Prevention-Research Centers Health Aging Research Network (PRC-HAN) Webinar Series Evidence-Based Depression Care Management: Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) Jürgen Unützer, MD, MPH, MA Tuesday, October 16th 2008 2-3:30 PM EST Moderated by: Cate Clegg Virna Little, PsyD, LCSW-R

Sponsors: Prevention Research Centers Healthy Aging Research Network

http://www.prc-han.org/

Retirement Research Foundation

http://www.rrf.org/

National Council on Aging

http://ncoa.org/index.cfm

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IMPACT

Primary Care Based Team Care for Late-Life Depression Jürgen Unützer, MD, MPH, MA Professor & Vice Chair Psychiatry & Behavioral Sciences University of Washington Virna Little, PsyD, LCSW-R Vice President for Psychosocial Services and Community Affairs Institute for Family Health

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Depression

Common 10% in primary care Disabling #2 cause of disability (WHO) Expensive 50-100% higher health care costs Deadly Over 30,000 suicides / year

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Depression is deadly

Older men have the highest rate of suicide.

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Depression is often not the only health problem

Chronic Pain 40-60% Cancer 10-20 % Depression Geriatric Syndromes 20-40% Heart Disease 20-40 % Neurologic Disorders 10-20% Diabetes 10-20%

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Efficacious treatments for depression

Antidepressant Medications

–

Over 20 FDA approved

Psychotherapy

–

CBT, IPT, PST, brief dynamic, etc.

Other somatic treatments

–

ECT

Physical activity / exercise

Unutzer et al, NEJM 2008.

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But: few older adults get effective treatment

Only half are ‘recognized’

a particular problem for older men & minorities – – –

“I didn’t know what hit me …” “I am not crazy” “Isn’t depression just a part of ‘normal aging?”

Fewer than 10 % seek care from a mental health specialist. Most prefer their primary care physician.

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Depression Treatment in Primary Care

50 % are recognized and started on treatment or referred Limited access to evidence-based psychosocial treatments (psychotherapy) Increasing use of antidepressants • • •

PCPs prescribe 70 – 90 % of antidepressants 10 - 30 % of older adults are on antidepressants MAJOR OPPORTUNITIES for Quality Improvement – even for nonprescribing providers

But treatment is often not effective –

Only 20 – 40 % improve substantially over 12 months

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Home & Community based social services?

Why integrate care?

Primary Care PC Alcohol & substance abuse care?

CM HC Community Mental Health Center 10

Depression Care Management in Primary Care

Limited access to / use of mental health specialists Treat mental health disorders where the patients are Established provider-patient relationship - Less stigma - Better coordination with medical care 11

Components of evidence based integrated care programs

Screening / case finding Patient education / self-management support Support medication treatment prescribed in primary care –

Monitor adherence, side effects, effectiveness [Nonprescribing providers function as the ‘eyes and ears of the doctor’]

Proactive outcome measurement / tracking –

e.g., PHQ-9, GDS, CES-D

Brief counseling (e.g., Behavioral Activation, PST-PC, IPT, CBT) Stepped care (initial treatments often are not enough) – –

increase treatment intensity as needed mental health consultation to help guide or provide care for patients not responding as expected

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IMPACT Study

Funded by

John A. Hartford Foundation California Healthcare Foundation Robert Wood Johnson Foundation Hogg Foundation

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IMPACT Team

“None of us is as smart as all of us” Study coordinating center

Jürgen Unützer (PI), Sabine Oishi, Diane Powers, Michael Schoenbaum, Tom Belin, Linqui Tang, Ian Cook. PST-PC experts: Patricia Arean, Mark Hegel

Study sites University of Washington / Group Health Cooperative

Wayne Katon (PI), Elizabeth Lin (Co-PI), Paul Ciechanowski

Duke University

Linda Harpole (PI), Eugene Oddone (Co-PI), David Steffens

Kaiser Permanente, Southern CA (La Mesa, CA)

