1. Mental Health in Primary Care Sheila Botts, PharmD, FCCP, BCPP Chief, Clinical Pharmacy Research and Academic Affairs Kaiser Permanente Colorado

2. Disclosures/Conflict of Interest Content of this presentation supported by resources from: Patient-Centered Primacy Care Collaborative (https://www.pcpcc.org/)https://www.pcpcc.org/ SAMHSA-HRSA Center for Integrated Solutions: Integrating Beahvioral Health into Primary Care I have no conflicts of interest to disclose.

3. Objectives Review epidemiology of common psychiatric disorders presenting to primary care settings Discuss the impact of untreated depression and anxiety on other chronic medical illnesses Review recommended treatment guidelines and measurement based outcomes for depression and anxiety disorders Identify strategies for integrating behavioral health care in primary care settings

4. Which of the following best describes the burden of mental illness? A.(green) Alzheimer’s Disease is associated with a higher disability adjusted life years (DALY) than Depression. B.(pink) Individuals with schizophrenia die ~25 years earlier due to genetic risk. C.(purple) Individuals with serious mental illness have similar rates of HTN and Diabetes as the general population. D.(yellow) Individuals with depression and anxiety disorders are less likely to be adherent to medication regimens.

5. Impact of Mental Health

6. Prevalence of Mental Disorders 46.4% of Americans will experience some form of mental illness in their lifetime 20% of women and 13% of men are affected by major depressive disorder each year; 6% of women and 3% of men are diagnosed with panic disorder; 9.7% of women and 3.6% of men are diagnosed with PTSD Men have higher rates of impulse-control disorders, substance use disorders, and suicide completion than women Galson, S.K. (2009). Public Health Reports,124 (March/April); 189-191.

7. Impact Mental disorders are disabling and can affect all aspects of life: Physical health Parenting Work Finances Care giving Relationships with family and friends Common daily activities Galson, S.K. 2009. Public Health Reports 124 (March/April), 189-191.

8. Burden of Disease: Disability-Adjusted Life Years (DALYs) DALYs represent the total number of years lost to illness, disability, or premature death within a given population. They are calculated by adding the number of years of life lost to the number of years lived with disability for a certain disease or disorder. Neuropsychiatric disorders are the leading contributor to DALYs in the US & Canada, and they contribute nearly twice as many DALYS as cardiovascular diseases and cancers. National Institute of Mental Health. (2012). http://www.nimh.nih.gov/statistics/2CDNC.shtmlhttp://www.nimh.nih.gov/statistics/2CDNC.shtml

9. Olfson et al. JAMA Psychiatry.doi:10.1001/jamapsychiatry.2015.1737

10. Cardiovascular Disease (CVD) Risk Factors Modifiable Risk Factors Estimated Prevalence and Relative Risk (RR) SchizophreniaBipolar Disorder Obesity45–55%, 1.5-2X RR 1 26% 5 Smoking50–80%, 2-3X RR 2 55% 6 Diabetes10–14%, 2X RR 3 10% 7 Hypertension≥18% 4 15% 5 Dyslipidemia Up to 5X RR 8 1. Davidson S, et al. Aust N Z J Psychiatry. 2001;35:196-202. 2. Allison DB, et al. J Clin Psychiatry. 1999; 60:215-220. 3. Dixon L, et al. J Nerv Ment Dis. 1999;187:496-502. 4. Herran A, et al. Schizophr Res. 2000;41:373-381. 5. MeElroy SL, et al. J Clin Psychiatry. 2002;63:207-213. 6. Ucok A, et al. Psychiatry Clin Neurosci. 2004;58:434-437. 7. Cassidy F, et al. Am J Psychiatry. 1999;156:1417-1420. 8. Allebeck. Schizophr Bull. 1999;15(1)81-89. 10

11. Sources: 1 McGinnis JM et al. JAMA 1993; 270:2207-12. 2 Mokdad AH, et al. JAMA 2004; 291:1230-1245.

12. Modifiable Behavioral Risk Factors Behavioral risk factors (smoking, obesity, sedentary lifestyle) account for approximately 40% of all deaths in the U.S. Depression associated with all 3 98,000 postmenopausal women followed prospectively (WHI, Wassertheil-Smoller 2004) with depression had higher rates: smoking, lack of exercise, obesity, diabetes, high cholesterol levels and hypertension compared to non-depressed populations cardiovascular related mortality

