Hanover, NH -- A team care approach more than doubles the effectiveness of depression treatment for older adults in general medical settings, according to a new UCLA/Dartmouth study. The findings reported in the December 11 Journal of the American Medical Association (JAMA), show the benefits of a model primary care program to treat late life depression.

The study followed 1,801 depressed older adults from primary care clinics in California, Indiana, North Carolina, Texas and Washington for one year. Half were assigned to care as usual and the other half were assigned to a new model of team care, an approach Dartmouth Medical School investigators helped develop.

The model program, Improving Mood -- Promoting Access to Collaborative Treatment (IMPACT), assigned patients age 60 and older to a depression care manager -- specially trained nurses or psychologists-- in their usual primary care clinic. The managers worked with a consulting psychiatrist, and in close collaboration with the patients' regular physicians for up to 12 months to educate and support patients, track symptoms and side effects, assist with changes in antidepressant treatment and provide counseling.

The IMPACT care model was significantly more effective than usual care for depression at each of the eight participating sites, the study found. Almost half of the participants assigned to the IMPACT program reported a 50 percent or greater reduction in depression symptoms at 12 months, compared with 19 percent of those in usual care.

"Most of the patients in usual care received prescriptions for antidepressant medications from their primary care physicians, but it may not be enough for physicians to diagnose depression and write a prescription. We found that, with the added support and the close follow-up provided by the IMPACT team, patients felt better, functioned better, and enjoyed life more fully than patients treated in usual care," said Dr. Jurgen Unutzer, associate professor of psychiatry at the David Geffen School of Medicine at UCLA who directed the study coordinating center at the UCLA Neuropsychiatric Institute.

"As a psychologist working in primary care I am particularly pleased that this collaborative treatment model was also able to make an effective counseling intervention available to older patients who preferred this approach over medication," said Dr. Mark Hegel, associate professor of psychiatry and community and family medicine at Dartmouth Medical School, a co-author who trained and supervised the depression care managers in the counseling intervention aspect of the study.

"Patients assigned to the IMPACT intervention, when they preferred a counseling approach, were six-times more likely to receive counseling, usually a very brief and practical type of counseling called problem solving treatment, than patients assigned to the usual care condition. Collaborative team care makes counseling an option in primary care; an option not typically available without this approach."

Dr. Thomas Oxman, DMS professor of psychiatry and of community and family medicine, a nationally recognized expert on primary care mental health issues, served on the study advisory board.

Other findings include:

* IMPACT patients reported less depression, less impairment in day-to-day functioning and greater improvements in quality of life at three-, six- and 12-month evaluations.
* IMPACT patients had closer follow-up and more frequent adjustments in medications.
* IMPACT patients were more likely to receive desired counseling.
* The average cost of providing IMPACT services totaled $550 per person for 12 months, modest, say the investigators, given total annual Medicare spending of over $ 6,000 for each depressed enrollee.

Of the 31 million Americans age 65 and older, nearly 5 million experience symptoms of depression. Five to ten percent of older adults who visit a primary care physician suffer from major depression. The condition causes functional impairment, diminished quality of life and considerable suffering for patients and their families, as well as increased health care costs and deaths from medical illnesses and suicide.

While late life depression can be treated successfully with antidepressant medications or counseling, few older adults receive effective treatment. Many may view depression as a "normal" part of the aging process, not a medical illness that can or should be treated.

The John A. Hartford Foundation of New York City, the California HealthCare Foundation, the Hogg Foundation and the Robert Wood Johnson Foundation funded the $11 million study. Corinne H. Rieder, executive director of the Hartford Foundation, the lead sponsor of the project, said, "These findings demonstrate how effective team work by trained health care professionals can improve the health of older people and are an example of how health care must change to increase its capacity to meet the needs of our nation's aging population."

---Dartmouth-Hitchcock Medical Center