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.
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.