Transcript Addressing the Impact of Behavioral and Mental Health in Diabetes

Addressing the Impact of
Behavioral Health in Diabetes
Neda Laiteerapong, MD, MS
Michael Quinn, PhD
Department of Medicine
University of Chicago
in collaboration with MWCN
Disclosures
• none
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Learning Objectives
• Understand prevalence and impact of
behavioral health issues in patients with
diabetes
• Understand facilitators and barriers of providing
evidence based behavioral health care in
primary care
• Become aware of efforts at MWCN to improve
behavioral health care for patients with diabetes
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CASE STUDY: BOB
45 YO “HEALTHY” MAN
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Bob’s History
• Urgent visit
– Acute chest pain
– Shortness of breath
• 1 pack per day smoker of 30 years
• Family history of heart attack
• Diagnosis: Pneumonia
Bob At First Office Visit
• Chest pain, shortness of breath resolved
• Still smoking, desire to quit
• Family history:
– Father: smoker, died of MI at 60 yo
– Mother: Type 2 DM, insulin therapy
• BP 140/92, BMI 29
Bob At First Office Visit
• Recommendations
– Smoking cessation counseling, bupropion
– Fasting blood work
– Follow-up in 3 months
Bob At First Office Visit
• Recommendations
– Smoking cessation counseling, bupropion
– Fasting blood work
– Follow-up in 3 months
“OK”
Bob At Second Office Visit
• 7 months later
• Smoke-free since quit date 6 mos prior
• BP 148/96, BMI 31
• Total cholesterol 220 mg/dL
• HDL 26 mg/dL
• FBG 110 mg/dL
Bob At Second Office Visit
• Recommendations
– Acknowledge smoking cessation
– High cholesterol - Atorvastatin
– Hypertension - Lisinopril + HCTZ
– Pre-diabetes - Offered metformin
Bob At Second Office Visit
• Recommendations
– Acknowledge smoking cessation
– High cholesterol - Atorvastatin
– Hypertension - Lisinopril + HCTZ
– Pre-diabetes - Offered metformin
“I don’t want to start
any pills”
“I’ll watch my diet and
get more exercise”
Bob 10 years Later
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Bob returns to clinic 10 years later
Smoking relapse, 1 pack per day
BP 150/96
BMI 32 kg/m2
TC 210 mg/dL, HDL 25 mg/dL
FBG 160 mg/dL
Bob 10 Years Later
• Recommendations
– Smoking cessation counseling, bupropion
– High cholesterol - Atorvastatin
– Hypertension - Lisinopril + HCTZ
– Diabetes - Metformin
“I don’t want to start any pills.
That’s why I didn’t come back to
see you earlier.”
“I’ll quit smoking, watch my
diet and exercise”
Bob 20 Years Later
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Still smoking, 1-2 packs/day
Appears depressed, c/o sleep disorder
BP 150/96, BMI 36 kg/m2
TC 220 mg/dL, HDL 20 mg/dL
FBG 180 mg/dL
Bob 20 Years Later
• Atorvastatin- stopped taking
• Lisinopril + HCTZ – skips when feeling OK
• Metformin – skips when stomach upset
Bob 20 Years Later
• Recommendations
– High cholesterol – Atorvastatin- increase
– Hypertension - Lisinopril + HCTZ
– Diabetes – Start insulin
“I’m tired of being sick. These
pills don’t help.”
“No insulin. It killed my mother.”
Bob’s Current
Behavioral Health Needs
• Health behavior changes
– Intensive smoking cessation counseling
– Medication adherence counseling
– Diet and exercise counseling
• Assessment and treatment of mental
health
Bob’s Past
Behavioral Health Needs
What behavioral health services
could have helped Bob 20 years ago?
