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Disease ManagementDisease Management With Comorbidities: With Comorbidities: Depression and Chronic IllnessesDepression and Chronic Illnesses

Integration of Behavioral Health and Primary CareIntegration of Behavioral Health and Primary CareMSPPMSPP June 12, 2009June 12, 2009

Steven E. Locke, MDSteven E. Locke, MDAssociate Professor of Psychiatry Associate Professor of Psychiatry

Harvard Medical SchoolHarvard Medical SchoolAssociate Professor of Health Sciences & TechnologyAssociate Professor of Health Sciences & Technology

Massachusetts Institute of TechnologyMassachusetts Institute of Technology

DisclosuresDisclosures

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Company Relationship Content AreaVeritas Health Solutions LLC

Owner Behavioral Telehealth

Veritas Health Associates LLC

Principal, Owner

Healthcare Consulting

Mensante Corporation

Consultant Behavioral Telehealth

Life Options Consultant Behavioral Telehealth

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Definition of Disease Definition of Disease ManagementManagement

““MultiMulti--disciplinary, coordinated, continuumdisciplinary, coordinated, continuum--based approach to healthcare delivery and based approach to healthcare delivery and communications for populations with, or at communications for populations with, or at risk for, established medical conditions.risk for, established medical conditions.””

-- Disease Management Association of America, 2004

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Comorbidity = Diagnosis ChallengeComorbidity = Diagnosis Challenge

Depressed moodDepressed moodGuilt, feeling Guilt, feeling worthlessworthlessSuicidalSuicidalthoughtsthoughts

FatigueFatigueWeight lossWeight lossLoss of interestLoss of interestDecreased libidoDecreased libidoDecreased Decreased appetiteappetitePain/Increased Pain/Increased painpainImpaired Impaired cognitioncognitionSocial withdrawalSocial withdrawalSleep alterationsSleep alterations

FeverFever

Major Major DepressionDepression

Medical Medical IllnessIllness

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Chronic Diseases Are CostlyChronic Diseases Are Costly

100 million 100 million Americans with chronic Americans with chronic conditionsconditionsConsume >60% of medical care dollarsConsume >60% of medical care dollarsMost patients will have more than once Most patients will have more than once chronic condition (comorbidity)chronic condition (comorbidity)Modifiable risk factors often not Modifiable risk factors often not addressedaddressed

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Depression and Anxiety Are Common Depression and Anxiety Are Common Comorbid Conditions of High Cost, Comorbid Conditions of High Cost,

Chronic DiseasesChronic Diseases

CADCAD (depression, anxiety)(depression, anxiety)CHFCHF (depression, anxiety)(depression, anxiety)DiabetesDiabetes (depression)(depression)ESRDESRD (depression)(depression)Asthma Asthma (anxiety)(anxiety)COPD COPD (anxiety)(anxiety)

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Informed,Activated Patient

& FamilyProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

SystemsSelf-

Management Support

Health SystemResources and Policies

Community Health Care Organization

Chronic Care Model

Wagner EH, et al. Milbank Q. 74(4)511-44.1996

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Depression in Medical IllnessDepression in Medical Illness

Heart attack: 40Heart attack: 40--65% experience depression 65% experience depression Coronary artery disease (without MI): 18Coronary artery disease (without MI): 18--20%20%Parkinson's disease: 40% Parkinson's disease: 40% Multiple sclerosis: 40% Multiple sclerosis: 40% Stroke: 10Stroke: 10--27%27%Cancer: 25%Cancer: 25%Diabetes: 25%Diabetes: 25%

http://www.webmd.com/depression/guide/depression-caused-chronic-illness

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Adverse Bidirectional InteractionAdverse Bidirectional Interaction

Major Depression

• Smoking

• Sedentary lifestyle

• Obesity

• Lack of adherence to medical regimens

• Psychophysiologic

Insulin sensitivityAutonomic NSInflammatory markers

• Medical illness at earlier age

• Poor symptom control

• functional impairment

• complications of medical illness

• mortality

Katon et al. Biol Psychiatry 2003

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35% 39% 41%

Prevalence of Any Depression (BDI Prevalence of Any Depression (BDI >> 10)10)in Hospitalized ACS in Hospitalized ACS PatientsPatients

N=222 Post-MI

(JAMA,1993;

Circulation, 1995)

N=183 Post-MI

(subset of Lancet, 1997)

N=430 Unstable Angina

(Arch Int Med, 2000)

Adapted from Frasure-Smith, Lesperance, et al.

