IMPACT Team CareIMPACT Team CareFor Depression For Depression

VA Puget Sound V-tel conference

February 23, 2009

DisclosureDisclosure Grant funding (current & recent)

• NIH (NIMH)• American Federation for Aging Research (AFAR)• John A. Hartford Foundation• George Foundation• Red Cross (RAND)• California HealthCare Foundation• Robert Wood Johnson Foundation• Hogg Foundation

Contracts• Community Health Plan of Washington• King County Department of Public Health

Consultant• AARP Services Incorporated (ASI)• National Council of Community Behavioral Health Care (NCCBH)

Advisor• Carter Center Mental Health Program• Institute for Clinical Systems Research (ICSI)

DepressionDepression

More than having a bad day or a bad week

Pervasive depressed mood / sadness

Loss of interest / pleasureLack of energy, fatigue, poor sleep and appetite, physical slowing or agitation, poor concentration, physical symptoms (aches and pains), irritability, thoughts of guilt, and thoughts of suicide

A miserable state that can last for months or even years

DepressionDepression

Common

10% in primary care

Disabling

#2 cause of disability (WHO)

Expensive

50-100% higher health care costs

Deadly

Over 30,000 suicides / year

Depression is often notDepression is often notthe only health problem the only health problem

DepressionNeurologicDisorders

Geriatric Syndromes

Diabetes

20-40%

10-20%

10-20%

Heart Disease

20-40%

Chronic Pain

40-60%

10-20%

Cancer

Depression is deadlyDepression is deadlyOlder men have the highest rate of suicide.Older men have the highest rate of suicide.

Guidelines for DepressionGuidelines for DepressionTreatment in Primary CareTreatment in Primary Care

VA

Institute for Clinical Systems Improvement (ICSI)• http://www.icsi.org/guidelines_and_more/gl_os_prot/

behavioral_health/depression_5/depression__major__in_adults_in_primary_care_4.html

American College of Physicians (ACP) Clinical Practice Guidelines

• Ann Int Med 2008; 149:725-733

Efficacious treatments Efficacious treatments for depressionfor 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.

Antidepressant MedicationsAntidepressant Medications

There are over 20 FDA approved antidepressants.

- All are effective in 40 - 50 % of patients if taken correctly

- It often takes several trials until Rx is effective

- Patients need support during this time

If medications are not effective after 8-10 weeks at a therapeutic dose

- make sure patient is taking medication as prescribed

- verify diagnosis

- consult: a change in treatment plan is likely indicated

Fewer than 1 in 10 depressed older adults seek specialty mental health care

• and if they did we wouldn’t have the mental health specialists needed to treat them

Most present for help in primary care Quality of care for depression is worse than for most

other chronic medical problems

Quality of Depression CareQuality of Depression Care

Depression Treatment Depression Treatment in Primary Care in Primary Care

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

• 30 % drop out of treatment within 4 weeks

• Only 25 % receive adequate follow-up care

• Only 20 – 40 % improve substantially over 12 months

Limited access to evidence-based psychosocial treatments (psychotherapy)

Evidence for Collaborative Care Evidence for Collaborative Care for Depressionfor Depression

Metaanalysis by Gilbody S. et al,

Archives of Internal Medicine; 2006

- 37 trials of collaborative care for depression in primary care (US and Europe)

- cc consistently more effective than usual care

- successful programs include

- active care management & follow-up

- support of medication management in primary care

- psychiatric consultation

IMPACT TrialIMPACT Trial

John A. Hartford Foundation Planning grant (1996)

IMPACT Study(1999-2003)

Additional funding from

California Healthcare Foundation

Robert Wood Johnson Foundation

Hogg Foundation

IMPACT Study MethodsIMPACT Study MethodsDesign:

1,801 depressed adults (60 and older) with major depression and / or chronic depression, randomly assigned to IMPACT or to Care as Usual

Usual Care:

Primary care or referral to specialty mental health

IMPACT Care:

Collaborative / stepped care disease management program for depression in primary care offered for up to 12 months

Analyses:

Independent assessments of health outcomes and costs for 24 months. Intent to treat analyses

Unützer et al, Med Care 2001; 39(8):785-99

IMPACT Team Care ModelIMPACT Team Care Model

Prepared, Pro-active Practice Team

Informed, Activated Patient

Practice Support

Photo: Courtesy D. Battershall & John A. Hartford Foundation Photo credit: J. Lott, Seattle Times

EffectiveCollaboration

Collaborative CareCollaborative Care

Patient Chooses treatment in consultation with

provider(s):

• antidepressants and / or brief psychotherapy

Primary care provider (PCP) Refers; prescribes antidepressant medications

+ Depression Care Manager

+ Consulting Psychiatrist

Unützer et al, Med Care 2001; 39(8):785-99

Treatment ProtocolTreatment Protocol

(1) Assessment and education,

(2) Behavioral Activation / Pleasant Events Scheduling

(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

Stepped CareStepped 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

What if patients don’t improve?What if patients don’t improve?

