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The question is not whether to integrate, but how Eric Goplerud, Ph.D. The 17th Annual Commemoration of World Mental Health Day The World Federation for.

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Presentation on theme: "The question is not whether to integrate, but how Eric Goplerud, Ph.D. The 17th Annual Commemoration of World Mental Health Day The World Federation for."— Presentation transcript:

1 The question is not whether to integrate, but how Eric Goplerud, Ph.D. The 17th Annual Commemoration of World Mental Health Day The World Federation for Mental Health and the Pan American Health Organization Thursday, October 8, 2009 Center for Integrated Behavioral Health Policy Department of Health Policy, The George Washington University Medical Center

2 Prince et al, Lancet, 2007 Contribution by different non-communicable diseases to disability-adjusted life-years worldwide in 2005

3 Leading Causes of Disease Burden by Select World Bank Region, 2001 Rank East Asia/ Pacific Europe/ Central Asia Latin America/ Caribbean High-income Countries 1 Cerebrovascular diseases Ischemic heart disease Perinatal Conditions Ischemic heart disease 2Perinatal conditions Cerebrovascular diseases Unipolar depressive disorders Cerebrovascular disease 3 Chronic obstructive pulmonary disease Unipolar depressive disorders Homicide and violence Unipolar depressive disorders 4 Ischemic heart disease Self-inflicted injuries Ischemic heart disease Alzheimers disease and other dementias 5 Unipolar depressive disorders Chronic obstructive pulmonary disease Cerebrovascular disease Tracheal and lung cancer Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 4.2

4 WHO, mhGAP, 2006

5 Proportion of specified budget allocated for mental health out of total health budget in each country Redrawn from WHO Mental Health Atlas

6 Burden of mental disorders and budget for mental health * Proportion of disability-adjusted life-years (DALYs), defined as the sum of the years of life lost due to premature mortality in the population and the years lost due to disability for incident cases of mental disorders.36 Median values for proportion of total health budget allocated to mental health.5 Sexenar et al, Lancet, 2007)

7 Years of Potential Life Lost to Persons with Serious Mental Illnesses Compared to the general population, persons with major mental illness typically lose more than 25 years of normal life span. Premature mortality among addicts up to 18 years. In DC, average age of death of DMH patients – 54 years, average life expectancy in DC – 72 years Colton CW, Manderscheid RW. Prev Chronic Dis] 2006 Apr ; Hser et al, 2003 YearAZMOOKRITXUTVA 199726.325.128.5 199827.325.128.829.315.5 199932.226.826.329.326.914.0 200031.827.924.913.5

8 Causes of Morbidity and Mortality in People with Serious Mental Illness Suicide and injury account for about 30- 40% of excess mortality About 60% of premature deaths are due to natural causes –Cardiovascular disease –Diabetes –Respiratory diseases –Infectious diseases Colton CW, Manderscheid RW. Prev Chronic Dis] 2006 ; Lutterman et al, 2003; Apr ; Hser et al, 2003

9 Smoking, Serious Mental Illness and Addiction Prevalence=75% to 85% Consume 44% of all cigarettes nationally Smoke heavier Smoke more efficiently Ziedonis et al, 2003

10 Co-occurrence of Mental Illness and Addiction: US SAMHSA, 2003

11 WHO, mhGAP, 2006

12 Cost-effectiveness of Interventions for Mental Disorders in Low- and Middle-Income Countries Source: Disease Control Priorities in Developing Countries, second edition, 2006, Figures 2.2 and 2.3 ConditionIntervention Cost-effectiveness ($ per DALY averted) Schizophrenia Antipsychotic drugs with optional psychosocial treatment (hospital-based)4,105-19,736 Schizophrenia Antipsychotic drugs with optional psychosocial treatment (community-based)2,472-17,197 Bipolar Disorder Mood-stabilizing drugs with optional psychosocial treatment (hospital-based)3,590-5,244 Bipolar Disorder Mood-stabilizing drugs with optional psychosocial treatment (community-based)2,498-3,728 DepressionDrugs with optional psychosocial treatment657-2,741 Panic DisorderDrugs with optional psychosocial treatment384-1,084