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Depression Increases Cardiac RiskDepression Increases Cardiac Risk

CHD + Depression CHD + Depression 2X risk of 2X risk of cardiac event over next 12 monthscardiac event over next 12 months

MI + Depression MI + Depression 44--5X risk5X risk of of mortality during the first 6mortality during the first 6--months months postpost--MIMI11

CHF + Depression CHF + Depression higher higher readmission ratesreadmission rates

1. 1. FrasureFrasure--Smith, Smith, LesperanceLesperance, et al. 1996., et al. 1996.

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LongLong--term Survival and Levels of term Survival and Levels of PostPost--MI DepressionMI Depression

0

5

10

15

20

25

30

< 5 5-9 10-18 >/= 19

In-Hospital BDI Score

5-Y

ear C

ardi

ac M

orta

lity

(%)

Adapted from FrasureAdapted from Frasure--Smith, Lesperance, et al. 1996Smith, Lesperance, et al. 1996

N=886

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Depression and 1-Year Cardiac Prognosis in Unstable Angina

4003002001000

100%

95%

90%

85%

80%

Not Depressed (BDI < 10)

Depressed (BDI > 10)

Odds Ratio = 4.7 (1.9 – 11.3)

P< 0.001

Time After Discharge for Unstable Angina, DaysLespérance et al. Arch Int Med, 2000.

N=430N=430

Surv

ival

Fre

beof

Non

-Fat

al M

I or

Car

diac

Mor

talit

y, %

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CHF and DepressionCHF and Depression

CHF is a leading cause of hospitalization for Medicare CHF is a leading cause of hospitalization for Medicare 1/31/3rdrd of all CHF hospitalizations may be preventableof all CHF hospitalizations may be preventable11

40% of CHF patients are depressed40% of CHF patients are depressed22

–– more severe CHF symptomsmore severe CHF symptoms–– impairs functional statusimpairs functional status

Higher readmission rates may interfere with adherenceHigher readmission rates may interfere with adherenceReduced quality of lifeReduced quality of life

1. 1. Vinson J, Rich MW, Sperry JC, Shah AS, McNamara T. Vinson J, Rich MW, Sperry JC, Shah AS, McNamara T. J Am J Am GeriatrGeriatr Soc.Soc. 199019902. 2. LopezLopez--CandalesCandales AL, Carron C, Schwartz J. AL, Carron C, Schwartz J. ClinClin CardiolCardiol 2004. Jan;27(1):232004. Jan;27(1):23--8.8.

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CHD and Mental Disorders CHD and Mental Disorders Mental Mental

disorderdisorderCHDCHD End PointsEnd Points RRRR

Januzzi JL, et al. Januzzi JL, et al. Arch Int MedArch Int Med, 2000., 2000.

Prior Prior depressiondepression

Onset CHDOnset CHD fatal & fatal & nonfatal MInonfatal MI

1.51.5--4.54.5

DepressionDepression Established Established CHDCHD

MI, MI, reinfarction, reinfarction, revascularizarevasculariza--tion, death tion, death

2.52.5--4.34.3

Prior anxietyPrior anxiety Onset CHDOnset CHD fatal & fatal & nonfatal MI nonfatal MI fatal CHDfatal CHD

