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

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

Occupational Functioning Persons with major depression had a 4.78 greater risk of disability Broadhead, WE et al, JAMA, 1990;264:2524-2528 Productivity losses related to depression exceed the costs of effective treatment. Wang, PS, et al, Am J Psych 2004; 161:1885-1891

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

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

Full Costs – Medical, Pharmacy, Absence and Presenteeism

Full Costs – Medical, Pharmacy, Absence and Presenteeism

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

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.

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; 19:138-143.)

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.

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

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

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

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

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

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

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

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

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

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 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

*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

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

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.

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

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

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

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

Mean Health Scores

Mean Dysfunction Scores

Changes in PHQ-9 mean scores

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):1403-1409

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

Key recent findings

“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.)

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

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

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

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

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

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

Beyond the Mental Health Parity Act REIMBURSEMENT ISSUES Beyond the Mental Health Parity Act Affordable Care Act, issues with planned 2014 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

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

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

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, 70-83. 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

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, 70-83. 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

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

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

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)

APPENDIX

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):513-520

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

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;288:1403-1409

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;288:1403-1409 Copyright restrictions may apply.

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;288:1403-1409

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.

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

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

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

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

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

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

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

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

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

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.

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