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Am Fam Physician. 2003;67(5):1107-1111

Five to 10 percent of older adults seen in a primary care setting have depression, but screening, practitioner feedback, and education do not appear to result in consistent improvements in this subset of patients. A study undertaken by Unützer and colleagues hypothesizes that a more comprehensive intervention is needed to improve depression in the elderly.

The study group performed a multicenter, randomized controlled trial using the Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) program. Patients were recruited through screening and referral, with 1,801 depressed or dysthymic elderly patients randomized to usual care or to the intervention. Intervention patients received an educational video and booklet and were encouraged to visit with a depression care manager (a psychologist or a nurse trained as a depression clinical specialist). At the initial visit, an extensive history and educational review were conducted, and patients, in collaboration with their primary care physician, elected antidepressant medication or a six- to eight-session structured psychotherapy program. In a 12-month period of follow-up, medication could be adjusted and patients could add or switch to the alternate treatment modality if they were still depressed.

Data were collected in baseline interviews followed by blinded interviews at three, six, and 12 months. Variables included self-reported use of antidepressants, satisfaction with depression care, and symptom scores. The mean age of the sociodemographically diverse sample was 71.2 years, and 65 percent of the participants were women. Intervention patients were significantly more likely to use antidepressants or psychotherapy than usual-care patients.

The intervention group had significantly lower depression severity as measured by depression scores during all follow-up points, with the differences increasing over the study period. They also had a reduction of at least 50 percent in depression scores, a significantly higher reduction than the usual-care patients. Usual-care patients had a 19 percent reduction in depression symptoms during the treatment period. The intervention patients had a higher rate of complete remission of depression symptoms. The estimated cost of the IMPACT intervention is $553 per patient per year.

The authors conclude that this collaborative care model is more efficacious in treating late-life depression than usual-care models. Benefits might include decreased comorbidities, improved medication adherence, and improved quality of life. Although a cost-benefit analysis was not performed, the authors suggest that the cost might be offset by the potential savings, given the overall cost of caring for older adults who are depressed, which is 50 percent higher than the cost of caring for those who are not depressed.

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