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