0.90.9--6.16.1

AnxietyAnxiety Established Established CHDCHD

MI, VT/VF, MI, VT/VF, UAP, deathUAP, death

1.11.1--4.94.9

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9,275

3,473

4,531

2,496

1,270

0 2,000 4,000 6,000 8,000 10,000 12,000

Dollars

Panic + Depression (25)

Panic Disorder (20)

Depression (62)

Cardiac-Non MH (396)

Non-Cardiac (80)

Total Mean Annual Medical Total Mean Annual Medical Utilization CostsUtilization Costs

KatzelnickKatzelnick et al, Annual Meeting, APA, 1998et al, Annual Meeting, APA, 1998

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Chronic Pain Chronic Pain and Depressionand Depression

50% with chronic pain are depressed50% with chronic pain are depressed60% report pain symptoms when diagnosed60% report pain symptoms when diagnosedBack pain patients: 3Back pain patients: 3--4X more MDD*4X more MDD*PrePre--op MDD in patients undergoing back op MDD in patients undergoing back surgery had poorer 1surgery had poorer 1--yr outcomesyr outcomes

MagniMagni, et al., 1985; Smith, 1992; Reich, et., 1983; , et al., 1985; Smith, 1992; Reich, et., 1983; JungeJunge et al., 1995et al., 1995

*MDD = Major depressive disorder

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Implications of Implications of Identifying and Identifying and Diagnosing Depression and AnxietyDiagnosing Depression and Anxiety

•• PCP detection rates 30%PCP detection rates 30%--40% (740% (7--70%)70%)•• Only half who need medication receive itOnly half who need medication receive it

of those, 1 in 4 receive adequate doseof those, 1 in 4 receive adequate dose1 out of 20 get correct treatment!1 out of 20 get correct treatment!

•• Collaborative care and integrative models improve Collaborative care and integrative models improve outcomes with outcomes with

improved rates of detection improved rates of detection better clinical managementbetter clinical management

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22--Item Depression ScreenerItem Depression Screener

Most people living with chronic conditions Most people living with chronic conditions like yours find it stressful and many like yours find it stressful and many even become depressedeven become depressed……

How has your mood been during the How has your mood been during the past two weeks? (sad, depressed, past two weeks? (sad, depressed, hopeless, or down = hopeless, or down = ++))

Have you lost interest in doing things Have you lost interest in doing things that you usually enjoy? (Yes = that you usually enjoy? (Yes = ++))

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Emerging Efficacy in Patient Emerging Efficacy in Patient Identification, Treatment, ManagementIdentification, Treatment, Management

Specialized care managers (RNSpecialized care managers (RN--CS)CS)Collaborative care model Collaborative care model 1,21,2

Integrative care modelIntegrative care model33ComputerComputer--assisted care managementassisted care managementIVR telephonic supportIVR telephonic supportPatient selfPatient self--assessment toolsassessment toolsIT infrastructure buildIT infrastructure build--outoutCommunications support collaborative and Communications support collaborative and integrative careintegrative care

1. Bodenheimer T, Wagner EH, Grumbach K. 1. Bodenheimer T, Wagner EH, Grumbach K. JAMA. JAMA. 2002;288;14:17752002;288;14:1775--79.79.2. Bodenheimer T, Wagner EH, Grumbach K. 2. Bodenheimer T, Wagner EH, Grumbach K. JAMA. JAMA. 2002;288;15:19092002;288;15:1909--14.14.3. Kathol RG , Stoudemire A. 20023. Kathol RG , Stoudemire A. 2002

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Industry is Attempting to Identify Patients Industry is Attempting to Identify Patients with Costwith Cost--Driving Mental IllnessesDriving Mental Illnesses

Humana Humana BCBSBCBSTufts Health PlanTufts Health PlanAetnaAetnaHarvard PilgrimHarvard PilgrimWellPointWellPointUnited HealthcareUnited HealthcareCignaCigna

* List is an example and not exhaustive* List is an example and not exhaustive

MatriaMatriaLifeMastersLifeMastersHealthwaysHealthwaysHealth DialogHealth DialogMcKessonMcKessonMagellanMagellan

