The question is not whether to integrate, but how

1
The question is not whether to integrate, but
how
Center for Integrated Behavioral Health
Policy Department of Health Policy, The George
Washington University Medical Center

• Eric Goplerud, Ph.D.
• The 17th Annual Commemoration of World Mental
  Health Day The World Federation for Mental
  Health and the Pan American Health Organization
• Thursday, October 8, 2009

2
Contribution by different non-communicable
diseases to disability-adjusted life-years
worldwide in 2005

• Prince et al, Lancet, 2007

3
Leading Causes of Disease Burden by Select World
Bank Region, 2001
Source Disease Control Priorities in Developing
Countries, second edition, 2006, Table 4.2
4
WHO, mhGAP, 2006
5
Proportion of specified budget allocated for
mental health out of total health budget in each
country
Redrawn from WHO Mental Health Atlas
6
Burden of mental disorders and
budget for mental health
                                                  
              Proportion of disability-adjusted
life-years (DALYs), defined as the sum of the
years of life lost due to premature mortality in
the population and the years lost due to
disability for incident cases of mental
disorders.36 Median values for proportion of
total health budget allocated to mental health.5

Sexenar et al, Lancet, 2007)
7
Years of Potential Life Lost to Persons with
Serious Mental Illnesses

• Compared to the general population, persons with
  major mental illness typically lose more than 25
  years of normal life span. Premature mortality
  among addicts up to 18 years.
• In DC, average age of death of DMH patients 54
  years, average life expectancy in DC 72 years

Colton CW, Manderscheid RW. Prev Chronic Dis
2006 Apr Hser et al, 2003
8
Causes of Morbidity and Mortality in People with
Serious Mental Illness

• Suicide and injury account for about 30-40 of
  excess mortality
• About 60 of premature deaths are due to natural
  causes
• Cardiovascular disease
• Diabetes
• Respiratory diseases
• Infectious diseases

Colton CW, Manderscheid RW. Prev Chronic Dis
2006 Lutterman et al, 2003 Apr Hser et al,
2003
9
Smoking, Serious Mental Illness and Addiction

• Prevalence75 to 85
• Consume 44 of all cigarettes nationally
• Smoke heavier
• Smoke more efficiently

Ziedonis et al, 2003
10
Co-occurrence of Mental Illness and Addiction US
SAMHSA, 2003
11
WHO, mhGAP, 2006
12
Cost-effectiveness of Interventions for Mental
Disorders in Low- and Middle-Income Countries
Source Disease Control Priorities in Developing
Countries, second edition, 2006, Figures 2.2 and
2.3
13
Costs of a Mental Health Care PackageBy Region
Source Disease Control Priorities in Developing
Countries, second edition, 2006, Table 31.7
14
Cost-effectiveness of Interventions for Alcohol
Abuse in Low- and Middle-Income Countries
Source Disease Control Priorities in Developing
Countries, second edition, 2006, Figure 2.2
15
Estimated Impact of Interventions to Reduce
High-Risk Drinking
Notes Coverage (modeled percentage of all
high-risk drinkers exposed to the intervention)
95, 80, 50. Source Disease Control
Priorities in Developing Countries, second
edition, 2006, Table 47.6
16
What would a primary care-led MH/SA package cost?
For schizophrenia, bipolar disorder, depression
and hazardous use of alcohol --- over a 10-year
period US 1.85 to US 2.60 per capita in
low-income countries US 3.20 to US
6.25 per capita in lower-middle income
countries -- US 0.20 per capita per year in
low-income countries US 0.30 per capita
per year in lower-middle-income countries
National Institute for Health and Clinical
Excellence. Depression management of depression
in primary and secondary care. British
Psychological Society, Gaskell, 2004. National
Institute for Health and Clinical Excellence.
Schizophrenia full national clinical guidelines
on core interventions in primary and secondary
care. British Psychological Society, Gaskell,
2003.
17
WHO, mhGAP, 2006
18
WHO, mhGAP, 2006
19
Care Model Integration is the Expectation
California Primary Care,2009
20
(No Transcript)
21
(No Transcript)
22
Lessons learned Culture change

• Primary care culture Acute focus
• Mental health culture Individual (not
  population) focus
• Adjusting to a public health approach can be
  challenging, especially for experienced mental
  health professionals
• Examples of chronic disease management (e.g., for
  diabetes) can help make it clear for PCPs

23
Lessons learned Staff buy-in

• Most providers understand why this is needed, but
  feasibility must be demonstrated
• Administrative support and PCP champions are
  critical
• Psychiatrist and care managers need to establish
  trust with PCPs Takes time
• Once implemented, PCPs see the benefits, and late
  adopters come on board

24
Lessons learned Workforce

• Even with collaborative care, workforce issues
  have impact
• Limited availability of psychiatrists care
  managers, especially in rural areas
• Child mental health providers particularly hard
  to find
• Care managers personality or orientation may be
  more important than credentials
• For partnerships across distances, a web-based
  registry facilitates communication

25
Lessons learned Clinical issues

• Collaborative care approach can reduce stigma as
  barrier to treatment seeking in populations of
  color
• Severity of mental health problems in CHCs is
  high
• Co-morbid conditions (especially SU chronic
  pain) must be addressed
• Demand is great Have to be creative
• Specialty mental health partners are critical
  Cant do this alone

26
Lessons learned Sustainability

• Policy piece is critical to address state and
  federal barriers
• Financial solutions require state and local
  problem-solving
• Creative partnerships facilitate model
• Need to promote collaborations between primary
  care provider organization, hospitals / hospital
  districts, mental health partners, and others