Evidence-Based Reviews

Making an IMPACT on late-life depression

Steven Vannoy, PhD
Senior fellow
Diane Powers, MA
Research scientist

Jürgen Unützer, MD, MPH, MA
Professor and vice chair

Department of psychiatry and behavioral sciences University of Washington, Seattle

Partnering with primary care providers can double the effect of treatment.


Few depressed older adults seek help from psychiatrists. Those who receive mental health treatment most likely do so in primary care settings. Yet primary care physicians (PCPs) often are ill-equipped to effectively treat depression while managing older patients’ numerous acute and chronic medical conditions.

If depressed older patients won’t go to a psychiatrist, why not bring the psychiatrist to the patients? This article describes a clinically tested approach called project IMPACT that links psychiatrists to primary care teams and dramatically improves depression treatment in older adults.

Untreated geriatric depression

Preference for primary care. Major depression is rare in community-living older adults (1% to 3% prevalence), but:

  • 5% to 10% of older primary care patients meet DSM-IV-TR criteria for major depression1
  • approximately one-half of depressed older adults report a primary care visit when a mental health problem was addressed during the past year.2

Box 1

Older adults: Usual patterns of depression treatment

  • Prefer treatment in primary care instead of mental health settings
  • Only 50% follow through on mental health referrals
  • Only 20% improve when treated in primary care without a team approach
  • Chronic medical illnesses often complicate diagnosis and treatment
  • Often complain of somatic symptoms of depression
  • May believe depression is a ‘normal’ part of aging
  • May receive subtherapeutic antidepressant dosages because of physician concerns about side effects

Source: References 2-4

Box 2

Double trouble: Medical illness and geriatric depression

Depression is rarely the only illness an older adult is experiencing:

  • 10% to 25% of adults with chronic medical illnesses such as diabetes or heart disease have major depression.
  • Medical illness is associated with increased rates of depression, and depression is associated with poorer physical health.6

Depression diminishes self-care, which is key to managing chronic medical illnesses in late life. Depressed patients have higher rates of obesity and smoking. They are less likely to exercise, eat well, or adhere to complex treatment regimens with oral hypoglycemics, antihypertensives, and lipid-lowering drugs.7

Depression also substantially increases total health care costs among older adults.8

Only 8% of depressed older adults visit a mental health specialist in a given year, compared with 25% of depressed younger adults.2 Even when PCPs refer older patients to a mental health specialist, only 50% follow through (Box 1).3,4

Barriers to effective care. Depression diagnosis and treatment by PCPs has improved, but a recent survey suggests that with usual treatment:

  • only 1 in 5 depressed older adults treated in a primary care practice experiences substantial improvement over 12 months
  • only 1 in 10 becomes symptom-free.5

Many depressed older adults do not realize they have depression and visit their PCPs complaining of physical symptoms (Box 2).6-8 Their limited knowledge about depression or fear of being labeled “mentally ill” deters them from disclosing a depressed mood. They and their PCPs may think depression is inevitable with aging.

PCPs also may lack training to differentiate mood disorders, transitory reactions to life-events, or depression caused by medical illness. Their busy schedules limit time to address and prioritize patient concerns about acute and chronic medical problems (Box 3). Thus depression “falls through the cracks.”

Prescribing concerns. PCPs who feel uncomfortable prescribing antidepressants to older patients may be concerned about side effects and maintain dosages at low starting levels instead of titrating up to a therapeutic range.

Collaborative care

One way to overcome these barriers is to integrate mental health providers into primary care to support and augment PCP-prescribed depression treatment. Collaborative care can become an effective, efficient way to provide high-quality depression care to older patients who might otherwise go untreated.9

Box 3

Why primary care providers may fail to treat late-life depression

  • Concerns about discussing a socially stigmatized condition with older adults
  • Buying into the fallacy that depression is ‘normal’ in late life
  • Missing the diagnosis because of medical comorbidity and older adults’ focus on physical versus emotional symptoms
  • Unfamiliarity with how to prescribe antidepressants, particularly for patients with complex medical comorbidity
  • Time constraints may discourage opening ‘Pandora’s box’ of depression

Project IMPACT. One such model—project IMPACT (Improving Mood: Promoting Access to Collaborative Treatment for Late-life Depression)—was developed with support from the John A. Hartford Foundation and California Healthcare Foundation. At its heart is a depression care manager or depression clinical specialist—typically a nurse, social worker, or psychologist—who works in a primary care practice. Other team members include the patient’s PCP, the patient, and a consulting psychiatrist.

The care manager works closely with the PCP by:

  • educating patients about depression
  • coaching patients in pleasant events scheduling/behavioral activation
  • supporting the PCP’s antidepressant management
  • offering patients a brief course of evidence-based counseling, such as Problem Solving Treatment in Primary Care10
  • measuring patients’ depressive symptoms at treatment onset and regularly thereafter with a tool such as the 9-item depression scale of the Patient Health Questionnaire (PHQ-9).11