The Role of Behavioral Health Management in Chronic Medical Disorders

Eva Szigethy MD PhDProfessor of Psychiatry, Medicine and Pediatrics

Co-Director, IBD Total Care Medical HomeBehavioral Director, UPMC Chief Medical and Scientific Office

October 11, 2019

Conflict of Interest Disclosure(over the past 24 months)

Commercial or Non-Profit Interest Relationship

PCORI Research Contract

APPI Royalties as book editor

NIH Research grant

Eva Szigethy

Objectives

• Why integrating behavioral health management into medical care is critical.

• How to deliver measurement-based behavioral management in medical settings.

• The importance of treatment to target of behavioral conditions.

……………………………………….AND……………………………………..Total healthcare costs 2-3x higher in patients with comorbid behavioral conditions

Milliman Report, 2018

Changes in Health Care Delivery

Shifting emphasis to consider value-improving care quality while reducing costs

Requires new disease management strategies from acute, episodic reactionary encounters to proactive, planned, long-term care to reduce risk of downstream costly complications.

Click & Regueiro, IBD, 2019

Behavioral Health Management as Quality and Cost Savings Opportunity

Behavioral Management in Medical Settings

Population-based

Measurement-based

Treatment to target

Behavioral therapies

Psychiatric medication management

Care management

Population-based Behavioral Management

• Population Health: “An approach to care that uses information on a group of patients within a primary care practice or group of practices to improve the care and clinical outcomes of patients within that practice”- AHRQ

• Identify all patients with a particular disease in systematic way to provide appropriate treatment and track outcomes.

• Knowing the rates of co-morbid mental health conditions so behavioral resources can be appropriately prioritized.

Major Depression as an example• Mood (irritable or depressed) or

Anhedonia5 of following symptoms:• Fatigue• Change in appetite• Change in sleep• Reduced concentration• Motor retardation or agitation

• Thoughts of death or suicide

• Guilt• Worthlessness

Active Physical Disease

Over a two week period

DSM-V

Major Depression Risk Factors in General Population

• Female 2:1 (higher comorbid anxiety disorders in women and alcohol abuse in men)

• Early (childhood) onset- more severe depression, increased suicide attempts

• Medical comorbidity (especially if functional impairment)• Positive family history (2-3x increased risk)• Childhood trauma, stressful life events (losses)

Lifetime Prevalence of Depression and Total Healthcare Costs in Other Chronic Diseases

CDC, NIMH, Milliman Report, 2017; Katon, 2011

DISEASE RATE OF DEPRESSION

2017 PMPM Total Costs without MH

2017 PMPM Total Costs with MH

PMPM Total Cost Difference

Cardiovascular diseases

17% $1,852 $2,824 $972

Anemia 26% $2,292 $3,534 $1,242Chronic Renal Disease

26% $4,598 $6,169 $1,571

Diabetes 27% $2,061 $3,041 $ 980Asthma 38% $ 817 $1,886 $1,069COPD 42% $1,446 $2,671 $1,225Chronic Pain 50-85% $1,609 $2,156 $ 547No Medical Disease

12-20% $247 $562 $ 315

• Significantly higher rates of depression with chronic disease

• Depression associated with increased physical disease morbidity and mortality

• Significantly greater total health care costs with comorbid depression

• Majority of additional costs experiences on medical side

• = Cost savings opportunity

Milliman Report Summary:

Economic Impact of Integrated

Medical-Behavioral Healthcare

• Key Findings: • “Significant general healthcare cost savings through

effective adoption of integrated care”

• Costs for treating people with chronic medical problems AND mental conditions 2-3 X higher than treating patients with chronic medical problems only

• Additional cost $293 billion in 2012

• “Effective integration of medical and behavioral care could save $26-48 billion annually in general healthcare costs”

https://www.milbank.org/wp-content/uploads/2016/05/Evolving-Models-of-BHI-Exec-Sum.pdf

Measurement-based Behavioral Management

• Patient-reported outcomes to guide therapy.

• Brief, self-report, public domain, multi-purpose (screening and severity over time), easy to score and interpret.