Health PlansHealth Plans DM VendorsDM Vendors

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Popular Screening Popular Screening ToolsToolsPHQPHQ--2, PHQ2, PHQ--44PHQPHQ--99Beck Beck Depression Depression Inventory*Inventory*Primary Care Evaluation of Mental Disorders (PRIMEPrimary Care Evaluation of Mental Disorders (PRIME--MD)MD)Behavior Behavior And Symptom Identification ScaleAnd Symptom Identification Scale––32 (BASIS32 (BASIS--32)*32)*Outcome Outcome QuestionnaireQuestionnaire--45 (OQ45 (OQ--4545))**SCLSCL--90R*, BSI*90R*, BSI*Center for Epidemiologic StudiesCenter for Epidemiologic Studies--Depression (CESDepression (CES--D)D)Edinburgh Edinburgh Postnatal Depression ScalePostnatal Depression ScaleMini Mini International Neuropsychiatric Interview (MINIInternational Neuropsychiatric Interview (MINI)*)*Hamilton Hamilton Rating Scale for Rating Scale for Depression*Depression*Geriatric Depression Geriatric Depression ScaleScaleHospital Anxiety and Depression Scale*Hospital Anxiety and Depression Scale*

*proprietary

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Remission as a Standard of Care Remission as a Standard of Care from the Managed Care Perspectivefrom the Managed Care Perspective

Many patients improve but fail to achieve full Many patients improve but fail to achieve full remission with antidepressant treatmentremission with antidepressant treatmentPatients are at higher risk for relapse and Patients are at higher risk for relapse and recurrence recurrence Leads to worsened productivity; increased Leads to worsened productivity; increased utilization of resourcesutilization of resources

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Depression and Medical SxsDepression and Medical Sxs

010203040506070

Unexplained Explained

Medical Symptoms

Dep

ress

ion

Pres

ent(

%)

Katon W, 1990

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Physical Symptom CountsPhysical Symptom Counts

Adopted from Kroenke, 2002

# ofSymptoms

%Anxiety

% Mood

0-1 1 22-3 7 124-5 13 236-8 30 449+ 48 60

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Effects of Phone Counseling on Psychological Effects of Phone Counseling on Psychological Distress and Work and Social Adjustment in Distress and Work and Social Adjustment in

Survivors of Acute Coronary EventsSurvivors of Acute Coronary Events

TJ McLaughlin, O Aupont , P Stone, TJ McLaughlin, O Aupont , P Stone, KZ Bambauer, J Colagiovanni, E Polishuk, KZ Bambauer, J Colagiovanni, E Polishuk,

L Griffin, MG Mullan, M Johnstone, SE Locke L Griffin, MG Mullan, M Johnstone, SE Locke

National Institute of Mental Health (MH-56217)Robert Wood Johnson Foundation (Grant # 038765)

McLaughlin T, et al. JGIM, 2006

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The Eight Fears of Chronic The Eight Fears of Chronic IllnessesIllnesses

Fear of loss of Fear of loss of controlcontrolFear of loss of selfFear of loss of self--imageimageFear of dependencyFear of dependencyFear of stigmaFear of stigma

Fear of Fear of abandonmentabandonmentFear of expressing Fear of expressing angerangerFear of isolationFear of isolationFear of deathFear of death

Polin I. Polin I. Medical Crisis Counseling: ShortMedical Crisis Counseling: Short--Term TherapyTerm Therapyfor Longfor Long--Term IllnessTerm Illness. New York: WW Norton, 1995.. New York: WW Norton, 1995.

