Team Program Touts Edge Against Depression

Abstract

A comprehensive team approach has been shown to help depressed older patients suffer less depression, function better physically, maintain better overall health, and enjoy better quality of life. The concept is part of a study utilizing a program that was designed specifically to meet the needs of older adults with depression. In the IMPACT (Improving Mood: Promoting Access to Collaborative Treatment) program, a depression care manager such as a nurse, social worker, or psychologist—in consultation with the primary care physician and a consulting psychiatrist—helps patients address their depression. The care manager educates patients about depression, tracks depressive symptoms and side effects, helps make changes in treatment when necessary, supports patients on antidepressant medications, and conducts brief courses of psychotherapy. Based on initial study results of 1,801 adults with depression in primary care settings and a mean age of 71 years, IMPACT patients did significantly better than patients in standard care. The benefits also continued 1 year after the program ended. IMPACT has been studied exclusively in primary care settings. However, principal investigator Jürgen Unützer, M.D., professor and vice chair of psychiatry and behavioral sciences at the University of Washington, Seattle, has partnered with other researchers to look at the possible utility of IMPACT in nursing homes, assisted-living facilities, and other settings. “We have anecdotal evidence that, with some adaptations, this program is effective in the long-term care setting,” Dr. Unützer said. Dr. Unützer said in many ways, nursing facilities are ideal settings for a team approach like IMPACT. “Nursing homes have an edge on providing nondrug treatments because they have those kinds of resources readily available. Various types of behavioral activation are a huge part of treating depression,” he said, adding, “Even long-term care facility residents need to do something with their energy.” These nondrug treatments don't have to be elaborate or extensive, Dr. Unützer said. He suggested starting with “pleasant event scheduling.” The goal of this is to identify several small activities or events that will bring patients joy and/or a sense of empowerment. “After a while, you see a light bulb go off, and these residents realize they aren't lost or hopeless. They become more active and interested.” A nurse in the facility could be identified to serve as the depression care manager, Dr. Unützer added. “The majority of managers in our study have been nurses, although—with enough training and structure—a number of professionals could be successful in this role,” he said. Care managers require some training to be effective. “We provided a 2-day training workshop that involved education about depression and training on issues such as behavioral activation and problem-solving,” he said. Currently, he is planning to launch Web-based modules to train a broad group of people on the IMPACT approach. “You need some kind of clinical practice guideline to support overall effort in the IMPACT program,” he said. Dr. Unützer said he is not familiar with the AMDA clinical practice guidelines, but suspects “that they line up reasonably well with similar guidelines for other settings and would be appropriate for use in implementing a team approach such as IMPACT.” A program like IMPACT actually may help facilities get psychiatric consultations for residents. “We had a psychiatrist spend an hour each week with the care manager. They would discuss all the cases, and the psychiatrist would make recommendations, changes, and so on. While the patients benefited from these consultations, only 10% of individuals actually saw a psychiatrist,” Dr. Unützer said, adding that this is a good way to make best use of limited resources.