• www.assessmentcenter.net or https://commonfund.nih.gov/promis/index

Patient-Reported Outcomes (PROS): PHQ9 and PROMIS (Depression)

• Range of scores 0-27• 5-9 mild depressive symptoms• 10-14 Moderate depressive severity

consistent with diagnosis• >= 15 Moderate- severe depression

• Affective-cognitive symptoms only• Computerized adaptive testing version• T-score <=60 positive for depression

Safety Evaluation: Psychiatric Risk in General Population

• Suicidal ideation: Frequency, intensity, duration, hopelessness• Recent plans or attempts- timing, location, likelihood of discovery,

expected lethality, access to methods, preparation for dying, rehearsal

• Ambivalence about life• History of suicide attempts• Homicidal ideation- (post-partum women, separated men in turmoil,

history of substance abuse, impulsivity, prior violence, paranoia, Cluster B personality traits. Explore gun ownership

Suicide Risk

RISK FACTORS

• Chronic, refractory disease with functional impairment (neurological, HIV, autoimmune)

• Chronic pain• Family history• Social history• Psychiatric diagnoses• Substance Abuse• Acute precipitants- losses, suicide

epidemics

PROTECTIVE FACTORS

• Internal- problem-solving skills, conflict resolution, adaptive coping

• Cultural and religious beliefs• Optimism• External –offspring, pets,

connectedness with family and community

• Effective clinical care with easy access to mental health and medical services.

Treatment to Target• 3-5 point change on PHQ-9 is clinically significant

• >=50% reduction or score < 10 on PHQ-9 is treatment response

• Score <5 on PHQ-9 is remission

• PROMIS-depression –treatment response =T-score >60 or 30% reduction in raw scores

• Scores taken in context of functional improvement

• Patient preference, formulary options, costs, and treatment tolerance taken into consideration.

Generational Differences in Healthcare DeliveryBaby Boomers (54-62) Generation X (39-52) Millennials (18-38)

Communication Preferences Value quality careMultiple office visits/ year

By digital means- schedule appointments, order refills

60% prefer telehealth and mHealth options

Healthcare Decisions Driver: Personal health needs and as caregiver advisors to family

Shop for healthcare providers Values brand reputation and checks provider online reviews

Seek info from multiple sources including online research and social networks.Influence by online ads

Physician Engagement Rely on physician’s expertise and knowledgeCheck information online

Short-term expectations of their doctor relationshipsFrequently switch providers

Access healthcare through primary care or urgent care.Value personal relationship with providers; loyal

Health Technology Active internet and social media users. 78% search online for health info (treatment, med SEs)

Spends most time online for dx and tx options; wearables and patient portals most

Want personalized experience but want to connect with providers via technology

PHYSICIAN TECH BEHAVIOR Provide online tools, access to patient portal as resource for info.

Proficient in online resources by providing medical records and offering information.

Limit in-person communication and embrace telehealth tools. Know how their brand is perceived online.

http:/health-system-management.advanceweb.com/generational-differences-in-healthcare-technology/

Moving Forward: Common Threads Across Generations

PATIENTS• Trusted doctor-patient relationship

• Involvement in care decision-making

• High quality easy-to-understand health information- preferably provided by their doctor and in digital format.

PROVIDERS• Understanding that consumer

decision-making and expectations regarding communication, engagement, and education can lead to greater patient compliance and better patient outcomes.

• Need to identify and address burnout

Behavioral Management

• Empirically supported brief behavioral therapies for symptoms/disorders• Cognitive behavioral therapy• Mindfulness meditation

• Psychotropic medications for symptoms/disorders

• Care management for psychosocial issues

• Integrated transdisciplinary team care

Behavioral Therapies as First Line

• For depression and anxiety disorders, cognitive behavioral therapy (CBT) has most empirical evidence.

• 70% response rate after 3-6 months of behavioral treatment

• Benefits maintained 1-3 years

• Limited data for combined behavioral and pharma treatment being better than behavioral alone

Bandelow, 2017; Gartlehner, 2017

Behavioral Interventions for Depression, Anxiety, and Pain

• Physical Symptoms (Sensations)

• Behaviors (Actions)

• Emotions (Feelings)

• Cognitions (Thoughts)

Pain catastrophizingUnhelpful beliefs about how to best copeLow self-esteemPunishment

Depressed moodAnger/Frustration

Anxiety/worry

PainPoor sleep

Fatigue/lethargyMuscle tension

Pain behaviors (sighing, groaning)

