1. Improving behavioral health through the power of clinical expertise and advanced technology New York Business Group on Health Maximizing Behavioral Health in Your Population: Programs, Plans, Providers & Parity September 28, 2010 September 28, 2010 Presented to:

2. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology Challenges & Opportunities to Improve Care 2 Using evidence-based medicine for behavioral and physical health Achieve mental health parity in a cost-effective way Understanding mental/physical health relationships Designing plan design and programs to support best treatment practices

3. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology How Four Conditions Impact Employees and Employers 3 Depression Diabetes Alcohol-Use Disorders Attention-Deficit Hyperactivity Disorder (ADHD)

4. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology 4 DEPRESSION

5. Improving behavioral health through the power of clinical expertise and advanced technology © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited 5 Depression: Impact on Workplace Depression  Among the costliest of health problems to employers Wang PS at al: Making the Business Case for Enhanced Depression Care. J Occup Environ Med 2008; 50(4):468-475  Afflicts individuals during prime working years  Associated with large short- term decrements in work performance

6. Improving behavioral health through the power of clinical expertise and advanced technology © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited 6 Depression: Effective Treatment When depression is effectively treated, work impairment resolves In only a minority of cases (42%) is depression being effectively treated – defined as:  At least six sessions of psychotherapy, each lasting 30+ minutes, or  Treatment with antidepressant, anxiolytic or mood stabilizer with 4+ physician visits Kessler RC at al: The Prevalence and Correlates of Workplace Depression in the National Comorbidity Replication. J Occup Environ Med 2008; 50(4):381-390

7. Improving behavioral health through the power of clinical expertise and advanced technology © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited 7 Depression: Urgent Unmet Needs Personalized treatment: “Genomics may help, but imaging, family history, and clinical characteristics will also contribute.” Effective treatments: “Current medications may be necessary but not sufficient for the treatment of depression.” Insel TR, Wang PS: The STAR*D Trial: Revealing the Need for Better Treatments. Psychiatr Serv 2009; 60(11):1466-67

8. Improving behavioral health through the power of clinical expertise and advanced technology © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited 8 Depression: Treatment Options Psychotherapies Medications Psychoeducation Neurostimulation: ECT, rTMS, etc. Light Therapy Sleep Deprivation Other (omega-3 fatty acids, SAMe, St John’s wort)

9. Improving behavioral health through the power of clinical expertise and advanced technology © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited 9 Poor Adherence Single most critical problem affecting outcome for all medical and behavioral conditions Especially problematic for people with psychiatric illnesses, elderly, and low-income “Drugs don’t work in patients who don’t take them.” C. Everett Koop, Former US Surgeon General 1.Clayton, C., et al: Assessment of Clinician Awareness of Nonadherence Using a New Structured Rating Scale. J Psychiatr Pract 2010;16:164-169. Poor adherence can be mistaken for lack of response, leading to unnecessary medication changes and polypharmacy CMT Study: clinicians do not know whether patients are taking their medications as prescribed 1

10. Improving behavioral health through the power of clinical expertise and advanced technology © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited MPR & Gap Analysis 10 Improving Adherence Reduces Adverse Events Source: Valenstein et al., 2002 MPR Range <0.8<0.9<1.0

11. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology 11 DIABETES

12. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology Bidirectional Relationship with Behavioral Health Conditions 12 Patients with diabetes have an elevated rate of depression Depression increases the risk for diabetes Antidepressant medications cause weight gain and increase risk for diabetes Depression activates the HPA access, which increases blood glucose levels Co-morbid depression-diabetes is associated with poorer glycemic control, more diabetes-related complications and accelerated mortality

13. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology Bidirectional Relationship (continued) 13 Depression leads to less adherence to medication, diet and exercise regimens for diabetes Antidepressant medications improve depression but do not improve diabetic glycemic control Collaborative care may improve outcomes in co-morbid depression/diabetes Attention must be paid to adherence to antidepressant medication and to behavioral change in patients with depression and diabetes

14. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology 14 ALCOHOL-USE DISORDERS

15. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology A Hidden Diagnosis 15 17 million adults have a serious problem with alcohol, yet only 3 million get help. Alcohol problems kill, sicken or injure hundreds of thousands of Americans every year, destroy families, contribute to violent crime, and reduce productivity. Ensuring Solutions to Alcohol problems – The George Washington University Medical Center http://www.ensuringsolutions.org/solutions/solutions_show.htm?doc_id=339028&cat_id=963

16. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology Underuse of Screening 16 “Physicians routinely measure a patient's blood pressure to diagnose hypertension but fewer than one in three carefully screen their patients for alcohol problems.”

17. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology Reasons Why Physicians Don’t Routinely Screen 17 Ensuring Solutions to Alcohol problems – The George Washington University Medical Center http://www.ensuringsolutions.org/solutions/solutions_show.htm?doc_id=339028&cat_id=963 Protecting patient (insurance issues) Doubt the effectiveness of alcohol screening Assume that the process is too difficult, time consuming, they aren't qualified, or that their patients will react badly

18. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology Screening, Brief Intervention, and Referral to Treatment (SBIRT) 18 Decrease the frequency and severity of drug and alcohol use Reduce the risk of trauma Increase the percentage of patients who enter specialized substance abuse treatment, and Fewer hospital days and fewer emergency department visits. SBIRT research shows that large numbers of individuals with or at risk of developing serious alcohol or other drug problems may be identified through primary care screening and successfully treated in that setting. Primary care treatment can…. “Screening, Brief Intervention and Referral to Treatment - “Is SBIRT Effective?” http://www.sbirt.samhsa.gov/ Cost-benefit and cost-effectiveness analyses have demonstrated net-cost savings from these interventions.

19. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology Treatment for Alcohol Dependence 19  Disulfiram  Acamprosate  Oral naltrexone  Injectable naltrexone  Counseling  Psychotherapy  Rehabilitation  12-Step Programs Medications Psychosocial Treatment

20. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology 20 ADHD

21. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology ADHD: Not Just a Childhood Disease 21 4.4% of adults are estimated to have ADHD 1 5% of children have ADHD alone (without learning disorder) Kessler RC, et al “The Prevalence and Correlates of Adult ADHD in the United States: Results From the National Comorbidity Survey Replication” Am J Psychiatry 163:716-723, April 2006

22. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology Accurate Diagnosis Is Problematic in Cases of ADHD 22 Over-diagnosis and missed-diagnosis is common Must use structured instrument (e.g. Connors scale) Important to get assessment from three sources: child, parent and teacher

23. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology Cost Data for ADHD 23 Individuals with ADHD have significantly higher inpatient and outpatient healthcare costs, including higher rates of accidents and medical illnesses.  $4,306 versus $1,944 for the non-ADHD group Leibson CL, et al. “Use and Costs of Medical Care for Children and Adolescents with and without Attention-Deficit/Hyperactivity Disorder. JAMA. 2001; 285: 60-66

24. Improving behavioral health through the power of clinical expertise and advanced technology © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited 24 Treatments: ADHD First line treatment: FDA-approved ADHD medication  Dextroamphetamine (Dexedrine ® )  d- & d,l-methylphenidate (Concerta ®, Daytrana ®, Focalin XR ®, Metadate ®, Ritalin LA ® )  Mixed salts amphetamine (Adderall XR ® )  Amphetamine pro-drug: lisdexamfetamine (Vyvanse ® )  Atomoxetine (Strattera ® )  Guanfacine (Intuniv ® ) AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents With ADHD. J Am Acad Child Adolesc Psychiatry 46(7): 894-921, July 2007

25. Improving behavioral health through the power of clinical expertise and advanced technology © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited 25 Treatments: ADHD Second line: medications not FDA approved for ADHD  Bupropion (Wellbutrin ®, Budeprion ® )  Clonidine (Catapres ® )  Imipramine (Tofranil ® )  Nortriptyline (Pamelor ®, Aventyl ® )  Modafanil (Provigil ® ) Monitor for side-effects such as aggression, mood liability, suicidal ideation. Cardiovascular issues: AHA recommendations AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents With ADHD, J Am Acad Child Adolesc Psychiatry 46(7): 894-921, July 2007

26. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology What Else is Effective? 26 Psychosocial Interventions are effective for ADHD and may work as well as or increase efficacy of psychostimulants in adults An MTA study showed that after three years no difference in outcome for children who originally received methylphenidate or psychotherapy Stimulant misuse is an increasing problem

27. © 2010 Care Management Technologies, Inc. Reprints and Distribution Prohibited Improving behavioral health through the power of clinical expertise and advanced technology Conclusion 27 Only by using evidence-based screening, medication and psychosocial treatment, behavioral health and substance abuse disorders can be treated in a cost-effective manner.