# Presentation: 258119

## Applying Research on Evidence-Based Mental Health Practices in Real-World Settings

**Michael Schoenbaum, PhD**
**Senior Advisor**
**Division of Services and Intervention Research**
**National Institute of Mental Health**
**July 16, 2008**

## Challenges to improving health

***Two transcendent problems predominate.***
***First, available care is not delivered well: Americans do not always obtain the interventions that would improve their health or prevent illness. ***
***Second, the interventions that Americans do receive have limited efficacy in improving outcomes. More lives could be saved by developing better drugs, technologies, and procedures. ***
***In effect, society faces a choice between these 2 strategies for bettering health and must strike a prudent balance in how many resources it allocates to each endeavor.***
**--Woolf & Johnson, *****Ann Fam Med*****, 2005**

## Margins for improvement

***Enhance the ******efficacy (and effectiveness)****** of interventions. Health can be improved if screening and diagnostic procedures are made more accurate and if treatments can perform better in reducing morbidity and mortality ***
***(Enhance the ******fidelity****** of interventions.) Independent of the efficacy or effectiveness of interventions, fidelity is the extent to which the system provides patients the precise interventions they need, delivered properly, precisely when they need them. ***
**--Woolf & Johnson, *****Ann Fam Med*****, 2005**

## Cumulative lifetime probability of treatment contact for anxiety disorders, from year of onset

**SOURCE: Wang et al. *****Arch Gen Psychiatry *****2005**

## Balancing Improved Efficacy vs. Improved “Fidelity”

**Balancing Improved Efficacy vs. Improved “Fidelity”**

**SOURCE: Woolf & Johnson, *****Ann Fam Med*****, 2005**

## NIMH’s mission (2007) is to reduce the burden of mental illness and behavioral disorders through research on mind, brain, and behavior

***Develop more reliable, valid diagnostic tests and biomarkers for mental disorders***
***Develop more effective, safer, and equitable treatments...to reduce symptoms, and improve daily functioning***
***Support clinical trials that will provide treatment options to deliver more effective personalized care...***
***Create improved pathways for rapid dissemination of science to mental health care and service efforts***

## NIMH’s mission (2008) is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure 

***Promote discovery in the brain and behavioral sciences to fuel research on the causes of mental disorders***
***Chart mental illness trajectories to determine when, where, and how to Intervene***
***Develop new and better interventions for mental disorders...***
***Strengthen the public health impact of NIMH-supported research***

## Margins for improvement

***The greater the gaps in delivery, the more efficacy must be increased to make that enterprise more beneficial than improving delivery...***
**--Woolf & Johnson, *****Ann Fam Med*****, 2005**

## Strategic Objective 4: Strengthen the Public Health Impact of NIMH-Supported Research

**% U.S. Adults**

**26.2%**

**10.8%**

** ****3.5%**

**Adapted from: Kessler et al, *****Arch Gen Psychiatry,***** 2005 & Wang et al, *****Arch Gen Psychiatry*****, 2006**

** ****Impact Gap**

**Any mental disorder**

**Any mental health treatment**

**Adequate treatment**

**Notes:**
12-month diagnosable disorders in the NCS-R

## Rates of Adequate Treatment for Serious Mental Illness

|  | % With Any
Treatment in
Prior Year |  |  | % With Minimally Adequate Treatment Among
Treated |  |  | % With Minimally Adequate Treatment |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Anxiety Disorder |  | 39.4 |  |  | 48.5 |  |  | 19.9 |  |
| Mood Disorder |  | 45.8 |  |  | 48.2 |  |  | 11.8 |  |
| Non-Affective Psychosis |  | 55.9 |  |  | 7.3 |  |  | 4.1 |  |
| Any of the Above |  | 40.0 |  |  | 38.9 |  |  | 15.3 |  |

**SOURCE: Wang et al. *****Am J Pub Health***** 2002**

## Margins for improvement

**Effect size**
**Efficacy**
**Effectiveness**
**Coverage**
**Adherence**
**Personalization**
**Cost of achieving the effect**

## Balancing Improved Efficacy vs. Improved “Fidelity”

**Balancing Improved Efficacy vs. Improved “Fidelity”**

**SOURCE: Woolf & Johnson, *****Ann Fam Med*****, 2005**

## Margins for improvement

**Effect size**
**Efficacy**
**Effectiveness**
**Coverage**
**Adherence**
**Personalization**
**Cost of achieving the effect**
**Confidence interval/precision **

## Balancing Improved Efficacy vs. Improved “Fidelity”

**Balancing Improved Efficacy vs. Improved “Fidelity”**

**SOURCE: Woolf & Johnson, *****Ann Fam Med*****, 2005**

## Precision

***At a threshold of $50K/QALY and assuming that the CATIE results about the mean outcomes across treatment arms are correct, which implies that the typical antipsychotics are the cost-effective first line treatment in this population, ******the value of more precisely determining the cost-effectiveness of atypical/typical antipsychotics in the US is $342 billion******...The probability that this current decision will be wrong is estimated to be 55%.***
***--Basu et al., poster presentation, 2007***

