Taking an evidence-based model of depression care from research to practice:
Making lemonade out of depression.
Grypma L, Haverkamp R, Little S, Unützer J.
General Hospital Psychiatry. 2006;28:101-107.
OBJECTIVE: The Improving Mood-Promoting Access to Collaborative Treatment (IMPACT)
trial [randomized controlled trial (RCT)] found that collaborative care management of
depression in older primary care patients was significantly more effective than the usual
care. We examined how an adapted version of IMPACT is working in the "real-world" setting
of an HMO 3 years after the conclusion of the trial.
METHOD: Two hundred ninety-seven adults treated according to IMPACT protocol
"poststudy" (PS) at a large group model HMO were compared to the 141 participants
(historical control) in the intervention arm of the RCT at the same site. The Patient Health
Questionnaire (PHQ-9) was used to compare depression severity at baseline and 6 months.
We also compared treatment contacts, use of antidepressants and psychotherapy and total
health care costs.
RESULTS: The RCT and PS groups were equivalent regarding baseline depression scores
(14.5 vs. 14.2, P= .72), 6-month scores (5.6 vs. 6.3, P= .28) and percent experiencing 50%
improvement in depression (68% vs. 70% , P= .83). Antidepressant use was similar (85%
and 90% , P= .57). Treatment contacts were fewer in PS than RCT (14 vs. 20, P< .001).
CONCLUSIONS: An adapted version of the IMPACT program implemented at a large HMO
achieved similar clinical improvements in depression as the clinical trial despite a lower
number of intervention contacts.
I mproving treatment of depression among Latinos w ith diabetes using Project
Dulce and I MPACT.
Gilmer TP, Walker C, Johnson ED, Philis-Tsimikas A, Unützer J.
Diabetes Care 2008;31(7):1324-6.
OBJECTIVE: To assess the feasibility and cost of integrating diabetes and depression care
management in three community clinics serving a low-income and predominantly Spanish-
speaking Latino population.
RESEARCH DESIGN AND METHODS: We screened diabetes patients for depression, and for
those with depressive symptoms, we provided depression care management. We assessed
changes in depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9),
diabetes self-care activities (nutrition, exercise, and medication adherence), and costs.
RESULTS: Thirty-three percent of patients with diabetes had symptoms of major
depression. Among 99 patients completing the study, PHQ-9 scores declined by an average
of 7.5 points from 14.8 to 7.3 (P < 0.001). Clients averaged 6.7 visits with the care
manager during the study period. Costs of depression care management were estimated to
be $512 per participant.
CONCLUSIONS: Adding a depression care manager to an existing diabetes management
team was effective at reducing depressive symptoms at a reasonable cost.
Randomized controlled trial of collaborative care management of depression
among low -income patients w ith cancer.
Ell K, Xie B, Quon B, Quinn D, Dwight-Johnson M, Lee PJ.
Journal of Clinical Oncology 2008;26(27):4488-4496.
PURPOSE: To determine the effectiveness of the Alleviating Depression Among Patients
With Cancer (ADAPt-C) collaborative care management for major depression or dysthymia.
PATIENTS AND METHODS: Study patients included 472 low-income, predominantly female
Hispanic patients with cancer age > or= 18 years with major depression (49% ), dysthymia
(5% ), or both (46% ). Patients were randomly assigned to intervention (n = 242) or
enhanced usual care (EUC; n = 230). Intervention patients had access for up to 12 months
to a depression clinical specialist (supervised by a psychiatrist) who offered education,
structured psychotherapy, and maintenance/relapse prevention support. The psychiatrist
prescribed antidepressant medications for patients preferring or assessed to require
RESULTS: At 12 months, 63% of intervention patients had a 50% or greater reduction in
depressive symptoms from baseline as assessed by the Patient Health Questionnaire-9
(PHQ-9) depression scale compared with 50% of EUC patients (odds ratio [OR] = 1.98;
95% CI, 1.16 to 3.38; P = .01). Improvement was also found for 5-point decrease in PHQ-9
score among 72.2% of intervention patients compared with 59.7% of EUC patients (OR =
1.99; 95% CI, 1.14 to 3.50; P = .02). Intervention patients also experienced greater rates
of depression treatment (72.3% v 10.4% of EUC patients; P < .0001) and significantly
better quality-of-life outcomes, including social/family (adjusted mean difference between
groups, 2.7; 95% CI, 1.22 to 4.17; P < .001), emotional (adjusted mean difference, 1.29;
95% CI, 0.26 to 2.22; P = .01), functional (adjusted mean difference, 1.34; 95% CI, 0.08
to 2.59; P = .04), and physical well-being (adjusted mean difference, 2.79; 95% CI, 0.49 to
5.1; P = .02).
CONCLUSION: ADAPt-C collaborative care is feasible and results in significant reduction in
depressive symptoms, improvement in quality of life, and lower pain levels compared with
EUC for patients with depressive disorders in a low-income, predominantly Hispanic
population in public sector oncology clinics.
Collaborative care for adolescent depression: a pilot study.
Richardson L, McCauley E, Katon WJ.
General Hospital Psychiatry 2009;3:36-45.
OBJECTIVE: The main objectives of this study were to explore the preliminary outcomes and
assess the feasibility and acceptability of a collaborative care intervention designed to
improve treatment and outcomes of depression among youth seen in primary care settings.
METHODS: We conducted a pilot intervention study at three clinics in a university affiliated
primary care clinic network. The intervention model was designed to support the provision
of depression treatment by primary care providers using methods adapted from the IMPACT
study developed for the improvement of depression among older adults. Specific
components include the provision of regular case management by a nurse depression care
manager (DCM), enhanced patient and parent education about depression and its
treatment, encouragement of patient self-management with a choice of starting
medications or therapy or both, and oversight of the DCM by a mental health specialist.
