1. Depression Care: Implementing Integrated Primary Care-Behavioral Health Solutions
Mark Dreskin, MD
Depression Care Program
Southern California Kaiser Permanente

2. Today Scope of the problem
Patients in primary care, patients with medical co-morbidities (heart disease, diabetes, other chronic diseases), and screening/identifying cases
“Treat-to-target” (depression remission) principles in primary care and how to implement (with return on investment, reimbursement)
Testimonials

3. Occupational Functioning
Persons with major depression had a greater risk of disability
Broadhead, WE et al, JAMA, 1990;264:
Productivity losses related to depression exceed the costs of effective treatment.
Wang, PS, et al, Am J Psych 2004; 161:

4. What Costs Are Under The Surface?
HealthCare Premiums - $1,400,000,000 (estimated 2008 forKFH Active Employees)
LTD - $21,895,487 (2007)
STD - $ 3,226,531 (2007)
Presenteeism is defined as an employee being at work but unable to perform at full capacity due to health concerns.
I’m sure you’re familiar with the research: indirect costs are approximately three times as much as direct medical costs. And presenteeism is 10 times more prevalent than absenteeism, not showing up for work at all.
Another indirect cost is our ability to walk the talk – if we’re not able to serve as a model that is needed and expected by our customers, they’ll go elsewhere, further eroding our ability to deliver on our Mission.
Helping employees to be healthy, engaged and committed, is not only the right thing to do, it’s also the cost effective thing to do for our members, our communities and yes, our organization.
Harvard Business Review, October 2004

5. What Costs Are Under The Surface?
HealthCare Premiums - $1,400,000,000 (estimated 2008 forKFH Active Employees)
LTD - $21,895,487 (2007)
STD - $ 3,226,531 (2007)
Presenteeism is defined as an employee being at work but unable to perform at full capacity due to health concerns.
I’m sure you’re familiar with the research: indirect costs are approximately three times as much as direct medical costs. And presenteeism is 10 times more prevalent than absenteeism, not showing up for work at all.
Another indirect cost is our ability to walk the talk – if we’re not able to serve as a model that is needed and expected by our customers, they’ll go elsewhere, further eroding our ability to deliver on our Mission.
Helping employees to be healthy, engaged and committed, is not only the right thing to do, it’s also the cost effective thing to do for our members, our communities and yes, our organization.
Harvard Business Review, October 2004

6. Full Costs – Medical, Pharmacy, Absence and Presenteeism

7. Full Costs – Medical, Pharmacy, Absence and Presenteeism

8. Recurrence risk
With initial episodes, the likelihood of future episodes is < 50%, but if left untreated, initial episodes can become chronic, and the higher the number of total episodes, the less likely depression- free intervals will be present at later stages of life
it is imperative that patients be treated early, and treated all the way to remission, wherever possible

9. Depression leads to medical morbidity in patients with chronic diseases
There is now robust evidence that depressive illness is an independent risk factor in several medical disease states, particularly CVD diseases, and predicts increased morbidity, mortality and healthcare utilization.

10. Depression leads to medical morbidity in patients with chronic diseases
Doubles the number of primary care visits/year compared to those who are not depressed
Doubles the number of hospital days over the expected length of stay compared to non- depressed patients
65% of depressed patients receive more than 5 medications
In diabetes, depression is associated with a 2% increase in glycosylated hemoglobin levels
(Lustman PJ et al. Gen Hosp Psychiatry.1997; 19: )

11. Possible Markers for Depression in the Medically Ill
Physical symptoms disproportionate to findings, e.g. multiple pain complaints
Excess functional disability
High utilization of medical care
Poor self-care
Decreased compliance with medical and/or lifestyle changing regimens
Reduced social content
Katon W, Sullivan MD. J Clin Psychiatry. 1990;51(suppl 6):311.

