Bipolar Disorder and Substance Abuse Joseph Goldberg, MD

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1 Diabetes and Depression in Older Adults: A Telehealth Intervention Julie E. Malphurs, PhD Asst. Professor of Psychiatry and Behavioral Science Miller School of Medicine, University of Miami Research Coordinator, Mental Health Miami VA Medical Center Disclosures No financial relationships with any commercial interests to report Learning Objectives To become familiar with the telehealth program and the use of this home-based technology in clinical care settings To examine the feasibility of using telehealth devices in a geriatric population with cooccurring depression and diabetes To discuss the potential role of telehealth in the treatment and management of cooccurring mental and physical illnesses in older populations 1

2 Late-Life Life Depression Incidence of major depression declines with age, but minor depression is much more common Depressive symptoms occur in 15% 25% of older adults (>65 years) that fail to meet criteria but cause distress and interfere with functioning Fewer than half of depressed seniors are recognized as being depressed and of those who are identified fewer than half receive treatment U.S. Dept of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, NIH, NIMH, 1999; JAGS December 2007 Major Depression Is Associated with Chronic Medical Illness % 25% Prevalence of Major Depression (%) % 4% 5% 10% 6% 14% 0 Community Primary Care Clinic Medical Inpatient Setting Katon W, Schulberg H. Gen Hosp Psychiatry. 1992;14: Rosen J, Mulsant BH, Pollock BG. Nursing Home Med. 1997;5: Nursing Home Impact of Untreated Depression: Morbidity & Mortality Patient morbidity Poorer health outcomes Suicide attempts Accidents Lost jobs Alcohol Use & Abuse Marital Problems Mortality Older white men have highest suicide rates Fatal accidents Death due to related medical complications Societal costs Caregiver burden Higher medical costs Increased healthcare utilization Preskorn SH. Outpatient Management of Depression: A Guide for the Primary Care Practitioner. 2nd ed. Caddo, OK: Professional Communications, Inc.; 1999: Chapter 2. 2

3 Prevalence of Diabetes in the United States In millions Type 2 Diagnosed Non-Insulin Using Type 2 Diagnosed Insulin 4.3 Using 1.1 Type 1 Diabetes Type 2 Undiagnosed Age-Specific Prevalence of Diagnosed Diabetes, by Race/Ethnicity and Sex, United States, 2002 (CDC, 2004) Ethnic Minority Elderly and Depression HISPANIC >65 will increase by more than 450% by 2050 Depressive disorder prevalence in primary care increased from 4.5% to 8.6% between Higher prevalence of depressive symptoms (11-40%) Higher depressionassociated mortality from both suicide and medical disorders AFRICAN-AMERICAN >65 will increase by 131% by 2030 Lower rates of depression recognition and treatment Poorer medical outcomes associated with comorbid depression (EX: diabetes and stroke/hyperglycemia/renal failure/hypertriglyceridemia) 3

4 DIABETES & OLDER ADULTS Diabetes affects at least 20% of persons over the age of 65 Total direct and indirect medical costs in US estimated at 102 billion per year AGS Guidelines (JAGS :S ) Major Depression and Diabetes Mellitus 28% (Lloyd, et al., 2000) 31% (Anderson, et al., 2001) 26% (Gavard, et al., 1993) Significant association between depressive symptoms and high Hgb A1C in men HbA1c & Depressive Symptoms Significant association between depressive symptoms and glucose dysregulation in persons with diabetes Self-care Glucose metabolism Ciechanowski, et al., 2003; Lustman, et al.,

5 Major Depression and Diabetes Mellitus Medline and PsycINFO databases and published reference lists were used to identify studies that measured the association of depression with glucose control. A total of 24 studies satisfied the inclusion and exclusion criteria for the meta-analysis. Depression was significantly associated with hyperglycemia (Z = 5.4, P < ). Lustman et.al. Diabetes Care 2000 Jul;23(7): Major Depression and Diabetes Mellitus 183 African-American men with diabetes 30% had significant depressive symptoms (CES-D >22) Greater depressive symptoms significantly associated with higher serum levels of cholesterol and triglycerides (P<0.050). Gary et.al. Diabetes Care 2000 Jan;23(1):23-9 Impact of Co-Occurring Diabetes and Depression Significantly poorer physical and mental functioning (SF-36; SF-12) Decreased adherence to dietary recommendations Decreased adherence to exercise Decreased adherence to medication use Increased symptom reporting Increased mortality Higher health care costs 5

