1. 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

2. 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

3. 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

4. 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

5. 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

6. 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:

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

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

9. 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: $ vs. $ (p=0.33)
For those who did not improve
Cost differential (pre and post) was: $ vs. $ (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.

10. 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?

11. 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):

12. 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 years of age (p=0.035)

13. 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

14. 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
0.288
Initial PHQ-9 score
0.9768
0.500
GAD-7 score
1.0571
0.029
MDQ Positive
3.4714
0.044

15. 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).

16. 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 (p=0.001)
Length of days in CCM treatment also increased in re-admission group
vs days (p=0.002)

17. 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 , CI to (p=0.0177)
Days in CCM treatment
OR , CI to (p=0.0033)

18. 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.

19. 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

20. 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

21. Questions?? THANK YOU!