Improving behavioral health through the power of clinical expertise and advanced technology New York Business Group on Health Maximizing Behavioral Health

Improving behavioral health

through the power of clinical

expertise and advanced

technology

New York Business Group on HealthNew York Business Group on Health

Maximizing Behavioral Health in Your Population:Maximizing Behavioral Health in Your Population:Programs, Plans, Providers & ParityPrograms, Plans, Providers & Parity

September 28, 2010September 28, 2010

Presented to:

© 2010 Care Management Technologies, Inc.Reprints and Distribution Prohibited

Improving behavioral health through the power of clinical expertise and advanced technology

Challenges & Opportunities to Improve Care

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• Using evidence-based medicine for behavioral and physical health

• Achieve mental health parity in a cost-effective way

• Understanding mental/physical health relationships

• Designing plan design and programs to support best treatment practices



How Four Conditions Impact Employees and Employers

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• Depression

• Diabetes

• Alcohol-Use Disorders

• Attention-Deficit Hyperactivity Disorder (ADHD)



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DEPRESSION


© 2010 Care Management Technologies, Inc.Reprints and Distribution Prohibited 5

Depression: Impact on Workplace

Depression

Among the costliest of health problems to employers

Wang PS at al: Making the Business Case for Enhanced Depression Care. J Occup Environ Med 2008; 50(4):468-475

Afflicts individuals during prime working years

Associated with large short-term decrements in work performance



Depression: Effective Treatment

• When depression is effectively treated, work impairment resolves

• In only a minority of cases (42%) is depression being effectively treated – defined as:

At least six sessions of psychotherapy, each lasting 30+ minutes, or

Treatment with antidepressant, anxiolytic or mood stabilizer with 4+ physician visits

Kessler RC at al: The Prevalence and Correlates of Workplace Depression in the National Comorbidity Replication. J Occup Environ Med 2008; 50(4):381-390



Depression: Urgent Unmet Needs

Personalized treatment:

“Genomics may help, but imaging, family history, and clinical characteristics will also contribute.”

Effective treatments:

“Current medications may be necessary but not sufficient for the treatment of depression.”

Insel TR, Wang PS: The STAR*D Trial: Revealing the Need for Better Treatments. Psychiatr Serv 2009; 60(11):1466-67



Depression: Treatment Options

• Psychotherapies

• Medications

• Psychoeducation

• Neurostimulation: ECT, rTMS, etc.

• Light Therapy

• Sleep Deprivation

• Other (omega-3 fatty acids, SAMe, St John’s wort)



Poor Adherence

• Single most critical problem affecting outcome for all medical and behavioral conditions

• Especially problematic for people with psychiatric illnesses, elderly, and low-income

“Drugs don’t work in patients who don’t take them.”

C. Everett Koop, Former US Surgeon General

1. Clayton, C., et al: Assessment of Clinician Awareness of Nonadherence Using a New Structured Rating Scale. J Psychiatr Pract 2010;16:164-169.

• Poor adherence can be mistaken for lack of response, leading to unnecessary medication changes and polypharmacy

• CMT Study: clinicians do not know whether patients are taking their medications as prescribed1



MPR & Gap Analysis

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Improving Adherence Reduces Adverse Events

Source: Valenstein et al., 2002

Percentage of Patients with a Psychiatric Admission

31.729.5 28.1

25.923.4

18.517.0

13.411.2

8.3

0

5

10

15

20

25

30

35

Per

cen

t

0 to <0.1

0.1 to <0.2

0.2 to <0.3

0.3 to <0.4

0.4 to <0.5

0.5 to <0.6

0.6 to <0.7

0.7 to 0.8 to 0.9 to

MPR Range<0.8 <0.9 <1.0



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DIABETES



Bidirectional Relationship with Behavioral Health Conditions

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• Patients with diabetes have an elevated rate of depression

• Depression increases the risk for diabetes

• Antidepressant medications cause weight gain and increase risk for diabetes

• Depression activates the HPA access, which increases blood glucose levels

• Co-morbid depression-diabetes is associated with poorer glycemic control, more diabetes-related complications and accelerated mortality



Bidirectional Relationship (continued)

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• Depression leads to less adherence to medication, diet and exercise regimens for diabetes

• Antidepressant medications improve depression but do not improve diabetic glycemic control

• Collaborative care may improve outcomes in co-morbiddepression/diabetes

• Attention must be paid to adherence to antidepressant medication and to behavioral change in patients with depression and diabetes



14

ALCOHOL-USE DISORDERS



A Hidden Diagnosis

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17 million adults have a serious problem with alcohol, yet only 3

million get help. Alcohol problems kill, sicken or injure hundreds of

thousands of Americans every year, destroy families, contribute to violent

crime, and reduce productivity.

