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