6 Models of Care UPBEAT (Unified Psychogeriatric Biopsychosocial Evaluation And Treatment) PRISM-E (Primary Care Research in Substance abuse and Mental health care for the Elderly) Pathways PROSPECT (Prevention of Suicide in Primary Care Elderly) IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) TACTICS (Telemedicine & Care Coordination to Improve Care for Seniors) Pathways Study Collaborative Care Model Depression (diabetes HMO patients) Randomized Controlled trial Improved depression and antidepressant adherence outcomes Katon, et al. (2004). The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression. Arch gen Psych. PROSPECT Study Collaborative Care Model Multi-Site; Randomized Control Primary Care Patients (depressed, 60+) Improved depression outcomes Reduced Mortality post-5 years in patients with diabetes Bruce, et al. (2004); JAMA; Bogner, et al. (2007); Diabetes Care 6

7 Models of Care for Late-life Depression: TACTICS Examine effectiveness of home-health monitoring device for daily management of depression and diabetes Medical and psychiatric outcomes and utilization tracked Llorente & Soto, in Psychiatric Disorders and Diabetes Mellitus TACTICS INTERVENTION Primary Objective: to examine the effectiveness of an intervention using care coordination with telemedicine for older veterans with co-occurring occurring Type II diabetes mellitus (DM) and depressive symptoms Home Telehealth 7

8 TACTICS Outcomes 128 veterans enrolled Enhance both Diabetes and Depression simultaneously 60 or older Diagnosis of Type II DM Significant depressive symptoms Baseline Characteristics from TACTICS Clinical Demonstration Program Demographics: Age 65.0 Gender M 92.5% F 7.5% Ethnicity African American 17.2% Latino 33.6% Non-Latino White 49.2 % Caregiver Yes 65% No 35% Baseline Clinical Characteristics from TACTICS Clinical Demonstration Program Baseline NLW Latino Black Measure Weight Depression Score (PHQ- 9) HgbA1c 7.35% 7.65% 7.56% Blood 129/71 132/75 130/76 Pressure Total Cholesterol Triglycerides* * Indicates significant difference between groups p<.05 8

9 Baseline-6- month Comparisons (Total Sample) Measure Baseline 6-months post Sig enrollment Depression Score (PHQ-9) HgbA1c 7.6% 7.1%.008* Weight Total Cholesterol * Triglycerides * Within-Group Comparisons (Baseline-6-months) Measure Baseline 6-months post enrollment Non-Latino White Depression Score (PHQ-9) HgbA1c 7.4% 7.0% Sig Weight Total Cholesterol * Triglycerides Within-Group Comparisons (Baseline-6-months) Measure Baseline 6-months post Sig enrollment Latino/Hispanic Depression Score (PHQ-9) HgbA1c 7.6% 6.9%.03* Weight Total Cholesterol * Triglycerides

10 Within-Group Comparisons (Baseline-6-months) Measure Baseline 6-months post Sig enrollment Black Depression Score (PHQ-9) HgbA1c 7.8% 7.3% Weight Total Cholesterol Triglycerides Limited data at 12-months, but preliminary data shows trend for maintenance of both decreased HgbA1c, Total Cholesterol and depressive symptoms TACTICS Outcomes Hospital admissions and ER visits were reduced by 67% and 60% 81% reduction in combined total cost for admissions and ER in FY 06 (from $56,794 6 months pre- to $10,906 6 months postenrollment) 10

11 Summary Diabetes and depression frequently co-occur Co-occurrence of these disorders is associated with poorer medical outcomes Addressing both disorders simultaneously is feasible Cultural aspects of care may improve outcomes A Care Coordination program that utilizes a home monitoring device was cost- and outcomes effective in improving disease self-management of both conditions Acknowledgements TACTICS Clinical Team: Maria Llorente, MD Jerry Steffe, ARNP y Jessica Soto, RD Fariba Ostovary, ARNP Yolette Olivier 11