Transcript Disclosure: Wayne Katon, MD

Disclosure: Wayne Katon, MD
Company
Lilly
Wyeth
Forest
Pfizer
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Employment
Management
Independent
Contractor
Consulting
Speaking &
Teaching
Board, Panel
or Committee
Membership
Enhancing Treatment for Patients with
Comorbid Depression, Diabetes
and Heart Disease
Wayne Katon, MD1
Mike VonKorff, ScD2
Elizabeth Lin, MD, MPH2
Paul Ciechanowski, MD, MPH1
Greg Simon, MD, MPH2
Evette Ludman, PhD2
Joan Russo, PhD1
Carolyn Rutter, PhD2
Bessie Young, MD, MPH1
1 University
of Washington School of Medicine
2 Center for Health Studies, Group Health Cooperative
NIMH Grants MH 4-1739 and MH 01643 (Dr. Katon)
Mrs. K is a 45-year-old female computer
programmer with a 5-year history of type 2
diabetes. She started the study in Sept.
2007 based on the following eligibility
criteria: PHQ-9 of 20, HbA1c 9.6.
Patient has a history of childhood sexual
abuse, has had recurrent depressive
episodes and obesity with a BMI of 51 (>30
meets obesity criteria). Prior history of
smoking and has sleep apnea Rxed with
CPAP.
Adverse Bidirectional Interaction
• Smoking
• Medical illness at
earlier age
• Sedentary lifestyle
• Obesity
Major
Depression • Lack of adherence to
medical regimens
• Psychophysiologic
 Insulin sensitivity
 Autonomic NS
 Inflammatory markers
• Poor symptom
control
•  functional
impairment
•  complications of
medical illness
•  mortality
Katon et al. Biol Psychiatry 2003
Premature Mortality and
Chronic Mental Illness
Schizophrenia: 20-25 years
 Bipolar: 10-15 years
 Major Depression: 5 to 10 years

Etiology of Premature Mortality


Suicide, accidents
Medical morbidity
Medical Morbidity




Chronic stress: effects on HPA axis,
autonomic nervous system, immune
system
Health risk behaviors: smoking,
sedentary lifestyle, diet/obesity,
alcohol/drugs
Lack of self care: adherence to
medication, diet, exercise, cessation of
smoking
Psychiatric medications: obesity,
metabolic syndrome, diabetes, CAD
Behavioral Risk Factors: Depression
Behavioral risk factors (smoking, obesity,
sedentary lifestyle) account for
approximately 40% of all deaths in the U.S.
 Depression is linked to all 3
 Wassertheil-Smoller (2004) have shown in
98,000 women that depression was
associated with higher rates of smoking,
lack of exercise, obesity, diabetes, high
cholesterol levels and rates of hypertension
compared to non-depressed populations

Meta-Analysis of the Effect of
Depression on Patient Adherence

Compared to nondepressed patients,
the odds are 3 times greater that
depressed patients would be
nonadherent with medical treatment
recommendations
DiMatteo MR et al. Arch Intern Med 2000
% Smoking
% Smoking by Depression Level
18
16
14
12
10
8
6
4
2
0
N = 4,225
None
p<0.001;
p<0.01;
Minor
Major > None
Minor > None
Major
Depression Group
Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type
and duration, treatment type , HbA1c and clinic
Katon et al. Diabetes Care 2004
% BMI > 30 kg/m2 by Depression
p<0.001;
p<0.01;
BMI > 30 kg/m2 (%)
N = 4,225
80
70
60
50
40
30
20
10
0
None
Minor
Major > None
Minor > None
Major
Depression Group
Adjusted for demographics, medical comorbidity, diabetes severity, diabetes
type and duration, treatment type, HbA1c and clinic
Katon et al. Diabetes Care 2004
HbA1c > 8% by Depression Level
p<0.001;
p<0.01;
N = 4,225
Major > None
Minor > None
HbA1c > 8% (%)
60
50
40
30
20
10
0
None
Minor
Major
Depression Group
Adjusted for demographics, medical comorbidity, diabetes severity,
diabetes type and duration, treatment type and clinic
Katon et al. Diabetes Care 2004
Nonadherent Days (%)
40
Medication Adherence in
Patients with Diabetes
Non Depressed
Depressed
30
24.5
20
18.8
27.9
27.2
21.6
19.3
10
0
Oral
Hypoglycemic
Lipid Lowering
Meds
ACE
Inhibitors
Lin et al. Diabetes Care 2004
Pathways Epidemiology Study
Baseline
Mail Survey
1
2
3
4
5-Year
Telephone
Survey
Disease control (HbA1c, LDLs, blood pressure)
Pharmacy refills (adherence)
ICD-9 diagnosis
Macrovascular/microvascular complications (chart
review)
Mortality (Washington State mortality data)
Depression: Association with
Complications and Mortality
Minor
Depression
Major
Depression
Microvascular
Complications
1.05 (0.83, 1.33) 1.33 (1.08, 1.65)
Macrovascular
Complications
1.32 (0.99, 1.75) 1.38 (1.08, 1.78)
Mortality
(All cause)
1.23 (0.94, 1.61) 1.53 (1.19, 196)
Foot Ulcers
1.50 (0.82, 2.60) 2.30 (1.50, 3.70)
Pathways Randomized Controlled Trial

