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IMPACT Team Care For Depression VA Puget Sound V-tel conference February 23, 2009 Disclosure Grant funding (current & recent) • • • • • NIH (NIMH) American Federation for Aging Research (AFAR) John A. Hartford Foundation George Foundation Red Cross (RAND) • California HealthCare Foundation • Robert Wood Johnson Foundation • Hogg Foundation Contracts • Community Health Plan of Washington • King County Department of Public Health Consultant • AARP Services Incorporated (ASI) • National Council of Community Behavioral Health Care (NCCBH) Advisor • Carter Center Mental Health Program • Institute for Clinical Systems Research (ICSI) Depression More than having a bad day or a bad week Pervasive depressed mood / sadness Loss of interest / pleasure Lack of energy, fatigue, poor sleep and appetite, physical slowing or agitation, poor concentration, physical symptoms (aches and pains), irritability, thoughts of guilt, and thoughts of suicide A miserable state that can last for months or even years 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 Depression is often not the only health problem Cancer Chronic Pain 10-20% 40-60% Depression Geriatric Syndromes 20-40% Heart Disease 20-40% Neurologic Disorders 10-20% Diabetes 10-20% Depression is deadly Older men have the highest rate of suicide. Guidelines for Depression Treatment in Primary Care VA Institute for Clinical Systems Improvement (ICSI) • http://www.icsi.org/guidelines_and_more/gl_os_prot/behavioral_he alth/depression_5/depression__major__in_adults_in_primary_care _4.html American College of Physicians (ACP) Clinical Practice Guidelines • Ann Int Med 2008; 149:725-733 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. Antidepressant Medications There are over 20 FDA approved antidepressants. - All are effective in 40 - 50 % of patients if taken correctly - It often takes several trials until Rx is effective - Patients need support during this time If medications are not effective after 8-10 weeks at a therapeutic dose - make sure patient is taking medication as prescribed - verify diagnosis - consult: a change in treatment plan is likely indicated Quality of Depression Care Fewer than 1 in 10 depressed older adults seek specialty mental health care • and if they did we wouldn’t have the mental health specialists needed to treat them Most present for help in primary care Quality of care for depression is worse than for most other chronic medical problems Depression Treatment in Primary Care 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 • 30 % drop out of treatment within 4 weeks • Only 25 % receive adequate follow-up care • Only 20 – 40 % improve substantially over 12 months Limited access to evidence-based psychosocial treatments (psychotherapy) Evidence for Collaborative Care for Depression Metaanalysis by Gilbody S. et al, Archives of Internal Medicine; 2006 - 37 trials of collaborative care for depression in primary care (US and Europe) - cc consistently more effective than usual care - successful programs include - active care management & follow-up - support of medication management in primary care - psychiatric consultation IMPACT Trial John A. Hartford Foundation Planning grant (1996) IMPACT Study(1999-2003) Additional funding from California Healthcare Foundation Robert Wood Johnson Foundation Hogg Foundation IMPACT Study Methods Design: 1,801 depressed adults (60 and older) with major depression and / or chronic depression, randomly assigned to IMPACT or to Care as Usual Usual Care: Primary care or referral to specialty mental health IMPACT Care: Collaborative / stepped care disease management program for depression in primary care offered for up to 12 months Analyses: Independent assessments of health outcomes and costs for 24 months. Intent to treat analyses Unützer et al, Med Care 2001; 39(8):785-99 IMPACT Team Care Model Photo credit: J. Lott, Seattle Times Photo: Courtesy D. Battershall & John A. Hartford Foundation Effective Collaboration Prepared, Pro-active Practice Team Informed, Activated Patient Practice Support Collaborative Care Patient Chooses treatment in consultation with provider(s): • antidepressants and / or brief psychotherapy