Depression Care: Translating Research into Practice

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1 Depression Care: Translating Research into Practice Michael Von Korff Center for Health Studies Group Health Cooperative Seattle, WA

2 A View from Seattle

3 Primary Care and Depression General medical services are the primary vehicle for controlling common mental disorders in the population-at-large The cardinal requirement for improvement of mental health services is strengthening family doctors in their therapeutic role. Michael Shepherd

4 The Burden of Depressive Illness In 1990, depression was the fourth highest cause of disability and premature death worldwide, and will be the second highest cause by Primary care is where most people with depression seek care. WHO Global Burden of Disease Report

5 Gaps in Depression Care Less than half of depressed adults are diagnosed and treated Among those treated, only about half receive guideline-level care

6 A B A A B A A B B A A Care Management Improves Depression Outcomes in Primary Care Randomized Trial Quality A=Good B=Fair C=Poor Katon 1995 Banerjee 1996 Katon 1999 Llewllyn 1999 Colmann 1999 Simon 2000 Katzelnick 2000 Hunkeler 2000 Rost 2001 Unutzer 2002 Hedrick 2003 No Benefit Moderate Benefit Effect Size of Care Management Interventions Meta analysis by Gensichen et al., Psychological Medicine, 2005 Large Benefit

7 The Effect Size that Really Matters Photo credit: J. Lott: Seattle Times After two years of depression, this IMPACT trial participant resumed his daily swim, was more outgoing, and was enjoying life again

8 Key Elements of Effective Depression Care Active follow-up to monitor treatment Standardized treatment monitoring (e.g. PHQ-9) Treatment modified as needed to optimize response Patient activation and self-management supported Specialist consultation readily available for difficult cases Von Korff & Goldberg, BMJ, 2001

9 Recognition and Antidepressant Treatment Has Increased Dramatically Percent of Visits Pirraglia et al., J Clin Psych, 2003 Percent of Primary Care Visits in Which Patients were Using Antidepressant Medications 8% 7% 6% 5% 4% 3% 2% 1% 0% 2.6% 7.1% U.S. National Ambulatory Medical Care Expenditures Survey)

10 Per Capita Anti-Depressant Sales 1993 vs Defined Daily Doses Per 1000 Population United States United Kingdom Germany

11 United States: No Evidence of Reduced Depression Morbidity Trends in Mentally Unhealthy Days: United States By Age and Sex Group (Behavioral Risk Factor Survey) 5 Mean Mentally Unhealthy Days, Prior Month F: F: F: 65 + M: M: M: Zack et al, Public Health reports, 2004

12 United Kingdom: No Evidence of Reduced Depression Morbidity Percent With Abnormal GHQ-12 Score Abnormal GHQ-12 Score: United Kingdom (British Household Panel Survey) 14% Females, GHQ 7+ 12% 10% 8% 6% 4% 2% Males, GHQ 7+ 0% David Pevalin, personal communication, unpublished data

13 Countries with Increasing Per Capita Use of Anti-Depressants Defined Daily Doses Per 1000 Population Anti-depressant Sales (Defined Daily Doses/1000) in Selected Countries: 1993 and U.S. U.K. Sweden France Australia Canada Germany

14 No Clear Trends in Male Suicide Rates: Male suicide rates stable since 1960 s in Europe and US Males: Age Standardized Suicide Rates per 100, Trends in Suicide Rates: Males All Ages France Sweden Canada Australia U.S. U.K. Germany Levi et al., Acta Psych Scand,

15 Modest Reductions in Female Suicide Rates (Pre-1993): Female suicide rates began to decline in the early 1980 s in Europe and US Females: Age Standardized Suicide rates per 100,000 Levi et al., Acta Psych Scand, 2003 Trends in Suicide Rates: Females All Ages France Sweden Canada Australia U.S. U.K. Germany

16 Why Is Increased Treatment Not Improving Population Health? Disorder (Severe) Disorder (Mild-Moderate) Symptoms Focus of Depression Care-as-Usual Care-as-Usual Normal 6-12 weeks 4-5 Months > 1 Year Maintenance Acute Continuation

