Post on 13-Jan-2016
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
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 President’s Commission on Mental Health
Estimated Prevalence of Major Psychiatric Disorders by Age Group
7
8
9
10
11
12
13
14
15
16
2000 2010 2020 2030
18-29 30-44 45-64 65 >
Jeste, Alexopoulus, Bartels, et al., 1999
Prevalence of Depression and Other Disorders in Primary Care
Major All All Study Depression Depression DisordersHoeper 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)
• 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)
Depression Associated with Depression Associated with Worse Health OutcomesWorse Health Outcomes
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
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, 10:417-427
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
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.
Health Service Use and Costs Associated with Depression for Older Primary Care Patients
Cost of Outpatient Services in Depression
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
0 (n=859) 1-2 (n=616) 3-5 (n=659) 6-16 (n=423)
Levels of Chronic Disease Score
None CES-D<8Moderate CES-D=8-15Severe CES-D>16
Unutzer, et al., 1997; JAMA
Cost of Prescriptions
$0
$500
$1,000
$1,500
Low High Hypertension
Low High Arthritis
Low High Ulcer/GI
US
Dol
lars
Medical Dx Only Medical Dx Plus Depression
Medical Severity:
Primary Diagnosis:
1,650 1,366 170342 41 747 149 70 21n: 277381 62
Number of Medical Visits
0
2
4
6
8
10
12
Low High Hypertension
Low High Arthritis
Low High Ulcer/GI
Medical Dx Only Medical Dx Plus Depression
Medical Severity:
Primary Diagnosis:
n: 2,053 314 470 75 1,509 210383 51 856 164 84
% Hospitalized
0%
5%
10%
15%
20%
25%
Low High Hypertension
Low High Arthritis
Low High Ulcer/GI
Medical Dx Only Medical Dx Plus Depression
Medical Severity:
Primary Diagnosis:
n: 2,053 314 470 75 1,509 210383 51 856 164 84
% Admitted to Emergency Room
0%
2%
4%
6%
8%
10%
Low High Hypertension
Low High Arthritis
Low High Ulcer/GI
Medical Dx Only Medical Dx Plus Depression
Medical Severity:
Primary Diagnosis:
n: 2,053 314 470 75 1,509 210383 51 856 164 84
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
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)
The Research Question:
What is the Most Effective Way to Organize and Deliver Mental Health Services to Older Persons in Primary Care Settings?
Primary Care Research in Substance Abuse and Mental Health for the Elderly
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
Primary Hypotheses
• Engagement Hypothesis
• Participation Hypothesis
• Outcomes Hypothesis
• Cost Hypothesis
Is the Integrated Model More Likely to Result in Engagement
in Mental Health Care by Older Persons?
STUDY TARGET CONDITIONSSTUDY TARGET CONDITIONS• Major Depression
• Dysthymic Disorder
• Minor Depression
• Depressive Disorder NOS
• Generalized Anxiety Disorder (GAD)
• Panic Disorder
• Anxiety Disorder NOS
• At-risk Alcohol Use
Sample Characteristics (n=2022)
Anxiety3%
Dual Disorders
7%
At-Risk Drinking
20%
Depression70%
Hispanic6%
Other9%
Asian8%
Black25%
Caucasian52%
Mean Age: 73.5 + 6.2
26% FemaleDiagnoses Ethnicity
Overall Engagement by Model
• Integrated: 71% (709/999)
• Referral: 49% (499/1023)
• Relative Risk: 1.45
RR = % engaged integrated / % engaged referral
Rates of Engagement in MHSA Care: By Diagnosis/Condition
0%
25%
50%
75%
100%
Overall Depression Anxiety At-riskdrinking
Dualdiagnosis
IntegratedReferral
Rates of Engagement in MHSA Care: By Level of Suicidal Ideation
83.0%
70.8% 70.9%
54.1%59.7%
41.4%
0%
25%
50%
75%
100%
Suicidal ideation(n=192)
Death ideation(n=530)
No ideation (n=1194)
IntegratedReferral
RR=1.53
RR=1.19
RR=1.71
Physical Proximity between Primary Care Clinic and MH/SA Clinic
70.4%
46.0% 44.2%
53.5%
0%
20%
40%
60%
80%
100%
% E
ng
ag
em
en
t
Same Practice Area(30 Clinics)
Same Building (11Clinics)
Same MedicalCampus (14 Clinics)
1-10 Miles (5 Clinics)Integrated Care
(n=991)Referral Care
(n=1002)
Legend
*Rates of engagement are significantly different across all four practice arrangements for the total sample (2(3)=103.15, p<.001) and across the three referral practice arrangements (2(2)=7.76, p=.02).
