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Integration of Mental Health and Primary Health Care for the Older Patient Stephen J. Bartels, M.D., M.S. Professor of Psychiatry and Community and Family Medicine Co-Director Dartmouth Center on Aging Overview • Background: Mental Health, Primary Care, and the Older Patient • Outcomes: Integration of Mental Health Services in Primary Care and the Older Patient • Policy Implications for The President’s Commission on Mental Health Estimated Prevalence of Major Psychiatric Disorders by Age Group Jeste, Alexopoulus, Bartels, et al., 1999 Prevalence of Depression and Other Disorders in Primary Care Study Hoeper et al. Schulberg et al. Von Korff et al. Barrett et al. Coyne et al. ECA (highest) Major Depression 5.8% ---5.0% 0.4% 13.5% 3.5% (6mo) All Depression 19.9% 9.2% 8.7% 10.0% 22.0% 6.5% (6mo) All Disorders 26.7% 30.3% 26.5% 26.4% ---8.8% (2wk) Depression Associated with Worse Health Outcomes • Worse outcomes – Hip fractures – Myocardial infarction – Cancer (Mossey 1990; Penninx et al. 2001; Evans 1999) • Increased mortality rates – Myocardial Infarction (Frasure-Smith 1993, 1995) – Long term Care Residents (Katz 1989, Rovner 1991, Parmelee 1992; Ashby1991; Shah 1993, Samuels 1997) Suicide and the Older Patient • Older adults: Highest risk of suicide of any age group • 70% of elderly completing suicide have seen their primary care physician in the prior month, 40% prior week, 20% same day (Conwell et al., 1994) • Screening all primary care patients impractical…. But identification of higher risk patients important Primary Care Elderly with Depression, Anxiety, or At-risk Alcohol Use • 27.5% Report Death Ideation • 10.5% Report Active Suicidal Ideation • Greatest Suicidal Ideation: Depression with Anxiety (18%), Poor Social Support • Suicidal Ideation NOT associated with increased visits to the PCP Bartels et al., Am J. Geriatric Psychiatry 2002, 10:417-427 Quality of Mental Health, Care and the Older Patient • Fragmentation of the Mental Health service delivery system for older persons • Primary Care as the “de facto” mental health system of care for the older person Quality of Mental Health Care for Older Primary Care Patients The older primary care patient with depression compared to younger: • More likely to receive benzodiazepines • Less likely to receive SSRIs • Less likely to receive psychotherapy Bartels et al., International J. Psychiatry in Medicine 27 (3):215-231, 1997. Health Service Use and Costs Associated with Depression for Older Primary Care Patients Cost of Outpatient Services in Depression Unutzer, et al., 1997; JAMA Cost of Prescriptions US Dollars $1,500 $1,000 $500 $0 n: 1,650 381 277 62 Medical Severity: Primary Diagnosis: 1,366 342 170 41 747 149 70 21 Low High Low High Low High Hypertension Arthritis Ulcer/GI Medical Dx Only Medical Dx Plus Depression Number of Medical Visits % Hospitalized % Admitted to Emergency Room Depression as a Costly Chronic Disease Individuals with these 5 conditions account for 49% of total health care costs, 42% of illness-related lost wages Health Care Costs (per capita/total) Work Loss Costs For Individuals with Condition Health care and Total Costs for Individuals with Condition 3 1 2 4 3 3 Heart Disease 1 5 4 Hypertension 2 1 1 Asthma 5 4 5 Mood Disorders Diabetes Summary of Findings • Comorbid Depression in Medical Disorders Commonly Affecting Older Patients • Greater Use and Costs of Medications • Greater Use of Health Services (medical outpatient visits, emergency visits, and hospitalizations) The Research Question: What is the Most Effective Way to Organize and Deliver Mental Health Services to Older Persons in Primary Care Settings? Primary Care Research in Substance Abuse and Mental Health for the Elderly A Comparison of Two Service Models • Integrated/Collaborative Care – Co-Located – Concurrent – Collaborative • Enhanced Referral to Specialty Mental Health and Substance Abuse Clinics – Preferred Providers and Facilitated appointments, transportation, payment Primary Hypotheses • Engagement Hypothesis • Participation Hypothesis • Outcomes Hypothesis • Cost Hypothesis