Integration of Mental Health and Primary Health Care for the Older Patient

1
Integration of Mental Health and Primary Health
Care for the Older Patient

• Stephen J. Bartels, M.D., M.S.
• Professor of Psychiatry and Community and Family
  Medicine
• Co-Director Dartmouth Center on Aging

2
Overview

• Background Mental Health, Primary Care, and the
  Older Patient
• Outcomes Integration of Mental Health Services
  in Primary Care and the Older Patient
• Policy Implications for The Presidents
  Commission on Mental Health

3
Estimated Prevalence of Major Psychiatric
Disorders by Age Group
Jeste, Alexopoulus, Bartels, et al., 1999
4
Prevalence of Depression and Other Disorders in
Primary Care
Major All All Study
Depression Depression Disorders Hoeper et
al. 5.8 19.9 26.7 Schulberg et
al. ---- 9.2 30.3 Von
Korff et al. 5.0 8.7 26.5 Barrett
et al. 0.4 10.0 26.4 Coyne et
al. 13.5 22.0 ---- ECA (highest)
3.5 (6mo) 6.5 (6mo) 8.8
(2wk)
5
Depression Associated with Worse Health Outcomes

• Worse outcomes
• Hip fractures
• Myocardial infarction
• Cancer (Mossey 1990 Penninx et al. 2001 Evans
  1999)
• Increased mortality rates
• Myocardial Infarction (Frasure-Smith 1993, 1995)
• Long term Care Residents (Katz 1989, Rovner 1991,
  Parmelee 1992 Ashby1991 Shah 1993, Samuels
  1997)

6
Suicide and the Older Patient

• Older adults Highest risk of suicide of any age
  group
• 70 of elderly completing suicide have seen their
  primary care physician in the prior month, 40
  prior week, 20 same day (Conwell et
  al., 1994)
• Screening all primary care patients impractical.
  But identification of higher risk patients
  important

7
Primary Care Elderly with Depression, Anxiety, or
At-risk Alcohol Use

• 27.5 Report Death Ideation
• 10.5 Report Active Suicidal Ideation
• Greatest Suicidal Ideation Depression with
  Anxiety (18), Poor Social Support
• Suicidal Ideation NOT associated with increased
  visits to the PCP Bartels et al., Am J.
  Geriatric Psychiatry 2002, 10417-427

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Quality of Mental Health, Care and the Older
Patient

• Fragmentation of the Mental Health service
  delivery system for older persons
• Primary Care as the de facto mental health
  system of care for the older person

9
Quality of Mental Health Care for Older Primary
Care Patients

• The older primary care patient with depression
  compared to younger
• More likely to receive benzodiazepines
• Less likely to receive SSRIs
• Less likely to receive psychotherapy Bartels et
  al., International J. Psychiatry in Medicine 27
  (3)215-231, 1997.

10
Health Service Use and Costs Associated with
Depression for Older Primary Care Patients
11
Cost of Outpatient Services in Depression
Unutzer, et al., 1997 JAMA
12
Cost of Prescriptions
13
Number of Medical Visits
14
Hospitalized
15
Admitted to Emergency Room
16
Depression as a Costly Chronic Disease
Individuals with these 5 conditions account for
49 of total health care costs, 42 of
illness-related lost wages
Health Care Costs (per capita/total) Work Loss Costs For Individuals with Condition Health care and Total Costs for Individuals with Condition
Mood Disorders 3 1 2
Diabetes 4 3 3
Heart Disease 1 5 4
Hypertension 2 1 1
Asthma 5 4 5
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Summary of Findings

• Comorbid Depression in Medical Disorders Commonly
  Affecting Older Patients
• Greater Use and Costs of Medications
• Greater Use of Health Services (medical
  outpatient visits, emergency visits, and
  hospitalizations)

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The Research Question

• What is the Most Effective Way to Organize and
  Deliver Mental Health Services to Older Persons
  in Primary Care Settings?

19
Primary Care Research in Substance Abuse and
Mental Health for the Elderly
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A Comparison of Two Service Models

• Integrated/Collaborative Care
• Co-Located
• Concurrent
• Collaborative
• Enhanced Referral to Specialty Mental Health and
  Substance Abuse Clinics
• Preferred Providers and Facilitated appointments,
  transportation, payment

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Primary Hypotheses

• Engagement Hypothesis
• Participation Hypothesis
• Outcomes Hypothesis
• Cost Hypothesis

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• Is the Integrated Model More Likely to Result in
  Engagement in Mental Health Care by Older Persons?