Richard Della Penna (Co-PI), Lydia Grypma (Co-PI), Mark Zweifach, MD, Rita Haverkamp, RN, MSN, CNS

Indiana University

Christopher Callahan (PI), Kurt. Kroenke, Hugh. Hendrie (Co-PI)

UT Health Sciences Center at San Antonio

John Williams (PI), Polly Hitchcock-Noel (Co-PI), Jason Worchel

Kaiser Permanente, Northern CA

Enid Hunkeler (PI), Patricia Arean (Co-PI)

Desert Medical Group

Marc Hoffing (PI); Stuart Levine (Co-PI)

Study advisory board

Lisa Goodale (NDMDA), Rick Birkel (NAMI), Thomas Oxman, Kenneth Wells, Cathy Sherbourne, Lisa Rubenstein, Howard Goldman 14

Study Methods

1998 – 2003 Randomized controlled trial 8 health care organizations in 5 states

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18 primary care clinics 1,801 older adults with major depression or chronic depression

– – –

450 primary care providers Patients randomly assigned to IMPACT or usual care Usual care = antidepressant Rx in primary care (~ 70 %) and / or referral to mental health specialists (20 %)

–

All followed with independent assessments for 2 years

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IMPACT Team Care Model

Prepared, Pro-active Practice Team Informed, Activated Patient

Effective Collaboration Photo credit: J. Lott, Seattle Times Photo: Courtesy D. Battershall & John A. Hartford Foundation

Practice Support

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Evidence-based ‘team care’ for depression

TWO NEW ‘TEAM MEMBERS’ TWO PROCESSES

1. Systematic diagnosis and outcomes tracking e.g., PHQ-9 to facilitate diagnosis and track depression outcomes 2. Stepped Care a) Change treatment according to evidence-based algorithm if patient is not improving b) Relapse prevention once patient is improved

Care Manager - Patient education / self management support Consulting Psychiatrist Caseload consultation for care manager and PCP (population-based) - Close follow-up to make sure pts don’t ‘fall through the cracks’ Support anti depressant Rx by PCP Diagnostic consultation on difficult cases Consultation focused on patients not improving as expected Brief counseling (behavioral activation, PST-PC, CBT, IPT) Facilitate treatment change / referral to mental health Recommendations for additional treatment / referral according to evidence-based guidelines 17 Relapse prevention

Treatment Protocol

Assessment and education, Behavioral Activation / Pleasant Events Scheduling AND (3) a) Antidepressant medication usually an SSRI or other newer antidepressant OR b) Problem Solving Treatment in Primary Care (PST-PC) 6-8 individual sessions followed by monthly group maintenance sessions (4) Maintenance and Relapse Prevention Plan for patients in remission

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Stepped Care

Systematic follow-up & outcomes tracking Patient Health Questionnaire (PHQ-9)

The “cheap suit”

Treatment adjustment as needed based on clinical outcomes - according to evidence-based algorithm - in consultation with team psychiatrist Relapse prevention

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100 80 60 40 20 0

Greater Satisfaction with Depression Care

P=.2375

(% Excellent, Very Good)

Usual Care Intervention

P<.0001

P<.0001

0 3 12

month Un ützer et al. JAMA. 2002; 288: 2836-2845.

%

IMPACT Doubles Effectiveness of Depression Care

50 % or greater improvement in depression at 12 months Usual Care IMPACT 30 20 10 0 70 60 50 40 1 2 3 4 5 6 7 8

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Participating Organizations

Evidence-based Care Benefits Disadvantaged Populations

50 % or greater improvement in depression at 12 months 60% 54% 50% 43% 42% IMPACT Care 40% 30% 20% 10% 0% 19% 23% 14% Care as Usual White Black Latino Are á n et al. Medical Care, 2005

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Improved Physical Functioning

SF-12 Physical Function Component Summary Score (PCS-12) 41 P<0.01

P<0.01

P<0.01

P=0.35

40.5

40 39.5

39 38.5

38 Baseline 3 mos Usual Care IMPACT 6 mos 12 mos

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Callahan et al. JAGS. 2005; 53:367-373.