## 2003 Medicare Modernization Act, Sec 103

***The Secretary (of HHS) shall conduct and support research to meet the priorities and requests for scientific evidence and information identified by (federal health care) programs with respect to:***
***The outcomes, comparative clinical effectiveness, and appropriateness of health care items and services (including prescription drugs)***
***Strategies for improving the efficiency and effectiveness of such programs, including the ways in which (health care) items and services are organized, managed, and delivered under such programs***

## Evidence-based opportunities to strengthen mental health in the US

**Evidence reviewed by:**
**President’s New Freedom Commission on Mental Health (2003) **
**Institute of Medicine, *****Improving the Quality of Health Care for Mental & Substance-Use Conditions***** (2006)**
**DHHS, Mental Health: A Report of the Surgeon General (1999)**
**Many common QI issues**
**Across mental health**
**Between medical & mental health**
**Illustrate with two major conditions**
**Depression**
**Schizophrenia/psychosis**

## Depression is prevalent

**7% overall ****(12-month prevalence, age 18+)**
**10% in primary care**
**15-40% in medically ill**
**Prevalence rises with severity of medical illness**
**15% of SSDI awards**

***Sources: *****Kessler et al., JAMA, 2003; ****Katon, Biol Psych, 2003; ****Social Security Administration, 2004; Aron et al., Urban Institute, 2005**

**Notes:**
SOURCES: overall from National Comorbidity Survey Replication. Primary care & medically ill, from Surgeon General’s Report & IOM.  SSDI from Social Security Administration and the Urban Institute. 

Q: Date for the data? List sources on the bottom of the slide.

## ‘Usual’ depression care is not effective

**Most cases of depression **_**can**_** be treated effectively in primary care**
**But currently...**
**Half of people with depression are not recognized or treated**
**No more than 1 in 4 get minimally adequate treatment**
**Among those treated, care is often ineffective**

***Sources:***** Unützer et al., *****JAMA***** 2002; Gilbody et al., *****Arch Intern Med***** 2006; Wang et al., *****Arch Gen Psych***** 2005; Young et al., *****Arch Gen Psych***** 2001**

## Key components of effective care

**Screening & assessment**
**Patient education and activation**
**Treatment**
**Care management**
**Mental health consultation**

**“****Collaborative Care”**

**Notes:**
Don’t necessarily need source

## “Collaborative care” has been tested

**Benefits of effective care**
**Less depression **
**Less physical pain**
**Better functioning**
**Increased employment & productivity**
**Higher quality of life**
**Greater patient & provider satisfaction**
**More cost-effective than usual care (cost-saving in high risk groups)**

**30+ randomized control trials**** **(reviewed in Gilbody et al., *Arch Intern Med* 2006)

**Notes:**
_x0010_(I’m not planning to present this slide...)

## “The Commission suggests that collaborative care models should be widely implemented in primary care settings and reimbursed by public and private insurers.” (Goal 4, Recommendation 4.4, p. 65)

**Notes:**
Also IOM recommendations (Chapter)

## “Core components” of evidence-based collaborative care

**Care manager time**
**In-clinic or telephone contact**
**Independently or incident to clinician**
**Mental health specialty consultation**
**Caseload supervision **
**Without face-to-face patient contact**
**Screening / outcome tracking as “lab test”**
**(Primary care & MH visits on same day)**

**Notes:**
Harold: there are also broader impediments (e.g., inadequacy of coding systems, poor quality monitoring infrastructure)

## Real-world collaborative care models

**Kaiser Permanente of Southern California**
**All components integrated within health plan**
**Aetna Depression Management initiative**
**Screening & assessment implemented via FFS**
**Care management & psych consults integrated within plan**
**(**_**[http://www.aetna.com/aetnadepressionmanagement/](http://www.aetna.com/aetnadepressionmanagement/)**_**)**
**ICSI “DIAMOND” initiative in Minnesota**
**All components implemented via FFS**
**(**_**[http://www.icsi.org/news/archive/diamond_project_launched_.html](http://www.icsi.org/news/archive/diamond_project_launched_.html)**_**)**

## Priorities for evidence

**Delivering at population level**
**Practice-based**
**Via 3rd party**
**Financing**
**FFS vs. case rate**
**Cost-sharing?**
**Incentivising quality**
**Developing & testing measures**
**PQRI / CPT Category 2**
**Other barriers to dissemination**
**E.g, provider/manager knowledge**
**Extending to “whole patient”**

