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Depression Care: Implementing Integrated Primary Care-Behavioral
Health Solutions
Mark Dreskin, MD
Depression Care ProgramSouthern California Kaiser
Permanente
Today• 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
• 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
• 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 depression-free intervals will be present at later stages of life
• 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
• 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
• 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 non-depressed 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.)
Possible Markers for Depressionin 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• BEHAVIORAL FACTORS
• Cigarette Smoking
• Alcohol Consumption
• Poor Diet (excess calories; low nutrient density)
• Sedentary Lifestyle
• Poor Treatment Adherence
• HEALTH PERCEPTION
• 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 detection• Depression presents but goes untreated in
general primary care settings
• 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
• 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
• Watchful Waiting
• May be briefly appropriate in minor depression
• Behavioral Activation
• Encourage exercise and increased activity in mild cases
• Pharmacotherapy (Antidepressant Medications)
• Psychotherapy (Problem-Solving or Cognitive Behavioral)
• Available within primary care in many integrated care programs
• Referral to Specialty Care
• Complicated, severe, non-responding, or suicide risk
and
• 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
Computer-Assisted Therapy
Psychoeducation
– Depression Classes from Health Education :
Depression Overview – single class
Overcoming Depression – series of 6 classes
Herbal : St. John’s Wort
Proven efficacy in mild depression but preparations may be inconsistent. (though can not be combined with most antidepressant meds)
Bibliotherapy
– eg “Feeling Good” by David Burns
Integrated care
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:
1. Treatment Coordination
2. Follow-up/Tracking Systems with Feedback to Practitioners
3. Outcomes Measurement
4. Patient Education and Self-Management Programs
5. Clinician Education
6. Mental Health/Behavioral Medicine Specialist Involvement
7. 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
Unutzer, IMPACT, 2002
Dietrich, RESPECT trial
PROSPECT trial
Katon, “Partners in Care”
also with dropping BMI in obese patients
also TEAM care (diabetics)
*improve remission rates
* improve compliance
*better patient and physician satisfaction*reduced ED
and clinic utilization
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)
*improve remission rates
* improve compliance
*better patient and physician satisfaction*reduced ED
and clinic utilization
morbidity and mortality
EHR based reportsGive me all
your information
…NOW!
I’m going to go lasso me that
information anytime I need it.
REGISTRY
EHR based reports
Reports only indicated 3 month window
Data entry
3 months
3 months
3 months
3 months
Prompts
Quarterly EHR report
REGISTRY
Snap shot views are “real-time”
Data entry
Prompts
Query
TIDES Study, 2008
90% Hispanic/Latino and Caucasian patients from underserved communities in California
Average age 41 years old
9 demonstration sites, with different levels of proximity, integration
TIDES Study, 2008 The Duke Health Profile
17 item generic self-report standard instrument
Health Measures
Physical health General health
Mental health Perceived health
Social health Self-esteem
Dysfunction measures
Anxiety Depression
Pain Disability
PHQ-9
5-14, consider active treatment
> 15, initiate active treatment
Mean Health Scores
Mean Dysfunction Scores
Changes in PHQ-9 mean scores
Discrepancies exist between instructions that physicians report they communicate to patients and what patients remember being told.
Explicit instructions about expected duration of therapy and discussions about medication adverse effects throughout treatment may reduce discontinuation of SSRI use.
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”
Initial treatment
Switch or augment (A)
Switch or augment (B)
“Last resort” (C)
Initial treatment: SSRI or Problem Solving Therapy
(A)
Switch to other SSRI, SNRI, or PST or other agent
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
ECT or other interventionRush et al, “STAR*D” study, Arch Gen Psychiatry, 2006
(often steps B & C above are usually done in Specialty Psychiatry setting.)
Factors associated with success
Interpersonal, professional relationship between physical and mental health staff
Co-location better
Consolidated electronic health records
Adequate staff training (especially in treatment of complex patients), both clinical skills, and and effective integrated services
Consistent champions
Factors associated with enhanced value
Use of depression care managers (dedicated to depression care)
Systematic involvement of psychiatrists
On hand for consultation with treating primary care providers
Perform supervision, and provide case review, with depression care managers
“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
FACTORS THAT REDUCED CLINIC/PRACTITIONER PARTICIPATION
Quality results from Minnesota DIAMOND-OutcomesResponse 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
Endorsement of “stepped care” (“treat-to-target”)
Back-office staff for core support functions, such as out-reach, tracking, evaluating for treatment side effects
Active dialogue and collaboration between primary care provider and the behavioral health provider
REIMBURSEMENT ISSUES
• Affordable Care Act, issues with planned 2014 implementation
• 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
• quality metrics including psychiatric in-patient follow-ups, childhood ADHD medication measures, HEDIS anti-depressant medication metrics
Beyond the Mental Health Parity Act
Medicare “Star Ratings” Quality measures
NCQA, HEDIS
Service measures
METEOR, others
Survey measures
Perceived health
Medicare “Star Ratings” Quality measures
NCQA, HEDIS
Service measures
METEOR, others
Survey measures
Perceived health
Slide 60
Average Impact on MCS Scores Observed in Veterans Health StudyKazis, 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
Average Impact on MCS Scores Observed in Veterans Health StudyKazis, 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
testimonials
• 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
• “I’m not crazy!”