Is the patient adhering to treatment?

Is the dose high enough?

- see max dose guidelines

Is the diagnosis correct?

? Bipolar depression

? Medical conditions (hypothyroidism, sleep apnea, pain)

? Meds: steroids, interferon, hormones

? Withdrawal: stimulants, anxiolytics

Are there untreated comorbid conditions / life stressors?

Is the patient at maximum Is the patient at maximum therapeutic dose?*therapeutic dose?*

Fluoxetine 60 mg

Paroxetine 60 mg

Escitalopram 30 mg

Citalopram 60 mg

Sertraline 200 mg

Venlafaxine 300 mg

Duloxetine 60 mg

Buproprion SR450 mg

Mirtazapine 60 mg

Nortriptyline 125 mg (check serum level)

Desipramine 200 mg (check serum level)Consider titrating to these doses unless patients do not tolerate these ‘maximum doses’ due to side effects.

IMPACT doubles the Effectiveness IMPACT doubles the Effectiveness of Depression Careof Depression Care

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8

Usual Care

IMPACT

50% or greater improvement in depression at 12 months

Participating Organizations

%

Unutzer et al, JAMA 2002; Psych Clin N America 2004.

IMPACT Improves IMPACT Improves Physical FunctioningPhysical Functioning

SF-12 Physical Function Component Summary Score (PCS-12)

P<0.01P<0.01 P<0.01

P=0.35

Callahan et al. JAGS. 2005; 53:367-373. Callahan C et al, JAGS 2004

IMPACT Saves MoneyIMPACT Saves Money

Cost Category

4-year costs

in $

Intervention group cost

in $

Usual care group cost in

$Difference in

$

IMPACT program cost 522 0 522

Outpatient mental health costs 661 558 767 -210

Pharmacy costs 7,284 6,942 7,636 -694

Other outpatient costs 14,306 14,160 14,456 -296

Inpatient medical costs 8,452 7,179 9,757 -2578

Inpatient mental health / substance abuse costs

114 61 169 -108

Total health care cost 31,082 29,422 32,785 -$3363

Unutzer et al. Am J Managed Care 2008.

Savings

IMPACT SummaryIMPACT Summary

Less depression

(IMPACT doubles effectiveness of usual care)

Less physical pain

Better physical functioning

Higher quality of life

Greater patient & provider satisfaction

Lower health care costs

Over 40 peer-reviewed publications

“I got my life back”

Photo credit: J. Lott, Seattle Times

Pain Impairs Response Pain Impairs Response to Depression Careto Depression Care

Source: Thielke, et al. Am J Geriatric Psych. 2007.

Baseline Pain Interference Category

Extremely

Quite a bit

Moderately

Slightly

Not at all

% w

ith d

epre

ssio

n r

esponse a

t 12 m

onth

s

60%

50%

40%

30%

20%

10%

0%

Treatment Group

Usual Care

Intervention

IMPACT-DPIMPACT-DPCare management for depression and painCare management for depression and pain

Less impairment in general activity, walking ability, work, relationships with others, sleep, and enjoyment in life

Unutzer et al, Int J Geriatr Psychiatry 2008.

IMPACT EndorsementsIMPACT 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

Taking IMPACT Taking IMPACT from Research to Practicefrom Research to Practice

Support from JAHF (2004-2009)

Over 3,000 clinicians trained

Almost 200 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

• Western WA: Virginia Mason, Community Health Plan of WA, King County Dept. of Public Health

• Iowa City VAMC

http://impact-uw.orghttp://impact-uw.org

Lessons Learned - IILessons Learned - II

• Teams don’t just happen

• Many of us are not trained to work effectively on interdisciplinary teams.

• Work at interfaces is challenging.

• Simplicity & effective communication

• Joint accountability for measurable outcomes can help.

• (e.g., # and % of population screened, treated, improved)

ConclusionConclusion

IMPACT can be adapted and effective in a wide range of health care settings and populations

Effective teamwork is key to the success of the program• Different professionals (nurses, social workers, psychologists, licensed

counselors, and medical assistants) can be trained to support primary care providers with evidence-based care management

• Care management is a function, not a person

• Psychiatric consultation provides important back-up to primary care based care management programs.

J a m e s D . R a l s t o n

Thank You