12. Depression leads to medical morbidity in patients with chronic diseases
BEHAVIORAL FACTORS
Cigarette Smoking
Alcohol Consumption
Poor Diet (excess calories; low nutrient density)
Sedentary Lifestyle
Poor Treatment Adherence
HEALTH PERCEPTION
one of the highest associations with morbidity and mortality in patients with heart disease and other chronic illnesses (more then smoking or left ventricular ejection fraction in Sperta study)
strongly correlated with quality of life
improves with depression treatment

13. Screening and detection
Depression presents but goes untreated in general primary care settings
Only 25% of depressed patients were recognized as such by their primary care physician
60-70% of patients with depression present and receive their treatment in primary care and not specialty care
Though problems of stigmatization and lack of identification are lessening, 40% of these patients still do not receive guideline-based care to effective remission

14. Treatment Setting: Primary Care vs. Specialty Psychiatry
Patient preference
Trust in primary care physician
Integrated care
Less stigma
Lower cost
Convenience
Referral may delay initiation of care

15. Treatment Options in Primary Care
Watchful Waiting
May be briefly appropriate in minor depression
Behavioral Activation
Encourage exercise and increased activity in mild cases
Pharmacotherapy (Antidepressant Medications)
Psychotherapy (Problem-Solving or Cognitive Behavioral)
Available within primary care in many integrated care programs
Referral to Specialty Care
Complicated, severe, non-responding, or suicide risk

16. and
medicines plus psychotherapy provide 1.5 times greater chance of full remission, and greatest probability of sustained remission after one year

17. Other Treatment Options in Primary Care setting
Computer-Assisted Therapy
Psychoeducation
– Depression Classes from Health Education :
Depression Overview – single class
Overcoming Depression – series of 6 classes
Herbal : St. John’s Wort
Proven efficacy in mild depression but preparations may be inconsistent. (though can not be combined with most antidepressant meds)
Bibliotherapy
– eg “Feeling Good” by David Burns

18. Integrated care Psychotherapy
While we list the seven elements individually, there is evidence that it is the integration of these structural elements with each other and with evidence-based clinical practice guidelines that leads to superior patient outcomes. The seven core elements of care are:
Treatment Coordination
Follow-up/Tracking Systems with Feedback to Practitioners
Outcomes Measurement
Patient Education and Self-Management Programs
Clinician Education
Mental Health/Behavioral Medicine Specialist Involvement
Detection and Diagnosis Strategies
Psychotherapy

19. Integrated care
The best outcomes are at sites where an integrated model of care is employed,
following evidence-based guidelines for accurately detecting, diagnosing and treating depression
treatment coordination
consistent and frequent follow-up
opportunity for “stepped care”
outcomes monitoring
patient education
care conferences with liaison psychiatrists

20. Allow for
care managers following their case loads and surveillance for due dates of actively managed patients
supervisors analyzing the work being done
reporting-out to senior leadership, i.e. for snap shot view of program
for ensuring all patients appropriate follow-up, i.e. per trends in scores, number of treatment trials, high risk factors that require that patient be followed in psychiatry

21. Studies that have demonstrated enhanced value
Unutzer, IMPACT, 2002
Dietrich, RESPECT trial
PROSPECT trial
Katon, “Partners in Care”
also with dropping BMI in obese patients
also TEAM care (diabetics)

22. *improve remission rates
Studies that have demonstrated enhanced value
Unutzer, IMPACT, 2002
Dietrich, RESPECT trial
PROSPECT trial
Katon, “Partners in Care”
also with dropping BMI in obese patients
also TEAM care (diabetics)
*improve remission rates
* improve compliance
*better patient and physician satisfaction
*reduced ED and clinic utilization

23. *improve remission rates
Studies that have demonstrated enhanced value
Unutzer, IMPACT, 2002
Dietrich, RESPECT trial
PROSPECT trial
Katon, “Partners in Care”
also with dropping BMI in obese patients
also TEAM care (diabetics)
*improve remission rates
* improve compliance
*better patient and physician satisfaction
*reduced ED and clinic utilization
morbidity and mortality

24. Give me all your information… NOW!
EHR based reports
Give me all your information… NOW!

25. I’m going to go lasso me that information anytime I need it.
REGISTRY
I’m going to go lasso me that information anytime I need it.