Participants randomly assigned to
Pathways nurse collaborative care
intervention (N = 165) vs. usual care (N =
164)

Usual Care


Primary care or referral to specialty MH care
as available
Pathways Care

Collaborative/stepped care disease
management program for depression in
primary care
Katon et al. Arch Gen Psych
2004
Treatment Protocol


Behavioral activation/pleasant events
scheduling
Antidepressant medication


Problem Solving Treatment in Primary Care
(PST-PC)


Usually an SSRI or other newer antidepressant
OR
6-8 individual sessions followed by monthly group
maintenance sessions
Maintenance and Relapse Prevention Plan

For patients in remission
Katon et al. Arch Gen Psych 2004
Intervention vs Control Differences on Mean
SCL Depression Scores (Range 0 – 4)
Katon et al. Arch Gen Psych 2004
Mean SCL-20 Depression Score
2
I
UC
1.5
1
0.5
Baseline
3 mos
6 mos
12 mos
Intervention vs Control Differences on Mean HbA1c
Katon et al. Arch Gen Psych 2004
8
Mean HbA1C %
7.5
UC
I
7
6.5
6
Baseline
6 mos
12 mos
Intervention vs. Usual Care
Differences in Health Risk Behaviors
No significant I vs. UC differences in
exercise, diet, smoking or checking
blood glucose
 Intervention patients had a
significantly lower mean BMI level
compared to UC at 12 months

Lin et al. Arch Fam Med 2006
Depression: Diabetes Lower Total
Health Care Costs Over 2 Years
$22,258
$1,110
Savings
$5,000
Savings
$10,000
Usual Care
$15,000
Intervention
$20,000
$18,932
$18,035
Intervention
$21,148
Usual Care
$25,000
$897
$0
Pathways
IMPACT
Treating depression and other
mental Illness is a necessary
first step, but not sufficient
alone to improve health risk
behaviors and chronic medical
disease control
Health Services Models
TeamCare Approaches have been
shown to improve quality of care and
outcomes of patients with depression,
diabetes, asthma and CHF
 The most complex and medical costly
patients often have multiple
comorbidities including at least one
mental health diagnosis

Medicare Patients
Depression, diabetes and heart disease
are among the most common illnesses
in aging populations but fewer than 4%
of Medicare beneficiaries with any of
these three illnesses have no other
chronic medical conditions
 80% of those with CHF, 71% with
depression and 56% with diabetes have
4 or more chronic conditions

Partnership for Solutions 2001
Diabetes: Achieve Recommended
Risk Factor Targets
Schmittdiel J et al. JGIM 23:588-94, 2008

Less than 10% of diabetes patients attain
recommended goals for: HbA1c < 7.0%, Systolic
BP < 130 and LDL < 100mg

Poor Adherence found in 20% of patients

No evidence of poor adherence but lack of Rx
intensification found in 30% of hyperglycemia
patients, 47% of hyperlipidemia patients and 36%
of hypertensive patients
Challenge: Development of Health
Services Models for
“Natural” Clusters of Illness
Definition: Illnesses with high
prevalence, high comorbidity and
bidirectional adverse interactions
Examples:
 Diabetes, CAD, depression
 Depression, chronic pain, substance
abuse
New NIMH-Funded Study:
TeamCare Inclusion Criteria



