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Press Release
Depression-care Model is Cost-effective, Study Shows
December 1, 2005
An innovative model of depression care for older primary-care patients yields big improvements for little money, suggests a new analysis of a study involving the Veterans Health Administration and seven other health systems. The findings, which bolster the case for an overhaul of how U.S. healthcare providers manage depression, especially in the elderly, appear in the December Archives of General Psychiatry.
"These results show it's possible to achieve significant improvements in the health outcomes of older adults with depression for very modest costs," said one of the authors, John W. Williams Jr., MD, of the Durham Veterans Affairs Medical Center and Duke University. Lead author was Wayne J. Katon, MD, of the University of Washington School of Medicine.
As many as 10 percent of older adults seen in primary-care offices have depression. But the illness often goes undiagnosed in the face of more urgent medical concerns. Even when primary-care doctors do recognize the problem and prescribe medication, follow-up is often too uneven to ensure good results. Plus, many older patients do not take advantage of psychotherapy because of issues with access, insurance or transportation, or because they fear being seen as having a mental health problem.
The new care model, known as "IMPACT"—"Improving Mood: Promoting Access to Collaborative Treatment-was tested from July 1999 to August 2001 with 1,801 depressed adults, aged 60 or older, at 18 primary-care clinics in five states, including two VA sites in Texas. Specially trained
nurses, social workers or psychologists, serving as depression-care managers, worked closely with primary-care physicians for up to a year to educate, support and monitor patients in the IMPACT arm of the study. Psychiatrists consulted on the care of all IMPACT patients and saw about 10 percent in office visits.
The original study, published in the Journal of the American Medical Association in 2002, found that the team model was considerably more effective than usual care in easing depression and boosting function. IMPACT patients were more likely to be treated for their depression, either with antidepressants or brief psychotherapy sessions. Nearly half of the 906 IMPACT patients reported a 50-percent or greater reduction in depression symptoms after one year, compared with only 1 in 5 among the 895 usual-care patients.
In 2003, the President's New Freedom Commission on Mental Health cited the IMPACT model as a potentially life-saving approach that should be widely used in primary-care settings and reimbursed by public and private insurers. The group's report is on the Internet at http://www.mentalhealthcommission.gov.
The new analysis appearing this month, one of the most rigorous studies ever of the costs of collaborative depression care, found that IMPACT patients experienced 107 more depression-free days over a two-year period than their usual-care peers. The incremental outpatient cost to their health system was about $2.76 per depression-free day, or $148 per year. By comparison, studies of other models of collaborative depression care have reported far higher per-day costs, ranging from $10.30 to $35.20.
While the IMPACT model entailed some additional expenses relative to usual care—such as salary for extra nurses or psychologists—these costs were offset to a large extent by patients' needing fewer mental-health visits outside of primary care.
According to Williams, the cost-benefit analysis of IMPACT compares favorably—and dramatically so—with that of commonly accepted medical interventions such as hypertension screening and treatment, or statin use to prevent heart attacks. Previous analyses of IMPACT showed that beyond reducing depression symptoms, the model resulted in improved quality of life and physical functioning; higher patient satisfaction with care; decreased burden from pain in patients with depression and arthritis; and better adherence to exercise regimens.
"There are relatively few bargains in healthcare, and IMPACT is clearly one of them," said Williams.
The VA's Veterans Health Administration, the nation's largest healthcare network, is working toward national implementation of a model similar to IMPACT to serve veterans of all ages. More information on the effort can be found at http://www.va.gov/tides_waves. Details on IMPACT are available at http://www.impact.ucla.edu.
The research was funded by the John A. Hartford Foundation, National Institute of Mental Health, and California Health Care Foundation.
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