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

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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”

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

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12-month diagnosable disorders in the NCS-R

Rates of Adequate Treatment for Serious Mental Illness

SOURCE: Wang et al. Am J Pub Health 2002
| % With AnyTreatment inPrior Year | % With Minimally Adequate Treatment AmongTreated | % 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 |

Margins for improvement
        - Effect size

Efficacy

Effectiveness

Coverage

Adherence

Personalization
        - Cost of achieving the effect

(Basic science)

CATIE/STAR-D/ TADS/STEP-BD

PIC/IMPACT

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 

(Basic science)

CATIE/STAR-D/ TADS/STEP-BD

PIC/IMPACT

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

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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

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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

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Key components of effective care
        - Screening & assessment
        - Patient education and activation
        - Treatment
        - Care management
        - Mental health consultation

“Collaborative Care”

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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)

“I got my life back”

Photo credit: J. Lott, Seattle Times

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�(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)

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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)

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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/)
        - ICSI “DIAMOND” initiative in Minnesota

All components implemented via FFS

(http://www.icsi.org/news/archive/diamond_project_launched_.html)

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Kaiser Southern California

Available to ~3 million members

Implemented via “population health management” division

Trained care managers in all 40 regional health centers

~40,000 beneficiares under active care management

Aetna Depression Management initiative

Primary care providers reimbursed for depression screening & assessment

PCPs have access to on-call psychiatrists

Aetna care managers follow patients

Institute for Clinical Systems Improvement (ICSI) “DIAMOND” initiative in Minnesota

5 largest commercial payers, & Medicaid

New billing code for depression care management

To bill, practices need

Trained & certified care managers

Consulting psychiatrist

To submit data on patients’ outcomes

Awarded NIMH grant for evaluation

SOURCES:  Aetna - http://www.aetna.com/aetnadepressionmanagement/ , http://www.aetna.com/news/2005/pr_20051102.htm, and http://www.aetna.com/about/aoti/business_solutions/depression_management.html

ICSI - http://www.icsi.org/news/diamond_project_launched_.html and http://www.icsi.org/colloquium_-_2007/diamond_panel.html

ICSI stands for “Institute for Clinical Systems Improvement”, and DIAMOND stands for “Depression Improvement Across Minnesota Offering a New Direction”. ICSI principal sponsors are BlueCross BlueShield of Minnesota, HealthPartners, and Medica, and they have about 60 member delivery systems across Minnesota.

(all web links as of September 27, 2007)

ADD RWJ PROGRAMS, ALSO KAISER NORTHERN CALIFORNIA / IMPACT TRAINING ETC

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”

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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

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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

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SOURCES for epi data: Overall from Surgeon General’s Report (http://www.surgeongeneral.gov/library/mentalhealth/chapter2/sec2_1.html); and from Wu et al., Psychological Medicine, 2006.  SSDI from Social Security Administration and the Urban Institute. 

SOURCE for costs: as listed on slide.

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

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

Poor ‘usual’ care for people with severe mental illness
        - Fewer routine preventive services1
        - Worse diabetes care2

Fewer HbA1c tests, LDL tests, eye exams

Lower rate of monitoring

Poor glycemic control

Poor lipemic control
        - Lower rates of cardiovascular procedures3
        - High rates of nursing home use4

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

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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

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“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)

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Also IOM recommendations (Chapter)

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

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Possible “leverage points”
        - Coverage
        - Procedure codes & quality measures
        - Demonstration / pilot programs
        - Other initiatives

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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

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