Depression Management

1. Depression Management Moving IHS Practice Into the 21st Century Peter Stuart, MD Psychiatry, Colorado River Service Unit Parker, Arizona Peter.stuart@ihs.gov

2. Overview • Background – Understanding Depression and its Context • What Does Screening Do? • Moving from Screening to Collaborative Care • Collaborative Care Overview • IHS Issues

3. The New York TimesJuly 24, 2012Fighting Depression One Village at a Time ..Why did it take so long for health experts to see what now seems obvious: just as all people need access to health care, we all need access to mental health care. If depression can paralyze people who have everything, how could we ever have thought that it didn’t affect people who have nothing? “There’s an assumption that after you bury five of your kids you get used to it, and it doesn’t hurt as much,” said Verdeli. “People don’t realize you don’t get used to it. You just give up.”

4. Depression “The howling tempest of the brain ...” William Styron in “Darkness Visible” Now the Spirit of the Lord departed from Saul, and a harmful spirit from the Lord tormented him ... 1 Samuel 16:14 ESV “Depression is emotional pain without context.” Helen Mayberg, neuroscientist, as quoted in the NY Times in an article titled “Post-Prozac Nation” by Siddhartha Mukherjee, MD, 4/22/2012

5. Depression Pathophysiology • Sociological Perspective • Anomie • Community Adversity • Psychological Theories • Learned Hopelessness • Early trauma and loss • Serotonin Hypothesis • Nerve/Neuronal Plasticity • Nerve Growth Factor (NGF)

6. Diagnostic Criteria (DSM-IV) Major depression is present when the patient has had at least 5 of the 9 following symptoms for a minimum of two weeks. One of the symptoms must be either: • Depressed mood, or • Loss of interest or pleasure, and…

7. Diagnostic Criteria, cont. 3. Significant change in weight or appetite 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or guilt 8. Impaired concentration or ability to make decisions 9. Thoughts of suicide or self-harm

8. Diagnostic criteria, cont. • Symptoms must be accompanied by functional impairment in one or more of the following domains: • work/school • doing things at home • relationships with other people

9. Depression is common ... • The National Comorbidity Survey Replication • Lifetime prevalence: 16.2% • Annual prevalence: 6.6% • Populations below the US poverty levels: • Prevalence rates up to 20% • Primary Care Settings • Point Prevalence rates between 5 and 10% • In the setting of chronic illness • Diabetes – 12-18% • Coronary Artery Disease – 15-23% • Cancer patients – 24.6%

10. American Indian Service Utilization, Psychiatric Epidemiology, Riskand Protective Factors Project (AI-SUPERPFP) • Largest mental illness epidemiology study completed • 3084 tribal members surveyed (Plains and SW) in 1997-99 • Modeled on the National Comorbidity Survey (NCS) Findings included: • Major Depression prevalence (7.2-9.8%) LOWER than NCS prevalence of 12.8%. • Panic Disorder/PTSD 2-3x HIGHER than the NCS prevalence (2.0 and 4.3 respectively) Beals et al. Am J of Psychiatry, 2005. 162: 1723-1732.

11. Past Year Major Depressive Episode among Adults Aged 18 or Older, by Race/Ethnicity: 2002-2006 Percent in Past Year + + + + Difference between this estimate and American Indian/Alaska Native estimate is significant (p<.05). NOTE: Major Depressive Episode (MDE) is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms for depression as described in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

13. And contributes substantially to morbidity and mortality Coronary Artery Disease • SADHART study 1993 • The presence of unimproved major depression doubles long-term mortality in CAD • Depression more than doubles the likelihood of hospitalization Diabetes • Nurse Health Study • Relative Risk of all cause mortality • Depression only – 1.76 Diabetes only – 1.71 Dep+DM – 3.11

14. Overall, studies suggest the presence of depression and other mental health conditions in a variety of settings increases the relative risk of all cause mortality by a factor of 1.5-4x Druss et al. Mental disorders and medical comorbidity. RWJF Synthesis Project. Feb 2011.