Reduced activityIsolation/withdrawalAvoidance behaviors

CBT

Regueiro, Greer, Szigethy, Gastro 2016

How digital behavioral health tools can be engaging and useful to patients

• Access to behavioral therapy• Appealing content• Easy to use• Delivered in segmented (brief) sound bytes• Interactive technology• Human element with coach• Feedback about progress to patient and provider

UPMC Digital CBTInteractive CBT and mindfulness

program for depression and anxiety• Relaxation/mindfulness• Cognitive skills• Behavioral skills• Exposures• Distress tolerance

Guided by non-clinical coaches

Tracks outcomes and risk escalations

Snapshots of UPMC Digital Behavioral Program…Next in your plan In-the-moment relief Goals

Users are complete a personalize program, create their own goals, and always have access to in-the-moment relief.

Content is delivered via audio, video, and interactive text

Snapshots of UPMC Digital Behavioral Program…

Coach’s Dashboard

Coaches can view all techniques completed, view upcoming techniques, add new techniques, and chat with users

Integration of Digital CBT into Outpatient Clinic

Patient is screened at visit for DEP and ANX

Team orders digital CBT program directly in EHR

Patient leaves visit with sign-up materials

Team is kept updated of progress in EHR

Team receives a BPA, alerting to BH needs

Patient uses the program and takes ongoing assessments Szigethy DDW, 2017; 2018

Results of Digital Cognitive Behavioral Therapy versus Treatment as Usual for Anxiety and Depression

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Digital CBT TAU Control

Change in anxiety in total sample from baseline to 3 months in digital cognitive

behavioral therapy (dCBT) versus treatment as usual (TAU) controls (n=90)

** p=.001

ns

• Significant engagement in program (>75%)

• Significant clinical reduction in anxiety and depression

• Increased staff efficiency by 68%

Oser M, Szigethy E, Wallace M, et al. Randomized adaptive trial of digital behavioral program for anxiety and depression in IBD patient centered medical home. Digestive Disorder Week Abstract. 2018.

Digital Engagement at UPMC: 2020 and beyond

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Behavioral Health

Wellness

Odyssey

Behavioral Health

BetterYouBeating the Blues Brain Manager

Unified Engagement and Behavior Intervention App

CON

CEPT

2010 2016 2019

Better Index

Psychiatric Medication Management

Antidepressants- SpecificsTCA SSRI SNRI Miscellaneous

Classes/dosing (mg/d)

Amitriptyline (10-100)Imipramine (25-100)Nortriptyline (50-150)Desipramine (50-200)

Fluoxetine (20-80)Citalopram (20-40)Escitalopram (10-20)Sertaline (50-200)Paroxetine (20-50)

Venlafaxine XR (37.5-375)Duloxetine (30-120)Vortioxetine (5-20)

Mirtazapine (15-45)Bupropion SR XL (100-450)

Timing Side effects-daysEfficacy 1-3 weeks

Side effects- daysEfficacy 2-4 weeks

Side effects- daysEfficacy 2-4 weeks

Side effects- daysEfficacy 1-2 weeks

Efficacy -Small controlled trials-Analgesic effect independent of mood effect

-Large randomizedtrials for depression and anxiety-Little efficacy for direct pain reduction

-Large randomized trials for depression and anxiety-Small controlled studies for chronic pain

Small RCTs for depression

Drossman 2009; Dekel 2013; Binion 2014; Mikocka-Walus; Szigethy & Thorkelson, 2016

https://aims.uw.edu/sites/default/files/PsychotropicMedications_0.pdf

Major Depression: Limited or No Treatment Response• Is the patient taking the medication?

• Intermittent adherence is common• Are side effects limiting adherence?• Genetic rapid metabolizer

• Is the dosage high enough? Increase dose to maximum doses if partial response but no remission after 4 weeks:

• Bupropion 450 mg• Citalopram 40 mg• Duloxetine 120 mg• Escitalopram 30 mg• Fluoxetine 60 mg• Mirtazapine 45 mg• Paroxetine 60 mg• Sertraline 200 mg• Venlafaxine 375 mg

• Is the diagnosis correct?• Bipolar depression• Depression due to medical condition

(hypothyroidism, stroke, sleep apnea, Parkinson’s disease)

• Substance-induced mood disorder (steroids, interferon, hormone therapy, opioids, alcohol)

• Are there untreated co-occurring behavioral conditions contributing to symptom burden?