Ensuring Solutions to Alcohol problems – The George Washington University Medical Center http://www.ensuringsolutions.org/solutions/solutions_show.htm?doc_id=339028&cat_id=963



Underuse of Screening

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“Physicians routinely measure a patient's blood pressure to diagnose hypertension

but fewer than one in three carefully screen their patients for alcohol problems.”



Reasons Why Physicians Don’t Routinely Screen

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Ensuring Solutions to Alcohol problems – The George Washington University Medical Center http://www.ensuringsolutions.org/solutions/solutions_show.htm?doc_id=339028&cat_id=963

• Protecting patient (insurance issues)

• Doubt the effectiveness of alcohol screening

• Assume that the process is too difficult, time consuming, they aren't qualified, or that their patients will react badly



Screening, Brief Intervention, and Referral to Treatment (SBIRT)

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• Decrease the frequency and severity of drug and alcohol use• Reduce the risk of trauma• Increase the percentage of patients who enter specialized

substance abuse treatment, and• Fewer hospital days and fewer emergency department visits.

SBIRT research shows that large numbers of individuals with or at risk of developing serious alcohol or other drug problems may be identified through primary care screening and successfully treated in that setting. Primary care treatment can….

“Screening, Brief Intervention and Referral to Treatment - “Is SBIRT Effective?” http://www.sbirt.samhsa.gov/

Cost-benefit and cost-effectiveness analyses have demonstrated net-cost savings from these interventions.



Treatment for Alcohol Dependence

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Disulfiram

Acamprosate

Oral naltrexone

Injectable naltrexone

Counseling

Psychotherapy

Rehabilitation

12-Step Programs

Medications Psychosocial Treatment



20

ADHD



ADHD: Not Just a Childhood Disease

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• 4.4% of adults are estimated to have ADHD1

• 5% of children have ADHD alone (without learning disorder)

Kessler RC, et al “The Prevalence and Correlates of Adult ADHD in the United States: Results From the National Comorbidity Survey Replication” Am J Psychiatry 163:716-723, April 2006



Accurate Diagnosis Is Problematic in Cases of ADHD

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• Over-diagnosis and missed-diagnosis is common

• Must use structured instrument (e.g. Connors scale)

• Important to get assessment from three sources: child, parent and teacher



Cost Data for ADHD

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• Individuals with ADHD have significantly higher inpatient and outpatient healthcare costs, including higher rates of accidents and medical illnesses.

$4,306 versus $1,944 for the non-ADHD group

Leibson CL, et al. “Use and Costs of Medical Care for Children and Adolescents with and without Attention-Deficit/Hyperactivity Disorder. JAMA. 2001; 285: 60-66



Treatments: ADHD

First line treatment: FDA-approved ADHD medication

Dextroamphetamine (Dexedrine®) d- & d,l-methylphenidate (Concerta®,

Daytrana®, Focalin XR®, Metadate®, Ritalin LA®)

Mixed salts amphetamine (Adderall XR ®) Amphetamine pro-drug: lisdexamfetamine

(Vyvanse®) Atomoxetine (Strattera®) Guanfacine (Intuniv®)

AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents With ADHD. J Am Acad Child Adolesc Psychiatry 46(7): 894-921, July 2007



Treatments: ADHD

• Second line: medications not FDA approved for ADHD Bupropion (Wellbutrin®, Budeprion®)

Clonidine (Catapres®)

Imipramine (Tofranil®)

Nortriptyline (Pamelor®, Aventyl®)

Modafanil (Provigil®)

• Monitor for side-effects such as aggression, mood liability, suicidal ideation.

• Cardiovascular issues: AHA recommendations

AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents With ADHD, J Am Acad Child Adolesc Psychiatry 46(7): 894-921, July 2007



What Else is Effective?

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• Psychosocial Interventions are effective for ADHD and may work as well as or increase efficacy of psychostimulants in adults

• An MTA study showed that after three years no difference in outcome for children who originally received methylphenidate or psychotherapy

• Stimulant misuse is an increasing problem



Conclusion

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Only by using evidence-based screening, medication and psychosocial treatment, behavioral health and substance abuse disorders can be treated in a cost-effective manner.

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Improving behavioral health through the power of clinical expertise and advanced technology New York Business Group on Health Maximizing Behavioral Health