Depression & Chronic Disease. Disclosures. Chronic Disease. Martha L Bruce, PhD, MPH Department of Psychiatry Weill Cornell Medical College

Transcription

1 Depression & Chronic Disease Martha L Bruce, PhD, MPH Department of Psychiatry Weill Cornell Medical College 1 Disclosures Grant funding from the National Institute Health Consultant reviewer for McKesson Chronic Disease 80% of Americans age >65 living with some form of chronic disease * Chronic disease drives healthcare costs Patients with chronic disease: Greater healthcare costs Poorer Outcomes * US Centers for Disease Control and Prevention 3 1

2 Chronic Care Model 4 Home Health Infrastructure Supports & Chronic Care Model Community: in home care, work w/ families Focus on self management System: point of care technology promotes Symptom monitoring Decision support Multidisciplinary teams manage patient care Evidence Based Care Management Models CARE TRANSITIONS e.g., Hospital to home Care Transitions Program Coleman (U. Colorado) 4 week intervention Transitional Care Model Naylor (U. Pennsylvania) 1 3 month intervention CARE COORDINATON e.g., 2+ providers at one time Guided Care Boult, Johns Hopkins Long term (for life) GRACE (Geriatric Resources for Assessment and Care of Elders) Counsel (Indiana U.) Up to two years 6 2

3 The Challenge and Potential Medicare Reimburses Intermittent Skilled Nursing Care Yet Home Healthcare nurses: face chronic disease every day Routinely follow Chronic Disease Care Management Models 7 HH Routinely Follow Chronic Disease Care Management Model Collaborate in patient care with primary care physician Coordinate care using nurse case management model Monitor symptom/functional progress over time Manage medications (adherence, side effects Educate patient and family Assist patient in setting goals Facilitate care transitions Depression in Home Healthcare 3

4 What is Depression? Everyday Blues to Clinical Diagnosis DSM IV Major Depression Five or more persistent symptoms, including 1. Depressed Mood and/or 2. Loss of interest or pleasure Symptoms cause distress or impairment in function Clinically Significant Depression Major Depression or persistent symptoms A medical illness A chronic illness A burdensome illness Responds to Chronic Disease Management The Burden of Depression on Patients & Families Suffering, poorer quality of life Declines in cognition and medical status Increased disability and self neglect Risk for falls Suicide and non suicide mortality 4

5 Factors That Increase the Risk Of Depression in Older Adults Medical Illness Disability Cognitive Decline Social Isolation Loss And Other Negative Events Note: these factors are increasingly common with aging and characterize much of home healthcare The Burden of Depression in Home Healthcare High prevalence Persistent and clinically meaningful Higher rates of suicide ideation Poorer Adherence Sometimes difficult & cranky patients High use of services Increased risk of adverse falls Increased risk of hospitalization Prevalence of Depression in HH Bruce et al., AJP

6 Depression Recognition & Treatment in Home Health: 10 Years Ago: 100% 80% 60% 40% 20% 0% 35.0% 22.0% 3.0% Diagnosed OASIS Treated Geriatric HH Patients Major Depression Bruce et al., AJP 2002 Changes in HH Patients Over the Past Decade: 2000* 2007** Diagnosis of depression 3.0% 6.4% Taking an antidepressant 11.5% 39.5% Depressed 23.0% 69.1% Not Depressed 14.6% 27.1% * Research data **2007 National Home and Hospice Care Survey Cornell s Interventions to Improve Detection, Documentation, and Care for Depression in HH Approach to development Partner with many HH agencies Build on clinical skills Minimize added burden Integrate into routine practice Implementation support 18 6

7 Interventions: Assessment Challenges to Identifying Depression In Older Adults Belief that depression is: Normal & Acceptable part of aging A reflection of poor moral character not treatable Symptoms overlap with medical illness & treatments Misattribution of physical symptoms to depression Misattribution of depression sx to medical illness Masked by: Atypical symptoms of depression like irritability Co existing psychiatric symptoms like anxiety Co existing disability, pain, cognitive impairment Screening Goals Intervene with patients who need it Don t intervene unnecessarily Screening should be: Sensitive (Correctly Identify as many depressed patients as possible Specific (Correctly identify patients are who not depressed) Positive Predictive Value: Yield (%) of screened positive 2010 Weill Cornell Homecare Research Partnership 21 7

8 Screening Goals: Sensitivity 22 Screening Goals: PPV (positive predictive value) 23 Training in Depression Assessment (OASIS B): Impact on Appropriate Care 60 % MH Evaluation p=0.60 p=0.47 Usual Practice Intervention 10 0 NO YES True Depression Bruce ML et al. J Am Geriatric Soc

