Prevention-Research Centers Health Aging Research Network (PRC-HAN)Webinar Series

Evidence-Based Depression Care Management:

Improving Mood-Promoting Access to Collaborative

Treatment (IMPACT)

Tuesday, October 16th 2008

2-3:30 PM EST

Moderated by: Cate Clegg

Jürgen Unützer, MD, MPH, MA Virna Little, PsyD, LCSW-R

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Sponsors:

Prevention Research Centers-Healthy Aging Research Network

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

Retirement Research Foundationhttp://www.rrf.org/

National Council on Aginghttp://ncoa.org/index.cfm

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IMPACT Primary Care Based

Team Care for

Late-Life Depression

Jürgen Unützer, MD, MPH, MAProfessor & Vice Chair

Psychiatry & Behavioral SciencesUniversity of Washington

Virna Little, PsyD, LCSW-RVice President for Psychosocial Services and

Community AffairsInstitute for Family Health

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Common 10% in primary care

Disabling #2 cause of disability (WHO)

Deadly Over 30,000 suicides / year

Expensive 50-100% higher health care costs

Depression

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Depression is deadlyOlder men have the highest rate of suicide.

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Depression is often notthe only health problem

DepressionNeurologicDisorders

Geriatric Syndromes

Diabetes

20-40%

10-20%

10-20%

Heart Disease

20-40%

Chronic Pain

40-60%

10-20%

Cancer

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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 / exerciseUnutzer 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 mentalhealth 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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Why integrate care?

Primary Care

Community Mental Health

Center

PC

CM

HC

Home & Community based social

services?

Alcohol & substance

abuse care?

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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

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Components of evidencebased 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 FoundationHogg 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 sitesUniversity of Washington / Group Health CooperativeWayne Katon (PI), Elizabeth Lin (Co-PI), Paul Ciechanowski Duke University Linda Harpole (PI), Eugene Oddone (Co-PI), David SteffensKaiser Permanente, Southern CA (La Mesa, CA)Richard Della Penna (Co-PI), Lydia Grypma (Co-PI), Mark Zweifach, MD, Rita Haverkamp, RN, MSN, CNSIndiana UniversityChristopher Callahan (PI), Kurt. Kroenke, Hugh. Hendrie (Co-PI)UT Health Sciences Center at San AntonioJohn Williams (PI), Polly Hitchcock-Noel (Co-PI), Jason WorchelKaiser Permanente, Northern CAEnid Hunkeler (PI), Patricia Arean (Co-PI)Desert Medical GroupMarc Hoffing (PI); Stuart Levine (Co-PI)

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

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Study Methods

1998 – 2003

Randomized controlled trial

8 health care organizations in 5 states– 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

Practice Support

Prepared, Pro-active Practice Team

Photo: Courtesy D. Battershall & John A. Hartford Foundation

Effective Collaboration

Informed, Activated Patient

Photo credit: J. Lott, Seattle Times

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Evidence-based ‘team care’ for depression

TWO PROCESSESTWO NEW ‘TEAM MEMBERS’Care Manager Consulting

Psychiatrist

1. Systematic diagnosis and outcomes tracking

e.g., PHQ-9 to facilitate diagnosis and track depression outcomes

- Patient education / self management support

- Close follow-up to make sure pts don’t ‘fall through the cracks’

- Caseload consultation for care manager and PCP (population-based)

- Diagnostic consultation on difficult cases

2. Stepped Care

a) Change treatment according to evidence-based algorithm if patient is not improving

b) Relapse prevention once patient is improved

- Support anti-depressant Rx by PCP

- Brief counseling (behavioral activation, PST-PC, CBT, IPT)

- Facilitate treatment change / referral to mental health

- Relapse prevention

- Consultation focused on patients not improving as expected

- Recommendations for additional treatment / referral according to evidence-based guidelines

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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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Greater Satisfaction with Depression Care

0

20

40

60

80

100

0 3 12

month

perc

ent

Usual Care Intervention

P<.0001 P<.0001P=.2375

Unützer et al. JAMA. 2002; 288: 2836-2845.

(% Excellent, Very Good)

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IMPACT Doubles Effectiveness of Depression Care

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8

Usual Care IMPACT

%

Participating Organizations

50 % or greater improvement in depression at 12 months

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43%

54%

42%

19%23%

14%

0%

10%

20%

30%

40%

50%

60%

White Black Latino

IMPACT Care

Care as Usual

Evidence-based Care BenefitsDisadvantaged Populations

Areán et al. Medical Care, 2005

50 % or greater improvement in depression at 12 months

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Improved Physical Functioning

38

38.5

39

39.5

40

40.5

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Baseline 3 mos 6 mos 12 mos

Usual Care

IMPACT

SF-12 Physical Function Component Summary Score (PCS-12)

P<0.01P<0.01 P<0.01

P=0.35

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

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Fewer thoughts of suicide

0

2

4

6

8

10

12

14

16

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Baseline 6 months 12 months

IMPACTUsual Care

% p

ati

ents

wit

h s

uic

idal

th

ou

gh

ts

Unützer et al, JAGS 2006

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IMPACT Saves Money

Cost Category

4-year costs in

$

Intervention group cost

in $

Usual care group cost in

$Difference in

$

IMPACT program cost 522 0 522

Outpatient mental health costs 661 558 767 -210

Pharmacy costs 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

Total health care cost 31,082 29,422 32,785 -$3363

Unutzer et al. Am J Managed Care 2008.