26. EHR based reports Reports only indicated 3 month window 3 months
Data entry
Prompts
3 months
Quarterly EHR report
3 months

27. REGISTRY
Snap shot views are “real-time”
Data entry
Prompts
Query

28. TIDES Study, 2008
90% Hispanic/Latino and Caucasian patients from underserved communities in California
Average age 41 years old
9 demonstration sites, with different levels of proximity, integration

29. TIDES Study, 2008 The Duke Health Profile PHQ-9
17 item generic self-report standard instrument
Health Measures
Physical health General health
Mental health Perceived health
Social health Self-esteem
Dysfunction measures
Anxiety Depression
Pain Disability
PHQ-9
5-14, consider active treatment
> 15, initiate active treatment

30. Mean Health Scores

31. Mean Dysfunction Scores

32. Changes in PHQ-9 mean scores

33. Discrepancies exist between instructions that physicians report they communicate to patients and what patients remember being told.
Explicit instructions about expected duration of therapy and discussions about medication adverse effects throughout treatment may reduce discontinuation of SSRI use.
Patients with 3 or more follow-up contacts were more likely to continue using the initially prescribed antidepressant medication, suggesting that frequent contact may increase the probability that patients will continue therapy.
Bull et al, JAMA. 2002;288(11):

34. Likelihood to follow-up on mental health services referral (on 0-5 scale)

35. Key recent findings

36. “Stepped Care” Initial treatment: SSRI or Problem Solving Therapy
Switch to other SSRI, SNRI, or PST or other agent
Augment with PST or other agent
(B)
Switch to TCA or other agent
Augment with Lithium, T3 or antipsychotic
Augment with intensive therapy
(C)
MAOi or novel combination
ECT or other intervention
Initial treatment
Switch or augment (A)
Switch or augment (B)
“Last resort” (C)
Rush et al, “STAR*D” study, Arch Gen Psychiatry, 2006
(often steps B & C above are usually done in Specialty Psychiatry setting.)

37. Factors associated with success
Interpersonal, professional relationship between physical and mental health staff
Co-location better
Consolidated electronic health records
Adequate staff training (especially in treatment of complex patients), both clinical skills, and and effective integrated services
Consistent champions

38. Factors associated with enhanced value
Use of depression care managers (dedicated to depression care)
Systematic involvement of psychiatrists
On hand for consultation with treating primary care providers
Perform supervision, and provide case review, with depression care managers

39. FACTORS THAT REDUCED CLINIC/PRACTITIONER PARTICIPATION
“Top down” program development, without “bottom-up” clinic participation
FACTORS ASSOCIATED WITH POOR SUSTAINABILITY
Difficulty recruiting mental health staff willing to adopt program role
Katon et al, 2010

40. Quality results from Minnesota DIAMOND-Outcomes
Response and remission rates at 6 month
Offedahl, ICSI

41. Quality results from Minnesota DIAMOND-Outcomes
Response and remission rates at 12 month
Offedahl, ICSI

42. Unutzer commentary Endorsement of “stepped care” (“treat-to-target”)
Back-office staff for core support functions, such as out-reach, tracking, evaluating for treatment side effects
Active dialogue and collaboration between primary care provider and the behavioral health provider

43. Beyond the Mental Health Parity Act
REIMBURSEMENT ISSUES
Beyond the Mental Health Parity Act
Affordable Care Act, issues with planned implementation
Medicare-changes had modest effect on how 5 Stars calculated, but will be combination metrics (quality and process metrics) and survey responses from VA/Rand HOS (non specific)
Patient-centered medical home
quality metrics including psychiatric in-patient follow-ups, childhood ADHD medication measures, HEDIS anti- depressant medication metrics

44. Medicare “Star Ratings”
Quality measures
NCQA, HEDIS
Service measures
METEOR, others
Survey measures
Perceived health

45. Medicare “Star Ratings”
Quality measures
NCQA, HEDIS
Service measures
METEOR, others
Survey measures
Perceived health