• Anxiety disorders• PTSD• Somatoform disorders• Personality disorder

AIMS, University Washington, 2018

Pharmacotherapy for Major Depression

• 1st line – psychotherapy- CBT• 2nd line- SSRI• 3rd line- another SSRI or bupropion or venlafaxine (SNRI)• 4th line – mirtazapine or nortriptyline or augmentation with lithium or

thyroxine (T3)

Gartlehner, 2017; Fava, 2005

Generalized Anxiety Disorder (GAD)• Excessive worry (apprehensive expectation) in

multiple areas -life events or health for at least 6 months

• At least 3 of following symptoms:• Restless• Fatigue• Concentration• Irritable• Muscle tension• Sleep disturbance

• Comorbid depression in 40% of patients

GAD Treatment

• 1st line- CBT• 2nd line- SSRIs, SNRIs• 3nd line**- benzos, bupropion XL, buspirone, hydroxyzine,

imipramine, quetiapine XR, vortioxetine, mirtazapine, trazadone

• ** Not all the pharmacological options are FDA approved for GAD

Bandelow, 2015

Panic Disorder

• Palpitations, increased HR• Sweating• Trembling/shaking• Shortness of breath• Feelings of choking• Chest pain/discomfort• Nausea/abdominal distress

• Dizzy, light-headed• Chills or heat sensations• Paresthesias• Derealization or

depersonalization• Fear of losing control or “going

crazy”• Fear of dying

Recurrent unexpected panic attacks; abrupt surge of intense fear/discomfort peaking within minutes, including at least 4 of these symptoms:

After attack, at least 1 month of persistent concern or worry or avoidance behavior

Panic Disorder Risk Factors

• Higher rates in Caucasians and American Indians• Female: 2:1• Median age 20-24; after age 45, think organic cause• History of abuse• Smoking• Extreme stressor in months before first panic attack

• Increased risk of suicide and substance abuse

Panic Disorder Treatment

• CBT significantly favored over medication

• Exposures are key component

• 12-14 weekly sessions

• CBT alone or CBT combined with SSRI or venlafaxine- first line

• Combination CBT and benzodiazepines inferior to CBT alone

• If medication works- recommend 12-24 months or longer maintenance and very slow discontinuations

Care Management

• Clinician with dedicated time to follow patients and their treatment response within a practice or group of practices.

• Can be nurse, social worker, medical assistant, pharmacist or other health care professional

• Tasks include maintaining disease registry, providing health education, tracking treatment adherence and clinical response

• Coordination of care and team meetings• Triage to more intensified behavioral management as needed.

“Whole Person Care Management: Models of Integration- Why?• Medical problems do not exist in silos

• Chronic illnesses negatively impact each other

• Insufficient access to behavioral care• Increased efficiency in healthcare delivery• Triple Aim

• Improved health for populations• Lower costs• Better patient experience

Models of IntegrationCollaborative Care• A team-based program combines primary care and mental health in one setting using two types of

services: Behavioral health care management and consultations with a mental health specialist.

• The behavioral health care manager becomes part of the patient’s treatment team and helps the primary care provider evaluate the patient’s mental health and come up with treatment plan.

Patient-Centered Medical Home (PCMH)• Team-based, whole-person approach with emphasis on integrating behavioral health and primary

care.

• Involves coordinating a patient’s overall health care needs at any age. Patients play active roles in their health care.

• Providers coordinate all aspects of preventive, acute, and chronic needs of patients using the best available evidence and appropriate technology.

Reed et al., JAMA 2016; Watson et al., J Prim Care Commun Health, 2013; Harkness, Cochrane Database, 2009; APA, 2019

Evidence for Collaborative Care

• Most evidence for treating depression- moderate effect size with sustained superiority to usual care for up to 2 years

• Improved depression in patients with arthritis, cancer, diabetes, heart disease, and HIV and improved medical outcomes.

• Some evidence for panic disorder and generalized anxiety disorder. Moderate effect size.

Archer et al., Cochrane Review, 2012; Rollman et al, J Gen Intern Med, 2016; Schnurr, JAMA, 2016; Fortney JC et al., JAMA 2015; Engel et al., JAMA, 2016. Watson et al., J Prim Care Commun Health, 2013; Katon et al., NEJM 2010; Rossom et al Gen Hosp Psychiatry 2016

Cost Effectiveness of Collaborative Care

$15,000-$80,000 PER QUALITY-ADJUSTED LIFE

YEAR GAINED VERSUS USUAL CARE.

