Transcript Depression - Florida Alcohol and Drug Abuse Association

Depression Care: Implementing
Integrated Primary CareBehavioral Health Solutions
Mark Dreskin, MD
Depression Care Program
Southern California Kaiser
Permanente
Today
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Scope of the problem
Patients in primary care, patients with
medical co-morbidities (heart disease,
diabetes, other chronic diseases), and
screening/identifying cases
“Treat-to-target” (depression remission)
principles in primary care and how to
implement (with return on investment,
reimbursement)
Testimonials
Occupational
Functioning
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Persons with major depression had a
4.78 greater risk of disability
Broadhead, WE et al, JAMA, 1990;264:2524-2528
Productivity losses related to depression
exceed the costs of effective treatment.
Wang, PS, et al, Am J Psych 2004; 161:1885-1891
What Costs Are Under The Surface?
Harvard Business Review, October 2004
What Costs Are Under The Surface?
Harvard Business Review, October 2004
Full Costs –
Medical, Pharmacy, Absence and Presenteeism
Full Costs –
Medical, Pharmacy, Absence and Presenteeism
Recurrence risk
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With initial episodes, the likelihood of
future episodes is < 50%, but if left
untreated, initial episodes can become
chronic, and the higher the number of
total episodes, the less likely depressionfree intervals will be present at later
stages of life
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it is imperative that patients be treated
early, and treated all the way to
remission, wherever possible
Depression leads to medical morbidity in
patients with chronic diseases
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There is now robust evidence that
depressive illness is an independent risk
factor in several medical disease states,
particularly CVD diseases, and predicts
increased morbidity, mortality and healthcare
utilization.
Depression leads to medical morbidity in
patients with chronic diseases
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Doubles the number of primary care visits/year
compared to those who are not depressed
Doubles the number of hospital days over the
expected length of stay compared to nondepressed patients
65% of depressed patients receive more than 5
medications
In diabetes, depression is associated with a 2%
increase in glycosylated hemoglobin levels
• (Lustman PJ et al. Gen Hosp Psychiatry.1997; 19:138-143.)
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Possible Markers for Depression
in the Medically Ill
Physical symptoms disproportionate to findings, e.g.
multiple pain complaints
Excess functional disability
High utilization of medical care
Poor self-care
Decreased compliance with medical and/or lifestyle
changing regimens
Reduced social content
Katon W, Sullivan MD. J Clin Psychiatry. 1990;51(suppl 6):311.
Depression leads to medical morbidity in
patients with chronic diseases
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BEHAVIORAL FACTORS
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Cigarette Smoking
Alcohol Consumption
Poor Diet (excess calories; low nutrient density)
Sedentary Lifestyle
Poor Treatment Adherence
HEALTH PERCEPTION
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one of the highest associations with morbidity and mortality in patients with
heart disease and other chronic illnesses (more then smoking or left
ventricular ejection fraction in Sperta study)
strongly correlated with quality of life
improves with depression treatment
Screening and
• Depressiondetection
presents but goes untreated in
general primary care settings
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Only 25% of depressed patients were
recognized as such by their primary care
physician
60-70% of patients with depression present
and receive their treatment in primary care
and not specialty care
Though problems of stigmatization and lack
of identification are lessening, 40% of these
patients still do not receive guideline-based
care to effective remission
Treatment Setting:
Primary Care vs. Specialty Psychiatry
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Patient preference
Trust in primary care physician
Integrated care
Less stigma
Lower cost
Convenience
Referral may delay initiation of care
Treatment Options in Primary
Care
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Watchful Waiting
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Behavioral Activation
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Encourage exercise and increased activity in mild cases
Pharmacotherapy (Antidepressant Medications)
Psychotherapy (Problem-Solving or Cognitive Behavioral)
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May be briefly appropriate in minor depression
Available within primary care in many integrated care programs
Referral to Specialty Care
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Complicated, severe, non-responding, or suicide risk
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medicines plus psychotherapy provide
1.5 times greater chance of full
remission, and greatest probability of
sustained remission after one year
Other Treatment Options
in Primary Care setting
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Computer-Assisted Therapy
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Psychoeducation
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– Depression Classes from Health Education :
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Depression Overview – single class
Overcoming Depression – series of 6 classes
Herbal : St. John’s Wort
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Proven efficacy in mild depression but preparations may be
inconsistent. (though can not be combined with most
antidepressant meds)
Bibliotherapy
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– eg “Feeling Good” by David Burns
Integrated care
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While we list the seven elements individually, there is evidence that it is the
integration of these structural elements with each other and with evidence-based
clinical practice guidelines that leads to superior patient outcomes. The seven
core elements of care are:
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Treatment Coordination
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Follow-up/Tracking Systems with Feedback to Practitioners
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Outcomes Measurement
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Patient Education and Self-Management Programs
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Clinician Education
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Mental Health/Behavioral Medicine Specialist Involvement
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Detection and Diagnosis Strategies
Psychotherapy
Integrated care
The best outcomes are at sites where an integrated model of
care is employed,
following evidence-based guidelines for accurately detecting,
diagnosing and treating depression
treatment coordination
consistent and frequent follow-up
opportunity for “stepped care”
outcomes monitoring
patient education
care conferences with liaison psychiatrists
Allow for
care managers following their case loads and
surveillance for due dates of actively managed
patients
supervisors analyzing the work being done
reporting-out to senior leadership, i.e. for snap shot
view of program
for ensuring all patients appropriate follow-up, i.e.
