# Presentation: 696133

## Is Everyone “Mind”ing the Farm?  VA Sponsored Tools for Mental HealthProvider Track #247

- Laura Bonner, PhD
- Katy Lysell, PsyD

## Why Now?

## Wounded Warrior Commission

## Secretary’s 12 Point Mental Health Plan

## Why Primary Care?

- Longitudinal relationships, frequent contact
- Mental and physical illness commonly coexist
- Opportunity to...
- Reduce stigma
- Reduce barriers & unmet needs
- Intervene early
- Good evidence about what does & doesn’t work

**	**

**Notes:**
Physician education
Screening for mental illness
Unfocused Quality improvement
Decision support alone

## Screening for Depression

- Up to 50% of patients seen in primary care may have undetected behavioral health problems
- Systematic, guideline based screening and assessment may improve detection

## Prevalence of Behavioral HealthProblems in Primary Care

- Mental Health/Substance Abuse
-                                   PHQ-3000  Merrilac 500
- Major Depression		= 10%        24%
- Panic Disorder		=  6%         16%
- Other Anxiety Disorders	=  7%         21%
- Alcohol Abuse 		=  7%         17%
- Any Mental Health Dx 	= 28%        52%

## Prevalence of Behavioral Health Issues in Primary Care

- Health Behavior Change
- Smoking				= 25%
- Obesity					= 30%
- Sedentary lifestyle		= 50%
- Non-adherence			= 20 - 50%

## Depression in Primary Care

**Treatment of Depression Improves Physical Functioning in Older Adults.** *Journal of the American Geriatrics Society. 53(3):367-373, March 2005.*
**Monitoring Depression Treatment Outcomes With the Patient Health Questionnaire-9***.Medical Care. 42(12):1194-1201, December 2004.**** ***
**Outcome and Impact of Mental Disorders in Primary Care at 5 years. ***Psychosomatic Medicine. 69(3):270-276, April 2007****.***
**The cost-utility of screening for depression in primary care**. *Ann Intern Med 2001 Mar 6;134(5):345-60.*

## Elements of Effective Treatment                   (Bartels, Stephen J., 2006, Summary of First and Second Generation Studies)

- Multiple component interventions
- Lectures &/or distributing guidelines do not change behavior nor outcomes
- Adding patient tracking with a care manager significantly improves outcomes
- Including a mental health specialist in an integrated treating or consulting role improves outcomes the most

## Depression Care Management

- Collaborative care (Wagner et al. 1999)
- Informed patient
- Prepared, proactive clinical team
- ReTIDES Model
- Depression detected in PC
- Appropriate patients treated in PC
- Nurse care manager supports patient & PC provider

## Depression Care Manager

- Follows patients for 6 months
- Addresses barriers
- Supports treatment adherence
- Tracks progress
- Favorable reaction from veterans
- End users of CHIACC software

## CHIACC Products 

- Literature review published
- Expert panel manuscript submitted
- Prototype depression software
- Schizophrenia software in progress
- Currently conducting usability testing for depression prototype

## Panel Management

## Patient Management

## CHIACC Usability Goals

- Determine user reactions to software
- Compare strengths of 3 software approaches
- CHIACC
- NetDCMS
- FileMan
- Inform future development efforts

## CHIACC Usability Methods

- Experienced nurse care managers from ReTIDES & TEAM
- Standardized patient role plays
- Quantitative rating forms
- Qualitative feedback & recommendations
- Content areas (suicide assessment, etc.)
- Features (panel management, decision support, etc.)

## CHIACC Usability Preliminary Results

- Self-scoring PHQ-9-positive
- Strong interest in panel management features
- Decision support
- Workload prioritization
- Graphical display of progress over time
- Suggestions: e.g., increase ease of access to suicide protocol

## CHIACC in Context

- CHIACC is intended as a prototype
- Adaptable to other disorders, recently received funding to do this (CHIACCPlus)
- Not currently implemented in clinical sites

##             Consensus Informatics Needs for Mental Health

- Tracking progress over time
- Decision support
- Assessment tools
- Comorbid conditions: data collection and monitoring
- Communication among team members
- Patient recovery

## Case Example

**A 29-year-old OIF/OEF female veteran presents to your clinic with a four-week history of fatigue, insomnia, headache, abdominal discomfort, and difficulty concentrating at work. She denies recent illness and did not have headache or abdominal pain before the previous month.  **
**She is separated from her spouse, employed as a computer programmer, with one young child (age three years). She has obtained intermittent relief from headache by using acetaminophen, and she takes a multivitamin regularly. She is appropriately and professionally dressed, and she has brought her child to the appointment. She appears tired but in no acute distress. Results of physical examination, including neurologic screening, are normal. **

## PM Screening for Depression

## Slide 23

## Evaluation of Positive Screen

**All positive screens should be carefully evaluated **
**Substance abuse**
**Medical conditions**
**Psychological factors**
**Follow up with thorough evaluation**
**VA using PHQ-9 with 10****th**** question regarding functioning as follow up for depression evaluation**