15. Depression and other mental disorders and Adversity Druss et al. Mental disorders and medical comorbidity. RWJF Synthesis Project. Feb 2011.

16. National Primary Care Trends • Primary Care settings treat 1/3 of people with Psychiatric Disorders <an increase of 153% in 1 decade> Wang et al. Changing profiles of services sectors used for mental health care in the United States. Am J Psychiatry 2006.

17. Trends In Prescription Of Antidepressants In Offices Of Primary Care Providers, 1996–2007. Mojtabai R , Olfson M Health Aff 2011;30:1434-1442 ©2011 by Project HOPE - The People-to-People Health Foundation, Inc.

18. Primary Care Realities • Older adults with Major Depression: • ~2/3 treated in Primary Care1 • Symptom severity equivalent to patients in MH settings1 • 1/8 patients in Primary Care practices suffer from MDD1 • 41% of those treated receive “adequate treatment”1 • Defined as: Min 8 psychotx visits and/or 4 medication visits/annually • 4/5 antidepressant prescriptions are written by non-psychiatrists.2 1Pence, BW et al. The Depression Treatment Cascade in Primary Care: A Public Health Perspective, Curr Psychiatry Rep , 2012. 2MojtabaiR , OlfsonM. Health Aff2011.

19. Druss et al. Mental disorders and medical comorbidity. RWJF Synthesis Project. Feb 2011.

20. How To Approach Given: • Patients seen primarily in Primary Care Settings • Communities are poor and families are exposed to significant adversities • Multiple medical co-morbidities are routine • Access can be challenging • High mental illness co-morbidity • Cross-cultural communication and understanding issues

21. Meeting Basic Treatment Requirements Psychotherapy • Most references suggest that a reasonable course of treatment includes about 8 sessions of therapy Pharmacotherapy • Treating at adequate doses over adequate periods • 4 visits in a year minimum • Adjusting therapy based on response Goal: • Treat to remission

22. Example of SU Antidepressant Tx Management Profile Acute Phase Management – patients with a new diagnosis who have filled a minimum of 84 days of continuous medication treatment with an antidepressant 42.7% Continuous Phase Management – patients with a diagnosis of depression who have filled sufficient medication refills for 180 continuous days of treatment 24.7% Optimal Practitioner Contacts – patients with a diagnosis of depression who have had a minimum of 3 mental health visits in the 12 weeks after diagnosis 32.6% See iCare “Other National Measures” section

23. The initial IHS approach Screen for Depression

24. Recommendation: Depression Screening Screening for Depression • Release Date: May 2002 Summary of Recommendations / Supporting DocumentsThe information found here is current for adults. This recommendation has been updated in part for children and adolescents. Go to http://www.ahrq.gov/clinic/uspstf/uspschdepr.htm to view the new recommendation for children and adolescents, published in March 2009. • Summary of Recommendations • The U.S. Preventive Services Task Force (USPSTF) recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and followup.Grade: B Recommendation. • The USPSTF concludes the evidence is insufficient to recommend for or against routine screening of children or adolescents for depression.Grade: I Statement.

25. IHS GPRA Measures GPRA BH Screens Share: Focus on primary care level identification of concern – early intervention where possible Follow generally accepted USPSTF guidelines (United State Preventive Services Task Force) Do NOT specifically identify activity in Behavioral Health settings but Behavioral Health activity across the entire system of care

26. Preferred Screening Tools PHQ-9 or PRIME-MD-Depression

27. Depression Screening – GPRA 06-09

28. The Difficult News Screening by itself or with simple provider/patient feedback does NOT improve population depression treatment outcomes

29. Patient with Depression Has Depression recognized Starts Treatment Treatment is adjusted to clinical need Remission and maintenance Adapted from: Pence, BW et al. The Depression Treatment Cascade in Primary Care: A Public Health Perspective, Curr Psychiatry Rep , 2012.

30. Pence, BW et al. The Depression Treatment Cascade in Primary Care: A Public Health Perspective, Curr Psychiatry Rep , 2012.

31. Pence, BW et al. The Depression Treatment Cascade in Primary Care: A Public Health Perspective, Curr Psychiatry Rep , 2012.