9 How Do You Screen for Depression using OASIS C? (to Maximize Sensitivity and PPV) 2010 Weill Cornell Homecare Research Partnership 25 Step 1 Use the PHQ 2 (Item M1730) Be generous (sensitive) 2010 Weill Cornell Homecare Research Partnership 26 Using the PHQ 9 with Older Adults: Depressed Mood Video Clip Video Clip 9

10 PHQ 2/M1730 Lack of Interest Mr. Smith Over the last two weeks, how often have you been bothered by any of the following problems: PHQ 2 a) Little interest or pleasure in doing things b) Feeling down, depressed, or hopeless? Not at all 0 1 day Several Days 2 6 days More than half of the days 7 11 days Nearly every day days Weill Cornell Homecare Research Partnership 28 Using the PHQ 9 with Older Adults: Anhedonia (Lack of Interest or Pleasure) Video Clip Video Clip PHQ 2/M1730 Depressed Mood Mr. Smith Over the last two weeks, how often have you been bothered by any of the following problems: PHQ 2 a) Little interest or pleasure in doing things b) Feeling down, depressed, or hopeless? Not at all 0 1 day Several Days 2 6 days More than half of the days 7 11 days Nearly every day days Weill Cornell Homecare Research Partnership 30 10

11 Step 2 Use the PHQ 9 Be targeted (specific) Kroenke K, Spitzer RL, Williams JB. The PHQ 9: validity of a brief depression severity measure. J Gen Intern Med Sep;16(9): PHQ 2 Scoring Guidelines: CMS Guidelines: If TOTAL PHQ 2 Score >3, further depression screening is indicated Cornell s Recommendation: If TOTAL PHQ 2 Score > 2 (sensitive), further depression screening is indicated using the PHQ 9 (PPV) 32 PHQ 9 Follows DSM diagnostic criteria Also measures symptom severity Can monitor depression course Physicians understand the scoring Kroenke K et al.,. J Gen Intern Med Sep;16(9):

12 2010 Weill Cornell Homecare Research Partnership PHQ 9 Score PHQ 9 to Assess Severity of Depressive Symptoms Provisional Diagnosis < 5 No Depression 5 9 Mild Depression Moderate Depression Moderately Severe Depression > 20 Severe Depression Start Depression Intervention Kroenke et al. Gen Intern Med Sep;16(9): PHQ 9: The Difficult Question 36 12

13 Q9 Follow up: Suicide Risk Assessment Protocol Step 2: Structured Additional questions and risk algorithm Nature & frequency of thoughts of inflicting self harm Past suicide attempts Specificity of current plans & means to implement Strength of death wishes Intensity of hopelessness Impulse control Presence or absence of preventive deterrents Recurrent Thoughts of Death (Passive Suicide Ideation) No Suicide Ideation ASSESSING SUICIDE RISK AS A SPECTRUM* Morbid preoccupation with death; thoughts that life is not worth living or that would be better off dead (e.g., I pray that God will take me soon ). Has not considered a method to harm self. Has considered a Method to harm self (eg, I ve thought about taking all my pills, but I would never do it ). Does not report a specific detailed plan or current intention to harm self. Demonstrates reasons for living and good impulse control. Thoughts of Suicide (Active Suicide Ideation) Specific Suicide Plan or Intent Normal focus on end of life issues due to advanced age, medical illness, or dwindling social networks. May have occasional thoughts about own mortality. Is not preoccupied with death; does not feel that would be better off dead. No Suicide Risk Very Low Risk Mild Risk: Requires referral Moderate Risk: Requires immediate referral HIGH RISK: CONTACT MH CLINICIAN DO NOT LEAVE ALONE Reports a specific detailed Plan and/or Intent to harm self (e.g., I m planning to take all my pills tomorrow morning before my aid arrives ), or does not have good impulse control (e.g,. I may not be able to stop myself from doing this ). Imminent *Always follow individual agency /organization s procedures for suicidal patients Raue et al., Journal of Family Practice, 55: ; 2006 Before Screening For Suicide Risk, Agencies/Organizations Should: Have agency specific protocols in place for use for patients identified as high suicide risk Such protocols should include, e.g.: Steps for each level of risk Strategies to ensure patient and assessor safety Identification (with phone numbers) of whom assessor should contact Telephone numbers for emergency services Plans for formal clinical assessment 13

14 Sequence of Suicide Risk Assessment. 1. No Suicide Ideation Martha L. Bruce, PhD, MPH; Weill Cornell Medical College (Click on picture to start film) Recurrent Thoughts of Death: Mild Suicide Risk Martha L. Bruce, PhD, MPH; Weill Cornell Medical College (Click on picture to start film) Active Suicide Ideation Martha L. Bruce, PhD, MPH; Weill Cornell Medical College (Click on picture to start film) 42 14

