The brash exuberance of flyboys in the 1986 hit movie “Top Gun” became a cultural phenomenon, a testament to youthful bravado, the ideal representation of a society enchanted with adrenaline and speed.
So when Tony Scott, the film’s 68-year-old director, committed suicide last month it illuminated an otherwise shadowy world of despair: elder depression.
The scourge of late life depression is wide-spread in the United States and California. As many as 10% of older adults who visit their primary care physician suffer from severe depression, while nearly 15% have been prescribed an anti-depressant.
As the state’s rapidly aging population of four million citizens 65 and up is expected to top eight million by 2030, several California health systems have adopted a popular treatment model for late life depression that – in some cases – has doubled the effectiveness of traditional care.
The IMPACT program (Improving Mood-Promoting Access to Collaborative Treatment for Late-Life Depression) pioneered by University of Washington geropsychiatrist Dr. Jürgen Unützer uses a team-based approach to depression in adults 60 and over that is led – not by a physician – but a depression care manager.
The depression care manager – often a nurse, but sometimes a social worker or psychologist – supervises the depressed patient’s treatment, providing education and support, and also acts as a liaison with the other two team members in the triumvirate: The patient’s primary care physician, and a designated psychiatrist.
“If you go to a primary care physician, you just go to your doctor,” says Rita Haverkamp, a depression care manager at Kaiser Permanente San Diego Medical Center. “If you go (to IMPACT) you get a care manager, and a psychiatrist who backs us up. You have this team approach, and stepped care, where you continue to make changes in the treatment plan if it’s not working.”
Goals are to reduce depressive symptoms by 50% in 10-12 weeks. If unsuccessful, the treatment plan is revised. Medication and dosages are tweaked; psychotherapy can be added.
Late life depression is often the result of loneliness and social isolation.
Dr. Dilip Jeste, director of UC San Diego’s Sam and Rose Stein Institute for Research on Aging, says it’s also “common after heart attacks, heart surgery, strokes and bereavement.”
When her daughter was killed by the son of a housekeeper, and six months later her husband died of cardiac failure, Elizabeth tried her best to stay focused on work. She eventually lost her home and rental property, yet tried to ignore her deepening despair.
“I try to be strong and deny myself ‘I’m ok I’m ok I’m ok.’ But I’m not. I’m bleeding inside,” she says. “One day I say no, I can’t handle this anymore.”
After 20 years of depression, the Latina finally revealed her despair to a San Diego primary care physician who referred her to Kaiser’s IMPACT program.
Haverkamp met with Elizabeth and coordinated her treatment plan, which included an anti-depressant and group depression meetings.
“Oh wow, somebody care for me,” recalls Elizabeth. When she met with her depression group she told them “I think you save my life.”
Elizabeth received all of her care through Haverkamp, who is a psychiatric nurse specialist, never seeing an actual psychiatrist. Now, three years later, Elizabeth says she’s happy again.
“Medicine help. It’s unbelievable,” she says. “And Rita call me once in awhile and tell me ‘I’m here if you need me.’”
Haverkamp, Kaiser’s original depression care manager during an eight-site assessment of IMPACT in 2005, was so impressed with the program she has become one of its leading evangelists. Today, she’s trained thousands of physicians, nurses, and other medical personnel around the world. In total, over 5,000 people have been received IMPACT training.
Unützer says California’s interest in the program is enormous.
“We have gotten, by far, more requests for training in IMPACT care from California than any other state in the country,” he says.
One reason for its popularity is the so-called “millionare tax” passed in 2004 which provided additional funding to California’s county mental health programs. Since then, Unützer says health workers from over 100 clinics within the Los Angeles County Department of Mental Health have been trained.
Kaiser’s version of IMPACT – Complete Care Depression – is used at all of its 37 medical centers, and has so far helped over 50,000 depressed patients.
In San Diego, seven different sites within the county’s Council of Community Clinics use IMPACT. Since instituting the program in 2006, it has been helped treat over 1,500 clients.
This success is due largely to the emphasis on pro-active behaviors – problem-solving, scheduling pleasant activities, and exercise – says Marty Adelman, mental health program coordinator for the council.
“You’re talking about getting them up, getting them going, and planning things to do during their day that make them feel better,” says Adelman. “It’s definitely incredibly effective.”
“Those small things can really make a big difference in their mental health,” says Dr. Mary Whooley, who led the three-year “Heart and Soul Study” which tracked 1,000 patients with depression over three years to measure its effects on cardiac health.
The study showed that depression contributed to a 31% higher rate of “cardiovascular events,” including heart attack.
Research indicates that depression can also affect health outcomes for diabetes, COPD, “even cancer progression,” says Whooley, professor of Medicine, Epidemiology and Biostatistics at UC San Francisco.
Experts estimate that serious mental illness – including depression — can reduce life expectancy by 20-25 years.
Launched in 1999 at UCLA with the help of several organizations – in particular the John A. Hartford Foundation, which targets improved health for the elderly – IMPACT results have also included lower treatment costs. A pilot study showed cost savings of $3,300 per patients.
Haverkamp says the program also reaches more older adults by phone – telehealth – which is ideal for those who can’t drive, or have limited mobility.
“For seniors, what a wonderful thing,” she says.
Haverkamp cites a “shared stigma” that prevents both doctors and patients from acknowledging the realities of mental illnesses like depression – a pervasive “don’t ask, don’t tell” philosphy.
This stigma is particularly acute with men and ethnic groups like Latinos and African-Americans.
“The likelihood that you were treated for depression by your doctor if you were an African-American older man was way less than if you were a white educated woman presenting in the same clinic,” says Unützer, who also directs the University of Washington’s AIMS Center – Adancing Integrated Mental Health Solutions.
Unützer is currently working with a UC Davis geriatric psychiatrist to study the Mexican-American community and assess barriers to depression treatment.
Depression’s reach also extends beyond patients to include caregivers, especially for family members suffering from dementia – which includes Alzheimer’s Disease.
Unützer says when a depressed patient has a caregiver who is also depressed, both are enrolled in the IMPACT program.
“Caregiving is a big risk factor for depression,” he says, noting that caregivers are often less likely to improve with treatment. “Those people definitely need attention. They probably need more attention.”
Adelman jokes that he and his staff learned IMPACT “on the fly” yet were still able to produce good results.
“I just think that speaks to the integrity of the model,” he says. “It’s very practical, and not incredibly difficult to implement.”
Haverkamp agrees completely.
“We’ve just reached a lot of people that wouldn’t have been reached before.”