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Disclosure: Wayne Katon, MD

Disclosure: Wayne Katon, MD. Company Employment Management Independent Contractor Consulting Speaking & Teaching Board, Panel or Committee Membership. Enhancing Treatment for Patients with Comorbid Depression, Diabetes and Heart Disease. Wayne Katon, MD 1 Mike VonKorff, ScD 2

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Disclosure: Wayne Katon, MD

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  1. Disclosure: Wayne Katon, MD Company Employment Management Independent Contractor Consulting Speaking & Teaching Board, Panel or Committee Membership

  2. Enhancing Treatment for Patients with Comorbid Depression, Diabetes and Heart Disease Wayne Katon, MD1 Mike VonKorff, ScD2 Elizabeth Lin, MD, MPH2 Paul Ciechanowski, MD, MPH1 Greg Simon, MD, MPH2 Evette Ludman, PhD2 Joan Russo, PhD1 Carolyn Rutter, PhD2 Bessie Young, MD, MPH1 1 University of Washington School of Medicine 2 Center for Health Studies, Group Health Cooperative NIMH Grants MH 4-1739 and MH 01643 (Dr. Katon)

  3. Mrs. K is a 45-year-old female computer programmer with a 5-year history of type 2 diabetes. She started the study in Sept. 2007 based on the following eligibility criteria: PHQ-9 of 20, HbA1c 9.6. Patient has a history of childhood sexual abuse, has had recurrent depressive episodes and obesity with a BMI of 51 (>30 meets obesity criteria). Prior history of smoking and has sleep apnea Rxed with CPAP.

  4. Adverse Bidirectional Interaction • Smoking • Sedentary lifestyle • Obesity • Lack of adherence to medical regimens • Psychophysiologic •  Insulin sensitivity •  Autonomic NS •  Inflammatory markers • Medical illness at earlier age • Poor symptom control •  functional impairment •  complications of medical illness •  mortality Major Depression Katon et al. Biol Psychiatry 2003

  5. Premature Mortality and Chronic Mental Illness • Schizophrenia: 20-25 years • Bipolar: 10-15 years • Major Depression: 5 to 10 years

  6. Etiology of Premature Mortality • Suicide, accidents • Medical morbidity

  7. Medical Morbidity • Chronic stress: effects on HPA axis, autonomic nervous system, immune system • Health risk behaviors: smoking, sedentary lifestyle, diet/obesity, alcohol/drugs • Lack of self care: adherence to medication, diet, exercise, cessation of smoking • Psychiatric medications: obesity, metabolic syndrome, diabetes, CAD

  8. Behavioral Risk Factors: Depression • Behavioral risk factors (smoking, obesity, sedentary lifestyle) account for approximately 40% of all deaths in the U.S. • Depression is linked to all 3 • Wassertheil-Smoller (2004) have shown in 98,000 women that depression was associated with higher rates of smoking, lack of exercise, obesity, diabetes, high cholesterol levels and rates of hypertension compared to non-depressed populations

  9. Meta-Analysis of the Effect of Depression on Patient Adherence • Compared to nondepressed patients, the odds are 3 times greater that depressed patients would be nonadherent with medical treatment recommendations DiMatteo MR et al. Arch Intern Med 2000

  10. % Smoking by Depression Level p<0.001; Major > None p<0.01; Minor > None N = 4,225 Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type and duration, treatment type , HbA1c and clinic Katon et al. Diabetes Care 2004

  11. % BMI > 30 kg/m2 by Depression p<0.001; Major > None p<0.01; Minor > None N = 4,225 Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type and duration, treatment type, HbA1c and clinic Katon et al. Diabetes Care 2004

  12. HbA1c > 8% by Depression Level p<0.001; Major > None p<0.01; Minor > None N = 4,225 Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type and duration, treatment type and clinic Katon et al. Diabetes Care 2004

  13. Medication Adherence in Patients with Diabetes Nonadherent Days (%) Oral Hypoglycemic ACE Inhibitors Lipid Lowering Meds Lin et al. Diabetes Care 2004

  14. Pathways Epidemiology Study Baseline Mail Survey 5-YearTelephone Survey 1 2 3 4 Disease control (HbA1c, LDLs, blood pressure) Pharmacy refills (adherence) ICD-9 diagnosis Macrovascular/microvascular complications (chart review) Mortality (Washington State mortality data)

  15. Depression: Association with Complications and Mortality

  16. Pathways Randomized Controlled Trial • Participants randomly assigned to Pathways nurse collaborative care intervention (N = 165) vs. usual care (N = 164) • Usual Care • Primary care or referral to specialty MH care as available • Pathways Care • Collaborative/stepped care disease management program for depression in primary care Katon et al. Arch Gen Psych 2004

  17. Treatment Protocol • Behavioral activation/pleasant events scheduling • Antidepressant medication • Usually an SSRI or other newer antidepressant OR • Problem Solving Treatment in Primary Care (PST-PC) • 6-8 individual sessions followed by monthly group maintenance sessions • Maintenance and Relapse Prevention Plan • For patients in remission Katon et al. Arch Gen Psych 2004

  18. Intervention vs Control Differences on Mean SCL Depression Scores (Range 0 – 4) Mean SCL-20 Depression Score Katon et al. Arch Gen Psych 2004 I UC Baseline 3 mos 6 mos 12 mos

