The Case for Physical-Behavioral Health Integration Tami Mark, Ph.D. Thomson Reuters Healthcare July 26, 2011

2. The Case for Physical-Behavioral Health Integration Tami Mark, Ph.D. Thomson Reuters Healthcare July 26, 2011

3. Outline of Material to be Presented • Behavioral disorders are common, costly, disabling and deadly • Behavioral and physical disorders commonly co-occur • Reasons for co-occurrence are complex • Co-occurrence leads to higher costs &worse outcomes • Currently US healthcare addresses co-occurrence poorly • Research suggests integration improves outcomes • Research suggests integration is cost effective 3

4. Outline • Behavioral disorders are common, costly, disabling and deadly • Behavioral and physical disorders commonly co-occur • Reasons for co-occurrence are complex • Co-occurrence leads to higher costs &worse outcomes • Currently US healthcare addresses co-occurrence poorly • Research suggests integration improves outcomes • Research suggests integration is cost effective 4

5. Behavioral Health Disorders are Common, Costly, Disabling, and Deadly • Almost 50% of Medicaid beneficiaries will have diagnosable mental health or substance abuse disorder in given year.1 • 11.5 % of Medicaid expenditures go to treating behavioral health disorders (10% mental health, 1.5% substance use disorders).2 • The World Health Organization ranks depression, alcohol, and tobacco use as among the top causes of disability.3 • Persons with mental illness die, on average, 25 years earlier than the general population and much of this gap can be attributable to medical conditions such as cardiovascular disease.4 5

6. Outline • Behavioral disorders are common, costly, disabling and deadly • Behavioral and physical disorders commonly co-occur • Reasons for co-occurrence are complex • Co-occurrence leads to higher costs &worse outcomes • Currently US healthcare addresses co-occurrence poorly • Research suggests integration improves outcomes • Research suggests integration is cost effective 6

7. Percentages of Adults with Mental Disorders and/or Medical Conditions5 National Comorbidity Survey Replication, 2001-2003 as Reported in Druss and Walker, 2011

8. Medical Comorbidities are Higher Among Persons with Mental Illness6 8

9. Physical Disorders Associated with Chronic Alcohol Use Cognitive disorders CVAPsychosis Head, Neck, GI cancers Neuropathies Anemias Nutritional Deficiencies Coronary Artery Disease CardiomyopathyArrhythmiasHypertension Stroke Liver Disease Cirrhosis Stomach ulcers Gastritis Pancreatitis Diabetes Duodenal ulcers Adapted from: Schuckit MA. In: Harrison’s Principles of Internal Medicine. New York: McGraw-Hill; 2001:2561-2566. .

10. Tobacco Use Cigarette smoking continues to be the leading cause of preventable disease & death in the US7 Nearly 1 in 5 adults in US currently smokes8 Extensive research shows psychiatric disorders and cigarette smoking are frequently comorbid9, 10, 11, 12, 13 Individuals diagnosed with a current psychiatric disorder smoked 46.3% of all cigarettes consumed in the U.S.(2001-2002 National Epidemiologic Survey on Alcohol & Related Conditions) Adults with lifetime depression, anxiety or major depressive episodes were more likely to be “current smokers, smoke with higher intensity and frequency, have more dependence, and have lower success at quitting” compared to individuals without these psychiatric conditions (2005-2006 NSDUH)

11. Outline • Behavioral disorders are common, costly, disabling and deadly • Behavioral and physical disorders commonly co-occur • Reasons for co-occurrence are complex • Co-occurrence leads to higher costs &worse outcomes • Currently US healthcare addresses co-occurrence poorly • Research suggests integration improves outcomes • Research suggests integration is cost effective 11

12. Medical and Behavioral Illness Interact in Complex and Important Ways Modified from Katon, 2003, by Druss and Walker, 2011 12

13. Outline • Behavioral disorders are common, costly, disabling and deadly • Behavioral and physical disorders commonly co-occur • Reasons for co-occurrence are complex • Co-occurrence leads to higher costs &worse outcomes • Currently US healthcare addresses co-occurrence poorly • Research suggests integration improves outcomes • Research suggests integration is cost effective 13