Study participants were assessed regularly by the DCM for 6 months and completed written
self-report assessments at baseline, 3, and 6 months after starting the intervention.
RESULTS: 40 youth (12-18 years) with major and minor depression enrolled in the
intervention. Study participants were predominantly female (90% ). The baseline Patient
Health Questionnaire (PHQ-9) score was 14.2 (SD= 4.5). Patients were similarly divided
among initiating medications (n= 12), therapy (n= 15), or combination therapy (n= 8). Five
patients withdrew prior to initiating treatment. The mean number of in person and
telephone contacts with the DCM was 9 (range= 5 to 17). Eighty-seven percent of youth
completed the 6-month intervention. At 6 month follow-up, 74% of youth had a 50% or
more reduction in depressive symptoms as measured by the PHQ-9. Parents, youth and
physicians indicated high levels of satisfaction with the intervention on written surveys and
in qualitative exit interviews.
CONCLUSION: The collaborative care model is feasible and highly acceptable to adolescents
and parents as demonstrated both by self-report and by engagement in the intervention. It
is also associated with improved depressive outcomes at similar levels to adult
interventions. Future studies should evaluate these models in a randomized
Evaluation of Project I MPACT and Development of a Tracking System.
This summary is based on a report created by Heyman J, Gutheil I, Dybing K, White-Ryan L,
Wang D, Little V, Collier J. February 15, 2006 (unpublished).
PURPOSE: The Institute for Family Health (IFH) was one of the first ‘real-world’ settings to
replicate* IMPACT after the end of the research trial. IFH worked with Fordham University’s
Ravazzin Center on Aging to evaluate program outcomes and to study factors that influence
changes in depression scores.
METHODS: The evaluation used data from three, six and 12 month periods after patient
enrollment to examine if patient depression scores decreased over time. Medical records for
a total of 243 patients were used in the analysis. All patients were 60 years of age or older
and had a PHQ-9 score of 10 or higher when they were enrolled in IMPACT. Depression was
measured at all time points with the PHQ-9.
DEMOGRAPHICS: The average age of participants was 71.6 years. About half the
participants (47.8% ) were married; 31% were male and 69% were female. Thirty-eight
percent were Latino, 29% African American, 23% Caucasian and 10% Other. One third of
the patients had a diagnosis of Type II diabetes in their medical record. Two-thirds has a
prior mental health diagnosis and 37% had previously been prescribed psychiatric
RESULTS: The average initial depression score on the PHQ-9 was 14.03 (SD= 3.88). There
was a statistically significant drop in depression scores at each of the data points: 3 months
(p< .001), 6 months (p< .05) and 12 months (p< .05) based on comparison of each patients’
scores to their baseline score. There was also a statistically significant drop in primary care
visits between the 3 and 6 month follow-ups.
*Implementation supported with funds from the Fan Fox and Leslie R. Samuels Foundation.
The Pathw ays Study: A randomized trial of collaborative care in patients w ith
diabetes and depression.
Katon WJ, Von Korff M, Lin EH, Simon G, Ludman E, Russo J, Ciechanowski P, Walker E,
Archives of General Psychiatry 2004;61:1042-1049.
BACKGROUND: There is a high prevalence of depression in patients with diabetes mellitus.
Depression has been shown to be associated with poor self-management (adherence to
diet, exercise, checking blood glucose levels) and high hemoglobin A1c (HbA1c) levels in
patients with diabetes.
OBJECTIVE: To determine whether enhancing quality of care for depression improves both
depression and diabetes outcomes in patients with depression and diabetes.
DESIGN: Randomized controlled trial with recruitment from March 1, 2001, to May 31,
SETTING: Nine primary care clinics from a large health maintenance organization.
PARTICIPANTS: A total of 329 patients with diabetes mellitus and comorbid major
depression and/or dysthymia. Intervention Patients were randomly assigned to the
Pathways case management intervention (n = 164) or usual care (n = 165). The
intervention provided enhanced education and support of antidepressant medication
treatment prescribed by the primary care physician or problem-solving therapy delivered in
MAIN OUTCOME MEASURES: Independent blinded assessments at baseline and 3, 6, and
12 months of depression (Hopkins Symptom Checklist 90), global improvement, and
satisfaction with care. Automated clinical data were used to evaluate adherence to
antidepressant regimens, percentage receiving specialty mental health visits, and HbA1c
RESULTS: When compared with usual care patients, intervention patients showed greater
improvement in adequacy of dosage of antidepressant medication treatment in the first 6-
month period (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.28-7.55) and the
second 6-month period (OR, 2.90; 95% CI, 1.69-4.98), less depression severity over time
(z = 2.84, P = .004), a higher rating of patient-rated global improvement at 6 months
(intervention 69.4% vs usual care 39.3% ; OR, 3.50; 95% CI, 2.16-5.68) and 12 months
(intervention 71.9% vs usual care 42.3% ; OR, 3.50; 95% CI, 2.14-5.72), and higher
satisfaction with care at 6 months (OR, 2.01; 95% CI, 1.18-3.43) and 12 months (OR,
2.88; 95% CI, 1.67-4.97). Although depressive outcomes were improved, no differences in
HbA1c outcomes were observed.
CONCLUSION: The Pathways collaborative care model improved depression care and
outcomes in patients with comorbid major depression and/or dysthymia and diabetes
mellitus, but improved depression care alone did not result in improved glycemic control.