13 Costs of a Mental Health Care Package By Region Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 31.7 Annual Cost ($ millions) per One Million Population Intervention Sub- Saharan Africa Latin America/ Caribbean Middle East/ North Africa Europe/ Central Asia South Asia East Asia/ Pacific Schizophrenia: older antipsychotic drugs plus psychosocial treatment0.471.811.611.320.520.75 Bipolar disorder: older mood-stabilizing drugs plus psychosocial treatment0.481.801.231.390.620.95 Depression: proactive care with newer antidepressant drugs1.804.803.993.562.812.59 Panic disorder: newer antidepressant drugs0.150.270.210.230.160.20 Total cost of interventions2.98.77.06.54.14.5

14 Cost-effectiveness of Interventions for Alcohol Abuse in Low- and Middle- Income Countries Source: Disease Control Priorities in Developing Countries, second edition, 2006, Figure 2.2 Intervention Cost-effectiveness Ratio ($ per DALY averted) Increased taxation on alcohol1,249-1,504 Brief advice by primary health care doctor about alcohol abuse642 Increased taxation, advertising ban, and brief advice by primary health care doctor601-661 Advertising ban and restrictions on alcohol sales367-441

15 Estimated Impact of Interventions to Reduce High-Risk Drinking Notes: Coverage (modeled percentage of all high-risk drinkers exposed to the intervention): *95%, **80%, ***50%. Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 47.6 DALYs Averted per Million Population per Year Intervention Europe/ Central Asia Latin America/ Caribbean Sub-Saharan Africa Excise tax (current situation)*685586697 Excise tax (25% increase)*756654724 Excise tax (50% increase)*828719764 Reduced access to retail outlets*441287386 Comprehensive advertising ban*395243406 Random breath testing of drivers**284307197 Brief advice to heavy drinkers by primary care physician***1,328713539

16 For schizophrenia, bipolar disorder, depression and hazardous use of alcohol --- over a 10-year period US$ 1.85 to US$ 2.60 per capita in low-income countries US$ 3.20 to US$ 6.25 per capita in lower-middle income countries -- US$ 0.20 per capita per year in low-income countries US$ 0.30 per capita per year in lower-middle-income countries National Institute for Health and Clinical Excellence. Depression: management of depression in primary and secondary care. British Psychological Society, Gaskell, 2004. National Institute for Health and Clinical Excellence. Schizophrenia: full national clinical guidelines on core interventions in primary and secondary care. British Psychological Society, Gaskell, 2003. What would a primary care-led MH/SA package cost?

17 WHO, mhGAP, 2006

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19 Care Model: Integration is the Expectation California Primary Care,2009

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22 Lessons learned – Culture change Primary care culture: Acute focus Mental health culture: Individual (not population) focus Adjusting to a public health approach can be challenging, especially for experienced mental health professionals Examples of chronic disease management (e.g., for diabetes) can help make it clear for PCPs

23 Lessons learned – Staff buy-in Most providers understand why this is needed, but feasibility must be demonstrated Administrative support and PCP champions are critical Psychiatrist and care managers need to establish trust with PCPs – Takes time Once implemented, PCPs see the benefits, and late adopters come on board

24 Lessons learned – Workforce Even with collaborative care, workforce issues have impact: Limited availability of psychiatrists & care managers, especially in rural areas Child mental health providers particularly hard to find Care managers personality or orientation may be more important than credentials For partnerships across distances, a web-based registry facilitates communication

25 Lessons learned – Clinical issues Collaborative care approach can reduce stigma as barrier to treatment seeking in populations of color Severity of mental health problems in CHCs is high Co-morbid conditions (especially SU & chronic pain) must be addressed Demand is great – Have to be creative Specialty mental health partners are critical – Cant do this alone

26 Lessons learned – Sustainability Policy piece is critical to address state and federal barriers Financial solutions require state and local problem-solving Creative partnerships facilitate model Need to promote collaborations between primary care provider organization, hospitals / hospital districts, mental health partners, and others


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