Fewer thoughts of suicide

18 16 14 12 10 8 6 4 2 0 Baseline Unützer et al, JAGS 2006 6 months 12 months IMPACT Usual Care 25

IMPACT Saves Money

Cost Category IMPACT program cost 4-year costs in $ Intervention group cost in $

522

Usual care group cost in $

0

Outpatient mental health costs

661 558 767

Difference in $

522

Savings

-210

Pharmacy costs

7,284

Other outpatient costs

14,306 6,942 14,160 7,636 14,456 -694 -296

Inpatient medical costs

8,452

Inpatient mental health / substance abuse costs

114

Total health care cost 31,082

7,179 61 29,422 9,757 169 32,785 -2578 -108

-$3363

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Unutzer et al. Am J Managed Care 2008.

IMPACT Summary

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Less depression IMPACT doubles effectiveness of usual care

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Less physical pain

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Better functioning

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Higher quality of life

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Greater patient and provider satisfaction

-

More cost-effective

Photo credit: J. Lott, Seattle Times

“I got my life back”

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IMPACT Endorsements

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President’s New Freedom Commission on Mental Health

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National Business Group on Health

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Institute of Medicine

(Retooling for An Aging America)

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POGOe

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CDC Consensus Panel

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Annapolis Coalition

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Partnership to Fight Chronic Disease

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SAMHSA NREPP

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Commonwealth Fund

–

Integrated Behavioral Health Partnership

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Taking IMPACT from Research to Practice

Support from JAHF (2004-2009) Over 170 clinics have implemented core components of the program to date –

DIAMOND program in Minnesota implementing the program state-wide in partnership with 25 medical groups and 9 health plans

Several large health plans and disease management organizations are incorporating core components of IMPACT 29

IMPACT Implementation

2004 2005 Trained over 3000

Over 3,000 clinicians

Providers in over 150 practices to date 2006 2007

Kaiser Permanente of Southern California

Pilot Study Compare 284 clients in ‘adapted program’ with 140 usual care patients and 140 intervention patients in the IMPACT study (Grypma et al, 2006) Dissemination - Implemented core components of program in 10 regional medical centers

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KPSC – San Diego ‘After IMPACT

’

Fewer care manager contacts

18.9

7.9

10.2

5.1

Total contacts Clinic visits Grypma et al, General Hospital Psychiatry, 2006. IMPACT Study Post-Study 8.7

2.8

Phone calls

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IMPACT Remains Effective

>= 50 % drop in PHQ-9 depression scores

68% 68% 66% 64% At 3 months IMPACT Post-Study At 6 months Grypma et al, General Hospital Psychiatry, 2006.

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Lower Total Health Care Costs

$8,800 $8,400 $ / year $8,000 $7,600 $7,200 $6,800 $8,588 $7,949 $7,471 Study Usual Care Study IMPACT Post Study IMPACT Grypma, et al; General Hospital Psychiatry, 2006

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Institute for Urban Family Health

Age at enrollment: Mean Range Gender: Female Male Ethnicity: Hispanic African American Caucasian Other Marital Status: Married Single, Widowed, Divorced/separated Number 71.6 years 60 – 99 years 165 74 90 70 56 23 44 48 Percent 69.0% 31.0% 37.7% 29.3% 23.4% 9.6% 47.8% 52.2% 35

IMPACT Effective for Depression

Mean PHQ-9 Depression Scores

10 8 2 0 6 4 20 18 16 14 12

14.03

Initial 8.14

3 Months Time 7.91

6 months

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Change in Depression Initial to 6 months

160 140 120 100 80 60 40 20 0

Initial PHQ-9 Depression Scores 63% 28% Under 10: Mild 10-14: Moderate 15-19: Mod. Severe PHQ-9 Score 9% 20+: Severe

160 140 120 100 80 60 40 20 0

6 Month PHQ-9 Depression Scores (Mean Score of 7.91) 65% 24% 5% Under 10: Mild 10-14: Moderate 15-19: Mod. Severe PHQ-9 Sore 6% 20+: Severe

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A word from providers…

“It is good to see that mental health is once again becoming part of the medical Interview, as so much of our patient's health depends on their mental well being.”