46. Average Impact on MCS Scores Observed in Veterans Health Study Kazis, LE, Miller, DR, Skinner, KM, et al. Patient reported measures of health: The Veterans Health Study. J of Ambulatory Care Mgmt, 2004; 27:1,
Condition
Impact on MCS*
Hypertension
-0.50
Angina
-0.64
Diabetes
-0.08
Osteoarthritis
-2.05
Chronic Low Back Pain
-2.83
Chronic Lung Disease --
Depression
-8.00
Alcohol Disorders
-6.59
*Impact of disease on MCS controlling for sociodemographic and co-morbid conditions
Slide 60

47. Average Impact on MCS Scores Observed in Veterans Health Study Kazis, LE, Miller, DR, Skinner, KM, et al. Patient reported measures of health: The Veterans Health Study. J of Ambulatory Care Mgmt, 2004; 27:1,
Condition
Impact on MCS*
Hypertension
-0.50
Angina
-0.64
Diabetes
-0.08
Osteoarthritis
-2.05
Chronic Low Back Pain
-2.83
Chronic Lung Disease --
Depression
-8.00
Alcohol Disorders
-6.59
*Impact of disease on MCS controlling for sociodemographic and co-morbid conditions
Slide 60

48. testimonials
a patient who was feeling suicidal received a call from a hospital clinic-based social worker, assigned to do depression program outreach. The patient came to the hospital at the case managers request, and states that it saved his life.
a patient who received a letter with a questionnaire, from the depression program, states that it brought to light issues he had been afraid to discuss with his doctor

49. testimonials “I’m not crazy!” “Who are you?”
Lesson learned: “Depression care program” sounds a little “cultish”

50. Future issues:
To what extent do integrated care programs need to be modified to adopt other populations at risk, i.e. adolescent depression, post-partum depression, axis I illnesses besides depression (substance abuse disorders, anxiety disorders, attention deficit disorder)
Reimbursable “care extender” training
New nationally recognized quality measures still up in the air, i.e. screening, follow-up, treatment effectiveness surrogates- (such as PHQ-9 or other quantifiable disease metric)

51. APPENDIX

52. PROGNOSIS & COURSE
50% of patients have a single episode of MDD with no subsequent episodes over 20 years of follow-up.
15% of subjects have an unremitting course without any true periods of full remission after an index episode
35% of subjects have a recurrent disorder with a variable course
Eaton WW et al Arch Gen Psychiatry. 2008;65(5):

53. Medicare “Star Ratings”
Quality measure:
HEDIS medication measures
Meant to ensure that plan coverage keeping patients med adherent
Foye, 2010; Bull et al, 2002
Patient survey data (“Health Outcome Survey)
Mental health wellness

54. Copyright restrictions may apply.
Table 3. Factors Associated With Discontinuing Use of the Initial Antidepressant Medication Within 3 Months of Starting Treatment: Results of Multivariate Model*.
Table 3. Factors Associated With Discontinuing Use of the Initial Antidepressant Medication Within 3 Months of Starting Treatment: Results of Multivariate Model*
Copyright restrictions may apply.
Bull, S. A. et al. JAMA 2002;288:

55. Copyright restrictions may apply.
Table 2. Antidepressant Treatment Status 3 Months After Start of Treatment in Relation to Patient-Physician Communication, Medication Adverse Effects, and Clinical Improvement*.
Table 2. Antidepressant Treatment Status 3 Months After Start of Treatment in Relation to Patient-Physician Communication, Medication Adverse Effects, and Clinical Improvement*
Bull, S. A. et al. JAMA 2002;288:
Copyright restrictions may apply.

56. Copyright restrictions may apply.
Table 4. Factors Associated With Switching the Initial Antidepressant Medication Within 3 Months of Starting Treatment: Results of Multivariate Model*.
Table 4. Factors Associated With Switching the Initial Antidepressant Medication Within 3 Months of Starting Treatment: Results of Multivariate Model*
Copyright restrictions may apply.
Bull, S. A. et al. JAMA 2002;288:

57. Medicare Advantage in One Slide
Plans contract with CMS to provide Medicare benefits to beneficiaries as an alternative to traditional Medicare FFS.
Plans receive non-negotiated, risk-adjusted, capitated payment from CMS based on the health status of each individual enrollee.
Plans have some flexibility to selectively contract with providers, do medical management and provide additional care support services.
However, CMS maintains substantial involvement in regulating and monitoring the services being provided by private plans.

