Successful Models for Treatment of Depression David Katzelnick January 17th, 2006

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Successful Models for Treatment of Depression
David KatzelnickJanuary 17th, 2006
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• If there be a hell upon earth, it is to be found
  in a melancholy mans heart.
• Robert Burton, 1621

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Hows everything?
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NCQA HEDIS MeasuresCommercial Plans
Acute Phase Antidepressant
Continuation Phase Antidepressant
Clinician Follow-up
Percent
Measurement Year
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One person in the U.S. dies by suicide every 17
minutesNational Center for Suicide Statistics
1997
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Quality of Care for Depressive and Anxiety
Disorder in US

• National telephone survey
• 1636 adults with depression or anxiety
  disorder - 83 saw health care provider - 30
  received some treatment - 19 received
  guideline recommended treatment

Young A Arch Gen Psychiatry 2001
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Who Treats People with Major Depression in U.S.?
Source MacArthur Foundation Midlife in the U.S.
Survey
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Competing Demands
PCP
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How can depression care be improved?

• Lessons from Randomized Clinical Trials

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Effectiveness Studies
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Core Elements of Effective Treatment

• Screening
• Patient Self-Management
• Clinician education
• Simple treatment algorithm
• Treatment coordinator
• Mental Health Clinician availability

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Simon GE
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Gilbody Systematic Review

• Successful Depression Interventions
• Complex including
• Clinician education
• Nurse care management
• Integration of primary and secondary care
• Simple guideline implementation and education
  strategies generally ineffective

Gilbody JAMA 2003
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Meta-Analysis of Disease Managemenent Programs
(DMP) for Depression

• DMP significantly enhanced the quality of care
  for depression
• DMP had relative risk of 0.75 on depression
  severity
• Cost per QALY 9,051 to 49,500
• Need longer studies and more studies outside
  managed-care systems

Neumeyer-Gromen, Medical Care December 2004
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Screening for Depression in Primary Care

• US Preventive Services Task Force recommends
  screening for depression in practices able to
  then actively manage patients who screen positive
• 2-question depression screen
• Over the past 2 weeks, have you felt down or
  hopeless?
• Over the past 2 weeks, have you felt little
  interest in doing things?
• A yes to either question is a positive screen
  for depression

Pignone MP, et al. Ann Intern Med.
2002136765-776.
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Collaborative Care Studies

• Randomized trial of primary care patients with
  major depression
• Collaborative Care by Primary care and mental
  health specialty clinicians
• Group Health Cooperative Pugent Sound

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Collaborative Care

• Major Depression Patients
• ? adherence adequacy of antidepressants (90
  days)

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Collaborative Care
Improved Depression Outcomes (SCL) 50 Reduction
of symptoms at 4 months
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www.improving chroniccare.org
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Dissemination Projects
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RESPECT TrialRe-engineering systems for the
treatment of depression in primary Care

• Research Goals
• To test the effectiveness, sustainability and
  dissemination potential of an evidence-based
  clinical model and dissemination approach
  designed to improve the quality of depression
  care.
• Test effectiveness of indirect implementation
  through an intermediary organization

Dietrich A BMJ 2004
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RESPECT-D Response Rate(50 Drop in HSCL)
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MacArthur Website Relevant articles, tools and
manuals are available at www.depression-primaryc
are.org
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Institute for Healthcare Improvement Breakthrough
Series

• Funded by National program for Improving Chronic
  Illness Care ( Robert Wood Johnson Foundation)
• 23 ethnically and geographically diverse health
  care organizations
• 15 Bureau of Primary Care sites
• 13 month program
• 2000 patients initiated treatment

Katzelnick Joint Commission J Quality and
Patient Safety July 2005
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Depression is also recurrent and frequently
chronic illness

• Can we transfer improvements made in the care of
  Diabetes and Congestive Heart Failure to the care
  of Depression?

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PHQ-9 Symptom Checklist
PHQ-9 Patient Health Questionnaire-9.
TOTAL 16
Kroenke K, et al. J Gen Intern Med.
200116606-613.
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Depression Faculty Initial Recommendations

• Depression registry
• Structured depression diagnosis
• Patient Health Questionnaire (PHQ)
• Care manager
• Proactive systematic follow up of depression
• Depression Severity (PHQ)
• Medication/ psychotherapy adherence

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Depression Faculty Initial Recommendations II

• Collaborative care plan using Mac Arthur tool
  kit www.depression-primarycare.org
• Utilize outcome data to refer complex and
  non-responding patients to Mental health
  specialists

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IHI Depression Breakthrough Series Outcomes
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Breakthrough Series Conclusions

• Research has shown that systematic programs can
  dramatically improve outcomes for people with
  depression
• Many breakthrough teams were able to achieve
  outcomes similar to successful depression
  randomized trials.

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Can clinicians agree on a common self-rated
depression severity metric that can do for
depression what HgbA1c has done for Diabetes ?
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AAFP/APA/ACP Initiative to Improve Depression Care
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Phase I Selecting Instruments for Diagnosis and
Assessment of Depression Severity

• Expert Meeting October 8th 2002 on
• Reviewed all currently available depression
  severity instruments
• Concluded that PHQ-9 best met criteria
• QIDS as alternative instrument

Phase I supported by an unrestrited research
grant from Wyeth Pharmaceticals
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Phase II and III Implementation of Systematic
Depression Severity Assessment in Primary and
Psychiatric Care

• Plan two parallel Breakthrough Series Model
  Improvement Collaboratives
• Introduce PHQ-9 and other tools for monitoring
  depression severity
• Evaluate feasibility in routine practices using
  quantitative and qualitative methods

Phase II supported by an unrestrited research
grant from Forest Pharmaceticals
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Project Overview

• 12 month Quality improvement project
• Conducted in professional organizations practice
  research networks
• 20 primary care (10 internal med and 10 family
  practice) and 20 psychiatric practices

Supported by Astra Zeneca , Forest, Lilly,
Pfizer, Sanofi and Wyeth,
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Summary

• Treatment of Depression currently is suboptimal
  in both primary care and psychiatric settings
• Depression outcomes can be substantially improved
  
• Implementation of Chronic Care Model
• Standardized depression monitoring (PHQ-9)
• Integration of primary and secondary care
• Alignment of reimbursement with evidence based
  care

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