Telehealth interventions for mood disorders: What? Who? How?

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1 Telehealth interventions for mood disorders: What? Who? How? Gregory Simon MD MPH Group Health Center for Health Studies, Seattle, WA

2 Public Health Impact Depression: Lifetime prevalence of 16%, One-year prevalence of 7% Projected to be 2 nd -leading cause of disability worldwide by 2020 Economic and social impacts include reduced educational attainment, relationship disruption, lost work productivity, increased health services costs, and increased welfare program costs Bipolar Disorder Prevalence of 1-2% (more if include less severe forms) 6 th leading cause of years lost to death and disability worldwide Economic and social impacts include lost work productivity, increased disability payments, increased criminal justice costs, and increased welfare program costs

3 Effective treatment for depression Antidepressant medication Specific psychotherapy Non-specific support

4 Effective treatment for bipolar disorder Medication (often complex) Specific psycho-education or psychotherapy Non-specific support

5 Problems in treatment of depression High rates of premature unplanned medication discontinuation Infrequent/erratic follow-up of medication treatment Poor availability of evidence-based psychotherapy High rates of drop-out from psychotherapy

6 Problems in treatment of bipolar disorder High rates of medication discontinuation Erratic follow-up care Poor availability of evidence-based psychotherapy High rates of drop-out from psychotherapy Poor adherence to recommended laboratory monitoring

7 Organized care for mood disorders Uniform monitoring of treatment adherence Outreach to assess treatment outcomes Outcomes-based treatment algorithms ( treat to target ) Communication and coordination across providers Structured psycho-education or psychotherapy Non-specific encouragement and support

8 Why telehealth interventions? Decreased cost Increased reach Greater convenience or acceptability Greater standardization or quality control

9 What? Monitoring continuity and intensity of treatment Monitoring clinical outcomes and adverse effects Guideline-based medication adjustment Structured psychoeducation Individualized psychotherapy Non-specific support

10 Cost of telehealth intervention depends on: Level of human skill or judgment required Need for synchronous contact

11 Who? (Is human skill or judgment needed)? Monitoring continuity and intensity of treatment Monitoring clinical outcomes and adverse effects Guideline-based medication adjustment Structured psycho-education Individualized psychotherapy Non-specific support NO MAYBE MAYBE N0 YES YES

12 How? (Is synchronous contact needed)? Monitoring continuity and intensity of treatment Monitoring clinical outcomes and adverse effects Guideline-based medication adjustment Structured psycho-education Individualized psychotherapy Non-specific support NO NO NO YES YES MAYBE

13 Example interventions (evaluations complete or ongoing) Telephone care management of antidepressant treatment Telephone psychotherapy for depression Secure messaging care managing of antidepressant treatment Web-based self-management program for bipolar disorder (with or without online coaching)

14 Telephone care management of antidepressant treatment in primary care Objective: Evaluate two low-intensity interventions to improve quality and continuity of antidepressant treatment in primary care Design: Randomized trial comparing two intervention programs to usual care Interventions: Feedback only: Used computerized pharmacy and visit to monitor continuity and intensity of treatment with algorithm-based feedback to treating physicians. Telephone care management: Used computerized pharmacy and visit to monitor continuity and intensity of treatment AND used 3 structured telephone contacts with patients to monitor clinical outcomes and adverse effects with structured educational messages for patients and algorithmbased feedback to treating physicians.

15 Telephone care management of antidepressant treatment in primary care (cont) Findings: Feedback only intervention had no effect on quality of treatment, patient satisfaction, or clinical outcomes. Telephone care management intervention led to moderate (but statistically and clinically significant) improvements in quality of treatment and clinical outcomes and large improvements in patient satisfaction. Vigorous outreach was necessary (i.e. mean of 3 attempts to complete each monitoring contact). Questions: Given the effort and expense needed to establish live telephone contact with a clinician, shouldn t we provide psychotherapy as well? OR is live telephone contact really necessary?

16 Telephone psychotherapy and telephone care management for depression Objective: Evaluate the benefits of a structured telephone psychotherapy program compared to both telephone care management and usual care Design: Randomized trial comparing two intervention programs to usual care Interventions: Telephone care management: (same as before) Used computerized pharmacy and visit to monitor continuity and intensity of treatment AND used 3 structured telephone contacts with patients to monitor clinical outcomes and adverse effects with structured educational messages for patients and algorithm-based feedback to treating physicians. Added two additional contacts by mail (with phone follow-up for non-respondents) Telephone psychotherapy: 8 structured telephone sessions using somewhat simplified version of cognitive-behavioral psychotherapy (also incorporating medication monitoring elements). Added two to four brief booster sessions

17 Effect on depression scores Usual Care Care Mgmt Phone Therapy Time Since Randomization, months

18 Telephone psychotherapy and telephone care management for depression (cont) Findings: Telephone care management intervention led to moderate improvements in quality of treatment and clinical outcomes and large improvements in patient satisfaction. Vigorous outreach was necessary. Telephone care management PLUS psychotherapy intervention led to large improvements in quality of treatment and clinical outcomes and large improvements in patient satisfaction. Again, vigorous outreach was necessary Questions: How would telephone psychotherapy compare to in-person psychotherapy (smaller impact per session BUT much greater adherence)? What about a hybrid model incorporating online psychoeducation supported by a human therapist (synchronous vs. asynchronous)?

19 Pilot trial of depression care management by electronic secure messaging Objective: Evaluate the feasibility and acceptability of an antidepressant care management program delivered by electronic secure messaging. Design: Pilot randomized trial comparing intervention program to usual care Intervention: Uses computerized pharmacy and visit to monitor continuity and intensity of treatment AND uses 3 structured contacts with patients to monitor clinical outcomes and adverse effects with structured educational messages for patients and algorithm-based feedback to treating physicians.

20 Pilot trial of depression care management by electronic secure messaging (cont) Challenges: Secure messaging technology not well suited to automated or batch messaging. Secure messaging technology not well suited to structured communication. Difficulty distinguishing acceptability of intervention from acceptability of research. Experience to date: Approx. 40% of those eligible have enrolled. 100% of those enrolled have participated in monitoring assessments.

21 Web-based self-management program for bipolar disorder (with or without online coaching) Objective: Evaluate the acceptability of a web-based self-management support program for people with bipolar disorder with and without support from an online peer coach. Design: Randomized trial comparing intensity and duration of participation among those offered and not offered coaching Intervention: MyRecoveryPlan.org Site for creating and using personal recovery plan. Incorporates video testimonials, slide show demonstrations, and selfmonitoring tools. Social networking features include discussion groups, messaging, and chat. Peer coaching Online support from trained peer coach via personal messages, discussion groups, and scheduled chat sessions. Experience: Approx. 70% of people registering start a personal recovery plan, approximately 25% remain active after 3 months.

22 Big Questions How much can we automate outreach and engagement? What are the relative contributions of specific communication (medication adjustment, specific psychotherapy) and non-specific support? How does non-specific support from peers compare to that from professionals? Are the things that make traditional interventions inefficient also the things that make them effective?

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