## F/U of Positive PHQ-2

**Due for positive PHQ-2 or positive PHQ-9 or for anyone who answered with a positive response to question #9 of the PHQ-9.**
**PHQ-9 button displays only if not already done since the most recent positive PHQ-2 **
**Suicide questions from the pocket card display only if not done since the most recent PHQ-2 or PHQ-9.**

## Case History	

**No alcohol or drug use—AUDC of 0**
**Denied history of abuse—MST screen negative**
**CBC, TSH normal**
**Weight—140 lb, Height—5’6”, BP—115/70**
**Depression Screen positive**

## Patient Health Questionnaire	Copyright ©1999 Pfizer Inc. All rights reserved.

**The Patient Health Questionnaire (PHQ-9) is a depression assessment questionnaire named for the nine signs and symptoms of depression, used in the DSM-IV for diagnosing major depression**
**10****th**** question to assess impact on functioning**
**The questionnaire can be used as a quick diagnostic screener for depression**
**Can also be given to patients at various stages of their treatment to evaluate depression **_***severity***_** and treatment progress**
**Tracking patient severity significantly improves **_***outcome***_

## Slide 28

## Slide 29

## Slide 30

## Slide 31

## Initial PHQ-9 Results

## Assess Severity of Symptoms

**5-9 - Mild/Minor Depression **
**10-14 - Moderate Depression                                   **
**15-19 - Moderately Severe Depression                        **
**20-27 - Severe Depression                                        **
***A positive PH-Q9 or affirmative question 9 merits suicide risk assessment.***

## Patient’s Primary Complaints

- Sleep Disturbance
- Decreased Energy, fatigue
- Poor Concentration
- Irritability
- Feeling inadequate
- Social Withdrawal

## Assess Suicidal Ideation

- All depressed patients should be assessed for suicidal ideation
- Performance Measure requirements will be:  Suicide risk assessment for a positive PHQ-2, positive PHQ-9 or an affirmative answer to the 9th question of the PHQ-9

## Suicide Risk Assessment

## Slide 37

## Slide 38

## Slide 39

## Slide 40

## Slide 41

## Slide 42

## Case Example Evaluation Results

- Not Suicidal
- No prior history of depression
- Father may have had depression, but not sure
- Diagnosis:  Major Depressive Disorder, single episode
- Initial Treatment Plan:  10 mg fluoxetine

## 2 week follow-up	

- Improved mood, but some depression
- Improved energy, but not as much as she’d like
- Difficulty concentrating
- Poor sleep
- Continued irritability
- PHQ9 Score=12
- Treatment modification:  increase fluoxetine to 20 mg and add 50 mg trazodone at bedtime

## Additional Follow-up

**6 weeks**
**Improved sleep, mood**
**Energy almost normal**
**Some worries about work stress**
**PHQ9 Score=6**
**3 months**
**Symptom resolution**
**PHQ9 Score=2**

## One year follow up

## One Year Follow-up

- At one year elected a trial of medication discontinuation
- Follow-up monitoring at one month, three months, and six months with no return of symptoms

## One year post med-discontinuation

## One year post med-discontinuation

**Routine evaluation found some increase in depressive symptoms**
**Not of clinically significant level**
**Found patient experiencing increased stress with new job**
**Elected education intervention, and increased follow up to monitor symptoms—”watchful waiting”**

## Follow-up 2 year post initial assessment

##                   Additional Enhancements MHA3Patch YS*5.01*85

**MHA3—revising file structure of the Mental Health Assistant**
**Current system scores tests on the fly; new structure will save responses, scale scores on local VistA system**
**Creation of national testing database, storing results of MHA instruments from all local VistA systems**
**Creation of progress note in CPRS for MHA assessments**

## MHA3 New Instruments

**BOMC **
**Braden Skin Risk Assessment**
**Morse Falls Assessment**
**PC-PTSD**
**PHQ-2**
**TBI 2****nd**** Level Evaluation**
**AUD-C modified **
**PHQ-9 modified**

##                  Additional Enhancements Clinical Reminders Patch PXRM*2.0*6

**New Reminders patch to work with new MHA file structure**
**Reminders will work with any mental health instrument, following rules for restricted instruments**
**MH results will be available in Health Summary components (health summary patch)**
**CPRS v27 will use MHA dll for administering MHA instruments through reminder dialogs**
**National reminders:  update to OIF/OEF; update to TBI screen; screens for Depression, PTSD, and Alcohol Misuse; f/u to positive Alcohol Misuse Screen**

## Use of Individual Mental Health Instrument Item Response in Reminder Logic	

- Patch 6 of reminders (PXRM*2.0*6) will allow reminders to use scale scores or individual item responses with MH Instruments in findings
- For instance, you could track patients with positive response to suicidal ideation question on PHQ-9

## MHA3 and Clinical Reminders

**What percentage of patients present with binge drinking patterns?**
**What is the severity of depression seen in patients enrolled in the pain clinic?**
**How many patients over the age of 65 endorsed suicidal ideation on depression screen?**

**Questions?**