Prevention-Research Centers Health Aging Research Network (PRC-HAN) Webinar Series

1. Prevention-Research Centers Health Aging Research Network (PRC-HAN) Webinar Series Evidence-Based Depression Care Management: Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) Tuesday, October 16th 2008 2-3:30 PM EST Moderated by: Cate Clegg Jürgen Unützer, MD, MPH, MA Virna Little, PsyD, LCSW-R

2. Sponsors: Prevention Research Centers-Healthy Aging Research Network http://www.prc-han.org/ Retirement Research Foundation http://www.rrf.org/ National Council on Aging http://ncoa.org/index.cfm 2

3. Jürgen Unützer, MD, MPH, MA Professor & Vice Chair Psychiatry & Behavioral Sciences University of Washington Virna Little, PsyD, LCSW-R Vice President for Psychosocial Services and Community Affairs Institute for Family Health IMPACT Primary Care Based Team Care for Late-Life Depression 3

4. Depression Common 10% in primary care • Disabling • #2 cause of disability (WHO) • Expensive • 50-100% higher health care costs • Deadly • Over 30,000 suicides / year

5. Depression is deadlyOlder men have the highest rate of suicide.

6. Depression is often notthe only health problem Cancer Chronic Pain 10-20% 40-60% Neurologic Disorders Depression Geriatric Syndromes 10-20% 20-40% Heart Disease Diabetes 10-20% 20-40%

7. Efficacious treatments for depression • Antidepressant Medications • Over 20 FDA approved • Psychotherapy • CBT, IPT, PST, brief dynamic, etc. • Other somatic treatments • ECT • Physical activity / exercise • Unutzer et al, NEJM 2008.

8. But: few older adults get effective treatment • Only half are ‘recognized’ • a particular problem for older men & minorities • “I didn’t know what hit me …” • “I am not crazy” • “Isn’t depression just a part of ‘normal aging?” • Fewer than 10 % seek care from a mental • health specialist. Most prefer their primary care physician.

9. Depression Treatment in Primary Care • 50 % are recognized and started on treatment or referred • Limited access to evidence-based psychosocial treatments (psychotherapy) • Increasing use of antidepressants • PCPs prescribe 70 – 90 % of antidepressants • 10 - 30 % of older adults are on antidepressants • MAJOR OPPORTUNITIES for Quality Improvement – even for nonprescribing providers • But treatment is often not effective • Only 20 – 40 % improve substantially over 12 months

10. Why integrate care? Home & Community based social services? Primary Care PC Alcohol & substance abuse care? Community Mental Health Center CM HC

11. Depression Care Management in Primary Care • Limited access to / use of mental health specialists • Treat mental health disorders where the patients are - Established provider-patient relationship - Less stigma - Better coordination with medical care

12. Components of evidencebased integrated care programs Screening / case finding Patient education / self-management support Support medication treatment prescribed in primary care Monitor adherence, side effects, effectiveness [Nonprescribing providers function as the ‘eyes and ears of the doctor’] Proactive outcome measurement / tracking e.g., PHQ-9, GDS, CES-D Brief counseling (e.g., Behavioral Activation, PST-PC, IPT, CBT) Stepped care (initial treatments often are not enough) increase treatment intensity as needed mental health consultation to help guide or provide care for patients not responding as expected

13. IMPACT Study Funded by John A. Hartford Foundation California Healthcare Foundation Robert Wood Johnson Foundation Hogg Foundation

14. IMPACT Team“None of us is as smart as all of us” • Study coordinating center • Jürgen Unützer (PI), Sabine Oishi, Diane Powers, Michael Schoenbaum, Tom Belin, • Linqui Tang, Ian Cook. PST-PC experts: Patricia Arean, Mark Hegel • Study sites • University of Washington / Group Health Cooperative • Wayne Katon (PI), Elizabeth Lin (Co-PI), Paul Ciechanowski • Duke University • Linda Harpole (PI), Eugene Oddone (Co-PI), David Steffens • Kaiser Permanente, Southern CA (La Mesa, CA) • Richard Della Penna (Co-PI), Lydia Grypma (Co-PI), Mark Zweifach, MD, • Rita Haverkamp, RN, MSN, CNS • Indiana University • Christopher Callahan (PI), Kurt. Kroenke, Hugh. Hendrie (Co-PI) • UT Health Sciences Center at San Antonio • John Williams (PI), Polly Hitchcock-Noel (Co-PI), Jason Worchel • Kaiser Permanente, Northern CA • Enid Hunkeler (PI), Patricia Arean (Co-PI) • Desert Medical Group • Marc Hoffing (PI); Stuart Levine (Co-PI) • Study advisory board • Lisa Goodale (NDMDA), Rick Birkel (NAMI), Thomas Oxman, Kenneth Wells, • Cathy Sherbourne, Lisa Rubenstein, Howard Goldman

