PreventionResearch Centers Health Aging Research Network PRCHAN

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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
2-330 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 Foundation
• http//www.rrf.org/
• National Council on Aging
• http//ncoa.org/index.cfm

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• IMPACT
• Primary Care Based
• Team Care for
• Late-Life Depression

Jürgen Unützer, MD, MPH, MA Professor Vice
Chair Psychiatry Behavioral Sciences University
of Washington Virna Little, PsyD, LCSW-R Vice
President for Psychosocial Services and Community
Affairs Institute for Family Health
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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
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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
Cancer
Chronic Pain
10-20
40-60
Neurologic Disorders
Depression
Geriatric Syndromes
10-20
20-40
Heart Disease
Diabetes
10-20
20-40
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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 / exercise
• Unutzer 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 didnt know what hit me
• I am not crazy
• Isnt depression just a part of normal aging?
• Fewer than 10 seek care from a mental
• health 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?
Home Community based social services?
Primary Care
PC
Alcohol substance abuse care?
Community Mental Health Center
CM HC
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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 Foundation Hogg Foundation
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IMPACT TeamNone 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 sites
• University of Washington / Group Health
  Cooperative
• Wayne Katon (PI), Elizabeth Lin (Co-PI), Paul
  Ciechanowski
• Duke University
• Linda Harpole (PI), Eugene Oddone (Co-PI), David
  Steffens
• Kaiser Permanente, Southern CA (La Mesa, CA)
• Richard Della Penna (Co-PI), Lydia Grypma
  (Co-PI), Mark Zweifach, MD,
• Rita Haverkamp, RN, MSN, CNS
• Indiana University
• Christopher Callahan (PI), Kurt. Kroenke, Hugh.
  Hendrie (Co-PI)
• UT Health Sciences Center at San Antonio
• John Williams (PI), Polly Hitchcock-Noel
  (Co-PI), Jason Worchel
• Kaiser Permanente, Northern CA
• Enid Hunkeler (PI), Patricia Arean (Co-PI)

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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
Prepared, Pro-active Practice Team
Effective Collaboration
Photo Courtesy D. Battershall John A. Hartford
Foundation
Practice Support
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Evidence-based team care for depression
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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
( Excellent, Very Good)
PPP.2375
Unützer et al. JAMA. 2002 288 2836-2845.
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IMPACT Doubles Effectiveness of Depression Care
50 or greater improvement in depression at 12
months

Participating Organizations
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Evidence-based Care Benefits Disadvantaged
Populations
50 or greater improvement in depression at 12
months
Areán et al. Medical Care, 2005
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Improved Physical Functioning
SF-12 Physical Function Component Summary Score
(PCS-12)
PPPP0.35
Callahan et al. JAGS. 2005 53367-373.
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Fewer thoughts of suicide
patients with suicidal thoughts
Unützer et al, JAGS 2006
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IMPACT Saves Money
Savings
Unutzer et al. Am J Managed Care 2008.
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IMPACT Summary

• Less depression
• IMPACT doubles effectiveness of usual care
• Less physical pain
• Better functioning
• Higher quality of life
• Greater patient and
• provider satisfaction
• More cost-effective

Photo credit J. Lott, Seattle Times
I got my life back
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IMPACT Endorsements

• Presidents 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
Over 3,000 clinicians trained
2004 2005 2006 2007 2008
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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 DiegoAfter IMPACT

• Fewer care manager contacts

Grypma et al, General Hospital Psychiatry, 2006.
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IMPACT Remains Effective
50 drop in PHQ-9 depression scores
Grypma et al, General Hospital Psychiatry, 2006.
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Lower Total Health Care Costs
/ year
Grypma, et al General Hospital Psychiatry, 2006
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Institute for Urban Family Health
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IMPACT Effective for Depression
14.03
8.14
7.91
3 Months
6 months
Initial
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Change in DepressionInitial to 6 months
63
65
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9
5
6
Under 10 Mild
10-14 Moderate
15-19 Mod. Severe
20 Severe
Under 10 Mild
10-14 Moderate
15-19 Mod. Severe
20 Severe
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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)

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Depression Is Associated With a Higher Number of
Cardiac Risk Factors
3 Cardiac Risk Factors ()
Diabetic Patients With CVD N3010
Diabetic Patients Without CVD N1215
Katon et al, J Gen Intern Med, 2004
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Depression Increases Mortality Rate in Patients
With Diabetes by 2-Fold
Katon et al. Diabetes Care, 2005
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Depression and Diabetes More Depression Free
Days over 2 Years
412
359
331
215.5
115.5
53
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Two Collaborative Care Trials Demonstrate
Improved Depression Care in Diabetes Lowers
Total Health Care Costs Over 2 Years
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.
Inter-Quartile Range (box) Highest and Lowest
(whiskers) Outlier (dots)
Median
Gilmer et al. Diabetes Care 2008
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Collaborative Care for Alzheimers Disease
Collaborative Care for Alzheimers Disease

• Christopher M. Callahan, MD
• Cornelius and Yvonne Pettinga Professor
• Director, Indiana University Center for Aging
  Research
• Research Scientist, Regenstrief Institute, Inc.

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Improvement in Dementia-related Problem Behaviors
Patient NPI Score
Callahan et al. JAMA 2006
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Improvement in Caregiver Stress
Caregiver NPI Score
Callahan et al. JAMA 2006
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Implementing Collaborative Care

• 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

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http//impact-uw.org