2008 Behavioral Health Symposium Christopher Mathews, M.D. Senior Vice President and Chief Medical Officer Community Health Plan Community Health Network of Washington

Welcome Conference Topics: Integration of Behavioral Health into the Primary Care Setting Relationship Between Depression and Chronic Illnesses

*Statistics provided by the NIMH Depressive Disorder 18.8 million (9%) American adults ages 18 and older have depressive disorders 4.5% of adolescents have a depressive disorder 2% of in-school-age children have a depressive disorder Over one million (4%) pre-schoolers are clinically depressed *Statistics provided by the NIMH In a recent study, the Australian Government statistics indicate that everyone in the world, will at some time in their life be affected by depression. Whether or not it is their own depression, or the depression of someone they are close to.

Total Population Effected 2% of the world’s population have depression (WHO) 4% of CHP’s member population have depression By the year 2020, unipolar depression is projected to be the second leading cause of death (WHO) Out of the 6,602,224,175 people in the world, the World Health Organization in 2007 estimated that 120 million people, or 2% have depression. When analyzing March 2008 data from Community Health Plan, 9, 733 out of 228, 195 members have depression; which is an average of 4%. In 2020, the WHO estimates that unipolar depression will be the second leading cause of death, rivaling heart disease. This projection is based upon the estimated rise in population by 2020, along with the increased association of depression with chronic illnesses.

*Costs provided by the Depression and Bipolar Support Alliance Cost of Depression $70 billion is spent annually in health care visits (U.S.) $12 billion of this total is a result of lost sick days (U.S.) $11 billion in ‘other costs’ (U.S.) *Costs provided by the Depression and Bipolar Support Alliance These ‘other costs’ can be attributed to the decreased productivity due to symptoms that sap energy, affect work habits and cause problems with concentration, memory and decision making.

Depression and Chronic Illness Rates of depression found in patients with: Heart Disease *Provided by Depression and Bipolar Support Alliance (DBSA) 1 in 3 people who have survived a heart attack HIV 1 in 3 people Cancer 25% Diabetes *American Diabetes Association 30% (depressive symptoms) 10% (major depression) The following slide displays the prevalence of depression associated with Heart Disease, HIV, Cancer and Diabetes.

*Statistics provided by the World Health Organization (WHO), 2006 Cultural Barriers 54% of people believe that depression is a personal weakness 41% of depressed women are too embarrassed to seek help 92% of African American males do not seek treatment Cultural beliefs surrounding illness As a result: - 80% of depressed people do not seek healthcare *Statistics provided by the World Health Organization (WHO), 2006 One of the major factors involved in the difficulty of recognizing depression and screening are the stigmas related to this illness. In fact, some ethnic groups believe that depression is the result of negative behavior and, as a result, do not want to inform their doctor of any symptoms that could be related to a diagnosis of depression.

*Statistics provided by the World Health Organization (WHO), 2006 The Screening Barrier Failure to detect depression is increased in the African American and Hispanic population Failure to detect depression is increased in people less than 35 years of age 50-80% of females develop postpartum depression within the first two weeks of delivery *Statistics provided by the World Health Organization (WHO), 2006 What can we do to increase the identification of patients who have depression?

* U.S. Preventive Services Task Force (USPSTF), 2006 The Diagnosis Barrier Studies have shown a failure to recognize and treat 30-50% of adult depressed patients. - Due to multiple competing demands - Complicating presentations - Limited time - Minimal training * U.S. Preventive Services Task Force (USPSTF), 2006 What can we do to increase the care being provided to this population? Research has shown the significant amount of patients with depressive disorders are more likely to be seen by their PCP due to continuity and coordination of care and limited access to behaviorists. Several clinics have been exploring integrated care models which involve the inclusion of a behaviorist among the primary care team. For example, in the Alaskan Native Care Model, the redesign had proven to be successful in improving communication between PCP and behaviorist, thereby increasing the treatment and care of behavioral health patients. It also decreased the ER visits, admits and hospitalizations, while increasing the overall access to the clinic for all patients.

Depression: A Potentially Lethal Illness Can result in suicide - Complete or Incomplete The National Institute of Mental Health (NIMH) has shown that 90% of people who die by suicide have the following risk factors: - Depression - Other mental disorder - Substance-abuse disorder If depression is not recognized and untreated, this can result in suicide. Depression can be attributed to 90% of global suicides 1 person attempts suicide every 39 seconds in the U.S. 1 person kills themselves every 16.1 minutes in the U.S. Each suicide intimately affects at least 6 other people. In 2005, suicide was one of the top ten leading causes of death among residents - 3,683 deaths related to suicide -12.7 deaths per 100,000 deaths - Compared to 11.9 deaths per 100,000 in 2001

Question Since depression has been shown to be a potentially lethal illness, killing more people than cardiovascular disease in the United States… → Why are patients not being screened for depression as frequently as they are for cardiovascular disease? → How many patients do you screen for depression?

Summary We have discussed the following topics: Impact of depression on quality of life Cost of depression The relationship between depression and chronic illness Stigmas surrounding depressive disorder Suicide Screening Diagnosis and Treatment

The relationship between depression and chronic illness Main Areas of Focus The integration of behavioral health care into the primary care setting Speakers: Jürgen Unützer, MD, MA, MPH Kirk Strosahl, PhD The relationship between depression and chronic illness Mercedes Carnethon, PhD Bruce Rabin, MD, PhD Dr. Jurgen Unutzer – Relationship Between Depression and Chronic Illness - Integration of Behavioral Health into the Primary Care Setting Dr. Kirk Strosahl – From Theory to the Exam Room - Clinical Pathways Dr. Mercedes Carnethon – Can Depression Cause Diabetes? Dr. Bruce Rabin – Coping with Stress for a Better Quality of Mental and Physical Health