1. IMPACT Team Care For Depression VA Puget Sound V-tel conference February 23, 2009

2. Disclosure  Grant funding (current & recent) NIH (NIMH) American Federation for Aging Research (AFAR) John A. Hartford Foundation George Foundation Red Cross (RAND) California HealthCare Foundation Robert Wood Johnson Foundation Hogg Foundation  Contracts Community Health Plan of Washington King County Department of Public Health  Consultant AARP Services Incorporated (ASI) National Council of Community Behavioral Health Care (NCCBH)  Advisor Carter Center Mental Health Program Institute for Clinical Systems Research (ICSI)

3. Depression  More than having a bad day or a bad week  Pervasive depressed mood / sadness  Loss of interest / pleasure Lack of energy, fatigue, poor sleep and appetite, physical slowing or agitation, poor concentration, physical symptoms (aches and pains), irritability, thoughts of guilt, and thoughts of suicide  A miserable state that can last for months or even years

4. 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

5. Depression is often not the only health problem Depression Neurologic Disorders Geriatric Syndromes Diabetes 20-40% 10-20% Heart Disease 20-40 % Chronic Pain 40-60% 10-20 % Cancer

6. Depression is deadly Older men have the highest rate of suicide. 

7. Guidelines for Depression Treatment in Primary Care  VA  Institute for Clinical Systems Improvement (ICSI) http://www.icsi.org/guidelines_and_more/gl_os_prot/behavioral_he alth/depression_5/depression__major__in_adults_in_primary_care _4.html  American College of Physicians (ACP) Clinical Practice Guidelines Ann Int Med 2008; 149:725-733

8. Efficacious treatments for depression 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.

9. Antidepressant Medications There are over 20 FDA approved antidepressants. - All are effective in 40 - 50 % of patients if taken correctly - It often takes several trials until Rx is effective - Patients need support during this time If medications are not effective after 8-10 weeks at a therapeutic dose - make sure patient is taking medication as prescribed - verify diagnosis - consult: a change in treatment plan is likely indicated

10.  Fewer than 1 in 10 depressed older adults seek specialty mental health care and if they did we wouldn’t have the mental health specialists needed to treat them  Most present for help in primary care  Quality of care for depression is worse than for most other chronic medical problems Quality of Depression Care

11. Depression Treatment in Primary Care  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 30 % drop out of treatment within 4 weeks Only 25 % receive adequate follow-up care Only 20 – 40 % improve substantially over 12 months  Limited access to evidence-based psychosocial treatments (psychotherapy)

12. Evidence for Collaborative Care for Depression Metaanalysis by Gilbody S. et al, Archives of Internal Medicine; 2006 - 37 trials of collaborative care for depression in primary care (US and Europe) - cc consistently more effective than usual care - successful programs include - active care management & follow-up - support of medication management in primary care - psychiatric consultation

13. IMPACT Trial John A. Hartford Foundation  Planning grant (1996)  IMPACT Study(1999-2003) Additional funding from California Healthcare Foundation Robert Wood Johnson Foundation Hogg Foundation

14. IMPACT Study Methods  Design: 1,801 depressed adults (60 and older) with major depression and / or chronic depression, randomly assigned to IMPACT or to Care as Usual  Usual Care: Primary care or referral to specialty mental health  IMPACT Care: Collaborative / stepped care disease management program for depression in primary care offered for up to 12 months  Analyses: Independent assessments of health outcomes and costs for 24 months. Intent to treat analyses Unützer et al, Med Care 2001; 39(8):785-99

15. IMPACT Team Care Model Prepared, Pro-active Practice Team Informed, Activated Patient Practice Support Photo: Courtesy D. Battershall & John A. Hartford Foundation Photo credit: J. Lott, Seattle Times Effective Collaboration

16. Collaborative Care Patient  Chooses treatment in consultation with provider(s): antidepressants and / or brief psychotherapy Primary care provider (PCP)  Refers; prescribes antidepressant medications + Depression Care Manager + Consulting Psychiatrist Unützer et al, Med Care 2001; 39(8):785-99

17. Treatment Protocol (1) Assessment and education, (2) Behavioral Activation / Pleasant Events Scheduling (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

18. 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

20. What if patients don’t improve? Is the patient adhering to treatment? Is the dose high enough? - see max dose guidelines Is the diagnosis correct? ? Bipolar depression ? Medical conditions (hypothyroidism, sleep apnea, pain) ? Meds: steroids, interferon, hormones ? Withdrawal: stimulants, anxiolytics Are there untreated comorbid conditions / life stressors?

21. Is the patient at maximum therapeutic dose?*  Fluoxetine60 mg  Paroxetine60 mg  Escitalopram30 mg  Citalopram60 mg  Sertraline200 mg  Venlafaxine300 mg  Duloxetine60 mg  Buproprion SR450 mg  Mirtazapine60 mg  Nortriptyline125 mg (check serum level)  Desipramine200 mg (check serum level) Consider titrating to these doses unless patients do not tolerate these ‘maximum doses’ due to side effects.

22. IMPACT doubles the Effectiveness of Depression Care 50% or greater improvement in depression at 12 months Participating Organizations % Unutzer et al, JAMA 2002; Psych Clin N America 2004.

23. IMPACT Improves Physical Functioning SF-12 Physical Function Component Summary Score (PCS-12) P<0.01 P=0.35 Callahan et al. JAGS. 2005; 53:367-373. Callahan C et al, JAGS 2004

24. IMPACT Saves Money Cost Category 4-year costs in $ Intervention group cost in $ Usual care group cost in $ Difference in $ IMPACT program cost 5220 Outpatient mental health costs 661558767-210 Pharmacy costs 7,2846,9427,636-694 Other outpatient costs 14,30614,16014,456-296 Inpatient medical costs 8,4527,1799,757-2578 Inpatient mental health / substance abuse costs 11461169-108 Total health care cost 31,08229,42232,785-$3363 Unutzer et al. Am J Managed Care 2008. Savings

25. IMPACT Summary  Less depression (IMPACT doubles effectiveness of usual care)  Less physical pain  Better physical functioning  Higher quality of life  Greater patient & provider satisfaction  Lower health care costs Over 40 peer-reviewed publications “I got my life back” Photo credit: J. Lott, Seattle Times

26. Pain Impairs Response to Depression Care Source: Thielke, et al. Am J Geriatric Psych. 2007.

27. IMPACT-DP Care management for depression and pain Less impairment in general activity, walking ability, work, relationships with others, sleep, and enjoyment in life Unutzer et al, Int J Geriatr Psychiatry 2008.

28. IMPACT Endorsements President’s 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

29. Taking IMPACT from Research to Practice  Support from JAHF (2004-2009)  Over 3,000 clinicians trained  Almost 200 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 Western WA: Virginia Mason, Community Health Plan of WA, King County Dept. of Public Health Iowa City VAMC

30. http://impact-uw.org

31. Lessons Learned - II Teams don’t just happen Many of us are not trained to work effectively on interdisciplinary teams. Work at interfaces is challenging. Simplicity & effective communication Joint accountability for measurable outcomes can help. (e.g., # and % of population screened, treated, improved)

32. Conclusion  IMPACT can be adapted and effective in a wide range of health care settings and populations  Effective teamwork is key to the success of the program Different professionals (nurses, social workers, psychologists, licensed counselors, and medical assistants) can be trained to support primary care providers with evidence-based care management Care management is a function, not a person Psychiatric consultation provides important back-up to primary care based care management programs.

33. Thank You