1. Caring for Youth: Building Partnerships with Primary Care to Improve Health and Functioning Joan R. Asarnow, Ph.D. Professor of Psychiatry & Biobehavioral Sciences UCLA School of Medicine

2. Presentation Goals Review rationale for building partnership with primary care To illustrate this approach, we present preliminary data from our current study aimed at improving care for adolescent depression through primary care Offer some conclusions and recommendations regarding directions for further clinical and research initiatives

3. Why Primary Care? Most children and adolescents have some contact with a primary care provider each year – 70% of youth, ages 10-18, visit a primary care provider a year, with an average of 3 visits Psychiatric and behavioral complaints more common among high utilizers of primary care –True for children and adolescents

4. Detection of Need in Primary Care Not currently a major source of mental health care Need identified in only a small subset of youth –Sensitivity Low: Primary care providers detect mental health problems in a small proportion of youth with need (Kramer & Garralda,1998) –Specificity high: When primary care providers detect mental health need it is likely to be present (Kramer & Garralda,1998)

5. Youth Partners in Care: A Research Project to Improve Treatment of Adolescent Depression in Primary Care Joan Asarnow, Ph.D., Lisa Jaycox, Ph.D., Ken Wells, M.D., M.P.H., Margaret Rea Ph.D., Emily McGrath, Ph.D., Janeen Armm, Ph.D., Anne LaBorde, Ph.D., Psy.D., Martin Anderson, M.D., Pamela Murray, M.D., Chris Landon, M.D., James McKowen and colleagues Sponsored by the Agency for Healthcare Research and Quality (AHRQ) 5-year study to identify ways to improve quality of care for adolescent depression in primary care

6.  Academic Medical Centers – UCLA Mattell Children’s Hospital & Satellite Clinics – University of Pittsburgh Children’s Hospital  Managed Care Clinics – Kaiser Permanente Los Angeles Medical Center – Family Practice & Pediatric Departments – Sunset & East LA Sites  Public Sector Clinics – Ventura County Medical Center-Family Practice & Pediatrics – Venice Family Clinic YPIC: Participating Sites

7. Study Flow Chart

8. Need: Rates of Depression

9. Need:Trauma Exposure and PTSD Symptoms 23% 17% 60%

10. Barriers to Detection in Primary Care Brief visits –About 10 minutes with children –About 16 minutes with adolescents Emphasis on physical health –Multiple health issues need to be addressed –Youth may not disclose difficulties

11. Barriers to Detection in Primary Care If detected, additional time required to address problem Lack of resources for addressing mental health needs in primary care Referral to specialty care often associated with lack of follow-up due to barriers to initiating care (e.g. perceived stigma, lack of insurance, transportation)

12. When is detection best? Continuity of care: best predictor of whether provider detects need is whether provider saw their own patient (Kelleher et al., 1997) Well child vs acute care visits (Horwitz et al., 1992) Severe impairment (Kramer & Iliffe, 1997)

13. Models for Treating Depression Within Primary Care Provider training and increased management by primary care providers –Little evidence of improvements in objective provider behavior or child outcomes –Some data suggest brief provider training may lead to changes in subjective outcomes, such as provider confidence and knowledge

14. Models for Treating Depression Within Primary Care Use of specialty mental health providers within primary care –Absence of adequately controlled evaluations of this approach –Likely that interventions that are effective in mental health settings will show comparable effects in primary care when delivered by comparable providers with similar patients –Patient characteristics may differ in primary care

15. Depression in Primary Care Populations: Comorbidity With Chronic Physical Health Problems

16. Models for Treating Depression Within Primary Care Consultation liason –Specialty mental health providers support primary care management –Mimimal data Some data suggests reduced rate of specialty referrals and more “appropriate” referrals Only small percentage of providers felt knowledge and skills had improved

17. Models for Treating Depression Within Primary Care Team based disease management program –Non-physicians play a major role in patient assessment, education, treatment, and monitoring –Mechanisms developed for improving partnerships between primary care and specialty mental health care –Addresses major barriers such as: inadequate practice resources, insufficient time in primary care visit, limited access to specialty services and evidence based treatments