per trends in scores, number of treatment trials,
high risk factors that require that patient be followed
in psychiatry
Studies that have demonstrated enhanced value
Unutzer, IMPACT, 2002
Dietrich, RESPECT trial
PROSPECT trial
Katon, “Partners in Care”
also with dropping BMI in obese patients
also TEAM care (diabetics)
Studies that have demonstrated enhanced value
*improve
remission rates
Unutzer, IMPACT, 2002
* improve compliance
Dietrich, RESPECT trial
PROSPECT trial
Katon, “Partners in Care”
*better patient and
physician
satisfaction
*reduced ED and
clinic utilization
also with dropping BMI in obese patients
also TEAM care (diabetics)
Studies that have demonstrated enhanced value
*improve
remission rates
Unutzer, IMPACT, 2002
* improve compliance
Dietrich, RESPECT trial
PROSPECT trial
Katon, “Partners in Care”
*better patient and
physician
satisfaction
*reduced ED and
clinic utilization
also with dropping BMI in obese patients
also TEAM care (diabetics)
morbidity and
mortality
EHR based reports
Give me all
your
information…
NOW!
REGISTRY
I’m going to go
lasso me that
information anytime
I need it.
EHR based reports
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Reports only indicated 3 months
3 month window
3
months
3 months
Quarterly
EHR
report
3 months
Data
entry
Prompts
REGISTRY
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Snap shot views are
“real-time”
Data
entry
Query
Prompts
TIDES Study, 2008
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90% Hispanic/Latino and Caucasian patients from
underserved communities in California
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Average age 41 years old
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9 demonstration sites, with different levels of proximity,
integration
TIDES Study, 2008
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The Duke Health Profile
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17 item generic self-report standard instrument
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Physical health
General health
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Mental health
Perceived health
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Social health
Self-esteem
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Health Measures
Dysfunction measures
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Anxiety
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Pain
PHQ-9
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5-14, consider active treatment
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> 15, initiate active treatment
Depression
Disability
Mean Health Scores
Mean Dysfunction Scores
Changes in PHQ-9 mean
scores
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Discrepancies exist between instructions that physicians report
they communicate to patients and what patients remember being
told.
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Explicit instructions about expected duration of therapy and
discussions about medication adverse effects throughout
treatment may reduce discontinuation of SSRI use.
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Patients with 3 or more follow-up contacts were more likely to
continue using the initially prescribed antidepressant medication,
suggesting that frequent contact may increase the probability that
patients will continue therapy.
Bull et al, JAMA. 2002;288(11):1403-1409
Likelihood to follow-up on mental health
services referral
(on 0-5 scale)
Key recent findings
“Stepped Care”
“Last resort” (C)
Initial treatment:
SSRI or Problem
Solving Therapy
Switch or augment (B)
(A)
Switch or augment (A)
Switch to other SSRI, SNRI, or PST
or other agent
Initial treatment
Augment with PST or other agent
(B)
Switch to TCA or other agent
Augment with Lithium, T3 or
antipsychotic
Augment with intensive therapy
(C)
MAOi or novel combination
Rush et al, “STAR*D” study, Arch Gen Psychiatry, 2006
ECT or other intervention
(often steps B & C above are usually done in Specialty Psychiatry setting.)
