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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