14. Average Monthly Expenditures for Medicaid Beneficiaries With and Without Co-Occurring Costly Physical Conditions (2003) Source: Medicaid Analytic eXtract (MAX), 2003 Substance Abuse and Mental Health Services Administration. (2010). Mental health and substance abuse services in Medicaid , 2003: Charts and state tables. HHS Publication No. (SMA) 10-XXXX. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

15. Spending among dual eligibles with mental and physical conditions

16. Mental Illness Worsens Diabetes Outcomes14 • Persons with diabetes who are depressed have increased rates of adverse health outcomes relative to persons with diabetes who are not depressed: • Mortality • Cardiac events • Hospitalizations • Diabetes-related complications • Functional impairment • Quality of life 16

17. BH Illness Complicates Treatment • Substance abuse co-occurrence with diabetes has been shown to significantly complicate the diabetes treatment regime. • The occurrence of depression in patients with coronary heart disease substantially increases the likelihood of poor cardiovascular prognosis. • Patients with post-heart attack depression are about three times more likely to die from a future attack or other heart problem. 17

18. Outline • Behavioral disorders are common, costly, disabling and deadly • Behavioral and physical disorders commonly co-occur • Reasons for co-occurrence are complex • Co-occurrence leads to higher costs &worse outcomes • Currently US healthcare addresses co-occurrence poorly • Research suggests integration improves outcomes • Research suggests integration is cost effective 18

19. Institute of Medicine15 • Multiple clinicians and health care organizations serving patients in the American health care system typically fail to coordinate their care. • The resulting gaps in care, miscommunication, and redundancy are sources of significant patient suffering. IOM: Improving the Quality of Health Care for Mental Health and Substance-Use Conditions: Quality Chasm Series (2005) 19

20. IOM Report: Improving the Quality of Health Care for Mental Health and Substance-Use Conditions: Quality Chasm Services (2006) Overarching Recommendation 1 Health care for general, mental, and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body. 20

21. President’s New Freedom Commission16 Consumers often feel overwhelmed and bewildered when they must access and integrate mental health care and other services across multiple, disconnected providers in the public and private sectors. (2003) 21

22. Reasons for Readmission in Medicaid (age 21 – 64)17

23. Medicaid - Follow-up after Discharge for Mental Illness in Reporting HMOs18 Source: HEDIS (National Committee for Quality Assurance, 2010)

24. Medicaid - Initiation and Engagement of SUD Treatment18 Source: HEDIS (National Committee for Quality Assurance, 2010)

25. Percent of Adolescents who Received Antidepressants and Therapy19

26. PCPs Unable to Get MH Services20

27. Provision of Medical Services by Community Mental Health Centers21

28. What Does Integration Mean? • Communication: Sharing of information among providers • Comprehensiveness: Meeting all health care needs • Continuity of care: Timely, uninterrupted delivery of appropriate services over time (IOM, 2001:62) 28

29. How Can We Better Integrate Care for Medical and Behavioral Conditions? • Train behavioral health providers in screening, preventive care, and routine medical services • Train medical providers in behavioral health • Leverage non-MD providers • Increase communication between behavioral health and medical care providers with: • Co-location • Enhanced referral • Team meetings • Verbal/Written consults • Coordinated treatment plan • Integrated medical record • Telemedicine • Case management • Outreach and follow-up 29

30. Outline • Behavioral disorders are common, costly, disabling and deadly • Behavioral and physical disorders commonly co-occur • Reasons for co-occurrence are complex • Co-occurrence leads to higher costs &worse outcomes • Currently US healthcare addresses co-occurrence poorly • Research suggests integration improves outcomes • Research suggests integration is cost effective 30

31. AHQR Technology Assessment: Integration of MHSA with Primary Care22 • Intervention: Integrating mental health specialists into primary care. • Analysis: 33 RCTs examined (26 studies address depression) • Conclusions: • “There is reasonably strong evidence to encourage use of integrated services.” • “The major obstacles to encouraging the use of integrated services appear to be financial and organizational.” 31