Is the Integrated Model More Likely to Result in Engagement in Mental Health Care by Older Persons? STUDY TARGET CONDITIONS • • • • Major Depression Dysthymic Disorder Minor Depression Depressive Disorder NOS • Generalized Anxiety Disorder (GAD) • Panic Disorder • Anxiety Disorder NOS • At-risk Alcohol Use Sample Characteristics (n=2022) Mean Age: 73.5 + 6.2 26% Female Diagnoses Ethnicity At-Risk Drinking 20% Caucasian 52% Black 25% Anxiety 3% Hispanic 6% Dual Disorders 7% Depression 70% Asian 8% Other 9% Overall Engagement by Model • Integrated: • Referral: 71% 49% • Relative Risk: 1.45 (709/999) (499/1023) RR = % engaged integrated / % engaged referral Rates of Engagement in MHSA Care: By Diagnosis/Condition Rates of Engagement in MHSA Care: By Level of Suicidal Ideation 100% 83.0% 75% 54.1% 70.8% 59.7% 50% 70.9% 41.4% 25% 0% Suicidal ideation (n=192) RR=1.53 Death ideation (n=530) RR=1.19 No ideation (n=1194) RR=1.71 Integrated Referral Physical Proximity between Primary Care Clinic and MH/SA Clinic 100% % Engagement 80% Legend Same Practice Area (30 Clinics) 70.4% 60% 53.5% 46.0% 44.2% 40% Same Building (11 Clinics) 20% Same Medical Campus (14 Clinics) 0% 1-10 Miles (5 Clinics) Integrated Care (n=991) Referral Care (n=1002) *Rates of engagement are significantly different across all four practice arrangements for the total sample (2(3)=103.15, p<.001) and across the three referral practice arrangements (2(2)=7.76, p=.02). Bartels et al., American Journal of Psychiatry, 161:1455-1462, 2004. Outcomes • Integrated Care (compared to specialty referral) Associated with Greater Engagement in Treatment …….Similar Outcomes (slightly better for major depression in specialty referral) • Are Integrated Services with Depression Care Management (including use of specified treatment protocols) Better than Usual Care? – IMPACT (Hartford Foundation) – PROSPECT (NIMH) The IMPACT Treatment Model • Collaborative care model includes: – Care manager: Depression Clinical Specialist • Patient education • Symptom and Side effect tracking • Brief, structured psychotherapy: PST-PC – Consultation / weekly supervision meetings with • Primary care physician • Team psychiatrist • Stepped protocol in primary care using antidepressant medications and / or 6-8 sessions of psychotherapy (PST-PC) Antidepressant Use Any Antide pre s s ant Us e in Pas t 3 or 6 M onths 80 P<.0001 70 P<.0001 60 percent 50 P<.0001 P=.6995 40 30 20 10 0 0 3 6 month Usual Care Unützer et al, JAMA 2002; 288:2836-2845. Intervention 12 Mental Health / Psychotherapy / PST-PC Any Specialty Mental Health / Psychotherapy Visits in Past 3 Months 50 P<.0001 45 40 Usual Care P<.0001 Intervention P<.0001 percent 35 30 25 20 15 10 P=.2375 5 0 0 3 6 month Unutzer et al, JAMA 2002. Unützer 2002; 288:2836-2845. 12 Mean SCL-20 Score Collaborative Management of Late-Life Depression in Primary Care 2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 Mean SCL-20 Depression Score P=.55 P<.001 P<.001 0 3 6 P<.001 Usual Care Intervention 12 Follow-up Month IMPACT Study :Unutzer, et al., 2002 - JAMA Patients in REMISSION (HSCL<0.5) IMPACT Unutzer et al, 2002 1,801 patients ≥60 yrs in 18 Primary care clinics in 8 Health care organizations. 35% “Cadillac model of system change” 30% 25% 20% Usual Care Intervention 15% 10% 5% 0% 3-mos 6-mos 12-mos PROSPECT • USUAL CARE vs. INTERVENTION: • Clinical Algorithm for Geriatric Depression Consisting of Citalopram or IPT (based on patient preference) • Depression Care Manager: Social Workers, Nurses, Psychologists in Primary Care: Depression recognition, guideline based treatment, monitoring of response to treatment, follow-up PROSPECT Improvement in Depression (≥50% Drop on HDRS Depression Score from Baseline) Response (³50% drop on SCL-20 depression score from baseline) 60 50 P<.05 P<.05 P<.001 percent 40 30 20 10 0 3 4 86 month Usual care 12 12 Intervention Bruce, et al., 2004 - JAMA PROSPECT Depression Specialist with Treatment Algorithm • Practices with Depression Specialist Using Treatment Algorithm for Depression had Greater Reduction in Depression Compared to Usual Care Practices • However, Better Outcomes