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Over the past decade, trials based in primary care have shown the effectiveness of collaborative care models in treating depression. Essential elements of these collaborative care programmes are the use of evidence based protocols for treatment, structured collaboration between primary care providers and mental health specialists, active monitoring of adherence to treatment and of outcomes, and (in some cases) structured programmes of psychotherapy delivered in primary care. A paper by Hunkeler and colleagues (p 259) extends the evidence for collaborative care in depression in three important ways, finding that such care is acceptable to older patients, is effective, and has benefits that are sustained over at least two years.1
The initial studies on collaborative care for depression showed the value of psychiatrists or psychologists working in primary care settings to improve the quality of pharmacotherapy or provide brief psychotherapy.2,3 Subsequent programmes attempted to improve the availability and efficiency of collaborative care through structured telephone calls with participants and nurses and bachelor-level mental health workers.4,5 Studies of disseminating and implementing collaborative care proved the acceptability and effectiveness of these strategies for quality improvement and care management strategies in a range of healthcare settings and patient populations.6,7
The IMPACT study shows that the strategies for quality improvement and care management proved effective in younger adults with depression can be extended to older people. Acceptability of the IMPACT treatment programme was high, and clinical benefits were at least as large as those seen in younger or mixed age samples. Clearly, depression is not an inevitable consequence of ageing, functional limitation, and chronic illness. The belief that older people have “good reason to be depressed” has sometimes led to misplaced nihilism regarding treatment for depression.
These data show that relatively modest levels of continuity of care and of maintenance treatment yield important and sustained benefits. Initial evaluations of collaborative care for depression showed that short term interventions produced only short term benefits.8 The IMPACT stepped care programme allowed for varying intensity of long term treatment. Follow-up and monitoring for most patients who were responding well to initial treatment was provided through brief monthly phone calls from their depression care manager (usually a primary care nurse). Those not responding were offered augmented treatment and consultation with a specialist. Patients in the intervention group maintained important clinical gains through the 12 month intervention period and the following year.
These findings suggest that the value of improving care for depression should be judged over a period of two years or more. The largest investments in improved treatment are made in the first three to six months, but the maximal benefits do not occur until six or 12 months. When you're measuring the number of miles travelled per gallon of gas, you have to include the time that you spend coasting (an analogy useful beyond US and UK readers).
It is refreshing that the paper by Hunkeler and colleagues does not end with the customary call for additional research. The evidence base is now sufficient for the emphasis to shift from research to dissemination and implementation.
Competing interests: GS has collaborated with Drs Hunkeler, Katon, Lin, and Unutzer.
Research p 259