15 5. Very High Suicide Risk Martha L. Bruce, PhD, MPH; Weill Cornell Medical College (Click on picture to start film) 43 Interventions: Depression Care Management Depression Care Management/Collaborative Care Models in Older Primary Care Patients Key Elements: Guideline-based treatments (antidepressants, psychotherapies) New Role: Depression Care Manager Evidence Base PROSPECT (Bruce et al, 2004, JAMA) IMPACT (Unützer et al, 2002, JAMA) PRISM E (Bartels et al, 2004, AJP) RESPECT(Dietrich et al, 2004, BMJ) 15

16 Primary Care: Depression Care Management Remission (HDSR<10) from Major Depression: PROSPECT STUDY 70% 60% 50% 40% 30% 20% 10% Intervention PROSPECT Enhanced Care 0% Baseline 4 mo 8 mo 12 mo 18 mo 24 mo Model X2=22.3 (df=5) p=.001 Bruce et al. JAMA. 2004; 291(9): Alexopoulos et al., Am J Psych. 2009;166(8): Impact of Depression on 9 Year Mortality Intervention vs. Usual Care Usual Care practices PROSPECT practices Major Depression 1.90 (1.57 to 2.31) 1.09 (0.83 to 1.44) Minor Depression 1.32 (0.92 to 1.90) 1.19 (0.88 to 1.60) Non depressed Adjusted Hazard Ratios; N=1238 (Age > 65) Adjusted for baseline age, gender, education, marital status, smoking, cardiovascular disease, stroke, diabetes, cancer, cognition, and suicidal ideation. Gallo et al., Ann Intern Med. 2007; Gallo et al., BMJ, in press DCM in Primary Care 16

17 Delivery of Home Healthcare Services Depression CAREPATH Depression Care for Patients in Homecare 1. Every nurse provides basic Depression Care Management (DCM) Managing depression is comparable to other chronic diseases Collaboration & signals for consultation or referral essential Do not ask Nurses to give psychotherapy 2. Intervention has two components Depression Care Management Protocol Implementation Strategy Screening Protocol 17

18 CAREPATH DCM Functions Assessment Monitor symptoms severity and course of illness Case Coordination Communicate with the MD, consulting specialists Manage Monitor side effects and treatment adherence Educate and Instruction Education patients and families Assist Depression CAREPATH Protocol: Components Promote self management, goal setting, pleasurable activities Depression CAREPATH Management Protocol First DCM Visit Assess depression severity using the PHQ-9 Coordinate care by preparing the Depression Case Presentation Template and contacting physician or specialist (per agency guidelines) Manage antidepressants: dosage, adherence, side effects Instruct patients and family with the Depression Education Toolkit Assist patients in goal setting: self care and pleasurable activities Weekly (or at next visit) Monitor depression severity using the PHQ-9 Coordinate as needed Manage antidepressants: dosage, adherence, side effects Instruct patients and family about ongoing depression care Assist patient by reviewing goals for self care and pleasurable activities Discharge Coordinate next level of care by giving patient Depression Discharge Summary and review referral options with patient and family Recontact Physician or Mental Health Specialist when: PHQ-9 score remains the same or worsens over 4 weeks Suicide ideation (PHQ-9 item 9 ) emerges or worsens Patient reports significant side effects Otherwise clinically indicated 2010 Weill Cornell Homecare Research Partnership 53 Depression CAREPATH Resources: MentalHealthTrainingNetwork.org 18

19 19

20 20

21 Evidence of Impact of Depression CAREPATH NIH randomized trial of Protocol in 11 agencies NIH evaluation of implementation resources 2 Agencies (Ohio, Florida) with nine sites Long distance implementation support by Cornell Outcomes Impact on nursing practice Impact on patient clinical outcomes 2010 Weill Cornell Homecare Research Partnership 62 Change in Depressive Symptoms HH Patients (N=84) with PHQ>10 at Start of Care PHQ 9 Score Start of Care Follow up Clinically Significant Depression CAREPATH Pre CAREPATH 63 21

22 Hospitalization HH Patients (N=84) with PHQ>10 at Start of Care 40% Percent Hospitalized 30% 20% 10% 26.7% 16.3% 0% Pre CAREPATH CAREPATH 64 In Closing Chronic diseases are pervasive & burdensome in HH Depression is a chronic disease Depression undermines all care Depression, like other chronic diseases, responds to care management (DCM) Evidence that integrating DCM into HH works Cornell s Depression CAREPATH is one approach to effective DCM. 65 Free Resources to Support Depression CAREPATH Take a look at the website Simply refer clinicians to training (CEUs) OR Use tools to develop in service +/or QI initiative WEBSITE: MentalHealthTrainingNetwork.org DepressionCAREPATH@med.cornell.edu 66 22

23 Thank You and Questions