..........Having an IMPACT on Depression

Pamela B. Smith, Director, County's Aging & Independence Services

...Depression is not a direct result of aging, however, physical problems and losses that might befall us as we get older can spark emotional trouble. Likewise, mental and emotional difficulties can manifest as physical problems.

A patient might go into the primary doctor and say, “I’m tired all the time,” but the patient doesn’t tell the doctor he or she is having problems with stress, anxiety and depression, says Dr. Jürgen Unützer, a geriatric psychiatrist and researcher at the University of Washington. So the emotional root of the physical problem may never be treated.

Dr. Unützer was the keynote speaker on the topic of Older Adult Mental Health at our 2006 Aging Summit. He was joined by Barry Lebowitz, Ph.D., UCSD professor of Psychiatry and deputy director of the Stein Institute for Research on Aging.

The Aging Summit is a biennial forum, created by Supervisors Dianne Jacob and Pam Slater-Price, that brings a wide spectrum of stakeholders together to propose new approaches for enhancing the quality of life for our older population. At each summit, selected topics are spotlighted by keynote speakers and discussed in detail during break-out sessions.

Older adults are generally not forthcoming with their doctors when it comes to mental health problems. They focus instead on physical symptoms, says Dr. Unützer. Some patients don’t even think of their doctor as treating anything but physical problems.

Dr. Unützer was the lead researcher in the largest treatment trial for late-life depression (www.impact.ucla.edu), which followed 1,801 depressed, older adults from 18 diverse primary care clinics across the United States. Half of the participants were enrolled in a depression treatment model called IMPACT. After a year of treatment in the study, IMPACT patients were more than twice as likely as patients in usual care to report at least a 50 percent reduction in depressive symptoms. They also reported better physical function, less pain, higher satisfaction with care, and a better overall quality of life than those in usual care. Because of the success of this study, several health care organizations in the U.S. and Canada are adopting the IMPACT model or researching the program’s effectiveness in other populations.

Of great interest to this Seattle-based researcher is the link of “the medical and the mental,” he says. “A chronic physical problem, like arthritis may keep adults from being mobile. They might wake up frequently during the night and then the next day they’re not feeling good. They become more withdrawn and isolated. This can lead to thoughts that people don’t like having them around, that they’re no fun to be around. They stop doing the things that give them pleasure and their inactivity makes them worse physically. It’s a vicious cycle of physical and emotional pain.”

...How do you break this cycle when seniors shy away from pursing psychological help?

....One key element of IMPACT is providing depression treatment in the office of the primary care physician, says Dr. Unützer. Participating doctors do a brief depression assessment of their older clients, and those with depressive symptoms are linked in the doctor’s office with a “depression case manager” (usually a registered nurse, a social worker, or a psychiatrist), who does a more complete assessment and educates them about depression. Those older adults who need additional help may receive both antidepressant medication prescribed by the primary physician plus brief counseling from the case manager. The counseling may include different cognitive-behavioral techniques such as “behavioral activation,” where patients are asked to schedule a pleasurable activity each week. If depressive symptoms persist, a psychiatrist is consulted for a possible change in medication or additional treatments. In the initial study, 98 percent of the seniors identified by their physician as having depressive symptoms took advantage of talking with the depression case manager. Generally when physicians make referrals for outside help, the rate of follow-through is not as high, according to Dr. Unützer.

....San Diego County was set to be a study site for the IMPACT program in 2006, with the focus on clients who are both depressed and have diabetes, says Viviana Criado, coordinator for the County’s Older Adult Mental Health Program. People with diabetes have a greater likelihood of becoming depressed and when they are depressed they may not manage their diabetes well.

The hope is that by reducing depression in this population, there will be better adherence to diabetes management and, thus, healthier patients.

...Dr. Unützer says that the IMPACT program has been shown to be cost-effective for physicians and the health care system. “Costs are no higher than the usual treatment and in some cases lower than with the control group,” he says. “When the depression is treated effectively, people tend to make fewer visits to their doctor in the long run.” He says that the greatest reward is the appreciation of the patients who get relief from the depression many didn’t even recognize in themselves. He talked about one older man who had become homebound with his depression after his wife’s death and complications from diabetes that threatened the amputation of one leg. After treatment through the IMPACT program, the man began taking better care of himself and was able to avoid surgery. “I got my life back,” he said.

...Dr. Unützer received his MD from Vanderbilt University, his MA in Public Policy from the University of Chicago, and his MPH in Health Services from the University of Washington. He completed fellowships in Geriatric Psychiatry at UCLA and in Primary Care Psychiatry / Health Services Research at the University of Washington.

...Dr. Unützer is currently Professor and Vice-Chair of Psychiatry and Behavioral Sciences at the University of Washington and Chief of Psychiatric Services at the UW Medical Center. He is also an Adjunct Professor of Health Services at the UW School of Public Health and an Affiliate Investigator at the Center for Health Studies, Group Health Cooperative. Dr. Unützer recently served as Senior Scientific Advisor to the World Health Organization and as an advisor to the President’s New Freedom Commission on Mental Health. His awards include the Paul Beeson Physician Faculty Scholars Award in Aging Research from the American Foundation for Aging Research, the Gerald L. Klerman Investigator Award from the Depression and Bipolar Support Alliance, and the Distinguished Scientist Award from the American Association of Geriatric Psychiatry. More

For more information about the IMPACT Program pleasse visit: http://impact-uw.org/