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

1. Prevention Research Centers (PRC)-Healthy Aging Research Network (HAN) Webinar Series Evidence-Based Mental Health Practices for Older Adults: The Latest Data, Strategies and Funding Options December 2, 2008, 3:00 - 4:30 P.M. EST Margaret Moore, MPH, MSSW, CDC Stephen J. Bartels, MD, MS Dartmouth Moderated by: Doris M. Clanton, MA, JD, GA DHR/DAS Not Pictured: Suzanne Bosstick, MS & Mary Sowers, CMS

2. Audio Portion of this Presentation • If you are having difficulty accessing the audio portion of this call and received the “The Conference is Full” message, please dial the backup number listed below: Backup Phone Line 888-209-3778

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

4. Funding National Association of State Mental Health Program Directors, Office of Technical Assistance (NASMHPD OTA) http://www.nasmhpd.org/ntac.cfm through funding for the Georgia Department of Human Resources, Division of Aging Services and Division of Mental Health, Developmental Disabilities and Addictive Diseases http://aging.dhr.georgia.gov http://mhddad.dhr.georgia.gov

5. This webinar will… • highlight recent CDC findings related to the mental health of older adults; • identify roles for public health, mental health, aging network systems to promote older adult mental health; • identify recently developed SAMHSA implementation resource kit materials that can be used by administrators, clinical providers, consumers, and program managers to help guide the process of selecting and implementing evidence-based interventions and services for depression in older adults; • highlight practical information about Medicaid coverage/reimbursement for evidence-based depression programs for older adults; and • identify issues, risks, strategies and potential funding sources for evidence-based programs and practices.

6. Evidence-Based Mental Health Practices for Older Adults: The Latest Data Maggie Moore, MPH CDC Healthy Aging Program December 2, 2008

7. Mental Health as an Emerging Public Health Issue Evolution of the public health mission Mental health (MH) essential to overall health Links between MH and chronic conditions Now part of priority setting

8. Public Health’s Roles Monitor MH indicators Support development, translation, implementation, and dissemination of evidence-based programs Identify risk factors Source: Marshall Williams S, Chapman D, Lando J (2005). The role of public health in mental health promotion. MMWR 54(34):841-842.

9. Public Health’s Roles Increase awareness / reduce stigma Eliminate health disparities Improve access to services Source: Marshall Williams S, Chapman D, Lando J (2005). The role of public health in mental health promotion. MMWR 54(34):841-842.

10. CDC Healthy Aging Program’s Current Projects Examining MH indicators Supporting the translation, implementation, and dissemination of evidence-based programs Sharing what we’ve learned

11. Using Data for Action What gets measured, gets done! Needs to be easily accessible Data needed for: Grant writing Planning/priority setting Measuring progress

12. Examining the Data • 2006 Behavioral Risk Factor Surveillance System (BRFSS) • Core questions and Depression and Anxiety Module • Adults aged 50+

13. 6 Indicators Core BRFSS • Social and emotional support • Life satisfaction • Frequent mental distress Dep/Anx Module • Current depression • Lifetime diagnosis of depression • Lifetime diagnosis of anxiety disorder

15. Social and Emotional Support US Virgin Islands District of Columbia 0 – 7.87% 7.88 – 9.41% 9.42 – 11.18% 11.19 – 17.74% Percentage of adults aged 50 or older who reported that they “rarely” or “never” received the social support that they needed Source: CDC, BRFSS 2006

16. Social and Emotional SupportHighlights • Nearly 90% of adults 50+ receive adequate amounts of support • Adults 65+ were more likely than those 50-64 to report not receiving adequate support • Men 50+ were more likely than women to report not receiving needed support

17. Life Satisfaction US Virgin Islands District of Columbia 0 – 4.06% 4.07 – 4.57% 4.58 – 5.04% 5.05 – 7.16% Percentage of adults aged 50 or older who responded that they were “dissatisfied” or “very dissatisfied” with their lives Source: CDC, BRFSS 2006

18. Life SatisfactionHighlights • Nearly 95% of adults 50+ reported being “satisfied” or “very satisfied” with their lives • Adults 50-64 were more likely than those 65+ to report being dissatisfied with their lives • White, non-Hispanic adults in all age groupings were least likely to report dissatisfaction with their lives

19. Frequent Mental Distress US Virgin Islands District of Columbia 0 – 7.23% 7.24 – 8.52% 8.53 – 9.82% 9.83 – 14.45% Percentage of adults aged 50 or older who, in the past 30 days, experienced frequent mental distress Source: CDC, BRFSS 2006

20. Frequent Mental DistressHighlights • Greater than 90% of older adults do not experience Frequent Mental Distress (FMD) • Hispanic adults 50+ reported more slightly more FMD than other racial/ethnic groups • Women in all age groupings reported more FMD than men

21. Current Depression US Virgin Islands District of Columbia No Data 0 – 5.41% 5.42 – 6.66% 6.67 – 8.57% 8.58 – 12.43% Percentage of adults aged 50 or older who had current depression (defined by a PHQ-8 score of 10 or greater) Source: CDC, BRFSS 2006

22. Current DepressionHighlights • Only 7.7% of adults 50+ reported current depression • Hispanic adults 50+ reported more current depression than other racial/ethnic groups • Women 50+ reported more current depression than men