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STUDY TARGET CONDITIONS

• Major Depression
• Dysthymic Disorder
• Minor Depression
• Depressive Disorder NOS
• Generalized Anxiety Disorder (GAD)
• Panic Disorder
• Anxiety Disorder NOS
• At-risk Alcohol Use

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Sample Characteristics (n2022)
Mean Age 73.5 6.2 26 Female
Diagnoses
Ethnicity
25
Overall Engagement by Model

• Integrated 71 (709/999)
• Referral 49 (499/1023)
• Relative Risk 1.45
• RR engaged integrated / engaged referral

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Rates of Engagement in MHSA Care By
Diagnosis/Condition
27
Rates of Engagement in MHSA Care By Level of
Suicidal Ideation
RR1.53
RR1.19
RR1.71
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Physical Proximity between Primary Care Clinic
and MH/SA Clinic
Rates of engagement are significantly different
across all four practice arrangements for the
total sample (?2(3)103.15, plt.001) and across
the three referral practice arrangements
(?2(2)7.76, p.02).
Bartels et al., American Journal of Psychiatry,
1611455-1462, 2004.
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Outcomes

• Integrated Care (compared to specialty referral)
  Associated with Greater Engagement in Treatment
• .Similar Outcomes (slightly better for
  major depression in specialty referral)
• Are Integrated Services with Depression Care
  Management (including use of specified treatment
  protocols) Better than Usual Care?
• IMPACT (Hartford Foundation)
• PROSPECT (NIMH)

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The IMPACT Treatment Model

• Collaborative care model includes
• Care manager Depression Clinical Specialist
• Patient education
• Symptom and Side effect tracking
• Brief, structured psychotherapy PST-PC
• Consultation / weekly supervision meetings with
• Primary care physician
• Team psychiatrist
• Stepped protocol in primary care using
  antidepressant medications and / or 6-8 sessions
  of psychotherapy (PST-PC)

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Antidepressant Use
Plt.0001
Plt.0001
Plt.0001
P.6995
Unützer et al, JAMA 2002 2882836-2845.
32
Mental Health / Psychotherapy / PST-PC
Plt.0001
Plt.0001
Plt.0001
P.2375
Unutzer et al, JAMA 2002.
Unützer et al, JAMA 2002 2882836-2845.
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Collaborative Management of Late-Life Depression
in Primary Care
P.55
Plt.001
Plt.001
Plt.001
IMPACT Study Unutzer, et al., 2002 - JAMA
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IMPACT Unutzer et al, 2002
1,801 patients 60 yrs in 18 Primary care clinics
in 8 Health care organizations.
Cadillac
model of
system change
Patients in REMISSION (HSCLlt0.5)
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PROSPECT

• USUAL CARE vs. INTERVENTION
• Clinical Algorithm for Geriatric Depression
  Consisting of Citalopram or IPT (based on
  patient preference)
• Depression Care Manager Social Workers, Nurses,
  Psychologists in Primary Care Depression
  recognition, guideline based treatment,
  monitoring of response to treatment, follow-up

36
PROSPECTImprovement in Depression (50 Drop
on HDRS Depression Score from Baseline)
Plt.05
Plt.05
Plt.001
4
8
12
Bruce, et al., 2004 - JAMA
37
PROSPECT Depression Specialist with Treatment
Algorithm

• Practices with Depression Specialist Using
  Treatment Algorithm for Depression had Greater
  Reduction in Depression Compared to Usual Care
  Practices
• However, Better Outcomes Only For Major
  Depression, Not for Minor Depression

Bruce, et al., 2004 - JAMA
38
Conclusions Integrated Mental Health Services in
Primary Care

• Better engagement .similar outcomes compared to
  referral care (perhaps slightly less effective
  for major depression)
• Better engagement and outcomes compared to usual
  care..especially with care management,
  standardized screening and outcome tracking, and
  treatment protocols

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Summary of 1st 2nd Generation Studies

• Multiple component interventions
• Lectures /or distributing guidelines do not
  change behavior nor outcomes
• Adding patient tracking with a care manager
  significantly improves outcomes
• Including a mental health specialist in an
  integrated treating or consulting role improves
  outcomes the most

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From Simon
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Greater Patient Improvement with System Changes
vs. Usual care
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Summary of 1st 2nd Generation Studies

• Multiple component interventions
• Lectures /or distributing guidelines do not
  change behavior nor outcomes
• Adding patient tracking with a care manager
  significantly improves outcomes
• Including a mental health specialist in an
  integrated treating or consulting role improves
  outcomes the most

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3rd Generation Depression System Change
Interventions
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Sustainability of Interventions?
Lin et al 1997
Appropriate Antidepressant Rx
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Long-term Depression Rx System Need
Remission
Recovery
Normalacy Symptoms Syndrome
Recurrence
Relapse
Only 25 Have 3 Visits
Relapse
Response
Severity
gt 50 STOP Rx
65 to 70 STOP Rx
Continuation Phase
Maintenance Phase
Acute Phase
Time
46
Non-adherence to Antidepressants
47
NCQA HEDIS Measure Long-Term Treatment
Adherence
 