  19. Intervention vs Control Differences on Mean HbA1c Katon et al. Arch Gen Psych 2004 Mean HbA1C % UC I Baseline 6 mos 12 mos

  20. Intervention vs. Usual Care Differences in Health Risk Behaviors • No significant I vs. UC differences in exercise, diet, smoking or checking blood glucose • Intervention patients had a significantly lower mean BMI level compared to UC at 12 months Lin et al. Arch Fam Med 2006

  21. Depression: Diabetes Lower Total Health Care Costs Over 2 Years $22,258 $21,148 $18,932 $18,035 $1,110 $897

  22. Treating depression and other mental Illness is a necessary first step, but not sufficient alone to improve health risk behaviors and chronic medical disease control

  23. Health Services Models • TeamCare Approaches have been shown to improve quality of care and outcomes of patients with depression, diabetes, asthma and CHF • The most complex and medical costly patients often have multiple comorbidities including at least one mental health diagnosis

  24. Medicare Patients • Depression, diabetes and heart disease are among the most common illnesses in aging populations but fewer than 4% of Medicare beneficiaries with any of these three illnesses have no other chronic medical conditions • 80% of those with CHF, 71% with depression and 56% with diabetes have 4 or more chronic conditions Partnership for Solutions 2001

  25. Diabetes: Achieve Recommended Risk Factor Targets Schmittdiel J et al. JGIM 23:588-94, 2008 • Less than 10% of diabetes patients attain recommended goals for: HbA1c < 7.0%, Systolic BP < 130 and LDL < 100mg • Poor Adherence found in 20% of patients • No evidence of poor adherence but lack of Rx intensification found in 30% of hyperglycemia patients, 47% of hyperlipidemia patients and 36% of hypertensive patients

  26. Challenge: Development of Health Services Models for “Natural” Clusters of Illness Examples: • Diabetes, CAD, depression • Depression, chronic pain, substance abuse Definition: Illnesses with high prevalence, high comorbidity and bidirectional adverse interactions

  27. New NIMH-Funded Study: TeamCare Inclusion Criteria • Evidence via automated date (ICD-9) of having diabetes and/or coronary artery disease (CAD) • Evidence of poor disease control (HbA1c> 8.5, blood pressure >140/90, LDL >130) • PHQ-9 > 10

  28. 10,000 Group Health patients with diabetes and/or CAD & poor disease control Screen 1: PHQ-2 (response rate 82.6%) 14.8% positive (>3 on PHQ-2) Screen 2: 1066 eligible for SQ-2 with PHQ-9 268 with PHQ-9 >10 completed baseline >200 randomized

  29. TeamCare Intervention Goals • Improve depression care: behavioral activation and antidepressants • Improve medical disease control: HbA1c, HTN, LDL • Improve self-care (diet, exercise, cessation of smoking, glucose checks)

  30. TeamCare Interventionists • 3 diabetes nurse educators • Caseload supervision • Depression: 2 psychiatrists • Diabetes and CAD: nephrologist, family doctor • E-Mail to diabetologist for complex cases

  31. Nurse Training • Motivational interviewing • Problem solving • Behavioral activation • Antidepressants • TREAT-to-TARGET: blood glucose, HTN, LDLS

  32. Initially, the case manager increased the patient’s Celexa from 20 to 60 mg and also began working with the patient on monitoring blood sugars more frequently and increasing NPH insulin. Trazadone was also added to help with sleep. Her HbA1c decreased by December to 8.4%. PHQ score initially decreased from 20 to 12 on Celexa 60 mg. and Trazodone 50 mg and Wellbutrin was added at 100 SR with gradually increasing dosages. By mid-November, her PHQ had decreased to a 5 on Celexa 40 mg, Wellbutrin SR 200 mg BID, Trazodone 50 mg.

  33. TeamCare Summary Report

  34. Improving Adherence • Patient self-care materials: book and video on depression, patient manual (Tools for Managing Your Chronic Disease) • Nurse support/education/motivational interviewing • Medisets • Simplifying medication regimen • $4 generics to avoid $10 co-pays

  35. Self-Care Enhancements • Glucometers: Group Health provides • Home blood pressure monitors • Pedometers to increase exercise • Medisets to improve adherence

  36. Phases of Treatment • Intervene on depression initially • Behavioral activation • Antidepressant medication

  37. Medical Disease Control • Is patient adhering to medication regimen? • If adhering and in poor control, is patient on optimal dosage? • If maximum dosage has been reached should a new medication be tried instead or augmentation of initial medication? • Team recommendations of medication changes are reviewed with primary care physician for approval

  38. Behavioral Goals • Behavioral activation/exercise • Dietary changes • Checking blood glucose/altering insulin • Cessation of smoking

  39. The nurse worked with the patient in January/February 2008 on increasing exercise and weight reduction. Patient also began to gather information about gastric bypass surgery. She began to watch food proportion sizes, worked out on a treadmill and joined a pregastric bypass group. Her PHQ-9 in June was a 7, HbA1c 7.4%, blood pressure 113/82 (had decreased from 132/80) and LDL was 77 (had decreased from 101). .

  40. Conclusions • Patients with common psychiatric illnesses have significantly shorter life spans due to premature development of medical illnesses. • Economies of scale: New health services interventions are needed for patients with multiple comorbidities (one of which is a psychiatric disorder). • Integration of evidence-based mental health interventions into primary care and preventative medical interventions into community mental health care are needed to enhance outcomes of patients with comorbidities.

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