Transcript IMPACT Team Care

IMPACT Team Care
For Depression
VA Puget Sound V-tel conference
February 23, 2009
Disclosure
 Grant funding (current & recent)
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NIH (NIMH)
American Federation for Aging Research (AFAR)
John A. Hartford Foundation
George Foundation
Red Cross (RAND)
• California HealthCare Foundation
• Robert Wood Johnson Foundation
• Hogg Foundation
 Contracts
• Community Health Plan of Washington
• King County Department of Public Health
 Consultant
• AARP Services Incorporated (ASI)
• National Council of Community Behavioral Health Care (NCCBH)
 Advisor
• Carter Center Mental Health Program
• Institute for Clinical Systems Research (ICSI)
Depression
 More than having a bad day
or a bad week
 Pervasive depressed mood /
sadness
 Loss of interest / pleasure
Lack of energy, fatigue, poor sleep and
appetite, physical slowing or agitation,
poor concentration, physical symptoms
(aches and pains), irritability, thoughts
of guilt, and thoughts of suicide
 A miserable state that can
last for months or even years
Depression
 Common
10% in primary care
 Disabling
#2 cause of disability (WHO)
 Expensive
50-100% higher health care costs
 Deadly
Over 30,000 suicides / year
Depression is often not
the only health problem
Cancer
Chronic
Pain
10-20%
40-60%
Depression
Geriatric
Syndromes
20-40%
Heart
Disease
20-40%
Neurologic
Disorders
10-20%
Diabetes
10-20%
Depression is deadly
Older men have the highest rate of suicide.

Guidelines for Depression
Treatment in Primary Care
 VA
 Institute for Clinical Systems
Improvement (ICSI)
• http://www.icsi.org/guidelines_and_more/gl_os_prot/behavioral_he
alth/depression_5/depression__major__in_adults_in_primary_care
_4.html
 American College of Physicians (ACP)
Clinical Practice Guidelines
• Ann Int Med 2008; 149:725-733
Efficacious treatments
for depression
Antidepressant Medications
• Over 20 FDA approved
Psychotherapy
• CBT, IPT, PST, brief dynamic, etc.
Other somatic treatments
• ECT
Physical activity / exercise
Unutzer et al, NEJM 2008.
Antidepressant Medications
There are over 20 FDA approved antidepressants.
- All are effective in 40 - 50 % of patients if taken correctly
- It often takes several trials until Rx is effective
- Patients need support during this time
If medications are not effective after 8-10 weeks at a
therapeutic dose
- make sure patient is taking medication as prescribed
- verify diagnosis
- consult: a change in treatment plan is likely indicated
Quality of Depression Care
 Fewer than 1 in 10 depressed older adults
seek specialty mental health care
• and if they did we wouldn’t have the mental health
specialists needed to treat them
 Most present for help in primary care
 Quality of care for depression is worse than for most
other chronic medical problems
Depression Treatment
in Primary Care