Primary care provider (PCP) Refers; prescribes antidepressant medications + Depression Care Manager + Consulting Psychiatrist Unützer et al, Med Care 2001; 39(8):785-99 Treatment Protocol (1) Assessment and education, (2) Behavioral Activation / Pleasant Events Scheduling (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 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 What if patients don’t improve? Is the patient adhering to treatment? Is the dose high enough? - see max dose guidelines Is the diagnosis correct? ? Bipolar depression ? Medical conditions (hypothyroidism, sleep apnea, pain) ? Meds: steroids, interferon, hormones ? Withdrawal: stimulants, anxiolytics Are there untreated comorbid conditions / life stressors? Is the patient at maximum therapeutic dose?* Fluoxetine 60 mg Paroxetine 60 mg Escitalopram 30 mg Citalopram 60 mg Sertraline 200 mg Venlafaxine 300 mg Duloxetine 60 mg Buproprion SR 450 mg Mirtazapine 60 mg Nortriptyline 125 mg (check serum level) Desipramine 200 mg (check serum level) Consider titrating to these doses unless patients do not tolerate these ‘maximum doses’ due to side effects. IMPACT doubles the Effectiveness of Depression Care 50% or greater improvement in depression at 12 months Usual Care IMPACT 70 60 50 % 40 30 20 10 0 1 2 3 4 5 6 7 8 Participating Organizations Unutzer et al, JAMA 2002; Psych Clin N America 2004. IMPACT Improves Physical Functioning SF-12 Physical Function Component Summary Score (PCS-12) P<0.01 P<0.01 P<0.01 P=0.35 Callahan C et al, JAGS 2004 Callahan et al. JAGS. 2005; 53:367-373. IMPACT Saves Money Intervention group cost in $ Usual care group cost in $ Difference in $ 522 0 522 661 558 767 -210 7,284 6,942 7,636 -694 Other outpatient costs 14,306 14,160 14,456 -296 Inpatient medical costs 8,452 7,179 9,757 -2578 Inpatient mental health / substance abuse costs 114 61 169 -108 31,082 29,422 32,785 -$3363 Cost Category 4-year costs in $ IMPACT program cost Outpatient mental health costs Pharmacy costs Total health care cost Savings Unutzer et al. Am J Managed Care 2008. IMPACT Summary Less depression Photo credit: J. Lott, Seattle Times (IMPACT doubles effectiveness of usual care) Less physical pain Better physical functioning Higher quality of life Greater patient & provider satisfaction Lower health care costs Over 40 peer-reviewed publications “I got my life back” Pain Impairs Response to Depression Care 60% 50% 40% 30% 20% Treatment Group 10% Usual Care 0% Intervention Not at all Moderately Slightly Extremely Quit e a bit Baseline Pain Interference Category Source: Thielke, et al. Am J Geriatric Psych. 2007. IMPACT-DP Care management for depression and pain Less impairment in general activity, walking ability, work, relationships with others, sleep, and enjoyment in life Unutzer et al, Int J Geriatr Psychiatry 2008. IMPACT Endorsements • President’s New Freedom Commission on Mental Health • National Business Group on Health • Institute of Medicine (Retooling for An Aging America) • POGOe • CDC Consensus Panel • Annapolis Coalition • Partnership to Fight Chronic Disease • SAMHSA NREPP Taking IMPACT from Research to Practice Support from JAHF (2004-2009) Over 3,000 clinicians trained Almost 200 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 • Western WA: Virginia Mason, Community Health Plan of WA, King County Dept. of Public Health • Iowa City VAMC http://impact-uw.org Lessons Learned - II • Teams don’t just happen • Many of us are not trained to work effectively on interdisciplinary teams. • Work at interfaces is challenging. • Simplicity & effective communication • Joint accountability for measurable outcomes can help. • (e.g., # and % of population screened, treated, improved) Conclusion IMPACT can be adapted and effective in a wide range of health care settings and populations Effective teamwork is key to the success of the program • Different professionals (nurses, social workers, psychologists, licensed counselors, and medical assistants) can be trained to support primary care providers with evidence-based care management • Care management is a function, not a person • Psychiatric consultation provides important back-up to primary care based care management programs. Thank You