58. VR-12 Questions Physical Health (Summary Measure)
Mental Health (Summary Measure)
1. Your
Health
2a. Moderate
Activities
2b.Climbing
Several
Stairs
3a. Accomplished Less
3b. Limited in Kind
4a. Accomplished Less
4. Limited in Kind
5. Pain Interference
6a. Peaceful
6b. Energy
6c. Down-
Hearted
7. Interference in Social 9.
Change in Emotional 8.
Change in Physical
SCALES
General
Physical
Functioning
Change
Emotional
Role-Physical
Social
Vitality/Mental
Bodily Pain
Role-Emotional
Source: Lewis Kazis, et. al
Slide 53

59. Veterans Rand 12-Item Health Survey (VR-12)
First 12 questions of HOS.
Extensively tested, shown to be reliable and valid in ambulatory care populations.
8 scales of health include mental health.
Physical Functioning,
Role-Physical,
Role-Emotional,
Bodily Pain,
Social Functioning,
Mental Health,
Vitality,
General Health.
6 questions used to calculate the mental health composite score (MCS).
Slide 52

60. What is the MCS? (Mental Health Composite Score)
The change in a plan’s MCS score from baseline to 2-year follow-up is used to assess a Medicare Advantage (MAO) Plan’s ability to sustain or improve the mental health of its population.
The six questions above are weighted and impact the MCS score, some more than others.
The change in this score is the basis for the CMS Star ratings.
The CMS Star ratings will impact quality bonus payments for Medicare Advantage plans as of 2012.
Slide 54

61. VR-12 Question 4a & 4b Mental Health (Summary Measure) Role-Emotional
4a. Accomplished Less
4b Limited in Kind
Role-Emotional
Source: Lewis Kazis, et. al
Slide 55

62. VR-12 Question 6a, 6b, & 6c Mental Health (Summary Measure)
6a. Peaceful
6b. Energy
6c. Down-Hearted
Vitality/Mental
Health
Source: Lewis Kazis, et. al
Slide 56

63. VR-12 Question 7 Mental Health (Summary Measure) Social Functioning
7. Interference in Social Activities
Social
Functioning
Source: Lewis Kazis, et. al
Slide 57

64. 1) Percentage measurement scores for “Improving and Maintaining Mental Health”
MCS scores are calculated per beneficiary at baseline and follow-up to determine the 2-year change.
These “change scores” are aggregated to the plan level and case-mix adjusted to show the percentage of enrollees whose MCS was the same, better, or worse after 2 years.
3. Outliers are identified based on whether a plan performed the same, better, or worse than the national average (statistically significant differences).
Slide 58

65. 5 HOS Mental Health Questions after VR-12…
Four depression screening questions
Mentally unhealthy days in past 30 days
Slide 59

66. MECHANISMS (GENERAL)
Shared vulnerability hypotheses are increasingly popular in the academic literature. These propose an underlying predisposition to BOTH depression and chronic medical conditions, rather than simple cause & effect

67. CORONARY ARTERY DISEASE
Depression predicts increased risk of atherosclerosis, CHF, arrhythmias, MI and sudden cardiac death; both in previously healthy individuals and in cardiac patients.
Major Depression doubles the risk of an adverse CVD event within 12 months, independent of ejection fraction, HTN or smoking.
Depressed patients have a 4-fold risk of death after MI compared with non-depressed patients.
Both longitudinal observational studies and several prospective clinical trials have clearly shown that these associations persist after controlling for both psychosocial and behavioral risk factors.
Researchers have thus proposed and studied plausible biological mechanisms by which a direct causation effect or shared vulnerability might be mediated.

68. Also, other chronic illnesses
AUTO-IMMUNE DISORDERS
There is increasing interest in cytokine release as the common pathway mediating the linkage of depression and many different medical conditions.
CHRONIC PAIN
More than 50% of depressed patients c/o increased somatic pain
Unfortunately, in our modern world inactivity and increased pain sensitivity are more likely to result in missed work days, disruption of relationships and markedly worse quality of life.
Less pain after successful use of integrated model