15. Study Methods • 1998 – 2003 • Randomized controlled trial • 8 health care organizations in 5 states • 18 primary care clinics • 1,801 older adults with major depression or chronic depression • 450 primary care providers • Patients randomly assigned to IMPACT or usual care • Usual care = antidepressant Rx in primary care (~ 70 %) and / or referral to mental health specialists (20 %) • All followed with independent assessments for 2 years

16. IMPACT Team Care Model Informed, Activated Patient Photo credit: J. Lott, Seattle Times Prepared, Pro-active Practice Team Effective Collaboration Photo: Courtesy D. Battershall & John A. Hartford Foundation Practice Support

17. Evidence-based ‘team care’ for depression

18. Treatment Protocol • Assessment and education, • Behavioral Activation / Pleasant Events Scheduling AND • (3) a) Antidepressant medication usually an SSRI or other newer antidepressant OR • b) Problem Solving Treatment in Primary Care • (PST-PC) 6-8 individual sessions followed by monthly group maintenance sessions • (4) Maintenance and Relapse Prevention Plan for patients in remission

19. Stepped Care • Systematic follow-up & outcomes tracking • Patient Health Questionnaire (PHQ-9) • The “cheap suit” • Treatment adjustment as needed • - based on clinical outcomes • - according to evidence-based algorithm • - in consultation with team psychiatrist • Relapse prevention

21. Greater Satisfaction with Depression Care (% Excellent, Very Good) P=.2375 P<.0001 P<.0001 Unützer et al. JAMA. 2002; 288: 2836-2845.

22. IMPACT Doubles Effectiveness of Depression Care 50 % or greater improvement in depression at 12 months % Participating Organizations

23. Evidence-based Care Benefits Disadvantaged Populations 50 % or greater improvement in depression at 12 months Areán et al. Medical Care, 2005

24. Improved Physical Functioning SF-12 Physical Function Component Summary Score (PCS-12) P<0.01 P<0.01 P<0.01 P=0.35 Callahan et al. JAGS. 2005; 53:367-373.

25. Fewer thoughts of suicide % patients with suicidal thoughts Unützer et al, JAGS 2006

26. IMPACT Saves Money Savings Unutzer et al. Am J Managed Care 2008.

27. IMPACT Summary • Less depression • IMPACT doubles effectiveness of usual care • Less physical pain • Better functioning • Higher quality of life • Greater patient and • provider satisfaction • More cost-effective Photo credit: J. Lott, Seattle Times “I got my life back”

28. IMPACT Endorsements President’s New Freedom Commission on Mental Health National Business Group on Health Institute of Medicine (Retooling for An Aging America) POGOe CDC Consensus Panel Annapolis Coalition Partnership to Fight Chronic Disease SAMHSA NREPP Commonwealth Fund Integrated Behavioral Health Partnership

29. Taking IMPACT from Research to Practice • Support from JAHF (2004-2009) • Over 170 clinics have implemented core components of the program to date • DIAMOND program in Minnesota implementing the program state-wide in partnership with 25 medical groups and 9 health plans • Several large health plans and disease management organizations are incorporating core components of IMPACT

30. IMPACT Implementation Trained over 3000 Providers in over 150 practices to date Over 3,000 clinicians trained 2004 2005 2006 2007 2008

31. Kaiser Permanente of Southern California Pilot Study -Compare 284 clients in ‘adapted program’ with 140 usual care patients and 140 intervention patients in the IMPACT study (Grypma et al, 2006) Dissemination -Implemented core components of program in 10 regional medical centers