13. Depression and Chronic Medical Illness High rates of depression in the medically ill Depression amplifies physical symptoms associated with medical illness (pain, arthritis, diabetes) Depression worsens functional impairment Depression decreases adherence to prescribed regimens 3x more likely Depression is associated with adverse health behaviors (diet, exercise, smoking) Depression increases health care costs & mortality Suicide and medical causes Katon. Dialogues in Clinical Neuroscience - Vol 13. No. 1. 2011

14. Depression and Chronic Medical Disorders Katon. Dialogues in Clinical Neuroscience - Vol 13. No. 1. 2011

15. The Interface with Primary Care

16. What % of patients presenting to primary care have behavioral health needs? A.(green) 5-10% B.(pink) 30-40% C.(purple) 50-60% D.(yellow) >80%

17. Primary Care is the ‘De Facto’ Mental Health System Wang P et al. Arch Gen Psychiatry, 2005: 62. Adapted from Katon, Rundell, Unützer, Academy of PSM Integrated Behavioral Health 2014 Pie of all behavioral health needs

18. Epidemiology of Co- morbidity 16.8% of the US adult population has both a mental disorder and a medical condition 30% of adults with a chronic medical condition have a co- morbid mental health condition Source: http://www.rwjf.orghttp://www.rwjf.org

19. Epidemiology of Co- morbidity Odds ratio of alcohol/ drug disorders is 2.7 times more if any mental disorder exists This is 10-20 times greater than expected for schizophrenia, mania, antisocial personality disorder Kessler et al.1997 Archives of General Psychiatry, 43, 313–321.

20. 84% of the time, the 14 most common physical complaints have no identifiable organic etiology 1 80% of individuals with a behavioral health disorder will visit primary care at least 1 time in a calendar year 2 50% of all behavioral health disorders are treated in primary care 3 20-40% of primary care patients have behavioral health needs 4 48% of the appointments for all psychotropic agents are with a non- psychiatric primary care provider 5 Sources: 1 Kroenke & Mangelsdorf, Am J Med. 1989;86:262-266. 2 Narrow et al., Arch Gen Psychiatry. 1993;50:5-107. 3 Kessler et al., NEJM. 2006;353:2515-23. 4 Martin et al., Lancet. 2007; 370:859-877. 5 Pincus et al., JAMA. 1998;279:526-531. Behavioral Health Demand

21. Individuals with behavioral health and substance abuse conditions cost 2-3 times as much as those without 1 Behavioral health disorders account for half as many disability days as “all” physical conditions 2 Annual medical expenses--chronic medical & behavioral health conditions combined cost 46% more than those with only a chronic medical condition 3 Top five conditions driving overall health cost 4 1.Depression 2.Obesity 3.Arthritis 4.Back/Neck Pain 5.Anxiety 1 Milliman report to the APA, August 2013. 2 Merikangas et al., Arch Gen Psychiatry. 2007;64:1180-1188. 3 Original source data is the U.S. Dept of HHS the 2002 and 2003 MEPS. 4 Loeppke et al., J Occup Environ Med. 2009;51:411-428. High Cost of Unmet Behavioral Health Needs

22. Management of Depression and Anxiety Disorders A Population Approach

23. A patient presenting for a wellness visit, screens + for depression with a PHQ-9 score of 9. What is the most appropriate intervention? A.(green) Initiate an SSRI B.(pink) Implement watchful waiting C.(purple) Refer to Behavioral Health D.(yellow) Initiate Cognitive Behavioral Therapy

24. The Approach Identify/Screen Treat Monitor and Measure Progress Manage Comorbidities Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ©2013

25. Screening Depression – recommended by US Preventive Services Task Force (USPSTF) to screen adults and adolescents Anxiety disorders - not recommended by USPSTF, but a common co- morbidity with depression Substance use – recommended by USPSTF for adults

26. Which Population(s) to Screen? Health maintenance visits Chronic illnesses COPD CVD Diabetes Other high risk populations Chronic pain Children with home or school behavior problems People who have been hospitalized