## Possible “leverage points”

**Coverage**
**Procedure codes & quality measures**
**Information systems**
**Demonstration / pilot programs**
**Medicare Health Support **
**Medical Home **
**ICSI “DIAMOND” initiative**
**QIO scope of work / special projects**
**eRAP for Depression (nursing home pilot)**
**Other initiatives, e.g.,**
**VA, HRSA, SAMHSA, Soc. Sec. Admin.**** **
**Major purchasers**

## Epidemiology of schizophrenia

**0.5% overall ****(12-month diagnosed prevalence, all ages)**
**7% of SSDI awards**
**Very high costs**

***Sources:***** US Surgeon General, 1999; Wu et al., *****Psychol Med*****, 2006; Social Security Administration, 2004; Aron et al., Urban Institute, 2005  **

***Source:***** Bartels et al., *****Am J Geriatr Psychiatry*****, 2003**

## Premature mortality in schizophrenics

**Average lifespan reduction of ~25 years**
**30-40% due to suicide & injuries**
**60% due to “natural” causes**
**Cardiovascular disease (2.3x stand. mort. ratio) **
**Diabetes (2.7x SMR)**
**Respiratory diseases (3.2x SMR)**
**Infectious diseases (3.4x SMR)**
**Cardiovascular disease accounts for largest number of excess deaths**

***Sources:***** Colton & Manderscheid, *****Prev Chronic Dis***** 2006; ****Osby et al., *****Schizophr Res***** 2000; Osby et al., *****BMJ***** 2000**

**Notes:**
SOURCE: Osby U et al. Schizophr Res. 2000;45:21-28.

## Poor ‘usual’ care for people with severe mental illness

**Fewer routine preventive services****1**
**Worse diabetes care****2**
**Fewer HbA1c tests, LDL tests, eye exams**
**Lower rate of monitoring**
**Poor glycemic control**
**Poor lipemic control**
**Lower rates of cardiovascular procedures****3**
**High rates of nursing home use****4**

***Sources: *****1. Druss et al., *****Medical Care*****, 2002; Desai et al., *****J Gen Intern Med*****, 2002; Druss et al., *****Arch Gen Psych*****, 2001; 2. Desai et al., *****Am J Psychiatry*****, 2002; Frayne et al., *****Arch Intern Med*****, 2005;***** *****3. Druss, *****JAMA*****, 2000; Druss et al., *****JAMA*****, 2000; Desai et al., *****J Nerv Ment Dis*****, 2002; 4. Bartels et al., *****Am J Geriatr Psychiatry***** 2003**

## Effective strategies exist

**Medication management ****(e.g., Rosenheck et al., *****Am J Psychiatry***** 2006)**
**Assertive community treatment (ACT)**
**25+ trials ****(Phillips et al., *****Psych Services***** 2001)**
**Psychosocial interventions (incl. family interventions)**** ****(e.g., Lehman et al., *****Schizophrenia Bulletin***** 1998)**
**Integrated care**
**Primary care embedded in mental health program**** ****(e.g., Druss et al., *****Arch Gen Psych***** 2001)**
**Unified primary care & mental health program**** ****(e.g., Cherokee Health System in TN)**
**“****Linkage” care management - improved PCP-MH collaboration**** ****(e.g., Bartels et al., *****Comm Ment Health J***** 2004)**
**Core elements not always / fully available**

## “The Commission supports coordinated and, where appropriate, integrated mental health and substance abuse screening, assessment, early intervention, and treatment for co-occurring disorders...” (Goal 4, Recommendation 4.3, p. 64)

**Notes:**
Also IOM recommendations (Chapter)

## Priorities for evidence

**Effectiveness**
**Scalability**
**Financing evidence-based interventions**
**Boundaries of “health care”**
**Measuring quality & outcomes**

## Possible “leverage points”

**Coverage**
**Procedure codes & quality measures**
**Demonstration / pilot programs**
**Other initiatives**

## For more information:

Michael Schoenbaum, PhD
Senior Advisor for Mental Health Services, Epidemiology, and Economics [C]
Division of Services and Intervention Research
National Institute of Mental Health
6001 Executive Blvd, Room 7142 MSC 9629
Bethesda, MD 20892-9669
Tel. 301-435-8760
Fax 301-443-0118
Email: schoenbaumm@mail.nih.gov
www.nimh.nih.gov

**Michael Schoenbaum, PhD**
**Senior Advisor for Mental Health Services, Epidemiology, and Economics [C]**
**Division of Services and Intervention Research**
**National Institute of Mental Health**
**6001 Executive Blvd, Room 7142 MSC 9629**
**Bethesda, MD 20892-9669**
**Tel. 301-435-8760**
**Fax 301-443-0118**
**Email: **_**[schoenbaumm@mail.nih.gov](mailto:schoenbaumm@mail.nih.gov)**_
_**[www.nimh.nih.gov](http://www.nimh.nih.gov/)**_