32. Meta-analysis: Collaborative Care for Depression23 • Intervention: Collaborative care for Depression: • A multifaceted intervention. • Three distinct professionals working collaboratively within the primary care setting: a case manager, a primary care practitioner, and a mental health specialist. • Analysis: 37 RCTs include 12,355 patients receiving collaborative care. • Conclusion: Depression outcomes were improved at 6 months and evidence of longer term benefit was found for up to 5 years. 32

33. Effectiveness of Brief Alcohol Interventions in Primary Care24 • Intervention: Feedback on alcohol use and harms, identification of high risk situations for drinking and coping strategies, increased motivation and the development of a personal plan to reduce drinking. 5 to 15 minutes. • Analysis: Cochrane Collaboration Systematic Meta-Analysis of 29 RCTs in general practice (24) or emergency department (5), 7000 patients. • Conclusion: Significantly reductions in alcohol consumption

34. Assertive Community Treatment (ACT)25 • Intervention: Multidisciplinary team approach aimed at keeping people with severe mental illness in contact with services by using integrated and outreach-oriented services. • Analysis: Cochran Collaboration review 17 RCTs that compared ACT to standard community care. • Conclusion: • Reduces hospital days • Improves employment • Increases independent living • Improves quality of life 34

35. Discharge Planning26 • Interventions: Done while an inpatient to facilitate transition to outpatient treatment • Analysis: Steffen et al. (2009) Systematic Review and Meta-Analysis of 11 studies of inpatient discharge planning • Conclusions: • Reduced the relative risk of readmissions by 35% • Increased probability of adherence to outpatient treatment increased by 25%

36. Outline • Behavioral disorders are common, costly, disabling and deadly • Behavioral and physical disorders commonly co-occur • Reasons for co-occurrence are complex • Co-occurrence leads to higher costs &worse outcomes • Currently US healthcare addresses co-occurrence poorly • Research suggests integration improves outcomes • Research suggests integration is cost effective 36

37. Example: Weisner et al.. JAMA Study of Co-Location Medical Provider within SA Providers27,28 • Study Location: Kaiser Permanente’s Chemical Dependency Recovery Program • Intervention: Patients in integrated care model received primary medical care within the substance abuse program (3 MDs, 2 nurses, 1 medical assistant). • Analysis:Compared findings among patients in integrated and independent groups for patients with and without substance abuse-related medical conditions. 37

38. Results: Weisner et al, JAMA, 2003 • Integrated larger decline in: • Hospitalization rates • Inpatient Days • ED Use 38

39. Example: IMPACT Trial29 • Intervention: Collaborative program for depression (applied to other conditions) • Screening tool • Patient monitoring and follow-up • Case manager who coordinates, educates, trouble shoots • Evidence based guidelines and stepped care. • Psychiatric Consultations • Analysis: RCT of1801 depressed older primary care patients from 8 healthcare systems. • Findings: Effective in reducing depression, improving physical functioning, improving social functioning 39

40. Results: IMPACT TRIAL 40

41. Example: NIATx Project • Project: Process improvement model aiming to enhance effectiveness and efficiency of behavioral health treatment • Findings: • Reduced wait time from first contact to first treatment • Reduced no-shows • Increased continuation of treatment 41

42. Need for Future Research30 • Most models integrate mental health care into primary care, few do opposite • Who is most likely to benefit from treatment? • More examination of conditions other than depression and older adults – those with SMI, SUD, children • More models of integrated payment needed

43. Summary • Behavioral and physical conditions are closely intertwined. • Having a separate, fragmented system to address behavioral and physical illnesses is a bad idea. • Evidence has identified some effective and cost effective integration approaches. • More research and experimentation needs to be done. 43

44. References • Adelmann PK. Mental and substance use disorders among Medicaid recipients: prevalence estimates from two national surveys. Adm Policy Ment Health. 2003 Nov;31(2):111-29. • Mark TL, Levit KR, Vandivort-Warren R, Buck JA, Coffey RM. Changes In US spending on Mental Health And Substance Abuse Treatment, 1986-2005, and implications for policy. Health Aff (Millwood). 2011 Feb;30(2):284-92. • World Health Organization http://www.who.int/mental_health/management/depression/definition/en/ • National Association of State Mental Health Program Directors (NASMHPD) Morbidity and Mortality in People with Serious Mental Illness, 2006. • Druss BG and Walker ER. Mental Disorders and Medical Comorbidity. Robert Wood Johnson Foundation, Research Synthesis Report No 21, February 2011. www.policysynthesis.org • DE Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I, Detraux J, Gautam S, Möller HJ, Ndetei DM, Newcomer JW, Uwakwe R, Leucht S. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011 Feb;10(1):52-77. 44