27. PHQ-9 1.A validated tool for screening and diagnosing depression and for following response to treatment 2.Scoring parallels DSM-IV diagnosis for Major and Minor Depression 3.Can be administered in ‘interview’ style or completed by patient

29. Guideline for Using the PHQ-9 for Initial Management Score/ Symptom Level Treatment 0-4 No depression Consider other diagnoses 5-9 Mild  Consider other diagnoses  If diagnosis is depression, watchful waiting is appropriate initial management 10-14 Moderate  Consider watchful waiting  If active treatment is needed, medication or psychotherapy is equally effective 15-19 Moderately Severe  Active treatment with medication or psychotherapy is recommended  Medication or psychotherapy is equally effective 20-27 Severe  Medication treatment is recommended  For many people, psychotherapy is useful as an additional treatment  People with severe symptoms often benefit from consultation with a psychiatrist

30. Anxiety: GAD 7 GAD-2 used for screening (score 3+) GAD 7 useful for baseline and monitoring

31. Substance Misuse: SBIRT Screening — a healthcare professional assesses a patient for risky substance use behaviors using standardized screening tools. Screening can occur in any healthcare setting Brief Intervention — a healthcare professional engages a patient showing risky substance use behaviors in a short conversation, providing feedback and advice Referral to Treatment — a healthcare professional provides a referral to brief therapy or additional treatment to patients who screen in need of additional services

32. Treat to a Target

33. Treatment of Depression J Clin Psychiatry. 1994;55(suppl2):61. 12 weeks6 months determined by personal history

34. DepressionTreatment Goals Treat to Remission PHQ-9 <5 Continuation: maintain remission with continued treatment for additional 4-9 months Maintenance- patients at high risk of relapse, continue antidepressant > one year APA Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition, 2010

35. Star*D Treatment Outcome: Level 1 (N=2876) HAMD-17=17-item Hamilton Rating Scale for Depression QIDS-SR-16=16-item Quick Inventory of Depressive Symptomatology – Self-Report Trivedi et al., Am J Psychiatry 2006;163:28-40

36. Remission by Duration of Treatment n=2,876 Remission= QIDS-SR 16 < 5 Trivedi et al., Am J Psychiatry, 2006;163(1):28-40 52.9%

37. Monitor and Measure

38. Adequate Antidepressant Trial Patients frequently do not complete an adequate trial of an antidepressant Minimum 8-12 weeks Minimum dose targets Counsel patients on appropriate expectations Prescribers may not alter an unsuccessful treatment If patient does not have 12-week remission consider change TMAP. 2008. J Clin. Psychiatry. 2008;69(suppl E1):14-18.

39. PHQ-9 - Change from last score, measured monthly Treatment Response Treatment Plan Drop of 5 or more points each month GoodAntidepressant &/or Psychotherapy No treatment change needed. Follow-up in 4 weeks. Drop of 2-4 points each month FairAntidepressant: May warrant an increase in dose. Psychotherapy: Probably no treatment change needed. Share PHQ-9 with psychotherapist. Drop of 1 point, no change or increase each month PoorAntidepressant: Increase dose or augment or switch; informal or formal psychiatric consult; add psychotherapy. Psychotherapy: 1. If depression-specific psychotherapy discuss with supervising psychiatrist, consider adding antidepressant. 2. For patients satisfied in other psychotherapy consider adding antidepressant. 3. For patients dissatisfied in other psychotherapy, review treatment options and preferences. Interpreting PHQ-9 Follow Up Scores

40. Treatment Outcomes: STAR*D Level 2 Switch vs Augmentation (% remission) Rush et al., N Engl J Med 2006;354(12):1231-42 Trivedi et al., N Engl J Med 2006;354(12):1243-52

41. Pharmacological Options After Failure of First Antidepressant Optimize dose and address adherence Change to another antidepressant Same class Different class Add a second antidepressant Add a non-antidepressant Lithium or other mood stabilizer Thyroid hormone Psychostimulant Atypical antipsychotic Change to CBT or Add CBT Consider Referral to Behavioral Health APA Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition, 2010