Factors associated with
success
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Interpersonal, professional relationship between
physical and mental health staff
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Co-location better
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Consolidated electronic health records
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Adequate staff training (especially in treatment of
complex patients), both clinical skills, and and
effective integrated services
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Consistent champions
Factors associated with
enhanced value
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Use of depression care managers (dedicated to
depression care)
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Systematic involvement of psychiatrists
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On hand for consultation with treating primary care
providers
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Perform supervision, and provide case review, with
depression care managers
FACTORS THAT REDUCED
CLINIC/PRACTITIONER PARTICIPATION
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“Top down” program development, without “bottom-up”
clinic participation
FACTORS ASSOCIATED WITH POOR
SUSTAINABILITY
• Difficulty recruiting mental health staff willing to adopt
program role
Katon et al, 2010
Quality results from Minnesota
DIAMOND-Outcomes
Response and remission rates at 6 month
Offedahl, ICSI
Quality results from Minnesota
DIAMOND-Outcomes
Response and remission rates at 12 month
Offedahl, ICSI
Unutzer commentary
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Endorsement of “stepped care” (“treat-to-target”)
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Back-office staff for core support functions, such
as out-reach, tracking, evaluating for treatment
side effects
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Active dialogue and collaboration between
primary care provider and the behavioral health
provider
REIMBURSEMENT ISSUES
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Beyond the Mental Health Parity Act
Affordable Care Act, issues with planned 2014
implementation
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Medicare-changes had modest effect on how 5 Stars
calculated, but will be combination metrics (quality and
process metrics) and survey responses from VA/Rand
HOS (non specific)
Patient-centered medical home
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quality metrics including psychiatric in-patient follow-ups,
childhood ADHD medication measures, HEDIS antidepressant medication metrics
Medicare “Star Ratings”
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Quality measures
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Service measures
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NCQA, HEDIS
METEOR, others
Survey measures
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Perceived health
Medicare “Star Ratings”
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Quality measures
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Service measures
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NCQA, HEDIS
METEOR, others
Survey measures
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Perceived health
Average Impact on MCS Scores Observed
in Veterans Health Study
Kazis, LE, Miller, DR, Skinner, KM, et al. Patient reported measures of health: The Veterans Health
Study. J of Ambulatory Care Mgmt, 2004; 27:1, 70-83.
Condition
Impact on MCS*
Hypertension
-0.50
Angina
-0.64
Diabetes
-0.08
Osteoarthritis
-2.05
Chronic Low Back Pain
-2.83
Chronic Lung Disease
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Depression
-8.00
Alcohol Disorders
-6.59
*Impact of disease on MCS controlling for
sociodemographic and co-morbid conditions
Slide 60
Average Impact on MCS Scores Observed
in Veterans Health Study
Kazis, LE, Miller, DR, Skinner, KM, et al. Patient reported measures of health: The Veterans Health
Study. J of Ambulatory Care Mgmt, 2004; 27:1, 70-83.
Condition
Impact on MCS*
Hypertension
-0.50
Angina
-0.64
Diabetes
-0.08
Osteoarthritis
-2.05
Chronic Low Back Pain
-2.83
Chronic Lung Disease
--
Depression
-8.00
Alcohol Disorders
-6.59
*Impact of disease on MCS controlling for
sociodemographic and co-morbid conditions
Slide 60
testimonials
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a patient who was feeling suicidal received a
call from a hospital clinic-based social
worker, assigned to do depression program
outreach. The patient came to the hospital
at the case managers request, and states
that it saved his life.
a patient who received a letter with a
questionnaire, from the depression program,
states that it brought to light issues he had
been afraid to discuss with his doctor
testimonials
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“I’m not crazy!”
“Who are you?”
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Lesson learned: “Depression care
program” sounds a little “cultish”
Future issues:
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To what extent do integrated care programs need to be
modified to adopt other populations at risk, i.e. adolescent
depression, post-partum depression, axis I illnesses besides
depression (substance abuse disorders, anxiety disorders,
attention deficit disorder)
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Reimbursable “care extender” training
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New nationally recognized quality measures still up in the air,
i.e. screening, follow-up, treatment effectiveness surrogates(such as PHQ-9 or other quantifiable disease metric)
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APPENDIX
PROGNOSIS & COURSE
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50% of patients have a single episode of MDD
with no subsequent episodes over 20 years of
follow-up.
15% of subjects have an unremitting course
without any true periods of full remission after an
index episode
35% of subjects have a recurrent disorder with a
variable course
Medicare “Star Ratings”
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Quality measure:
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HEDIS medication measures
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Meant to ensure that plan coverage keeping
patients med adherent
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Foye, 2010; Bull et al, 2002
Patient survey data (“Health Outcome Survey)
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Mental health wellness
Table 3. Factors Associated With Discontinuing Use of the Initial Antidepressant Medication
Within 3 Months of Starting Treatment: Results of Multivariate Model*.
Copyright restrictions may apply.
Bull, S. A. et al. JAMA 2002;288:1403-1409
Table 2. Antidepressant Treatment Status 3 Months After Start of Treatment in Relation to
Patient-Physician Communication, Medication Adverse Effects, and Clinical Improvement*.
Bull, S. A. et al. JAMA 2002;288:1403-1409
Copyright restrictions may apply.
Table 4. Factors Associated With Switching the Initial Antidepressant Medication Within 3
Months of Starting Treatment: Results of Multivariate Model*.
Copyright restrictions may apply.
