The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices.

Collaborative care improves affective and functional status in older patients with depression and diabetes; however, among patients with good glycemic control, such care minimally affects diabetes-specific outcomes.

Objective To explore the collaborative care needs and preferences in primary care patients with multiple chronic illnesses.Design Focus groups utilizing a series of open-ended questions elicited self-identified problems, experiences in communicating with providers, self-management needs, and preferences for monitoring and follow-up. Responses were organized and interpreted in light of the essential elements of collaborative care for chronic illness.Setting and Participants Sixty patients having two or more chronic illnesses at eight geographically dispersed primary care clinics within the Veterans Health Administration in the United States.Results Identified problems included poor functioning, negative psychological reactions, negative effects on relationships and interference with work or leisure. Polypharmacy was a major concern. Problematic interactions with providers and the health care system were also mentioned, often in relation to specialty care and included incidents in which providers had ignored concerns or provided conflicting advice. Most participants, however, expressed overall satisfaction with their care and appreciation of their primary care physicians. Knowledge and skills deficits interfered with selfmanagement. Participants were willing to use technology for monitoring or educational purposes if it did not preclude human contact, and were receptive to non-physician providers as long as they were used to augment, not eliminate, a physician's care.Conclusions Findings are consistent with the basic tenets of patientcentred, collaborative care, and suggested that health care can be organized and delivered to meet the complex needs of patients with multimorbidity.

Multiple, practical questionnaires with reasonable performance characteristics are available to help clinicians identify and diagnose patients with major depression. Diagnostic confirmation by mental health care professionals using a clinical interview or by primary care physicians using a semistructured interview can be made with high reliability.

Newer antidepressants are clearly effective in treating depressive disorders in diverse settings. Because of similar efficacy, both newer and older antidepressants should be considered when making treatment decisions. Better information is urgently needed on the efficacy of newer antidepressants in patients with nonmajor depression and in special populations, including adolescents.

The findings suggest that there is considerable opportunity to improve care for older adults with depression. Particular efforts should be focused on improving access to depression care for older men, African Americans, Latinos, and patients who prefer treatments other than antidepressants.

PURPOSE Our objective was to examine the relative association of depression severity and chronicity, other comorbid psychiatric conditions, and coexisting medical illnesses with multiple domains of health status among primary care patients with clinical depression. METHODSWe collected cross-sectional data as part of a treatment effectiveness trial that was conducted in 8 diverse health care organizations. Patients aged 60 years and older (N = 1,801) who met diagnostic criteria for major depression or dysthymia participated in a baseline survey. A survey instrument included questions on sociodemographic characteristics, depression severity and chronicity, neuroticism, and the presence of 11 common chronic medical illnesses, as well as questions screening for panic disorder and posttraumatic stress disorder. Measures of 4 general health indicators (physical and mental component scales of the SF-12, Sheehan Disability Index, and global quality of life) were included. We conducted separate mixed-effect regression linear models predicting each of the 4 general health indicators.RESULTS Depression severity was signifi cantly associated with all 4 indicators of general health after controlling for sociodemographic differences, other psychological dysfunction, and the presence of 11 chronic medical conditions. Although study participants had an average of 3.8 chronic medical illnesses, depression severity made larger independent contributions to 3 of the 4 general health indicators (mental functional status, disability, and quality of life) than the medical comorbidities.CONCLUSIONS Recognition and treatment of depression has the potential to improve functioning and quality of life in spite of the presence of other medical comorbidities. 2004;2:555-562. DOI: 10.1370/afm.143. Ann Fam Med INTRODUCTIONE pidemiological and clinical studies consistently indicate that depression adversely affects the lives of older adults. The relative contribution to adverse effects is not entirely clear, because depression often occurs in conjunction with other psychiatric illnesses, such as anxiety disorders; somatic symptoms, such as pain; and chronic medical illnesses, such as diabetes. The latter is particularly of concern, because it is often diffi cult to know whether a particular symptom, such as lethargy, is caused by depression, a coexisting medical illness, or both. Patients with chronic medical illness are known to have a high prevalence of comorbid depression.1 Furthermore, both major depressive disorder and subsyndromal depression have been associated with increased somatic symptoms, morbidity, mortality, health care utilization, and costs in the presence of comorbidities. 5-7 Furthermore, severity of depressive symptoms is inversely related to patients' health-related quality of life, even after controlling for age, sex, and medical comorbidities. 8,9 Many older persons, however, have more than one chronic illness that may differentially impair health status. Elders with multiple comorbidities may be particularly vulne...

Continuity of care with a primary care provider is associated with better glucose control among patients with type 2 diabetes. This relationship appears to be mediated by changes in patient behavior regarding diet.