32. KPSC – San Diego‘After IMPACT’ • Fewer care manager contacts Grypma et al, General Hospital Psychiatry, 2006.

33. IMPACT Remains Effective >= 50 % drop in PHQ-9 depression scores Grypma et al, General Hospital Psychiatry, 2006.

34. Lower Total Health Care Costs $ / year Grypma, et al; General Hospital Psychiatry, 2006

35. Institute for Urban Family Health

36. IMPACT Effective for Depression 14.03 8.14 7.91 3 Months 6 months Initial

37. Change in DepressionInitial to 6 months 63% 65% 28% 24% 9% 5% 6% Under 10: Mild 10-14: Moderate 15-19: Mod. Severe 20+: Severe Under 10: Mild 10-14: Moderate 15-19: Mod. Severe 20+: Severe

38. A word from providers… • “It is good to see that mental health is • once again becoming part of the medical • Interview, as so much of our patient's • health depends on their mental well being.” • - Dr. Eric Gayle • “Project IMPACT has allowed me to incorporate • a new tool (PHQ-9)into my primary care practice, • which has improved the accuracy of my diagnosis • while increasing my efficiency and productivity as well. • It helped me identify patients I initially overlooked.” • -Dr. Joseph Lurio (68th Street)

39. Depression Is Associated With a Higher Number of Cardiac Risk Factors > 3 Cardiac Risk Factors (%) Diabetic Patients With CVD N=3010 Diabetic Patients Without CVD N=1215 Katon et al, J Gen Intern Med, 2004

40. Depression Increases Mortality Rate in Patients With Diabetes by 2-Fold Katon et al. Diabetes Care, 2005

41. Depression and Diabetes: More Depression Free Days over 2 Years 412 359 331 215.5 115.5 53

42. Two Collaborative Care Trials Demonstrate Improved Depression Care in Diabetes Lowers Total Health Care Costs Over 2 Years $22,258 $21,148 $18,932 $18,035 $1,110 $897 Katon et al. Diabetes Care 2006, Simon et al Arch Gen Psychiatry 2007

43. Project Dulce + IMPACTPrincipal Investigator: Todd Gilmer, UCSD • Combined diabetes and depression care management program targeting low-income and primarily Spanish speaking Latinos in San Diego community clinics • Added a depression care manager to an existing diabetes team (RN/CDE, promotoras) • Translation for Cultural Competency • DCM bilingual with experience serving Latino pop. • PST-PC adapted to low-literacy population

44. Project Dulce + IMPACT Results Screened 499 patients with PHQ9 31% with scores of 10+ 75% Latino, 70% Spanish speaking 65% had depressive symptoms for 2+ years 26% interested in pharmacological treatment 74% interested in psychological treatment 48% reported financial stressors

45. Depressive Symptoms at Baseline and Six-Month Follow-Up As Measure with PHQ-9. Inter-Quartile Range (box) Highest and Lowest (whiskers) Outlier (dots) Median Gilmer et al. Diabetes Care 2008

46. Collaborative Care for Alzheimer’s Disease Collaborative Care for Alzheimer’s Disease Christopher M. Callahan, MD Cornelius and Yvonne Pettinga Professor Director, Indiana University Center for Aging Research Research Scientist, Regenstrief Institute, Inc.

47. Improvement in Dementia-related Problem Behaviors Patient NPI Score IU Center for Aging Research Callahan et al. JAMA 2006

48. Improvement in Caregiver Stress Caregiver NPI Score Callahan et al. JAMA 2006 IU Center for Aging Research

49. Implementing Collaborative Care • Shared vision • How will we know success? • Shared, measurable outcomes • (e.g., # and % of population screened, treated, improved) • Engaged leaders & stakeholders • Clinic leaders & administration • PCPs, care managers, psychiatry, other mental health providers • Clinical & operational integration • Functioning teams, communication, and handoffs • Clear about ‘shared workflow’ & roles of various team members • Adequate resources • Personnel, IT support, funding • Proactive problem solving re barriers & competing demands • Minimize complexity, PDCA

50. http://impact-uw.org