- Dr. Eric Gayle

“Project IMPACT has allowed me to incorporate a new tool (PHQ-9)into my primary care practice, which has improved the accuracy of my diagnosis while increasing my efficiency and productivity as well. It helped me identify patients I initially overlooked.”

-Dr. Joseph Lurio (68 th

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Street)

Depression Is Associated With a Higher Number of Cardiac Risk Factors 100 90 80 70 60 50 40 30 20 10 0 Non Depressed 38.4

62.5

Depressed 35 61.3

Diabetic Patients With CVD N=3010 Diabetic Patients Without CVD N=1215 Katon et al, J Gen Intern Med, 2004

Depression Increases Mortality Rate in Patients With Diabetes by 2-Fold Katon et al. Diabetes Care, 2005

Depression and Diabetes: More Depression Free Days over 2 Years 500 400 300 200 100 0 412 359 53 Pathways 331 215.5

115.5

IMPACT Intervention Usual Care Increment

Two Collaborative Care Trials Demonstrate Improved Depression Care in Diabetes Lowers Total Health Care Costs Over 2 Years $25,000 $22,258 $21,148 $20,000 $18,932 $18,035 $15,000 $10,000 $5,000 $1,110 $897 $0 Pathways IMPACT Katon et al. Diabetes Care 2006, Simon et al Arch Gen Psychiatry 2007

Project Dulce + IMPACT

Principal Investigator: Todd Gilmer, UCSD Combined diabetes and depression care management program targeting low-income and primarily Spanish speaking Latinos in San Diego community clinics Added a depression care manager to an existing diabetes team (RN/CDE, promotoras) Translation for Cultural Competency

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DCM bilingual with experience serving Latino pop.

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PST-PC adapted to low-literacy population

Project Dulce + IMPACT Results

Screened 499 patients with PHQ9 31% with scores of 10+ 75% Latino, 70% Spanish speaking 65% had depressive symptoms for 2+ years 26% interested in pharmacological treatment 74% interested in psychological treatment 48% reported financial stressors

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Depressive Symptoms at Baseline and Six Month Follow-Up As Measure with PHQ-9 . Inter-Quartile Range (box) Highest and Lowest (whiskers) Outlier (dots) Median

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Gilmer et al. Diabetes Care 2008

Collaborative Care for Alzheimer’s Disease Collaborative Care for Alzheimer’s Disease Christopher M. Callahan, MD Cornelius and Yvonne Pettinga Professor Director, Indiana University Center for Aging Research Research Scientist, Regenstrief Institute, Inc.

Improvement in Dementia-related Problem Behaviors 20 15 10 5 0

IU Center for Aging Research

baseline 6 months 12 months Augmented Usual Care Intervention 18 months Callahan et al. JAMA 2006

Improvement in Caregiver Stress 10 5 0 baseline 6 months 12 months Augmented Usual Care Intervention 18 months Callahan et al. JAMA 2006

IU Center for Aging Research

Implementing Collaborative Care

Shared vision

– –

How will we know success?

Shared, measurable outcomes

•

(e.g., # and % of population screened, treated, improved) Engaged leaders & stakeholders

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Clinic leaders & administration PCPs, care managers, psychiatry, other mental health providers Clinical & operational integration

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Functioning teams, communication, and handoffs

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Clear about ‘shared workflow’ & roles of various team members Adequate resources

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Personnel, IT support, funding Proactive problem solving re barriers & competing demands

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Minimize complexity, PDCA

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http://impact-uw.org

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