BACKGROUND: DIABETES
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Diabetes
• 29.1 million U.S. adults
• FQHCs care for disproportionate share of
patients with diabetes
– 9% general population vs. 13% at FQHCs
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Early Diabetes: Usual care
• Patients receive:
– Advice to modify lifestyle (diet and exercise)
– medical nutrition therapy (nutrition referral)
• Patients may be prescribed oral agents
Goal of treatment is to prevent
long-term complications
Nathan, 2002; Edelman et al., 2003
Advanced Diabetes: Usual Care
• Patients receive:
– Continued advice to modify lifestyle
– Medical nutrition therapy (nutrition referral)
– Instructions to monitor blood glucose
• Patients prescribed multiple oral agents
and/or insulin
• Patients at risk for polypharmacy
Diabetes Management Challenge
• Daily responsibilities rests with patient
– Requires significant lifestyle change across
multiple target behaviors
• Multiple barriers to optimal selfmanagement
• Difficulty maintaining motivation
Adherence to
Diabetes Self-Care is Poor
Treatment
Oral medications (>80%)
Insulin
SMBG
Smoking cessation
Diet (< 30% fat)
Exercise (150 min/wk)
Rates of Adherence
20%
20%
35%
20%
70%
70%
Clinicians Can
Influence Behavior Change
22.1%
16.0%
Smoking
Cessation
Rate
13.4%
10.9%
No
Contact
<3
Minutes
3-10
Minutes
> 10
Minutes
(AHRQ, 2000)
Brief Counseling of 2-3 Minutes
Increases Exercise
80
Minutes per Week
70
60
50
40
30
20
10
0
Control
Baseline
6 Weeks
Brief Counseling
N = 255
Calfas et al., 1996
BEHAVIORAL HEALTH
INTEGRATION: OVERVIEW
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Behavioral Health and Primary
Care Integration Definitions
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Definition: Behavioral Health Care
• Umbrella term that addresses behavioral
problems bearing on health including:
– Health behaviors and patient activation
– Stress-linked physical symptoms
– Mental health
– Substance abuse
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Health Centers Care About
Behavioral Health
• Onsite counseling and treatment
– Mental health: 70%
– Substance abuse: 40%
• 20% offer 24-hour crisis intervention
• All provide outside referrals to substance
abuse and mental health services
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MENTAL HEALTH AND
DIABETES
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Mental Health
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Percentage of persons aged 12 and over with
depression, by age and sex: United States, 2009–2012
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http://www.cdc.gov/nchs/data/databriefs/db172.htm
Mental Health and Diabetes
In patients with diabetes
– 41% have poor psychological well being
– 25% have depressive symptoms
– 15% have elevated anxiety symptoms
In people with depression, anxiety, bipolar
disorder, and schizophrenia
– Higher prevalence of diabetes
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Mental Health Illnesses and
Diabetes: Share Risk Factors
• Unhealthy lifestyles
– Diets high in processed sugars, fats
– Inadequate activity and sleep
• Poor resources
– Low income, low education, unsafe
neighborhoods
– Poor health literacy
• Chronic stress response
– Cortisol, proinflammatory cytokines
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Comorbid Diabetes and Depression:
Worsens Self-Management
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Lower self-efficacy
Less physical activity
Worse diet
Lower treatment adherence
Comorbid Diabetes and Depression:
Worsens Outcomes
• Higher incidence of complications and at an
earlier age
– Heart attack, stroke, blindness, renal disease,
dementia, foot ulcers, major amputations
• Higher cardiovascular and all-cause mortality
– Mortality rate 1.5 times higher than diabetes alone
• Higher health care utilization
– 50-75% greater total medical costs
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Behavioral Health and Diabetes:
Opportunity for Improving Care
• Unmet mental health needs
– Only 12% of people with diabetes receive psychological
treatment
– 55% of people with diabetes and serious psychological
distress receive treatment
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Behavioral Health and Diabetes:
Opportunity for Improving Care
• Access to patients in primary care
– People with diabetes actually more likely to receive
treatment than others with serious psychological distress
