Assistant Professor of Family Medicine Care Management for Depression: Improving outcomes---but can we do better?? STFM April 2011 Kurt B. Angstman, MS MD Assistant Professor of Family Medicine Mayo Clinic Rochester MN

Disclosures I do not have any financial disclosures. I will not be discussing off-label use of medications or devices. Studies described have been approved by IRB

What does the evidence say for Depression in Primary Care? 37 trials of collaborative care for depression in primary care (US and Europe) Meta-analysis by Gilbody et al, Archives of Internal Medicine; 2006 Consistently more effective than usual care Unutzer et al, Report to President’s Commission on Mental Health; Psychiatric Services; 2006. When your outnumbered, join forces… 3

Care delivery redesign based on best practices DIAMOND: Depression Improvement Across Minnesota, Offering a New Direction Designed in Minnesota by the Institute for Clinical Systems Improvement (ICSI) Care delivery redesign based on best practices Payment redesign aimed at aligning incentives www.icsi.org

The DIAMOND Model Consistent with evidence on collaborative care: Four Processes: Consistent method for assessment/monitoring (PHQ-9) Presence of tracking system (registry) Stepped care approach to intensify/modify treatment Relapse prevention Two Roles: Care manager for follow up, support, coordination Consulting psychiatrist for caseload review and recommendations 5 5

Collaborative care (CCM) vs. usual care (UC) at six months Angstman KB, Williams MD. Patients in a depression collaborative care model of care: Comparison of six month cost utilization data with usual care. Journal of Primary Care and Community Health April 2010; 1: 12-16.

Minnesota HealthScores Remission at six months-intent to treat methodology (all in remission/all activated initially)

Minnesota HealthScores Remission at twelve months-intent to treat methodology (all in remission/all activated initially)

CAN WE DO BETTER??? Preliminary study of 200 patients in collaborative care management (CCM) and 119 in usual care. For those who improved Costs within first six months were similar between those in CCM and in usual care Cost differential (pre and post) was: $216.29 vs. $239.94 (p=0.33) For those who did not improve Cost differential (pre and post) was: $365.84 vs. $194.40 (p=0.003) Angstman KB, DeJesus R, Williams, M. Collaborative care management for depression: Comparison of cost metrics, clinical response to usual care. Journal of Primary Care and Community Health 2010 July; 1(2):73-7.

CAN WE DO BETTER??? What factors drive success in CCM Screening Activation into CCM Staying in CCM (not dropping out) Stepped care for therapy Since increased costs are related to those who are not improving at six months; what factors drive persistent depression in CCM patient?

Study Design Retrospective review of CCM database 334 patients initially seen with diagnosis of depression or dysthymia and PHQ-9 score of 10 or more 100 with non-responding to therapy after six months in CCM PHQ-9 score of >50% of initial or greater 234 with clinical remission at six months PHQ-9 score of < 5 Angstman KB, DeJesus RS, Rohrer JE. Correlation between mental health comorbidity screening scores and clinical response in collaborative care treatment for depression. Ment. Health Fam. Med. 2010; 7(3):129-33.

Results Non-responsive to treatment group was not statistically different from remission group in regard to marital status, gender, or race. A lower age in the non responsive to treatment group 39.76 vs. 43.75 years of age (p=0.035)

Results P= Non-responsive N= 100 Clinical remission N= 234 Initial PHQ-9 14.82 (10-27) 14.79 0.816 GAD-7 score 11.53 (0-21) 9.85 0.009 Audit Score 2.89 (0-28) 3.07 (0-29) 0.143 MDQ score Negative Partially positive Positive 90 (90.0%) 2 (2.0%) 8 (8.0%) 225 (96.2%) 4 (1.7%) 5 (2.1%) 0.049 0.780 0.026

Logistic regression (does not show age, gender, marital status, or race, which were not significant) Odd Ratio (Not respond to treatment at six months) CI P= Audit Score 0.9663 0.907-1.029 0.288 Initial PHQ-9 score 0.9768 0.912-1.046 0.500 GAD-7 score 1.0571 1.0006-1.1110 0.029 MDQ Positive 3.4714 1.034-11.661 0.044

Study Design Retrospective analysis Patients who have “graduated” from CCM 145 patients 113 with no evidence of recurrent depression at 4 months 32 with recurrent depression requiring re-admission to CCM Angstman KB, MacLaughlin KL, Williams MD, Rasmussen NH, DeJesus RS. Anxiety and length in treatment impact early re-admission to collaborative care treatment for depression. Journal of Primary Care and Community Health January 2011; 2(1).

Comparison of re-admission group vs. no recurrence group No difference in age, gender, race, marital status, initial PHQ-9 score, AUDIT and MDQ scores Initial screening GAD-7 score increased in re-admission group 12.81 vs. 9.20 (p=0.001) Length of days in CCM treatment also increased in re-admission group 168.09 vs. 120.99 days (p=0.002)

Multiple logistic regression model for re-admission Clinical predictors associated with re-admission for depression treatment compared to no recurrence group Multiple logistic regression model for re-admission When controlling for all other variables (age, gender, marital status, race, initial PHQ-9 score, and a negative MDQ- score)… GAD-7 OR 1.1156, CI 1.0192 to 1.2212 (p=0.0177) Days in CCM treatment OR 1.0123, CI 1.0041 to 1.0206 (p=0.0033)

Conclusions Significant increased risk of not responding with CCM for depression at six months with increased GAD-7 score and a positive MDQ score. Significant risk for relapse of depression after CCM treatment in those patients with increased GAD-7 score at intake and who take longer to get to initial remission.

Future Directions Confirmation of studies using larger statewide database Closer following of GAD-7 Institute anxiety management program in addition to depression care management (CALM?) At relapse prevention evaluation, use initial GAD-7 and length of treatment in CCM as guidelines for defining risk of recurrence

Mayo Diamond Team Members Dr. David Katzelnick, Psychiatry - Director of IBH Dr. Mark Williams, Psychiatry Dr. Kristin Somers, Psychiatry Dr. Kurt Angstman, Family Medicine Dr. Steven Bruce, Family Medicine Dr. Jay Mitchell, Family Medicine Dr. John Wilkinson, Family Medicine Dr. Ramona DeJesus, Primary Care Internal Medicine Dr. Marcie Billings, Community Pediatrics Mr. Rob Bender, Operations Manager Stephanie Witwer, Nursing Administration Angela Kaderlik, RN Coordinator and 11 care managers

Questions?? THANK YOU! angstman.kurt@mayo.edu