Only For Major Depression, Not for Minor Depression Bruce, et al., 2004 - JAMA Conclusions: Integrated Mental Health Services in Primary Care • Better engagement ….similar outcomes compared to referral care (perhaps slightly less effective for major depression) • Better engagement and outcomes compared to usual care…..especially with care management, standardized screening and outcome tracking, and treatment protocols Summary of st 1 nd 2 & Generation Studies • Multiple component interventions • Lectures &/or distributing guidelines do not change behavior nor outcomes • Adding patient tracking with a care manager significantly improves outcomes • Including a mental health specialist in an integrated treating or consulting role improves outcomes the most Effectiveness Studies of Depression in Primary Care Tx Case ID/ Patient Physician Tracking Tx MH Effective Guidelines Screening Ed. Ed. Systems Schulberg + + + + + + ++++ Yes Mynors-Wallis + + + + + + +++ Yes Katon + + + + + + ++ Yes Katzelnick + + + + + + ++ Yes Rost + + + + + + +/- Yes Hunkeler + + + + + + +/- Yes Simon + + + + + + - Yes Simon + + + + + - - No Callahan + + + + - - - No Goldberg + + + - - - - No Dowrick + + - - - - - No Coord. Spec. From Simon Greater Patient Improvement with System Changes vs. Usual care 30% 25% 20% 15% 10% 5% 0% Simon 2000 Wells 2000 Rost 2001 Katzelnick Hunkeler 2000 2000 Unutzer 2002 Summary of st 1 nd 2 & Generation Studies • Multiple component interventions • Lectures &/or distributing guidelines do not change behavior nor outcomes • Adding patient tracking with a care manager significantly improves outcomes • Including a mental health specialist in an integrated treating or consulting role improves outcomes the most 3rd Generation Depression System Change Interventions IMPACT RESPECT PRISMe PROSPECT Depression Specialist TCM Integrated Mental health Care Mgmt On-site Off-site N/A On-site Patient Education Yes Yes Variable Yes Psychiatric supervision Face to face Telephone N/A Face to face Telephone N/A N/A Face to face Yes No Change Psychotherapy supervision Rx algorithm No Depression Specialist Yes Sustainability of Interventions? Appropriate Antidepressant Rx Lin et al 1997 40% 35% 30% 25% 20% 15% 10% 5% 0% PreIntervention 1-6 mos Collaborative Care 7-12 mos Usual Care PostIntervention Long-term Depression Rx System Need Normalacy Remission Symptoms Only 25% Relapse Have ≥ 3 Visits Response > 50% STOP Rx Syndrome Acute Phase Recovery Relapse 65 to 70% STOP Rx Continuation Phase Time Maintenance Phase Recurrence Non-adherence to Antidepressants 100% amitriptyline trazodone nortriptyline fluoxetine 90% PROPORTION OF PATIENTS REFILLING PRESCRIPTION 80% 70% 60% 50% AHCPR recommended treatment duration 40% 30% 20% 10% Mean persistence on antidepressants = 90 to 102 days 0% 0 mos. 3 mos. 6 mos. 9 mos. 12 mos. MONTHS OF TREATMENT Pharmacy data from 1994 on 100,000 patients 15 mos. NCQA HEDIS* Measure: Long-Term Treatment Adherence Rates Across Plans (2000 Results) 100 Follow-up with MD After Diagnosis of Depression 3 acute Phase visits Percentage 80 59% 60 42% 40 20 0 21% Acute Phase Treatment (84 Days Continuity) Treatment (6 Months Continuity) Mean * National Committee for Quality Assurance (of Managed Care Organizations) annual database of Health Plan Employer Data and Information Set (HEDIS ®) http://www.ncqa.org Usual Care PRIMARY CARE CLINICIAN PATIENT MENTAL HEALTH SPECIALIST MacArthur Initiative Three Component Model (TCM) PRIMARY CARE CLINICIAN PHQ-9 CARE MANAGER MENTAL HEALTH SPECIALIST PHQ-9 PATIENT Care Manager Encourage Adherence Problem Solve Barriers Measure Treatment Response Monitor Remission Two Question Screen U.S. Preventive Services Task Force Ann Intern Med 2002;136:760-4 Over the past 2 weeks, have you: • Felt little interest or pleasure in doing things? • Felt down, depressed, or hopeless? PHQ-9 Spitzer R, et al. Validation and utility of a self-report version of PRIMEMD: the PHQ Primary Care Study. JAMA 1999; 282: 1737-1744 Kroenke K, et al. The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 2001; 16: 606-613 Sensitivity = 73% Specificity = 94% Correlation between