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InterventionIntervention

6 sessions of focused, time6 sessions of focused, time--limited counselinglimited counselingAdministered by telephoneAdministered by telephoneProblemProblem--solving orientationsolving orientationFocus: adjustment to living with chronic illnessFocus: adjustment to living with chronic illnessMost effective at 3 points in course of illnessMost effective at 3 points in course of illness

»» DiagnosisDiagnosis»» HospitalizationHospitalization (TRANSITIONS)(TRANSITIONS)»» Increased severityIncreased severity

Deals with 8 fears of living with chronic illnessDeals with 8 fears of living with chronic illness

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Depression (HADS)Depression (HADS)

Intervention Effects on Depression

4

6

8

10

0 1 2 3 4 5 6

Month

Dep

ress

ion

Scor

e

ControlExperimental

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Anxiety (HADS)Anxiety (HADS)

Intervention Effects on Anxiety

6

8

10

0 1 2 3 4 5 6

Month

Anx

iety

Sco

re

ControlEx perimental

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Total HADS ScoreTotal HADS Score

Intervention Effects on Total HADS Scores

10

12

14

16

18

20

0 1 2 3 4 5 6

Month

Tota

l Sco

re

ControlEx perimental

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Diabetes and DepressionDiabetes and Depression

Depression prevalence among patients with diabetes Depression prevalence among patients with diabetes is twice that seen in general medicine (15is twice that seen in general medicine (15--25%) 25%) Depression often precedes the onset of diabetesDepression often precedes the onset of diabetesDepression associated with poorer glycemic control Depression associated with poorer glycemic control (higher HgbA1c)(higher HgbA1c)Rx of depression (TCA, SSRI, or CBT) associated Rx of depression (TCA, SSRI, or CBT) associated with improved mood as well as tighter glycemic with improved mood as well as tighter glycemic control in some studies, not otherscontrol in some studies, not othersChronic care model DM intervention reduced cost of Chronic care model DM intervention reduced cost of care (IMPACT)care (IMPACT)

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Cardiac Risk Factors in Patients with Cardiac Risk Factors in Patients with Diabetes Mellitus and Major DepressionDiabetes Mellitus and Major Depression

0%10%20%30%40%50%60%70%

% with > 3 Risk

Factors

MajorDepression

No Depression

Patients without CVDKaton et al JGIM 2004

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HbAHbA1c1c > 8% by Depression Level> 8% by Depression Level

0

10

20

30

40

50

60

None Minor Major

Depression Group

HbA

1c >

8%

(%)

Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type and duration, treatment type and clinic

N = 4,225 p<0.001; Major > Nonep<0.01; Minor > None

Katon et al. Diabetes Care 2004

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18.8 19.321.6

24.527.2 27.9

0

10

20

30

40Non DepressedDepressed

Medication Adherence in Medication Adherence in Patients with DiabetesPatients with Diabetes

Oral Hypoglycemic Lipid Lowering

MedsACE

Inhibitors

Non

adhe

rent

Day

s (%

)

Lin et al. Diabetes Care 2004

Cost of Comorbid DepressionCost of Comorbid Depression

““Depression in both primary care patients Depression in both primary care patients and in those with comorbid diabetes is and in those with comorbid diabetes is associated with increased medical costs associated with increased medical costs in every category measured, including in every category measured, including primary care and medical specialty visits, primary care and medical specialty visits, emergency room, pharmacy, laboratory emergency room, pharmacy, laboratory and Xand X--rays, and inpatient days.rays, and inpatient days.””

Katon W, 2009Katon W, 200938

Depression Management in DMDepression Management in DM

Pathways Pathways Study (Katon, et al. 2004, 2009)Study (Katon, et al. 2004, 2009)The intervention was a stepped collaborative The intervention was a stepped collaborative care program that was delivered by a nurse care program that was delivered by a nurse depression care manager (DCM). depression care manager (DCM). The intervention was designed to improve The intervention was designed to improve quality of care and outcomes of depression quality of care and outcomes of depression but not to directly improve diabetes education but not to directly improve diabetes education or care.or care.