32. Pence, BW et al. The Depression Treatment Cascade in Primary Care: A Public Health Perspective, Curr Psychiatry Rep , 2012.

33. Screening Burden by Task

34. Comparison of Patient, Staff, and Provider Time (min) for One and Two Stage Screeners Adapted from: Screening for Depression in Primary Care. Kathryn M. Magruder, M.P.H., Ph.D. and Derik E. Yeager, M.B.S..VA.

35. Relationship Screening Strategies Use Screening as part of relationship enhancement • Consider screening after your visit • Validate usefulness of screen and why it matters to you as the patient’s provider and to the treatment team • Screen at change or inflection points • New diagnoses of chronic illness • Personal loss • New patient • Patient not seen in clinic for 6-12 months • Use Screen as assessment anchor to drive protocol initation • Use Screen for patients with difficulty adjusting • To you To the Treatment Team To their diagnosis

36. Taking the Next Step Collaborative Care

37. The evolution of collaborative care Episodic Acute Care Widely Variable Disease Management Approaches Disease specific Protocol Driven Chronic Care Model Collaborative Care Integrated Multi-condition Care

38. The Collaborative Care Evidence Base Community Preventive Services Task Force Community Guide Systematic Review “Collaborative Care to Improve the Management of Depressive Disorders” • Meta-analysis of 69 RCT studies of collaborative care published through 2009 • Clinically meaningful effects noted in: • Depression Symptom Improvement • Adherence • Response • Remission • Recovery • Satisfaction with care Thota et al. Am J Prev Med 2012; 42.

39. IMPACT Katon et al, Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression, Diabetes Care. 2006 Feb;29(2):265-70. Cost = 25 cents per additional depression free day

40. Jacob et al. Economics of Collaborative Care for Management of Depressive Disorders. Am J Prev Med 2012. 42(5). “Good Economic Value ...” in review of 30 studies – with cost/QALY at or below standard threshold.

41. Davis TD, et al. Does Minority Racial-Ethnic Status Moderate Outcomes for Collaborative Care for Depression? Psychiatric Services, 2011.

42. Use of Psychotherapy Arean PA et al. Improving Depression Care for Older, Minority Patients in Primary Care. Medical Care. 2005.

43. Depression Symptom Improvement Arean PA et al. Improving Depression Care for Older, Minority Patients in Primary Care. Medical Care. 2005.

44. The Washington MHIP

45. The Washington MHIP • 107 Community Health Centers and 36 mental health centers in Washington State • Over 18,000 patients served • 125 care coordinators/managers trained • Based on IMPACT Care Collaboration model • Track PHQ-9 and GAD-7 • Targeting poor and high risk populations Accessed on-line 7/20/12 at http://www.advancingcaretogether.org/pdfs/Case%20Study%20MHIP_updated.pdf

46. Recent Research The TEAMcare Study • Washington State • Builds on the IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) studies • 14 Primary Care Clinics • Multi-condition Care Management • Depression + DM or CAD • Outcomes: • Significantly improved depression symptoms; HgA1C; BP and lipid profiles • Also resulted in greater satisfaction in care for all conditions KatonWJ et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010; 363(27):2611-20.

47. Collaborative Care Gold Standard for treatment of mental health conditions presenting to primary care

48. Collaborative Care Team Care Manager Primary Care Provider Psychiatrist

49. Collaborative Care Components • Explicit Protocols and Treatment Planning • Enhanced Patient Education and Self-Management Support • Care Team • Care Manager • Primary Care Practitioner • Psychiatrist • Stepped Care • Access to Caseload Review/Population Management Support • Information System Support

50. Use Protocols and Treatment Planning Tools • VA http://www.healthquality.va.gov/ • MacArthur Initiative www.depression-primarycare.org/ • ICSI (Institute for Clinical System Improvement) www.icsi.org • IMPACT, TEAMcareand AIMS Center (University of Washington) • http://uwaims.org/ • http://impact-uw.org/ • http://integratedcare-nw.org/index.html • http://www.teamcarehealth.org/