PHQ self-report and psychiatrist interview = .84 PHQ - 9 Symptom Checklist More than Nearly Not Several half the every at all days days day 0 1 2 3 1. Over the last two weeks have you been bothered by the following problems? a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless c. Trouble falling or staying asleep, or sleeping too much d. Feeling tired or having little energy e. Poor appetite or overeating f. Feeling bad about yourself, or that you are a failure . . . g. Trouble concentrating on things, such as reading . . . h. Moving or speaking so slowly . . . i. Thoughts that you would be better off dead . . . 2. ... how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Subtotals: TOTAL: 4 16 6 6 Typical Frequency of Patient Contacts PCC Care Manager CM Phone Call Primary Care Clinician Visit Acute Phase PCC CM 1 PCC PCC CM 5 6 Continuation Phase CM 9 PCC CM 12 18 WEEK PCC CM 24 32 36 Conceptual Treatment Algorithm ASSESS FOR REMISSION CONTINUE SAME TREATMENT REMISSION CONTINUE SAME TREATMENT is k CLINICALLY SIGNIFICANT RESPONSE MONITOR CONTINUATION & EVALUATE FOR MAINTENANCE STOP TREATMENT -r MEASURE ACUTE TREATMENT RESPONSE REMISSION QUESTIONABLE RESPONSE INCREASE SAME TREATMENT NO RESPONSE SWITCH OR ADD TREATMENT IMPROVEMENT BUT NOT REMISSION NO IMPROVEMENT + CONT./INCREASE SAME TREATMENT SWITCH OR ADD TREATMENT RELAPSE ris k CONTINUE SAME TREATMENT Conceptual Treatment Algorithm- I MEASURE ACUT E T REAT MENT RESPONSE CLINICALLY SIGNIFICANT RESPONSE CONTINUE SAME TREATMENT QUESTIONABLE RESPONSE INCREASE SAME TREATMENT NO RESPONSE SWITCH OR ADD TREATMENT Conceptual Treatment Algorithm- II ASSESS FOR REMISSION REMISSION CONTINUE SAME TREATMENT IMPROVEMENT BUT NOT REMISSION CONT./ INCREASE SAME TREATMENT NO IMPROVEMENT SWITCH OR ADD TREATMENT Conceptual Treatment Algorithm- III STOP TREATMENT -r is k MONITOR CONTINUATION & EVALUATE FOR MAINTENANCE REMISSION + RELAPSE ris k CONTINUE SAME TREATMENT TCM Phase Two Remission (HSCL <0.5) Outcomes 60% UC TCM Percent Remission 50% (p=.05) n=323 pts 55 practices 40% (p=.04) n=335 pts 56 practices 30% 20% 10% 0% 3 Months 6 Months Differences Between System Changes & Usual Care 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Simon 2000 Wells 2000 Rost 2001 Katzelnick 2000 Hunkeler 2000 Unutzer 2002 Respect 2003 3rd Generation Depression System Change Interventions IMPACT RESPECT PRISMe PROSPECT Depression Specialist TCM Integrated Mental health Care Mgmt On-site Off-site N/A On-site Patient Education Yes Yes Variable Yes Psychiatric supervision Face to face Telephone N/A Face to face Telephone N/A N/A Face to face Yes No Change Psychotherapy supervision Rx algorithm No Depression Specialist Yes Implications for Applied Policy and Practice Leon Eisenberg SOUNDING BOARD TREATING DEPRESSION AND ANXIETY IN PRIMARY CARE. Closing the gap between knowledge and practice N Engl J Med 1992; 326:1080-1084, Apr 16, 1992 7th Annual Rosalyn Carter Symposium on Mental Health Policy, Atlanta, Nov 21, 1991 •Depression is common in primary care, with substantial morbidity •Under recognized - not because of curriculum, but values of patients and physicians, inappropriate DSM nosology •Target physicians in practice, involve patient, more follow-up consider special nurses, improve payment - reward time, assess quality • Subcommittee on Mental Health and Aging: Recommendations on Policy • Subcommittee on the Mental Health Interface with General Medicine • Integrating Mental Health and General Health Care • Implementing Evidence-based Medicine • “The Federal Government should add evidence-based collaborative care services for psychiatric disorders to the list of covered services through the Medicare National Coverage Process” Evidence-Based Chronic Disease Management Approaches for Treating Depression Are Effective Ed Wagner & Institute for Healthcare Innovation (IHI) Community Resources and Policies Health System Health Care Organization SelfManagement Support Informed, Activated Patient Delivery System Design Productive Interactions Decision Support Clinical Information Systems Prepared, Proactive Practice Team Functional and Clinical Outcomes