Applying Research on Evidence-Based Mental Health Practices in Real-World Settings

1
Applying Research on Evidence-Based Mental Health
Practices in Real-World Settings
Michael Schoenbaum, PhD Senior Advisor Division
of Services and Intervention Research National
Institute of Mental Health July 16, 2008
2
Challenges to improving health

• Two transcendent problems predominate.
• First, available care is not delivered well
  Americans do not always obtain the interventions
  that would improve their health or prevent
  illness.
• Second, the interventions that Americans do
  receive have limited efficacy in improving
  outcomes. More lives could be saved by developing
  better drugs, technologies, and procedures.
• In effect, society faces a choice between these 2
  strategies for bettering health and must strike a
  prudent balance in how many resources it
  allocates to each endeavor.
• --Woolf Johnson, Ann Fam Med, 2005

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Margins for improvement

• Enhance the efficacy (and effectiveness) of
  interventions. Health can be improved if
  screening and diagnostic procedures are made more
  accurate and if treatments can perform better in
  reducing morbidity and mortality
• (Enhance the fidelity of interventions.)
  Independent of the efficacy or effectiveness of
  interventions, fidelity is the extent to which
  the system provides patients the precise
  interventions they need, delivered properly,
  precisely when they need them.
• --Woolf Johnson, Ann Fam Med, 2005

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Cumulative lifetime probability of treatment
contact for anxiety disorders, from year of onset
SOURCE Wang et al. Arch Gen Psychiatry 2005
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Balancing Improved Efficacy vs. Improved
Fidelity
SOURCE Woolf Johnson, Ann Fam Med, 2005
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NIMHs mission (2007) is to reduce the burden of
mental illness and behavioral disorders through
research on mind, brain, and behavior

• Develop more reliable, valid diagnostic tests and
  biomarkers for mental disorders
• Develop more effective, safer, and equitable
  treatmentsto reduce symptoms, and improve daily
  functioning
• Support clinical trials that will provide
  treatment options to deliver more effective
  personalized care
• Create improved pathways for rapid dissemination
  of science to mental health care and service
  efforts

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NIMHs mission (2008) is to transform the
understanding and treatment of mental illnesses
through basic and clinical research, paving the
way for prevention, recovery, and cure

• Promote discovery in the brain and behavioral
  sciences to fuel research on the causes of mental
  disorders
• Chart mental illness trajectories to determine
  when, where, and how to Intervene
• Develop new and better interventions for mental
  disorders
• Strengthen the public health impact of
  NIMH-supported research

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Margins for improvement

• The greater the gaps in delivery, the more
  efficacy must be increased to make that
  enterprise more beneficial than improving
  delivery...
• --Woolf Johnson, Ann Fam Med, 2005

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Strategic Objective 4 Strengthen the Public
Health Impact of NIMH-Supported Research
26.2
Impact Gap
10.8
U.S. Adults
3.5
Any mental disorder
Any mental health treatment
Adequate treatment
Adapted from Kessler et al, Arch Gen Psychiatry,
2005 Wang et al, Arch Gen Psychiatry, 2006
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Rates of Adequate Treatment for Serious Mental
Illness
SOURCE Wang et al. Am J Pub Health 2002
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Margins for improvement

• Effect size
• Efficacy
• Effectiveness
• Coverage
• Adherence
• Personalization
• Cost of achieving the effect

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Balancing Improved Efficacy vs. Improved
Fidelity
SOURCE Woolf Johnson, Ann Fam Med, 2005
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Margins for improvement

• Effect size
• Efficacy
• Effectiveness
• Coverage
• Adherence
• Personalization
• Cost of achieving the effect
• Confidence interval/precision

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Balancing Improved Efficacy vs. Improved
Fidelity
SOURCE Woolf Johnson, Ann Fam Med, 2005
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Precision

• At a threshold of 50K/QALY and assuming that the
  CATIE results about the mean outcomes across
  treatment arms are correct, which implies that
  the typical antipsychotics are the cost-effective
  first line treatment in this population, the
  value of more precisely determining the
  cost-effectiveness of atypical/typical
  antipsychotics in the US is 342 billionThe
  probability that this current decision will be
  wrong is estimated to be 55.
• --Basu et al., poster presentation, 2007

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2003 Medicare Modernization Act, Sec 103

• The Secretary (of HHS) shall conduct and support
  research to meet the priorities and requests for
  scientific evidence and information identified by
  (federal health care) programs with respect to
• The outcomes, comparative clinical effectiveness,
  and appropriateness of health care items and
  services (including prescription drugs)
• Strategies for improving the efficiency and
  effectiveness of such programs, including the
  ways in which (health care) items and services
  are organized, managed, and delivered under such
  programs

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Evidence-based opportunities to strengthen mental
health in the US

• Evidence reviewed by
• Presidents New Freedom Commission on Mental
  Health (2003)
• Institute of Medicine, Improving the Quality of
  Health Care for Mental Substance-Use Conditions
  (2006)
• DHHS, Mental Health A Report of the Surgeon
  General (1999)
• Many common QI issues
• Across mental health
• Between medical mental health
• Illustrate with two major conditions
• Depression
• Schizophrenia/psychosis

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Depression is prevalent

• 7 overall (12-month prevalence, age 18)
• 10 in primary care
• 15-40 in medically ill
• Prevalence rises with severity of medical illness
• 15 of SSDI awards

Sources Kessler et al., JAMA, 2003 Katon, Biol
Psych, 2003 Social Security Administration,
2004 Aron et al., Urban Institute, 2005
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Usual depression care is not effective

• Most cases of depression can be treated
  effectively in primary care
• But currently
• Half of people with depression are not recognized
  or treated
• No more than 1 in 4 get minimally adequate
  treatment
• Among those treated, care is often ineffective