Increasing use of antidepressants



PCPs prescribe 70 – 90 % of antidepressants

10 - 30 % of older adults are on antidepressants

MAJOR OPPORTUNITIES for Quality Improvement – even for
nonprescribing providers
But treatment is often not effective
•
30 % drop out of treatment within 4 weeks
•
Only 25 % receive adequate follow-up care
•
Only 20 – 40 % improve substantially over 12 months
Limited access to evidence-based psychosocial
treatments (psychotherapy)
Evidence for Collaborative Care
for Depression
Metaanalysis by Gilbody S. et al,
Archives of Internal Medicine; 2006
- 37 trials of collaborative care for depression in primary
care (US and Europe)
- cc consistently more effective than usual care
- successful programs include
- active care management & follow-up
- support of medication management in primary care
- psychiatric consultation
IMPACT Trial
John A. Hartford Foundation
 Planning grant (1996)
 IMPACT Study(1999-2003)
Additional funding from
California Healthcare Foundation
Robert Wood Johnson Foundation
Hogg Foundation
IMPACT Study Methods
Design:
1,801 depressed adults (60 and older) with major depression
and / or chronic depression, randomly assigned to IMPACT or to
Care as Usual
Usual Care:
Primary care or referral to specialty mental health
IMPACT Care:
Collaborative / stepped care disease management program for
depression in primary care offered for up to 12 months
Analyses:
Independent assessments of health outcomes and costs for 24
months. Intent to treat analyses
Unützer et al, Med Care 2001; 39(8):785-99
IMPACT Team Care Model
Photo credit: J. Lott, Seattle Times
Photo: Courtesy D. Battershall & John A. Hartford Foundation
Effective
Collaboration
Prepared, Pro-active
Practice Team
Informed, Activated Patient
Practice Support
Collaborative Care
Patient
 Chooses treatment in consultation with
provider(s):
• antidepressants and / or brief psychotherapy
Primary care provider (PCP)
 Refers; prescribes antidepressant medications
+ Depression Care Manager
+ Consulting Psychiatrist
Unützer et al, Med Care 2001; 39(8):785-99
Treatment Protocol
(1) Assessment and education,
(2) Behavioral Activation / Pleasant Events Scheduling
(3) a) Antidepressant medication
usually an SSRI or other newer antidepressant
OR
b) Problem Solving Treatment in Primary Care
(PST-PC)
6-8 individual sessions followed by monthly group
maintenance sessions
(4) Maintenance and Relapse Prevention Plan for patients in
remission
Stepped Care
Systematic follow-up & outcomes tracking
Patient Health Questionnaire (PHQ-9)
The “cheap suit”
Treatment adjustment as needed
- based on clinical outcomes
- according to evidence-based algorithm
- in consultation with team psychiatrist
Relapse prevention
What if patients don’t improve?
Is the patient adhering to treatment?
Is the dose high enough?
- see max dose guidelines
Is the diagnosis correct?
? Bipolar depression
? Medical conditions (hypothyroidism, sleep apnea, pain)
? Meds: steroids, interferon, hormones
? Withdrawal: stimulants, anxiolytics
Are there untreated comorbid conditions / life stressors?
Is the patient at maximum
therapeutic dose?*
 Fluoxetine
60 mg
 Paroxetine
60 mg
 Escitalopram
30 mg
 Citalopram
60 mg
 Sertraline
200 mg
 Venlafaxine
300 mg
 Duloxetine
60 mg
 Buproprion SR
450 mg
 Mirtazapine
60 mg
 Nortriptyline
125 mg (check serum level)
 Desipramine
200 mg (check serum level)
Consider titrating to these doses unless patients do not tolerate these
‘maximum doses’ due to side effects.
IMPACT doubles the Effectiveness
of Depression Care
50% or greater improvement in depression at 12 months
Usual Care
IMPACT
70
60
50
%
40
30
20
10
0
1
2
3
4
5
6
7
8
Participating Organizations
Unutzer et al, JAMA 2002; Psych Clin N America 2004.
IMPACT Improves
Physical Functioning
SF-12 Physical Function Component Summary Score (PCS-12)
P<0.01
P<0.01
P<0.01
P=0.35
Callahan C et al, JAGS 2004
Callahan et al. JAGS. 2005; 53:367-373.
IMPACT Saves Money
Intervention
group cost
in $
Usual care
group cost in
$
Difference in
$
522
0
522
661
558
767
-210
7,284
6,942
7,636
-694
Other outpatient costs
14,306
14,160
14,456
-296
Inpatient medical costs
8,452
7,179
9,757
-2578
Inpatient mental health /
substance abuse costs
114
61
169
-108
31,082
29,422
32,785
-$3363
Cost Category
4-year
costs
in $
IMPACT program cost
Outpatient mental health costs
Pharmacy costs
Total health care cost
Savings
Unutzer et al. Am J Managed Care 2008.
IMPACT Summary
 Less depression
Photo credit: J. Lott, Seattle Times
(IMPACT doubles effectiveness
of usual care)
 Less physical pain
 Better physical
functioning
 Higher quality of life
 Greater patient & provider
satisfaction
 Lower health care costs
Over 40 peer-reviewed publications
“I got my life back”
Pain Impairs Response
to Depression Care
60%
50%
40%
30%
20%
Treatment Group
10%
Usual Care
0%
Intervention
Not at all
Moderately
Slightly
Extrem ely
Quite a bit
Baseline Pain Interference Category
Source: Thielke, et al. Am J Geriatric Psych. 2007.
IMPACT-DP
Care management for depression and pain
Less impairment in general activity, walking ability, work, relationships
with others, sleep, and enjoyment in life
Unutzer et al, Int J Geriatr Psychiatry 2008.
IMPACT Endorsements
• President’s New Freedom
Commission on Mental
Health
• National Business Group
on Health
• Institute of Medicine
(Retooling for An Aging America)
• POGOe
• CDC Consensus Panel
• Annapolis Coalition
• Partnership to Fight
Chronic Disease
• SAMHSA NREPP
Taking IMPACT
from Research to Practice
 Support from JAHF (2004-2009)
 Over 3,000 clinicians trained
 Almost 200 clinics have implemented core
components of the program to date
• DIAMOND program in Minnesota implementing the
program state-wide in partnership with 25 medical
groups and 9 health plans
• Western WA: Virginia Mason, Community Health Plan
of WA, King County Dept. of Public Health
• Iowa City VAMC
http://impact-uw.org
Lessons Learned - II
• Teams don’t just happen
• Many of us are not trained to work effectively on
interdisciplinary teams.
• Work at interfaces is challenging.
• Simplicity & effective communication
• Joint accountability for measurable outcomes can help.
• (e.g., # and % of population screened, treated,
improved)
Conclusion
 IMPACT can be adapted and effective in a
wide range of health care settings and
populations
 Effective teamwork is key to the success
of the program
• Different professionals (nurses, social workers, psychologists, licensed
counselors, and medical assistants) can be trained to support primary
care providers with evidence-based care management
• Care management is a function, not a person
• Psychiatric consultation provides important back-up to primary care
based care management programs.
Thank You