1. 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

2. 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

3. 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

4. Cumulative lifetime probability of treatment contact for anxiety disorders, from year of onset SOURCE: Wang et al. Arch Gen Psychiatry 2005

5. Balancing Improved Efficacy vs. Improved “Fidelity” SOURCE: Woolf & Johnson, Ann Fam Med, 2005

6. 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

7. 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

8. 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

9. 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

10. 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 39.448.519.9 Mood Disorder 45.848.211.8 Non-Affective Psychosis 55.97.34.1 Any of the Above 40.038.915.3 SOURCE: Wang et al. Am J Pub Health 2002

11. 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

12. Balancing Improved Efficacy vs. Improved “Fidelity” SOURCE: Woolf & Johnson, Ann Fam Med, 2005

13. 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

14. Balancing Improved Efficacy vs. Improved “Fidelity” SOURCE: Woolf & Johnson, Ann Fam Med, 2005

15. 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

16. 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

17. 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

18. 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

19. ‘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

20. Key components of effective care Screening & assessment Patient education and activation Treatment Care management Mental health consultation “Collaborative Care”

21. “Collaborative care” has been tested “I got my life back” Photo credit: J. Lott, Seattle Times 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)

22. “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)

23. “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)

24. 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

25. 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”

26. 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

27. 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

28. 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

29. 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

30. 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

31. “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)

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

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

34. 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.govschoenbaumm@mail.nih.gov www.nimh.nih.gov