quality of life.

Results  At 12 months, 45% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.71-4.38; P<.001). Intervention patients also experienced greater rates of depression treatment (OR, 2.98; 95% CI, 2.34-3.79; P<.001), more satisfaction with depression care (OR, 3.38; 95% CI, 2.66-4.30; P<.001), lower depression severity (range, 0-4; between-group difference, -0.4; 95% CI, -0.46 to -0.33; P<.001), less functional impairment (range, 0-10; between-group difference, -0.91; 95% CI, -1.19 to -0.64; P<.001), and greater quality of life (range, 0-10; between-group difference, 0.56; 95% CI, 0.32-0.79; P<.001) than participants assigned to the usual care group.

Conclusion  The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices.

Author Affiliations: Center for Health Services Research, UCLA Neuropsychiatric Institute, Los Angeles, Calif (Drs Unützer, Tang, and Belin and Ms Oishi); Department of Psychiatry, University of Washington (Dr Katon), and Center for Health Studies, Group Health Cooperative of Puget Sound (Dr Lin), Seattle; Indiana University Center for Aging Research, Regenstrief Institute for Health Care, Indianapolis (Dr Callahan); Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center and Duke University Medical Center (Dr Williams), and Department of Medicine, Duke University Medical Center (Dr Harpole), Durham, NC; Division of Research, Kaiser Permanente of Northern California, Oakland (Ms Hunkeler); Desert Medical Group, Palm Springs, Calif (Dr Hoffing); Kaiser Permanente of Southern California, San Diego (Dr Penna); South Texas Veterans Health Care System/University of Texas Health Science Center, San Antonio (Dr Noël); Department of Psychiatry, University of California, San Francisco (Dr Areán); Department of Psychiatry, Dartmouth Medical School, Hanover, NH (Dr Hegel); and John A. Hartford Foundation, New York, NY (Dr Langston).

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