Savings

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IMPACT Summary

“I got my life back”

Photo credit: J. Lott, Seattle Times

- Less depressionIMPACT doubles effectiveness of usual care

- Less physical pain

- Better functioning

- Higher quality of life

- Greater patient and provider satisfaction

- More cost-effective

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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–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

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IMPACT Implementation

Trained over 3000 Providers in over 150 practices to date

2004 2005 2006 2007 2008

Over 3,000 clinicians trained

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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

10.28.77.9

5.12.8

Total contacts Clinic visits Phone calls

IMPACT Study

Post-Study

Grypma et al, General Hospital Psychiatry, 2006.

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IMPACT Remains Effective

66% 68%64% 68%

At 3 months At 6 months

IMPACT Post-Study

>= 50 % drop in PHQ-9 depression scores

Grypma et al, General Hospital Psychiatry, 2006.

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Lower Total Health Care Costs

$7,949

$7,471

$6,800

$7,200

$7,600

$8,000

$8,400

$8,800

Study UsualCare

StudyIMPACT

Post StudyIMPACT

$ / year

Grypma, et al; General Hospital Psychiatry, 2006

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Institute for Urban Family Health

Number Percent

Age at enrollment:Mean

Range

71.6 years60 – 99 years

Gender:Female

Male

16574

69.0%31.0%

Ethnicity:Hispanic

African AmericanCaucasian

Other

90705623

37.7%29.3%23.4%9.6%

Marital Status:Married

Single, Widowed, Divorced/separated

4448

47.8%52.2%

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IMPACT Effective for Depression

Mean PHQ-9 Depression Scores

0

2

4

6

8

10

12

14

16

18

20

Time

Mea

n D

epre

ssio

n S

core

s

Initial 3 Months 6 months

14.03

8.14 7.91

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Change in DepressionInitial to 6 months

6 Month PHQ-9 Depression Scores(Mean Score of 7.91)

0

20

40

60

80

100

120

140

160

PHQ-9 Sore

Nu

mb

er

of

Pa

tie

nts

Initial PHQ-9 Depression Scores

0

20

40

60

80

100

120

140

160

PHQ-9 Score

Nu

mb

er

of

Pa

tie

nts

Under 10:Mild

10-14:Moderate

15-19:Mod.

Severe

20+:Severe

28%

9%

63%

Under 10:Mild

10-14:Moderate

15-19:Mod.

Severe

20+:Severe

65%

24% 5% 6%

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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 (68th Street)

38.4 35

62.5 61.3

0102030405060708090

100

Non Depressed Depressed

Depression Is Associated With a Higher

Number of Cardiac Risk Factors

Diabetic Patients With CVDN=3010

Diabetic Patients Without CVDN=1215

> 3

Car

diac

Ris

k Fa

ctor

s (%

)

Katon et al, J Gen Intern Med, 2004

Depression Increases Mortality Rate in Patients With Diabetes by 2-Fold

Katon et al. Diabetes Care, 2005Katon et al. Diabetes Care, 2005Katon et al. Diabetes Care, 2005Katon et al. Diabetes Care, 2005

Depression and Diabetes: More

Depression Free Days over 2 Years

Inc

rem

en

t

Inc

rem

en

t0

100

200

300

400

500

Day

s

Pathways IMPACT

Intervention

Usual Care

Increment

412

359331

215.5

53

115.5

Two Collaborative Care Trials Demonstrate

Improved Depression Care in Diabetes Lowers Total Health Care Costs Over 2 Years

Usu

al C

are

Inte

rven

tio

n

Sav

ing

s

Usu

al C

are

Inte

rven

tio

n

Sav

ing

s$0

$5,000

$10,000

$15,000

$20,000

$25,000

Pathways IMPACT

$22,258

$21,148 $18,932

$18,035

$1,110$897

Katon et al. Diabetes Care 2006, Simon et al Arch Gen Psychiatry 2007

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Project Dulce + IMPACTPrincipal 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

– DCM bilingual with experience serving Latino pop.

– PST-PC adapted to low-literacy population

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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

.

Gilmer et al. Diabetes Care 2008

Inter-Quartile Range (box)Highest and Lowest (whiskers)Outlier (dots)

Median

Collaborative Care for Alzheimer’s Disease

Christopher M. Callahan, MD

Cornelius and Yvonne Pettinga ProfessorDirector, Indiana University Center for Aging Research

Research Scientist, Regenstrief Institute, Inc.

Collaborative Care for Alzheimer’s Disease

IU Center for Aging Research

Improvement in Dementia-related Problem Behaviors

0

5

10

15

20

baseline 6 months 12 months 18 months

Augmented Usual Care Intervention

Pati

en

t N

PI

Score

Callahan et al. JAMA 2006

IU Center for Aging Research

0

5

10

baseline 6 months 12 months 18 months

Augmented Usual Care Intervention

Improvement in Caregiver StressC

are

giv

er

NP

I S

core

Callahan et al. JAMA 2006

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Shared vision– How will we know success?

– Shared, measurable outcomes

• (e.g., # and % of population screened, treated, improved)

Engaged leaders & stakeholders– Clinic leaders & administration

– PCPs, care managers, psychiatry, other mental health providers

Clinical & operational integration– Functioning teams, communication, and handoffs

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

Adequate resources• Personnel, IT support, funding

Proactive problem solving re barriers & competing demands• Minimize complexity, PDCA

Implementing Collaborative Care

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http://impact-uw.org