45. References, Continued • USDHHS, 2004 • CDCP, 2010a • Dome et al, 201 • Brown et al, 2008 • Brown et al 2002 • Degenhardt and Hall, 2001 • Grant et al 2004 • Markowitz SM, Gonzalez JS, Wilkinson JL, Safren SA. A review of treating depression in diabetes: emerging findings. Psychosomatics. 2011 Jan-Feb;52(1):1-18. • Institute of Medicine. Improving the Quality of Health Care for Mental and Substance Use Conditions. National Academies Press, Washington, DC. 2006. • President’s New Freedom on Commission on Mental Health. Achieving the Promise. Transforming Mental Health Care in America. July 2003.3 • Jiang, JH and Wier LH. All-Cause Hospital Readmissions for Non-Elderly Medicaid Patients. 2007. HCUP Statistical Brief #89. April 2010. Agency for Healthcare Research and Quality, Rockville, MD. http//.hcup.us.ahrq.gov/reports/statbriefs/sb89.pdf 45

46. References, Continued • National Center for Quality Assurance. The State of Health Care Quality 2010. http://www.ncqa.org/Portals/0/State%20of%20Health%20Care/2010/SOHC%202010%20-%20Full2.pdf • Mark TL. Receipt of psychotherapy by adolescents taking antidepressants. Psychiatr Serv. 2008 Sep;59(9):963 • Cunningham PJ. Beyond Parity. Primary Care Physicians’ Perspectives on Access to Mental Health Affairs. 2009: 490 – 501. • Druss BG, Marcus SC, Campbell J, Cuffel B, Harnett J, Ingoglia C, Mauer B. Medical services for clients in community mental health centers: results from a national survey. Psychiatr Serv. 2008 Aug;59(8):917-20. • Butler M, Kane RL, McAlpine D, et al. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Oct. Integration of Mental Health/Substance Abuse and Primary Care. Evidence Reports/Technology Assessments, No. 173. • Gilbody S, Bower P, Fletcher J, et al. Collaborative Care for Depression: A Cumulative Meta-analysis and Review of Longer-term Outcomes. Arch Intern Med. 2006;166:2314-2321 46

47. References, Continued • Kaner EF.S., Dickinson HO, Beyer FR, Campbell F, Schlesinger C, Heather N, Saunders JB, Burnand B, Pienaar ED. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004148. DOI: 10.1002/14651858.CD004148.pub3 • Marshall M, Lockwood A. Assertive community treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews. 2002. • Steffen S, Kösters M, Becker T, Puschner B. Discharge planning in mental healthcare: a systematic review of the recent literature. Acta Psychiatr Scand. 2009 Jul;120(1):1-9. Epub 2009 Apr 8. Review. PubMed PMID: 19486329. • Weisner C, Mertens J, Parthasarathy S, Moore C, Lu Y. Integrating primary medical care with addiction treatment: a randomized controlled trial. JAMA. 2001 Oct 10;286(14):1715-23.

48. References, Continued • Parthasarathy S, Mertens J, Moore C, Weisner C. Utilization and cost impact of integrating substance abuse treatment and primary care. Med Care. 2003 Mar;41(3):357-67. • Unutzered J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008 Feb;14(2):95-100. • Carey TS, Crotty KA, Morrissey JP, Jonas DE, Viswanathan M, Thaker S, Ellis AR, Woodell C, Wines C. Future Needs for Integration of Mental Health/Substance Abuse and Primary Care. Future Research Needs Paper No. 3. (Prepared by the RTI International – University of North Caroline at Chapel Hill Evidence-based Practice Center under Contract No. 290-2007-10056-I.). AHRQ Publication No. 10-EHC0690EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2010.

49. QUESTIONS? 49