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Depression Management Depression Management Reduces Diabetes CostsReduces Diabetes Costs

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Trends Doctors FaceTrends Doctors Face

Better informed patients

Patients as active purchasers

Shift to shared decision-making

Provider-patient e-mail

Privacy concerns

Collaborative care

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EE--Health Consumers Interest in Health Consumers Interest in Customized Online ServicesCustomized Online Services

Personalized disease info Personalized disease info 82% 82% Risk AssessmentRisk Assessment 70% 70% Email doctorEmail doctor 59% 59% Universal recordUniversal record 59% 59% Email RemindersEmail Reminders 58% 58%

Source: Hospital & Health Networks, March 2000 Source: Hospital & Health Networks, March 2000 Publication: EPublication: E--Encounters, Prepared by First Consulting Group for the Encounters, Prepared by First Consulting Group for the California HealthCare Foundation, November 2001. California HealthCare Foundation, November 2001.

OnOn--line self assessmentline self assessmentDecision support toolsDecision support toolsSocial mediaSocial mediaOnline cognitive behavior therapyOnline cognitive behavior therapyVirtual reality therapyVirtual reality therapyRelaxation training and meditationRelaxation training and meditationStress managementStress managementHome monitoringHome monitoring

ComputerComputer--Assisted CareAssisted Care

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ComputerComputer--Assisted Care 2Assisted Care 2

Graphic reports to case managers and PCPsGraphic reports to case managers and PCPsAutomated alerts for adverse eventsAutomated alerts for adverse eventsAutomated alerts for suicide riskAutomated alerts for suicide riskAutomated pharmacy reports for adherenceAutomated pharmacy reports for adherenceInteractive patient education (IVR or Web)Interactive patient education (IVR or Web)Tailored patient education materialsTailored patient education materialsMobile telehealth platforms and appsMobile telehealth platforms and appsHealth 2.0 social networking toolsHealth 2.0 social networking tools

Aetna Behavioral Health Aetna Behavioral Health Ceridian (Lifeworks) Ceridian (Lifeworks) Cigna Behavioral Health (Emotional Well Being)Cigna Behavioral Health (Emotional Well Being)HealthMediaHealthMediaHealthcare Technology Systems (IVR systems)Healthcare Technology Systems (IVR systems)LifeOptions (LifeCoach, LifeOptions (LifeCoach, SleepCoachSleepCoach, , CrisisCoachCrisisCoach))Midwest Center Midwest Center –– depression, stress, and anxietydepression, stress, and anxietyMoodGYMMoodGYM –– depression onlydepression onlyUltrasisUltrasis (Beating the Blues)(Beating the Blues)Value Options (Achieve Solutions)Value Options (Achieve Solutions)

Behavioral Telehealth WebsitesBehavioral Telehealth Websites

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The ChallengesThe Challenges

Lowering of transaction costs via technologyLowering of transaction costs via technologyAdapting to patient empowermentAdapting to patient empowermentAddressing comorbiditiesAddressing comorbiditiesAchieving scale and critical massAchieving scale and critical massMore aggressively addressing behavior More aggressively addressing behavior change and depressionchange and depressionGaining greater physician buyGaining greater physician buy--in for DMin for DMMoving beyond DM to total population healthMoving beyond DM to total population health

Source: Warren Todd, 2001

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Barriers to AdoptionBarriers to Adoption

Failure to involve stakeholders in designFailure to involve stakeholders in designPrivacy concerns and data securityPrivacy concerns and data securityLack of robust outcomes data and data Lack of robust outcomes data and data systemssystemsAlienation of providersAlienation of providersMisalignment of financial incentivesMisalignment of financial incentivesLack of Lack of infrastructure, interoperabilityinfrastructure, interoperabilityLack of leadership supportLack of leadership support

Source: Warren Todd, 2001

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Challenges and PitfallsChallenges and Pitfalls

The risk of never startingThe risk of never startingThe risk of failureThe risk of failureWaning management focus or Waning management focus or commitmentcommitmentLack of internal skill setsLack of internal skill setsCost of lost opportunityCost of lost opportunityOperating outside oneOperating outside one’’s core s core competenciescompetencies

Source: American Healthways, 2002