(45%)
– Most patients with mental health needs seen in primary
care
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BEHAVIORAL HEALTH
INTEGRATION: RANGE OF
SERVICES
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Behavioral Health and Diabetes:
Different levels of services
• Population level
– Systematic screening and tracking
• Patient level
– Combine psychotherapy interventions (CBT,
motivational interviewing) with diabetes
education and self-management
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Integrated Care: Spectrum
• Enhanced referral relationships
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www.integration.samhsa.gov
Integrated Care: Spectrum
• Enhanced referral relationships
• Co-location
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www.integration.samhsa.gov
Integrated Care: Spectrum
• Enhanced referral relationships
• Co-location
• Co-habitation; staff integration
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www.integration.samhsa.gov
Integrated Care: Spectrum
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Enhanced referral relationships
Co-location
Co-habitation; staff integration
Full integration - multi-disciplinary team
www.integration.samhsa.gov
BEHAVIORAL HEALTH
INTEGRATION: EVIDENCE
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Evidence for Behavioral Health
Interventions: IMPACT
• 1801 adults over 65 years with
depression from primary care
• Usual care vs. Collaborative Care
• Collaborative Care:
– Team care, population-based care (registry),
treatment to target, evidence-based care
• 50% vs. 19% reduction in depressive
symptoms (p<.001)
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Unützer et al, JAMA 2002; 288:2836-2845
Evidence for Behavioral Health
Interventions: TEAMcare
• 214 adults with poorly controlled diabetes
or heart disease and comorbid
depression
• Usual care or intervention group
• Intervention included nurse working with
PCP to provide close attention to
diabetes control and depression care
• Improved HbA1c, LDL, BP and
depression outcomes; cost-savings
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N Engl J Med. 2010; 363(27):2611-20.
Summary of Evidence: Facilitators
• Patient-centered care
– Care at the right time and the right place
– Decreases stigma
• Improves outcomes
– Improves diabetes outcomes
– Improves mental health outcomes
• Cost-effective in sites with capitated
payment
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Barriers to Integrated Care
• Structural barriers
– Access to notes / EMR integration
– Scheduling
• Financial barrier
– Billing for services
• Knowledge barriers
– Local expertise
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BEHAVIORAL HEALTH
INTEGRATION: FUTURE
DIRECTIONS
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MWCN - BHIG
• Behavioral Health Interest Group
– Networking and sharing (webinars every other
month)
– Facilitated by Stacey R. Gedeon, Psy.D., MS
Clinical Psychopharmacology, Director of
Behavioral Health & Integrated Primary Care at
MidMichigan Community Health Services
– Next call April 20th at 12:00 EST (1 hour)
– To join email [email protected]
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MWCN Efforts
• To improve behavioral health care for
patients with diabetes at MWCN-affiliated
community health Centers
• UChicago and MWCN Behavioral Health
and Diabetes Surveys
– To understand current state of care in order
to inform the design of a future intervention
– Clinic-level Resources Survey
– Provider-level survey
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Useful Resources
• Screening tool for depression: www.cqaimh.org/pdf/tool_phq2.pdf
• Screening tool for anxiety: Spitzer RL, Kroenke K, Williams JBW,
Lowe B. Arch Intern Med. 2006;166:1092-1097.
• HRSA-specific: http://www.integration.samhsa.gov/integrated-caremodels/hrsa-supported-safety-net-providers
• Models of Behavioral Health Integration and Billing Codes (p.69):
Collins C, et al. Evolving Models of Behavioral Health Integration in
Primary Care. 2010. http://www.milbank.org/publications/milbankreports/32-reports-evolving-models-of-behavioral-healthintegration-in-primary-care
• AIMS Center: https://aims.uw.edu/
• HRSA: http://www.hrsa.gov/publichealth/clinical/behavioralhealth/
Questions?
Neda Laiteerapong, MD, MS
[email protected]
Michael Quinn, PhD
[email protected]
Erin Staab, MPH
[email protected]