Sources Unützer et al., JAMA 2002 Gilbody et
al., Arch Intern Med 2006 Wang et al., Arch Gen
Psych 2005 Young et al., Arch Gen Psych 2001
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Key components of effective care

• Screening assessment
• Patient education and activation
• Treatment
• Care management
• Mental health consultation

Collaborative Care
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Collaborative care has been tested

• 30 randomized control trials (reviewed in
  Gilbody et al., Arch Intern Med 2006)

• Benefits of effective care
• Less depression
• Less physical pain
• Better functioning
• Increased employment productivity
• Higher quality of life
• Greater patient provider satisfaction
• More cost-effective than usual care (cost-saving
  in high risk groups)

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• The Commission suggests that collaborative care
  models should be widely implemented in primary
  care settings and reimbursed by public and
  private insurers. (Goal 4, Recommendation 4.4,
  p. 65)

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Core components of evidence-based collaborative
care

• Care manager time
• In-clinic or telephone contact
• Independently or incident to clinician
• Mental health specialty consultation
• Caseload supervision
• Without face-to-face patient contact
• Screening / outcome tracking as lab test
• (Primary care MH visits on same day)

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Real-world collaborative care models

• Kaiser Permanente of Southern California
• All components integrated within health plan
• Aetna Depression Management initiative
• Screening assessment implemented via FFS
• Care management psych consults integrated
  within plan
• (http//www.aetna.com/aetnadepressionmanagement/)
• ICSI DIAMOND initiative in Minnesota
• All components implemented via FFS
• (http//www.icsi.org/news/archive/diamond_project_
  launched_.html)

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Priorities for evidence

• Delivering at population level
• Practice-based
• Via 3rd party
• Financing
• FFS vs. case rate
• Cost-sharing?
• Incentivising quality
• Developing testing measures
• PQRI / CPT Category 2
• Other barriers to dissemination
• E.g, provider/manager knowledge
• Extending to whole patient

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Possible leverage points

• Coverage
• Procedure codes quality measures
• Information systems
• Demonstration / pilot programs
• Medicare Health Support
• Medical Home
• ICSI DIAMOND initiative
• QIO scope of work / special projects
• eRAP for Depression (nursing home pilot)
• Other initiatives, e.g.,
• VA, HRSA, SAMHSA, Soc. Sec. Admin.
• Major purchasers

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Epidemiology of schizophrenia

• 0.5 overall (12-month diagnosed prevalence, all
  ages)
• 7 of SSDI awards
• Very high costs

Source Bartels et al., Am J Geriatr Psychiatry,
2003
Sources US Surgeon General, 1999 Wu et al.,
Psychol Med, 2006 Social Security
Administration, 2004 Aron et al., Urban
Institute, 2005
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Premature mortality in schizophrenics

• Average lifespan reduction of 25 years
• 30-40 due to suicide injuries
• 60 due to natural causes
• Cardiovascular disease (2.3x stand. mort. ratio)
• Diabetes (2.7x SMR)
• Respiratory diseases (3.2x SMR)
• Infectious diseases (3.4x SMR)
• Cardiovascular disease accounts for largest
  number of excess deaths

Sources Colton Manderscheid, Prev Chronic Dis
2006 Osby et al., Schizophr Res 2000 Osby et
al., BMJ 2000
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Poor usual care for people with severe mental
illness

• Fewer routine preventive services1
• Worse diabetes care2
• Fewer HbA1c tests, LDL tests, eye exams
• Lower rate of monitoring
• Poor glycemic control
• Poor lipemic control
• Lower rates of cardiovascular procedures3
• High rates of nursing home use4

Sources 1. Druss et al., Medical Care, 2002
Desai et al., J Gen Intern Med, 2002 Druss et
al., Arch Gen Psych, 2001 2. Desai et al., Am J
Psychiatry, 2002 Frayne et al., Arch Intern Med,
2005 3. Druss, JAMA, 2000 Druss et al., JAMA,
2000 Desai et al., J Nerv Ment Dis, 2002 4.
Bartels et al., Am J Geriatr Psychiatry 2003
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Effective strategies exist

• Medication management (e.g., Rosenheck et al., Am
  J Psychiatry 2006)
• Assertive community treatment (ACT)
• 25 trials (Phillips et al., Psych Services 2001)
• Psychosocial interventions (incl. family
  interventions) (e.g., Lehman et al.,
  Schizophrenia Bulletin 1998)
• Integrated care
• Primary care embedded in mental health program
  (e.g., Druss et al., Arch Gen Psych 2001)
• Unified primary care mental health program
  (e.g., Cherokee Health System in TN)
• Linkage care management - improved PCP-MH
  collaboration (e.g., Bartels et al., Comm Ment
  Health J 2004)
• Core elements not always / fully available

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• The Commission supports coordinated and, where
  appropriate, integrated mental health and
  substance abuse screening, assessment, early
  intervention, and treatment for co-occurring
  disorders... (Goal 4, Recommendation 4.3, p. 64)

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Priorities for evidence

• Effectiveness
• Scalability
• Financing evidence-based interventions
• Boundaries of health care
• Measuring quality outcomes

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Possible leverage points

• Coverage
• Procedure codes quality measures
• Demonstration / pilot programs
• Other initiatives

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• For more information
• Michael Schoenbaum, PhD
• Senior Advisor for Mental Health Services,
  Epidemiology, and Economics C
• Division of Services and Intervention Research
• National Institute of Mental Health
• 6001 Executive Blvd, Room 7142 MSC 9629
• Bethesda, MD 20892-9669
• Tel. [phone]
• Fax [phone]
• Email schoenbaumm_at_mail.nih.gov
• www.nimh.nih.gov