Bartels et al., American Journal of Psychiatry, 161:1455-1462, 2004.
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)
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)
Antidepressant Use
Any Antidepressant Use in Past 3 or 6 Months
0
10
20
30
40
50
60
70
80
0 3 6 12month
per
cen
t
Usual Care Intervention
P<.0001
P<.0001P<.0001
P=.6995
Unützer et al, JAMA 2002; 288:2836-2845.
Mental Health / Psychotherapy / PST-PC
Any Specialty Mental Health / Psychotherapy Visits in Past 3 Months
0
5
10
15
20
25
30
35
40
45
50
0 3 6 12month
perc
en
t
Usual Care InterventionP<.0001P<.0001
P<.0001
P=.2375
Unutzer et al, JAMA 2002.Unützer et al, JAMA 2002; 288:2836-2845.
Collaborative Management of Late-Life Depression in Primary Care
Mean SCL-20 Depression Score
0.00.20.4
0.60.81.01.21.4
1.61.82.0
0 3 6 12Follow-up Month
Mea
n S
CL
-20
Sco
re
Usual Care
Intervention
P=.55
P<.001
P<.001 P<.001
IMPACT Study :Unutzer, et al., 2002 - JAMA
IMPACT Unutzer et al, 2002
0%
5%
10%
15%
20%
25%
30%
35%
3-mos 6-mos 12-mos
Usual CareIntervention
Pat
ient
s in
RE
MIS
SIO
N (
HS
CL
<0.
5)
1,801 patients ≥60 yrs in 18Primary care clinics in 8Health care organizations. “Cadillac model of system change”
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
PROSPECTImprovement in Depression
(≥50% Drop on HDRS Depression Score from Baseline)
Response (³50% drop on SCL-20 depression score from baseline)
0
10
20
30
40
50
60
3 6 12
month
per
cen
t
Usual care Intervention
P<.001
P<.05P<.05
4 8 12
Bruce, et al., 2004 - JAMA
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
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
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
Effectiveness Studies of Depression in Primary Care
Tx Case ID/ Patient Physician Tracking Tx MH Effective
Guidelines Screening Ed. Ed. Systems Coord. Spec.
Schulberg + + + + + + ++++ Yes
Mynors-Wallis + + + + + + +++ Yes
Katon + + + + + + ++ Yes
Katzelnick + + + + + + ++ Yes
Rost + + + + + + +/- Yes
Hunkeler + + + + + + +/- Yes
Simon + + + + + + - Yes
Simon + + + + + - - No
Callahan + + + + - - - No
Goldberg + + + - - - - No
Dowrick + + - - - - - No
From Simon
Greater Patient Improvement with System Changes vs. Usual care
0%
5%
10%
15%
20%
25%
30%
Simon 2000
Wells 2000
Rost 2001
Katzelnick2000
Hunkeler2000
Unutzer2002
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
3rd Generation Depression System Change Interventions
YesNoNoYesRx algorithm
Face to faceN/AN/ATelephonePsychotherapy
supervision
Face to faceN/ATelephoneFace to facePsychiatric supervision
YesVariableYesYesPatient
Education
On-siteN/AOff-siteOn-siteCare Mgmt
Depression Specialist
Integrated
Mental health
TCMDepression
SpecialistChange
PROSPECTPRISMeRESPECTIMPACT
Sustainability of Interventions?
0%
5%
10%
15%
20%
25%
30%
35%
40%
Pre-Intervention
1-6 mos 7-12 mos Post-Intervention
Collaborative Care Usual Care
Lin et al 1997
App
ropr
iate
Ant
idep
ress
ant R
x
Long-term Depression Rx System Need
Time
Sev
erit
y
Normalacy
Symptoms
Syndrome
AcutePhase
ContinuationPhase
MaintenancePhase
Response
RemissionRemission
Relapse
RelapseRecurrence
> 50% STOP Rx
65 to 70% STOP Rx
Only 25% Have ≥ 3 Visits
RecoveryRecovery
Non-adherence to Antidepressants
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 mos. 3 mos. 6 mos. 9 mos. 12 mos. 15 mos.MONTHS OF TREATMENT
Pharmacy data from 1994 on 100,000 patients
PR
OP
OR
TIO
N O
F PA
TIE
NTS
R
EFI
LLIN
G P
RE
SC
RIP
TIO
N
amitriptylinetrazodonenortriptylinefluoxetine
Mean persistence on antidepressants
= 90 to 102 days
AHCPR recommended
treatment duration
NCQA HEDIS* Measure: Long-Term Treatment Adherence
Rates Across Plans (2000 Results)
http://www.ncqa.org
Per
cen
tag
e
100
80
60
40
20
0
Follow-up with MD After Diagnosis ofDepression 3 acutePhase visits
Acute Phase Treatment(84 Days Continuity)
Treatment (6 MonthsContinuity)
Mean
21%
59%
42%
* National Committee for Quality Assurance (of Managed Care Organizations)
annual database of Health Plan Employer Data and Information Set (HEDIS®)
Usual Care
PRIMARY CARECLINICIAN
MENTAL HEALTHSPECIALIST
PATIENT
MacArthur InitiativeThree Component Model (TCM)
PRIMARY CARECLINICIAN
CARE MANAGER
MENTAL HEALTH SPECIALIST
PATIENTPHQ-9
PHQ
-9
PH
Q-9
Care Manager
Encourage AdherenceProblem Solve Barriers
Measure Treatment Response
Monitor Remission
Com
mun
icat
e w
ith
Cli
nic i
a ns
Two Question ScreenU.S. Preventive Services Task Force
Ann Intern Med 2002;136:760-4
Over the past 2 weeks, have you:
• Felt little interest or pleasure in doing things?
