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Wayne J. Katon, MD; Michael Schoenbaum, PhD; Ming-Yu Fan, PhD; Christopher M. Callahan, MD; John Williams, Jr, MD, MHS; Enid Hunkeler, MA; Linda Harpole, MD, MPH; Xiao-Hua Andrew Zhou, PhD; Christopher Langston, PhD; Jürgen Unützer, MD, MPH; for the IMPACT Investigators

Arch Gen Psychiatry. 2005;62:1313-1320.

Context  Depression is a leading cause of functional impairment in elderly individuals and is associated with high medical costs, but there are large gaps in quality of treatment in primary care.

Objective  To determine the incremental cost-effectiveness of the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression.

Design  Randomized controlled trial with recruitment from July 1999 to August 2001.

Setting  Eighteen primary care clinics from 8 health care organizations in 5 states.

Participants  A total of 1801 patients 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%).

Intervention  Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual primary care (n = 895). Intervention patients were provided access to a depression care manager supervised by a psychiatrist and primary care physician. Depression care managers offered education, support of antidepressant medications prescribed in primary care, and problem-solving treatment in primary care (a brief psychotherapy).

Main Outcome Measures  Total outpatient costs, depression-free days, and quality-adjusted life-years.

Results  Relative to usual care, intervention patients experienced 107 (95% confidence interval [CI], 86 to 128) more depression-free days over 24 months. Total outpatient costs were $295 (95% CI, –$525 to $1115) higher during this period. The incremental outpatient cost per depression-free day was $2.76 (95% CI, –$4.95 to $10.47) and incremental outpatient costs per quality-adjusted life-year ranged from $2519 (95% CI, –$4517 to $9554) to $5037 (95% CI, –$9034 to $19 108). Results of a bootstrap analysis suggested a 25% probability that the IMPACT intervention was "dominant" (ie, lower costs and greater effectiveness).

Conclusions  The IMPACT intervention is a high-value investment for older adults; it is associated with high clinical benefits at a low increment in health care costs.

Author Affiliations: Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle.

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