COST SAVINGS LAG BEHIND MODEL

IMPLEMENTATION BY 3-4 YEARS

IMPACT STUDY SHOWED $6 SAVINGS FOR EVERY $1 SPENT ON COLLABORATIVE CARE FOR

DEPRESSION OVER A 4 YEAR PERIOD

Reed et al. JAMA 2016; Hunkeler et al. BMJ, 2006; Unutzer et al. 2008

Integrated Care: Subspecialty Medical Home• Provide patient-centered multidisciplinary coordinated care in

specialty outpatient settings.• Necessary components:

• Single or a few large players with an interest in specialty population-based chronic care

• A sizeable patient population to maximize potential value with an estimate of 1000 patients covered by single insurer or at least 300 high utilizing patients

• Physician champion of the model• Quality metrics and outcome measures with preset defined goals to identify

successes and areas for improvement• Incorporation of technology to help monitor, activate and engage patients• Upfront resources in exchange for downstream value and savings

Click & Regueiro Inflamm Bowel Dis 2019

Example of Subspecialty Medical Home: Inflammatory Bowel Disease (IBD)

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• IBD ranks as top three expensive medical diseases in most tertiary care medical centers

• 3 million patients with IBD cost between $6-30 billion in direct and in indirect costs annually in US

• Key drivers of cost: specific drugs (biologics, narcotics), ED use and healthcare service utilization associated with relapsing disease, anemia, and mental health conditions

• At UPMC, 4500 patients with IBD with 30% of patients being drivers of 50% of the total costs.

Parks et al., Inflamm Bowel Dis, 2019

Lifelong Prevalence of psychiatric disorders in IBD versus community (C) sample

• Major Depression 27% vs 12%• Panic Disorder 8% vs 5%• Social Anxiety Disorder 6% vs 11%• Generalized Anxiety DO 14% (IBD)• Bipolar I and II 1.7% (IBD)• PTSD 7.7% (IBD)• Any mood disorder 30% (IBD)

Structured psychiatric interview in 351 IBD patients and 779 matched controls in Manitoba IBD Cohort Study (Walker et al. 2008)

Statistically Significant Correlates of Depression in Inflammatory Bowel Disease

• Clinical recurrence of IBD over time stronger for depression than anxiety (n=2007 subjects; 56% CD in Swiss IBD Study) (Mikocka-Walus, CGH, 2016)

• More frequent IBD flares with depression (Mittermaier, 2004)

• Reduced treatment response to infliximab with depression (Persoons, 2005).

• Increased hospitalization rates (van Langerberg, 2010)

IBD Total Care Medical Home: Team-based, GI-point of care, Patient-centered, Coordinated care

Gastroenterologists

Nurses and Nurse

practitioner

Dietitian

Social worker

Psychiatrist

Regueiro, Greer, Szigethy, 2016

Medical home attributes:AccessibilityComprehensive coordinated careCompassionate, culturally sensitive, patient- and family centered.Age 17- 65 with IBD

IBD Total Care MEDICAL HOME

Behavioral Screening

digital care management + digital CBT

Social worker

(behavioral therapy)

Psychiatric consultation(medications)

Tele-medicine Availability

Medical nurses and nurse

practitioners

REMOTE MONITORING OF PATIENT REPORTED SYMPTOMS

Stepped Digital Behavioral Care

IBD Medical Home: Short-term Outcomes

• High patient engagement• High patient satisfaction• Reduced provider team burnout• Improved clinical outcomes• Reduced opioid use• Reduced medical utilization-

hospitalizations and ER visits

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Total ER visits 1 yearprior to Total Care in allenrolled patients

Total ER visits sinceenrollment in Total Careto date in all enrolledpatients

50.5 % decrease in ER visits total cohort*

*Based on clinical team analysis of EHR data.Regueiro et al., 2017, 2018; Goldblum et al, Gastroenterol Suppl 2019

Summary

• Behavioral health integration into medical care critical to improve quality of care and reduce total healthcare costs

• Measurement-based and treatment-to-target behavioral management are essential to optimize outcomes.

• Brief behavioral therapies are first line for many mental health disorders and increasingly accessible and effective when human clinical expertise is combined with health technology.