18. YPIC Goals  To test an innovative model of care for depression among youth in primary care  To evaluate intervention effects compared to “care as usual” on:  Quality of care  Clinical outcomes  Social outcomes  Costs

19. YPIC Intervention Goals  To improve initiation of and adherence to known effective treatment regiments – Psychotherapy (CBT) – Antidepressant medication  Taking into account patient, parent and provider preferences: can choose any treatment or no treatment  Enhancing the doctor-patient relationship and maintaining provider autonomy  Real-world practice conditions

20.  Provider education  Care managers to track cases and support primary care providers  Patient & family education  Study trained cognitive-behavioral therapists within primary care  Emphasis on patient, parent and provider choice  Local expert teams  Tailoring the depression management model to each system Intervention Components

21. Study Flow Chart

22. Figure 1. YPIC INTERVENTION FLOW CHART Initial Patient Visit with CM (45 min.)  Structured Evaluation  Basic Patient and Family Education Initial Patient Visit with CM (45 min.)  Structured Evaluation  Basic Patient and Family Education Patient Visit with Primary Care Provider (15 min.)  Develop Primary Care MD management plan  Consider specialty mental health consultation Patient Visit with Primary Care Provider (15 min.)  Develop Primary Care MD management plan  Consider specialty mental health consultation Patient contacted and visit with CM and Primary Care Provider scheduled Primary Care Provider contacted and briefed Referred to Care Manager (CM) Patient Identified: Screener indicates high levels of depressive symptoms Patient Identified: Screener indicates high levels of depressive symptoms

23. Follow-up visits/phone calls by CM and primary care clinicians Medication or medication plus psychotherapy is prescribed Psychotherapy is prescribed POST-VISIT EDUCATION WITH CM Patients not started on treatment CM re- contacts In 4 weeks for follow-up CM refers to therapist and arranges primary care follow- up

24. Intervention Implementation Site 1: Preliminary Data

25. Barriers to Intervention Implementation  Care Manager unable to reach patient – “Unable to schedule” was modal reason for no initial evaluation (75%) – “Unable to schedule” was modal reason for not following treatment plan (90%)  No perceived need for additional services, low motivation (Youth, Parent)  Access problems (no time, transportation, conflicting demands)

26. Barriers to Intervention Implementation  Stigma associated with care (e.g. “It’s against my religion to see social workers”)  Health care organization can’t implement and sustain treatment model (Motivation, flexibility, perceived value)  Discrepancy between Care Manager role and traditional psychotherapist role

27. Strategies for Addressing Barriers Telephone contacts Flexible hours Treatment provided through primary care setting

28. Pathways to care for depression through primary care

29. Conclusions: Access –Need to ensure access to primary care –Universal access not guaranteed in United States –Some youth, particularly uninsured and/or disadvantaged, never reach primary care –Outreach needed to emergency services, urgent care, and OB-GYN

30. Conclusions: Detection Need to develop and test strategies for improving detection –Will need to be brief and require minimal time from primary care provider –Use of practice assistants, nursing staff, or associated mental health workers –Brief self-report instruments likely to lead to over- identification and will need to be supplemented with additional evaluation and triage of youth to appropriate services

31. Conclusions: Issues Detection likely to yield a somewhat different population than the population of youth identified in specialty mental health clinic and schools (e.g. health problems Need for efforts to better understand barriers to care within primary care settings and develop intervention strategies to reduce barriers and improve access to high quality care

32. Conclusions: Motivation for Treatment Motivation for treatment may be low, particularly when youth have not identified themselves as needing or wanting mental health care Adolescents tend to seek care for sensitive issues (e.g. pregnancy) and parents may be unaware of youth problems and/or visits to primary care Need for effective strategies to work with families and help families to mobilize and support treatment

33. Conclusions: Treatment Collaborative care models have shown promise for improving patient care and outcomes This approach builds on the strengths of primary care settings, but supports primary care practices with resources needed to evaluate and treat depression and other mental health problems Future research is needed to clarify the effectiveness, costs, and benefits of this approach in real-world practice settings