Bull,
S. A. et al. JAMA 2002;288:1403-1409
Medicare Advantage in One Slide
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Plans contract with CMS to provide Medicare benefits to beneficiaries
as an alternative to traditional Medicare FFS.
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Plans receive non-negotiated, risk-adjusted, capitated payment from
CMS based on the health status of each individual enrollee.
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Plans have some flexibility to selectively contract with providers, do
medical management and provide additional care support services.
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However, CMS maintains substantial involvement in regulating and
monitoring the services being provided by private plans.
VR-12 Questions
Physical Health
(Summary Measure)
Source: Lewis Kazis, et. al
General
Health
Physical
Functioning
Mental Health
(Summary Measure)
Role-Physical
Role-Emotional
Bodily Pain
Vitality/Ment
al
Health
Social
Functioning
Change
Physical
Change
Emotional
SCALES
1. Your
Health
2a. Moderate
Activities
2b.Climbing
Several
Stairs
3a. Accomplished
4a. Accomplished
Less
Less
3b. Limited in
4. Limited in Kind
Kind
5. Pain
Interference
6a. Peaceful 7. Interference in
6b. Energy
Social
6c. DownActivities
Hearted
8.
Change in
Physical
Health
9.
Change in
Emotional
Health
Slide 53
Veterans Rand 12-Item Health Survey
(VR-12)
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First 12 questions of HOS.
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Extensively tested, shown to be reliable and valid in ambulatory care populations.
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8 scales of health include mental health.
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Physical Functioning,
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Role-Physical,
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Role-Emotional,
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Bodily Pain,
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Social Functioning,
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Mental Health,
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Vitality,
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General Health.
6 questions used to calculate the mental health composite score (MCS).
Slide 52
What is the MCS?
(Mental Health Composite Score)
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The change in a plan’s MCS score from baseline to
2-year follow-up is used to assess a Medicare Advantage (MAO) Plan’s ability to
sustain or improve the mental health of its population.
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The six questions above are weighted and impact the MCS score, some more
than others.
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The change in this score is the basis for the CMS Star ratings.
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The CMS Star ratings will impact quality bonus payments for Medicare
Advantage plans as of 2012.
Slide 54
VR-12 Question 4a & 4b
Mental Health
(Summary Measure)
Role-Emotional
4a. Accomplished
Less
Source: Lewis Kazis, et. al
4b Limited in Kind
Slide 55
VR-12 Question 6a, 6b, & 6c
Mental Health
(Summary Measure)
6a. Peaceful
Vitality/Mental
Health
6b. Energy
Source: Lewis Kazis, et. al
6c. Down-Hearted
Slide 56
VR-12 Question 7
Mental Health
(Summary Measure)
Social
Functioning
Source: Lewis Kazis, et. al
7. Interference in
Social Activities
Slide 57
1) Percentage measurement scores for
“Improving and Maintaining Mental Health”
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MCS scores are calculated per beneficiary at baseline and follow-up
to determine the 2-year change.
2.
These “change scores” are aggregated to the plan level and case-mix
adjusted to show the percentage of enrollees whose MCS was the
same, better, or worse after 2 years.
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3.
Outliers are identified based on whether a plan performed the
same, better, or worse than the national average (statistically
Slide 58
significant differences).
5 HOS Mental Health Questions after VR12…
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Four depression screening questions
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Mentally unhealthy days in past 30 days
Slide 59
MECHANISMS
(GENERAL)
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Shared vulnerability hypotheses are
increasingly popular in the academic literature.
These propose an underlying predisposition to
BOTH depression and chronic medical
conditions, rather than simple cause & effect
CORONARY ARTERY
DISEASE
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Depression predicts increased risk of atherosclerosis, CHF,
arrhythmias, MI and sudden cardiac death; both in previously
healthy individuals and in cardiac patients.
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Major Depression doubles the risk of an adverse CVD event
within 12 months, independent of ejection fraction, HTN or
smoking.
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Depressed patients have a 4-fold risk of death after MI
compared with non-depressed patients.
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Both longitudinal observational studies and several prospective
clinical trials have clearly shown that these associations persist
after controlling for both psychosocial and behavioral risk
factors.
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Researchers have thus proposed and studied plausible
biological mechanisms by which a direct causation effect or
shared vulnerability might be mediated.
Also, other chronic illnesses
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AUTO-IMMUNE DISORDERS
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There is increasing interest in cytokine release as the common
pathway mediating the linkage of depression and many
different medical conditions.
CHRONIC PAIN
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More than 50% of depressed patients c/o increased somatic
pain
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Unfortunately, in our modern world inactivity and
increased pain sensitivity are more likely to result in
missed work days, disruption of relationships and
markedly worse quality of life.
Less pain after successful use of integrated model