Evidence via automated date (ICD-9)
of having diabetes and/or coronary
artery disease (CAD)
Evidence of poor disease control
(HbA1c > 8.5, blood pressure >140/90,
LDL >130)
PHQ-9 > 10
10,000 Group Health patients with diabetes
and/or CAD & poor disease control
Screen 1: PHQ-2 (response rate 82.6%)
14.8% positive (>3 on PHQ-2)
Screen 2: 1066 eligible for SQ-2 with PHQ-9
268 with PHQ-9 >10 completed baseline
>200 randomized
TeamCare Intervention Goals



Improve depression care: behavioral
activation and antidepressants
Improve medical disease control:
HbA1c, HTN, LDL
Improve self-care (diet, exercise,
cessation of smoking, glucose
checks)
TeamCare Interventionists


3 diabetes nurse educators
Caseload supervision



Depression: 2 psychiatrists
Diabetes and CAD: nephrologist, family
doctor
E-Mail to diabetologist for complex
cases
Nurse Training





Motivational interviewing
Problem solving
Behavioral activation
Antidepressants
TREAT-to-TARGET: blood glucose,
HTN, LDLS
Initially, the case manager increased the
patient’s Celexa from 20 to 60 mg and also
began working with the patient on monitoring
blood sugars more frequently and increasing
NPH insulin. Trazadone was also added to help
with sleep. Her HbA1c decreased by December
to 8.4%. PHQ score initially decreased from 20
to 12 on Celexa 60 mg. and Trazodone 50 mg
and Wellbutrin was added at 100 SR with
gradually increasing dosages. By midNovember, her PHQ had decreased to a 5 on
Celexa 40 mg, Wellbutrin SR 200 mg BID,
Trazodone 50 mg.
TeamCare Summary Report
Initial Clinic
PHQ
Enroll Date
BL
Now
NSH
5/19/08
19
19
NSH
1/9/08
15
2
EVM 11/12/07 14
9
EVM 10/30/07 13
2
LYN
3
8/23/07
14
BP
BL Now
HbA1c
BL Now
LDL
BL Now
141/ 127/
7.3 6.8 168 138
69
77
118/ 130/
9.2 8.3 138 124
80
80
160/ 150/
6.4 6.8 108 67
98
85
209/ 126/
7.3 7.7 119 103
119 76
149/ 111/
8.1 7.7 85
71
58
82
Improving Adherence





Patient self-care materials: book and
video on depression, patient manual
(Tools for Managing Your Chronic
Disease)
Nurse support/education/motivational
interviewing
Medisets
Simplifying medication regimen
$4 generics to avoid $10 co-pays
Self-Care Enhancements




Glucometers: Group Health provides
Home blood pressure monitors
Pedometers to increase exercise
Medisets to improve adherence
Phases of Treatment

Intervene on depression initially
 Behavioral activation
 Antidepressant medication
Medical Disease Control




Is patient adhering to medication
regimen?
If adhering and in poor control, is patient
on optimal dosage?
If maximum dosage has been reached
should a new medication be tried instead
or augmentation of initial medication?
Team recommendations of medication
changes are reviewed with primary care
physician for approval
Behavioral Goals




Behavioral activation/exercise
Dietary changes
Checking blood glucose/altering
insulin
Cessation of smoking
The nurse worked with the patient in
January/February 2008 on increasing
exercise and weight reduction. Patient also
began to gather information about gastric
bypass surgery. She began to watch food
proportion sizes, worked out on a treadmill
and joined a pregastric bypass group. Her
PHQ-9 in June was a 7, HbA1c 7.4%, blood
pressure 113/82 (had decreased from
132/80) and LDL was 77 (had decreased
from 101).
.
Conclusions



Patients with common psychiatric illnesses
have significantly shorter life spans due to
premature development of medical
illnesses.
Economies of scale: New health services
interventions are needed for patients with
multiple comorbidities (one of which is a
psychiatric disorder).
Integration of evidence-based mental health
interventions into primary care and
preventative medical interventions into
community mental health care are needed
to enhance outcomes of patients with
comorbidities.