• Rates Across Plans (2000 Results)

100
Follow-up with MD After Diagnosis of Depression 3
acute Phase visits
80
59
60
Percentage
42
Acute Phase Treatment (84 Days Continuity)
40
21
Treatment (6 Months Continuity)
20
0
Mean
National Committee for Quality Assurance (of
Managed Care Organizations) annual database of
Health Plan Employer Data and Information Set
(HEDIS)
http//www.ncqa.org
48
Usual Care
PRIMARY CARE CLINICIAN
PATIENT
MENTAL HEALTH SPECIALIST
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MacArthur InitiativeThree Component Model (TCM)
PRIMARY CARE CLINICIAN
PHQ-9
CARE MANAGER
PATIENT
PHQ-9
PHQ-9
MENTAL HEALTH SPECIALIST
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Care Manager
Encourage Adherence Problem Solve Barriers
Communicate with Clinicians
Measure Treatment Response
Monitor Remission
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Two Question ScreenU.S. Preventive Services Task
ForceAnn Intern Med 2002136760-4

• Over the past 2 weeks, have you
• Felt little interest or pleasure in doing things?
• Felt down, depressed, or hopeless?

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PHQ-9

• Spitzer R, et al. Validation and utility of a
  self-report version of PRIME-MD the PHQ Primary
  Care Study. JAMA 1999 282 1737-1744
• Kroenke K, et al. The PHQ-9 validity of a brief
  depression severity measure. Journal of General
  Internal Medicine 2001 16 606-613

Sensitivity 73 Specificity 94 Correlation
between PHQ self-report and psychiatrist
interview .84
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PHQ - 9 Symptom Checklist
1. Over the last two weeks have you been
bothered by the following problems?
More than Nearly Not Several half the
every at all days days day 0 1 2 3
a. Little interest or pleasure in doing
things b. Feeling down, depressed, or hopeless
c. Trouble falling or staying asleep, or
sleeping too much d. Feeling tired or having
little energy e. Poor appetite or overeating
f. Feeling bad about yourself, or that you are a
failure . . . g. Trouble concentrating on things,
such as reading . . . h. Moving or speaking so
slowly . . . i. Thoughts that you would be better
off dead . . .
2. ... how difficult have these problems made it
for you to do your work, take care of things at
home, or get along with other people?
Subtotals 4 6 6
TOTAL 16
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Typical Frequency of Patient Contacts
Care Manager Phone Call
Primary Care Clinician Visit
PCC
CM
Acute Phase
Continuation Phase
PCC
PCC
PCC
PCC
PCC
CM
CM
CM
CM
CM
1 5 6 9 12
18 24 32
36
WEEK
55
Conceptual Treatment Algorithm
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Conceptual Treatment Algorithm- I
57
Conceptual Treatment Algorithm- II
58
Conceptual Treatment Algorithm- III
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TCM Phase Two Remission (HSCL lt0.5) Outcomes
(p.05) n323 pts 55 practices
(p.04) n335 pts 56 practices
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Differences Between System Changes Usual Care
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3rd Generation Depression System Change
Interventions
IMPACT RESPECT PRISMe PROSPECT
Change Depression Specialist TCM Integrated Mental health Depression Specialist
Care Mgmt On-site Off-site N/A On-site
Patient Education Yes Yes Variable Yes
Psychiatric supervision Face to face Telephone N/A Face to face
Psychotherapy supervision Telephone N/A N/A Face to face
Rx algorithm Yes No No Yes
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Implications for Applied Policy and Practice
63
Leon Eisenberg
SOUNDING BOARD TREATING DEPRESSION AND ANXIETY
IN PRIMARY CARE. Closing the gap between
knowledge and practice  N Engl J Med 1992
3261080-1084, Apr 16, 1992 7th Annual Rosalyn
Carter Symposium on Mental Health Policy,
Atlanta, Nov 21, 1991

• Depression is common in primary care, with
  substantial morbidity
• Under recognized - not because of curriculum, but
  values of patients
• and physicians, inappropriate DSM nosology
• Target physicians in practice, involve patient,
  more follow-up
• consider special nurses, improve payment -
  reward time, assess quality

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• Subcommittee on Mental Health and Aging
  Recommendations on Policy
• Subcommittee on the Mental Health Interface with
  General Medicine
• Integrating Mental Health and General Health Care
• Implementing Evidence-based Medicine

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• The Federal Government should add evidence-based
  collaborative care services for psychiatric
  disorders to the list of covered services through
  the Medicare National Coverage Process

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Evidence-Based Chronic Disease Management
Approaches for Treating Depression Are Effective
Ed Wagner Institute for Healthcare Innovation
(IHI)
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
Self-Management Support
DeliverySystem Design
Decision Support
Informed, Activated Patient
Prepared, Proactive Practice Team
Productive Interactions
Functional and Clinical Outcomes