such increases was comparable to other accepted medical interventions. The long-term cost-effectiveness of implementing the IMPACT model (for depression care later in life) lowered the mean total health care costs during 4 years compared with usual care (87 percent probability) (Unützer et al., 2008). The PIC and IMPACT evaluation studies have therefore demonstrated that QI efforts are feasible and cost-effective and can be implemented in “naturalistic” practice-based settings. Follow-up studies confirmed these findings for minorities and whites as well as for those with both depressive disorder and subthrehold depression.

The QI studies have reported cumulative prevention and treatment benefits beyond the short-term outcomes, especially for minorities. For example, comparison studies with usual care have demonstrated improvements in 5-year and 9-year outcomes after a 6-month intervention with the PIC model described above, including improved employment status (Wells et al., 2000); they also reduced stressful life events, equivalent to removing 6–12 deaths of a loved one over a 9-year interval (Sherbourne et al., 2008; Wells et al., 2005). Greater outcome improvements were reported for underserved minorities than whites (Miranda et al., 2003).

QI programs have also been successfully adapted to a variety of settings, populations, and those with co-occurring disorders. For example, the IMPACT model has been implemented in eight different health care systems (e.g., health maintenance organizations, fee for service, inner-city county hospitals, Veterans Administration clinics) and has been tested in African Americans, Latinos, and white patients. It has been tested as well in patients with and without comorbid medical illnesses (like diabetes and cancer) or anxiety disorders and in adults of all ages as well as adolescents (University of Washington, 2009). In all of these settings, populations, and conditions in which IMPACT has been adapted and implemented, it has been shown to be more effective in depression care than usual care (Ell et al., 2008; Grypma et al., 2006; Kinder et al., 2006; Richardson, McCauley, and Katon, 2009).

Although these QI programs focus on primary care settings, they should not be viewed as just health care interventions. Starting with patients who are receiving care in primary care settings, they then add a systems approach that often includes mental health specialists or outreach workers who can extend the program beyond primary care. The QI programs also adopt a user-friendly approach, supporting patient education and preferences in the choice of medications or therapeutic interventions, thus increasing the chances that patients will get the intervention they prefer (Dwight-Johnson et al., 2001).

It is important to note, however, that the existing QI studies do not differentiate outcomes based on the parental status of the individual adult patient. Nor do they address outcomes beyond those observed in the care



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