17 Shift the Focus from Treatment Initiation to Ongoing Management Disorder (Severe) Disorder (Mild-Moderate) Symptoms Normal Focus of Depression Care-as-Usual 6-12 weeks 4-5 Months > 1 Year Maintenance Acute Continuation Care-as-Usual Enhanced Care Focus of enhanced depression care

18 Strategies to Reduce Depression Prevalence: Expand Effectively Delivered Treatment Options To Maximize Clinical Response

19 Expand Effectively Delivered Treatment Options To Improve Clinical Response Percent with Adequate Clinical Response (>50% Sx reduction) at 6 Months 60% 50% 40% 43% 51% 58% Care as Usual 30% 20% 10% 0% Simon, Ludman et al., JAMA, 2004 Care Management Care management + Phone CBT

20 Strategies to Reduce Depression Prevalence: Prevent Chronicity & Relapse

21 Reduce Depression Prevalence by Preventing Chronicity and Relapse IN REMISSION Secondary prevention control points INCIDENCE RELAPSE Prevalence (acute) CHRONICITY Prevalence (chronic) ACUTE PHASE CHRONIC PHASE

22 Manage Patients Unimproved at 6-8 Weeks More Aggressively Percent Fully Recovered at Six Months: Among Depressed Patients Unimproved at 6-8 Weeks 60% 45% 30% 44% 31% Collaborative Care Care as Usual 15% 0% Percent Fully Recovered p=.05 Katon, Von Korff, Lin et al., Arch Gen Psych, 1999

23 Ensure Maintenance Treatment of Patients at High Relapse Risk Prophylactic Treatment of Patients at High Risk of Depression Relapse Lepine et al., Am J Psychiatry, 2004

24 Relapse Prevention Trials Among Typical Depressed Primary Care Patients Initial Results Have Been Mixed Which at-risk patients should be targeted? What relapse prevention interventions are most effective? How should relapse prevention be delivered?

25 Strategies to Reduce Depression Prevalence: Strengthen the Health Care Team s Abilities to Provide Pro-active Care

26 Effective Depression Treatment Requires Teamwork

27 Key Roles for Effective Depression Care Primary Care- Coordination Case Manager / Patient Educator Specialist- Consultant INFORMED, ACTIVATED PATIENT Katon, Von Korff, Lin & Simon, Gen Hosp Psych, 2001

28 Reorganizing Care Improves Depression Outcomes When Implemented by Real World Health Care Teams RESPECT-D Trial Percent with Clinical Response At 6 Months 75% 60% 45% 30% 15% 60% 47% Enhanced Care Care as Usual 0% Dietrich et al. BMJ 2004 Percent with 50% reduction in depressive symptoms p=.02

29 The Challenge Ahead: Can we cut the prevalence of major depression in half? Effective Collaboration Prepared, Pro-active Practice Teams Informed, Activated Patients

30 Cut the prevalence of major depression in half Key Steps to Achieve Goal Set a population goal to reduce depression prevalence Establish surveillance system: to monitor known cases, to ensure prompt treatment when needed, and to monitor progress towards reducing prevalence Establish specialist accountability for all cases in a defined population, not just cases they treat Develop efficient follow-up (care management) services Shift focus from recognition to optimal management

31 The Accountability Gap Care as Usual: Limited and Unclear Accountability Primary Care Care manager Specialists Initiates treatment for recognized cases Sporadic monitoring and follow-up No organized care management No capacity for monitoring outcomes Treats referred cases Limited consultation services

32 Closing The Accountability Gap Collaborative Care: Fixed and Clear Accountability Primary Care Care Manager Initiates treatment for recognized cases Accountable for less complex cases Co-manages more complex cases Organizes care registry and surveillance Accountable for more complex cases Specialist Accountable for most complex cases Limited supervision of care management Consults on more complex cases as needed

33 A Virtual Health Care Team: Linked via e-communication & EMR/Case register Care Manager Limited Supervision The Activated and Supported Patient Co-management Specialist Consultation & advice Primary Care

34 Jam es D. R alston The End of the beginning