Improving Mood–Promoting Access to Collaborative Treatment (IMPACT)

The Improving Mood—Promoting Access to Collaborative Treatment (IMPACT) program is a primary care-based integrated care approach for older adults with depression. It is not a single treatment, but rather a systematic and coordinated approach to providing stepped care according to a specific set of principles and structures. While designed as a treatment for depression rather than suicidal thoughts and behaviors (acutely suicidal patients were excluded from the research), IMPACT showed improvements in suicidal ideation (assessed with a single item) at 6, 12, 18, and 24 months, in addition to reducing depression and functional impairment and improving quality of life. 

Individuals in need of depression care are identified in the primary care setting through screening and referral strategies. After further assessment, an individual care plan is developed collaboratively by a team consisting of a trained primary care provider, the patient, a care manager, and an embedded consulting psychiatrist. Plans typically include patient education, self-management support, evidence-based treatments, such as medication and/or brief psychotherapy, and maintenance support once the patient has improved. Close follow-up and regular case consultation ensures that patients do not fall through the cracks. Patient goals and clinical outcomes are systematically tracked and monitored, and the team makes adjustments to the treatment plan as needed. If improvement does not occur, some patients may be referred to specialty mental health services.

IMPACT is one form of Collaborative Care, a specific type of integrated care that provides both medical and mental health care in primary care and other clinical settings. This approach was developed at the University of Washington to address conditions like depression that require systematic follow-up. More recently the approach has been applied to other conditions, including anxiety, PTSD, and co-morbid depression and medical conditions such as heart disease, diabetes, and cancer. Collaborative Care is not simply co-locating a mental health professional in a primary care clinic or simply adding members to a care team. A substantial body of evidence for Collaborative Care has developed over the past 20 years.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on its inclusion in three sources:

1. “A Systematic Review of Elderly Suicide Prevention Programs” (Lapierre et al., 2011)
2. The Centers for Disease Control and Prevention’s (CDC) Preventing Suicide: A Technical Package of Policy, Programs, and Practices (Stone et al., 2017)
3. The Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Programs and Practices (NREPP)

(1) Systematic Review

Lapierre et al. (2011) conducted a systematic review of elderly suicide prevention programs, including rating the level of evidence for each intervention on a scale of one (highest) to five (lowest) based on the Oxford Centre for Evidence-Based Medicine (Oxford CEBM, 2009). The IMPACT study used a randomized controlled trial design, which is level one (strongest evidence) on the Oxford classification of evidence. As noted above, IMPACT reduced suicidal ideation (assessed with a single item) at 6, 12, 18, and 24 months compared to patients who received usual care, in addition to reducing depression and functional impairment and improving quality of life. 

Lapierre, S., Erlangsen, A., Waern, M., De Leo, D., Oyama, H., Scocco, P., . . . International Research Group for Suicide among the Elderly. (2011). A systematic review of elderly suicide prevention programs. Crisis, 32(2), 88–98. Full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3728773/

(2) CDC Technical Package

The CDC’s Preventing Suicide: A Technical Package of Policy, Programs, and Practices lists IMPACT as an evidence-based treatment for people at risk of suicide (p. 37): “The program has been shown to significantly improve quality of life, and to reduce functional impairment, depression, and suicidal ideation over 24 months of follow-up relative to patients who received care as usual.”

Stone, D. M., Holland, K. M., Bartholow, B., Crosby, A. E., Davis, S., & Wilkins, N. (2017). Preventing suicide: A technical package of policy, programs, and practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Full text: https://www.cdc.gov/violenceprevention/pdf/suicide-technicalpackage.pdf

Study cited: Unutzer, J., Tang, L., Oishi, S, Katon, W., Williams, J. W., Hunkeler, E., . . . IMPACT Investigators. (2006). Reducing suicidal ideation in depressed older primary care patients. Journal of the American Geriatrics Society, 54(10):1550–1556.

(3) NREPP

The most recent NREPP review of IMPACT in 2012 provides a useful summary of the intervention and measurement of the outcomes related to depression, functional impairment, and quality of life (the summary does not discuss the research results specific to suicide that are cited in the two sources above).

Outcome(s) Reviewed (Overall Quality of Research Rating-scale of 0 to 4)*

1: Severity of depression (3.8)
2: Functional impairment (3.7)
3: Health-related quality of life (3.8)

Read more about this program’s ratings.

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* NREPP changed its review criteria in 2015. This program is a “legacy program,” meaning that it was reviewed under the previous criteria. The evidence for each outcome was reviewed and scored on a scale of 0-4, with 4 indicating the highest quality of evidence and 0 indicating very poor quality of evidence. The overall rating was based on ratings of six criteria: 1) reliability of measures, 2) validity of measures, 3) intervention fidelity, 4) missing data and attrition, 5) potential confounding variables, and 6) appropriateness of analysis.  Over time, all legacy programs will be re-reviewed using the current criteria. When considering programs, we recommend (a) assessing whether the specific outcomes achieved by the program are a fit for your needs; and (b) examining the strength of evidence for each outcome.

2012 NSSP Objectives Addressed: 

Objective 7.5: Develop and implement protocols and programs for clinicians and clinical supervisors, first responders, crisis staff, and others on how to implement effective strategies for communicating and collaboratively managing suicide risk.

Objective 8.2: Develop and implement protocols for delivering services for individuals with suicide risk in the most collaborative, responsive, and least restrictive settings.

Objective 9.1: Adopt, disseminate, and implement guidelines for the assessment of suicide risk among persons receiving care in all settings.

Objective 9.2: Develop, disseminate, and implement guidelines for clinical practice and continuity of care for providers who treat persons with suicide risk.