• Felt down, depressed, or hopeless?
PHQ-9Spitzer 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
More than Nearly Not Several half the every
at all days days day0 1 2 3
PHQ - 9 Symptom ChecklistPHQ - 9 Symptom Checklist
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 . . .
1. Over the last two weeks have you been bothered by the following problems?
Subtotals: 4 6 6TOTAL: 16
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?
Typical Frequency of Patient Contacts
1 5 6 9 12 18 24 32 36
PCC
CM CM CM CMCM
PCC PCC PCC PCC
PCC CMPrimary CareClinician Visit
Care ManagerPhone Call
Acute Phase Continuation Phase
WEEK
Conceptual Treatment Algorithm MEASURE ACUTE TREATMENT RESPONSE
CLINICALLY SIGNIFICANT RESPONSE
QUESTIONABLE RESPONSE
NO RESPONSE
CONTINUE SAME TREATMENT
INCREASE SAME TREATMENT
SWITCH OR ADD TREATMENT
ASSESS FOR REMISSION
REMISSION
IMPROVEMENT BUT NOT REMISSION
NO IMPROVEMENT
CONTINUE SAME TREATMENT
CONT./INCR-EASE SAME TREATMENT
SWITCH OR ADD TREATMENT
MONITOR CONTINUATION & EVALUATE FOR MAINTENANCE
REMISSION
CONTINUE SAME TREATMENT
STOP TREATMENT
RELAPSE
Conceptual Treatment Algorithm- I MEASURE ACUTE TREATMENT RESPONSE
CLINICALLY SIGNIFICANT RESPONSE
QUESTIONABLE RESPONSE
NO RESPONSE
CONTINUE SAME TREATMENT
INCREASE SAME TREATMENT
SWITCH OR ADD TREATMENT
Conceptual Treatment Algorithm- II ASSESS FOR REMISSION
REMISSION
IMPROVEMENT BUT NOT REMISSION
NO IMPROVEMENT
CONTINUE SAME TREATMENT
CONT./ INCR-EASE SAME TREATMENT
SWITCH OR ADD TREATMENT
Conceptual Treatment Algorithm- III MONITOR CONTINUATION & EVALUATE FOR MAINTENANCE
REMISSION
CONTINUE SAME TREATMENT
STOP TREATMENT
RELAPSE
TCM Phase Two Remission (HSCL <0.5) Outcomes
0%
10%
20%
30%
40%
50%
60%
3 Months 6 Months
Per
cent
Rem
issi
on
UC TCM
(p=.04) n=335 pts 56 practices
(p=.05) n=323 pts 55 practices
Differences Between System Changes & Usual Care
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Simon 2000
Wells 2000
Rost 2001
Katzelnick2000
Hunkeler2000
Unutzer2002
Respect2003
3rd Generation Depression System Change Interventions
IMPACT RESPECT PRISMe PROSPECT
ChangeDepression
SpecialistTCM
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
Implications for Applied Policy and Practice
Leon Eisenberg
SOUNDING BOARDTREATING DEPRESSION AND ANXIETY IN
PRIMARY CARE. Closing the gap between knowledge and practice
N Engl J Med 1992; 326:1080-1084, Apr 16, 19927th 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
• 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
• “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”
Evidence-Based Chronic Disease Management Evidence-Based Chronic Disease Management Approaches for Treating Depression Approaches for Treating Depression Are Effective Are Effective Ed Wagner & Institute for Healthcare Innovation (IHI)Ed Wagner & Institute for Healthcare Innovation (IHI)
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Functional and Clinical Outcomes
DeliverySystemDesign
Decision Support
ClinicalInformation
Systems
Self-Management
Support
Health SystemCommunity Health Care OrganizationResources and
Policies