• “Who are you?”
• Lesson learned: “Depression care program” sounds a little “cultish”
• 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)
• Reimbursable “care extender” training
• 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)
Future issues:
•APPENDIX
PROGNOSIS & COURSE
• 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
Eaton WW et al Arch Gen Psychiatry. 2008;65(5):513-520
Medicare “Star Ratings” Quality measure:
HEDIS medication measures
Meant to ensure that plan coverage keeping patients med adherent
Foye, 2010; Bull et al, 2002
Patient survey data (“Health Outcome Survey)
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*.
Bull, S. A. et al. JAMA 2002;288:1403-1409Copyright restrictions may apply.
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;288:1403-1409Copyright restrictions may apply.
Table 4. Factors Associated With Switching the Initial Antidepressant Medication Within 3 Months of Starting Treatment: Results of Multivariate Model*.
Bull, S. A. et al. JAMA 2002;288:1403-1409Copyright restrictions may apply.
Medicare Advantage in One Slide
Plans contract with CMS to provide Medicare benefits to beneficiaries as an alternative to traditional Medicare FFS.
Plans receive non-negotiated, risk-adjusted, capitated payment from CMS based on the health status of each individual enrollee.
Plans have some flexibility to selectively contract with providers, do medical management and provide additional care support services.
However, CMS maintains substantial involvement in regulating and monitoring the services being provided by private plans.
Slide 53
VR-12 Questions
Physical Health (Summary Measure)
Mental Health (Summary Measure)
1. Your Health
2a. Moderate Activities 2b.Climbing
Several Stairs
3a. Accomplished
Less3b. Limited in
Kind
4a. Accomplished
Less4. Limited in
Kind
5. Pain Interference
6a. Peaceful6b. Energy6c. Down-
Hearted
7. Interference in Social Activities
9. Change in Emotional
Health
8.Change in PhysicalHealth
SCALES
GeneralHealth
Physical Functioning
Change Emotional
Role-Physical
ChangePhysical
SocialFunctioning
Vitality/MentalHealth
Bodily PainRole-Emotional
Sou
rce:
Lew
is K
azi
s, e
t. a
l
Slide 52
Veterans Rand 12-Item Health Survey (VR-12)
First 12 questions of HOS.
Extensively tested, shown to be reliable and valid in ambulatory care populations.
8 scales of health include mental health.
Physical Functioning,
Role-Physical,
Role-Emotional,
Bodily Pain,
Social Functioning,
Mental Health,
Vitality,
General Health.
6 questions used to calculate the mental health composite score (MCS).
Slide 54
What is the MCS? (Mental Health Composite Score)
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.
The six questions above are weighted and impact the MCS score, some more than others.
The change in this score is the basis for the CMS Star ratings.
The CMS Star ratings will impact quality bonus payments for Medicare Advantage plans as of 2012.
Slide 55
VR-12 Question 4a & 4b
Mental Health (Summary Measure)
4a. Accomplished Less
4b Limited in Kind
Role-Emotional
Sou
rce:
Lew
is K
azi
s, e
t. a
l
Slide 56
VR-12 Question 6a, 6b, & 6c
Mental Health (Summary Measure)
6a. Peaceful
6b. Energy
6c. Down-Hearted
Vitality/MentalHealth
Sou
rce:
Lew
is K
azi
s, e
t. a
l
Slide 57
VR-12 Question 7
Mental Health (Summary Measure)
7. Interference in Social Activities
SocialFunctioning
Sou
rce:
Lew
is K
azi
s, e
t. a
l
Slide 58
1) Percentage measurement scores for “Improving and Maintaining Mental
Health”
1. 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.
3. Outliers are identified based on whether a plan performed the same, better, or worse than the national average (statistically significant differences).
Slide 59
5 HOS Mental Health Questions after
VR-12…
Four depression screening questions
Mentally unhealthy days in past 30 days
MECHANISMS (GENERAL)
• 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
Depression predicts increased risk of atherosclerosis, CHF, arrhythmias, MI and sudden cardiac death; both in previously healthy individuals and in cardiac patients.
Major Depression doubles the risk of an adverse CVD event within 12 months, independent of ejection fraction, HTN or smoking.
Depressed patients have a 4-fold risk of death after MI compared with non-depressed patients.
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.
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
• AUTO-IMMUNE DISORDERS
• There is increasing interest in cytokine release as the common pathway mediating the linkage of depression and many different medical conditions.
• CHRONIC PAIN
• More than 50% of depressed patients c/o increased somatic pain
• 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