1. Depression Care Management Lessons from Project IMPACT _____________________________________________________ Jürgen Unützer, MD, MPH Professor and Vice Chair of Psychiatry University of Washington unutzer@u.washington.edu

2. IMPACT Study Methods Design / Intervention: Randomized control trial of a collaborative care management program for depression (vs) care as usual Participants: 1,801 older adults with major depression/ dysthymia from 8 diverse health care systems in 5 states. 400 primary care providers Unützer et al, Med Care 2001; 39(8):785-99

3. Robust reduction in depression across diverse health care organizations > 50 % reduction in depression from baseline at 12 months Participating Organizations % all p < 0.01

4. Better Physical Function PCS-12 P<0.01 P=0.35 Callahan et al, in Press. JAGS.

5. Long-term: more Depression-Free Days IMPACT INTERVENTION NO IMPACT *Hunkeler, et al 2004 – unpublished data.

6. John A. Hartford Foundation Annual Report 2002, Photo - Courtesy of Don Battershall IMPACT ‘Key Ingredient’: Depression care manager

7. Core skills for Depression Care Managers - Educate about depression - Clarify treatment goals, expectations, and preferences - Convey hopefulness and encourage treatment adherence - Support antidepressant management (side effect management) - Teach - Problem Solving Skills - Pleasant Events Scheduling (Behavioral Activation)

8. Depression Care Manager: Core Skills (con’t) - Track treatment response (PHQ-9) - Provide updates and recommendations to PCP - Consult with team psychiatrist - Facilitate referrals to specialty care and community resources - Prepare for relapse prevention

9. Some Practice Considerations for Care Managers Practice Setting –Practice size: small practices, large group practices –Practice organization: primary care, multispecialty care, –Mental health on / off site Reimbursement –Fee-for service (e.g., Medicare), capitated (HMOs, VA, other) –Mental health coverage carved in / out Scope of Practice –National standards / professional certification –State practice acts (licensure) –Agency requirements (internal credentialing) –Third-party payor requirements (e.g., Medicare rules and regulations; independent or incident to physician billing) –Prescriptive privileges

10. What is the vision for depression care management? Program focus –‘Freestanding’ depression care management program –Depression care as part of a broader disease management effort? Depression and other common mental disorders Depression and other chronic medical illnesses Geriatric care management Setting / scope - On / off site; in person (vs) telephone - Number of practices, providers, patients Target Population - Age, gender, language, special needs, comorbid medical / psychiatric / substance abuse problems, insurance benefits