23. Lifetime Diagnosis of Depression US Virgin Islands District of Columbia No Data 0 – 5.41% 5.42 – 6.66% 6.67 – 8.57% 8.58 – 12.43% Percentage of adults aged 50 or older with a lifetime diagnosis of depression Source: CDC, BRFSS 2006

24. Lifetime Diagnosis of DepressionHighlights • Adults 50-64 reported more Lifetime Diagnosis of Depression (LDD) than those 65+ • Women 50+ reported more LDD than men

25. Lifetime Diagnosis of Anxiety US Virgin Islands District of Columbia No Data 0 – 5.41% 5.42 – 6.66% 6.67 – 8.57% 8.58 – 12.43% Percentage of adults aged 50 or older with a lifetime diagnosis of anxiety disorder Source: CDC, BRFSS 2006

26. Lifetime Diagnosis of Anxiety DisorderHighlights • More than 90% of adults 50+ did not report a Lifetime Diagnosis of Anxiety Disorder (LDAD) • Adults 50-64 were more likely to report a LDAD compared to those 65+ • Women 50-64 were more likely to report a LDAD than men

27. Next Steps for the CDC Healthy Aging Program • Disseminating Issue Brief #1 • Developing The State of Mental Health and Aging in America Issue Brief #2: Depression Programs and Resources • Releasing an interactive data website based on the data in Brief #1

28. Next Steps • Working with state health departments to see what roles they can play in MH • Encouraging inclusion of MH questions on BRFSS and the use of this data by states

29. For more information Maggie Moore, MPH mmoore6@cdc.gov www.cdc.gov/aging

30. Evidence-Based Integrated Models of Care for Older Adults with Mental Health Needs Stephen Bartels, MD, MS Professor of Psychiatry and Community and Family Medicine Director, Dartmouth Centers for Health and Aging

31. Overview • Background: Evidence-based Practices • Integration of Mental Health Services in Primary Care • Community Outreach • Technical Support Implementation Resource Materials

32. Setting Priorities for Older Adults Improving Access: • Integration of Mental Health and General Health Care • Home and Community-based Services Improving Quality: • Evidence-based Practice Implementation • Trained Healthcare Workforce with Expertise in Geriatrics

33. Integrated Mental Health Services in Primary Care The Vast Majority of Mental Health Services Provided to Older Persons are in Primary Care

34. Three RCT Studies of Integrated Mental Health in Primary Care • PRISMe (SAMHSA-VA) • PROSPECT (NIMH) • IMPACT (Hartford Foundation)

35. PRISMe Study: Primary Care Research in Substance Abuse and Mental Health for the Elderly Older Adults with Depression or At-Risk Alcohol Use Randomized Trial Comparing: • Integrated/Collaborative Care • Co-Located, Concurrent, Collaborative • Enhanced Referral to Specialty Mental Health and Substance Abuse Clinics • Preferred Providers and Facilitated appointments, transportation, payment

36. Rates of Engagement in MHSA Care: By Diagnosis/Condition(n=2022, mean age 73.5)

37. Implications • Engagement in treatment is substantially better for integrated MH and Substance abuse services in primary care • Under the most optimal of circumstances, enhanced referral to specialty providers results in successful engagement less than half of the time

38. 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)

39. Substantial Improvement in Depression(≥50% Drop on SCL-20 Depression Score from Baseline) P<.0001 P<.0001 P<.0001 3 6 12 Unutzer et al, JAMA 2002. Unützer et al, JAMA 2002; 288:2836-2845.

40. PROSPECTImprovement in Depression(≥50% Drop on HDRS Depression Score from Baseline) P<.05 P<.05 P<.05 P<.05 P<.001 P<.001 4 8 12 Bruce et al,JAMA, 2004;291:1081-1091

41. Integrated Care is More Cost Effective Than Usual Care IMPACT participants had lower mean total healthcare costs: $29,422 compared to usual care patients: $32, 785 over 4 years.

42. Impact Model Implementation Resources http://impact-uw.org/

43. Effectiveness of Community-Based Mental Health Outreach Services for Older Adults Results from a Systematic Review

44. Case Identification and Referral Models • “Gatekeeper” Model • Trains community members to identify and refer community-dwelling older adults who may need mental health services • Effective at identifying isolated elderly, who received no formal mental health services Florio & Raschko, 1998 • However…no empirical data on depression outcomes for referral model

45. Combined Case Identification and Treatment • Psychogeriatric Assessment and Treatment in City Housing (PATCH) program. • Serving Older Persons in Baltimore Public Housing • 3 elements • Train indigenous building workers (i.e.,managers, janitors,) to identify those at risk • Identification and referral to a psychiatric nurse • Psychiatric evaluation/treatment in the residents home • Effective in reducing psychiatric symptoms • Rabins, et al., 2000

46. RCTs of Geriatric Mental Health Community Outreach Models% Recovered from Depression* * Greater than 50% reduction in symptoms or meeting syndromal criteria

47. Home and Community Depression Treatment 8 Home-based sessions of manualized problem-solving therapy (PST) over a 19 week period Social & physical activation, pleasant events scheduling Clinical supervision by a psychiatrist, recommendations for medication (if needed) management by phone contact with physician and/or participant Follow-up phone calls (1/month, for 6 months) For Older Adults

48. PEARLS 12-Month Outcomes: Depression Symptom Reduction and Depression Remission %

50. Federal Technical Assistance Initiatives • SAMHSA’s Older Americans Substance Abuse and Mental Health Technical Assistance Center • SAMHSA’s Implementation Resource Kits for Depression in Older Adults