42. Integrating Care

43. Where would you prefer to address your behavioral health needs? In your family medicine clinic with behavioral medicine specialist? In your family medicine clinic with your PCP? In your family medicine clinic with a tele-consult from a psychiatrist? In the behavioral health clinic with a psychiatrist? In the complimentary medicine clinic (e.g.mindfulness meditation) In my running shoes

44. A Legacy of Separate and Parallel Systems Integrated behavioral health leads to a better match of clinical services to the realities that patients and their clinicians face daily. Medical Care Mental Health Care A forced choice between: 2 kinds of problems 2 kinds of clinicians 2 kinds of clinics 2 kinds of treatments 2 kinds of insurance Original Source: CJ Peek 1996

45. Meeting Patients Where They Are: Deploy integrated behavioral health expertise to reduce stigma against seeking mental health care Source: CJ Peek & Mac Baird, 2010 Integrated Care for Mental Health Conditions Depression/Anxiety Substance Abuse ADHD Other Integrated Care for Medical Conditions Diabetes/BP/Obesity Heart Disease Childhood Chronic Illness Stress-linked Physical Symptoms Integrated Care for Persons: Social and Care Complexity Functional impairments or diagnostic uncertainty Distress, distraction & readiness to engage in care Social safety, support & participation Organization of care / relationships in health system Shared language with providers / sufficient insurance

46. Range of Models Collaboration Co-location Integration Health Homes Primary Care Mental Health Centers

47. Behavioral Health Should be Part of the PCMH 1.High prevalence of behavioral health problems in primary care (needing long-term follow-up) 2.High burden of behavioral health in primary care 3.High cost of unmet behavioral health needs 4.Lower cost when behavioral health needs are met 5.Better health outcomes 6.Improved satisfaction Triple Aim

48. Source: Unützer et al., American Journal of Managed Care 2008;14:95-100 Cost Category 4-year costs in $ Intervention group cost in $ Usual care group cost in $ Difference in $ IMPACT program cost 5220 Outpatient mental health costs 661558767-210 Pharmacy costs 7,2846,9427,636-694 Other outpatient costs 14,30614,16014,456-296 Inpatient medical costs 8,4527,1799,757-2578 Inpatient mental health / substance abuse costs 11461169-108 Total health care cost 31,08229,42232,785-$3363 $avings IMPACT: Collaborative Care for Depression Reduces Costs Lower Cost when Behavioral Health Treated 48

49. Improved Mental Health Outcomes Over 75 trials in collaborative care in nearly 2 decades have proven significant benefit for depression and anxiety disorders 1 Interventions work in a wide variety of settings in a wide variety of mental health conditions 2 Sources: 1 Archer et al, Cochrane Syst Data Rev, 2012: 10. 2 Woltman et al, AJP, 2012: 169:790-784. 3 Gilbody et al, Arch Int Med, 2006:166:2314-2321 Improved Outcomes 2 Improved adherence to evidence-based treatment 3

50. Leading to Improved Physical Health Outcomes When treated in harmony with mental health, chronic physical health improves significantly 1 Sources: 1 Katon et al, NEJM, 2010:363:2611-2620. 2 Woltman et al, AJP, 2012: 169:790-784. Improved Diabetes 1 Improved BP 1 Improved Cholesterol 1 Overall quality of life and physical health improve consistently 2 Physical health Quality of life

51. Improved Patient Satisfaction After 12 months of care, multi-condition collaborative care improved patient satisfaction in depression AND diabetes care 1 Source: 1 Katon et al, NEJM, 2010:363:2611-2620 synergy Diabetes care Depression care Patient testimonial on integrated care: "...the staff at Marillac Clinic actually cared about what I had to say- they were there to help when I needed it - not just medical help, but counseling - and the medications I needed to get well. They helped me learn how to care for myself - I understood how to accept myself from the kindness in their eyes.” - Past patient of Marillac Clinic, Grand Junction, Colorado

52. Improved Provider Satisfaction Primary care physicians like integrated care for a variety of reasons 1 Sources: 1 Gallo et al, Ann Fam Med, 2004:2: 305-309. 2 Levine et al., Gen Hosp Psych. 2005; 27:383-391 Behavioral health specialists are also satisfied with working in integrated settings 2 photo courtesy: http://www.teamcarehealth.org/