Co-Management of Chronic Physical and Behavioral Health Conditions Ruth Shim, MD, MPH Assistant Professor, Department of Psychiatry and Behavioral Sciences.

Co-Management of Chronic Physical and Behavioral Health Conditions

Ruth Shim, MD, MPHAssistant Professor, Department of Psychiatry and Behavioral Sciences

Associate Director of Behavioral Health, National Center for Primary CareMorehouse School of Medicine

Chronic Diseases

• Leading cause of mortality in the world– Represents 63% of all deaths

• Causes 7 in 10 deaths each year in the United States

• 133 million Americans (almost 1 in 2 adults) live with at least one chronic illness

• More than 75% of health care costs are due to chronic conditions

• Affect people of all ages throughout the lifespanAccessed from: http://www.who.int/topics/chronic_diseases/en/ and http://www.cdc.gov/chronicdisease/index.htm

Disparities and Chronic Disease

• Chronic diseases affect vulnerable populations at greater rates– Racial/ethnic disparities– Rural/urban disparities– Socioeconomic status disparities

“An Unhealthy America: The Economic Impact of Chronic Disease”

Milken Institute. 2003

Reported Cases of Common Chronic Diseases Millions (% population)

Cancer 10.6 (3.6%)

Diabetes 13.7 (4.7%)

Heart Disease 19.1 (6.6.%)

Hypertension 36.8 (12.6%)

Stroke 2.4 (0.8%)

Mental Disorders 30.3 (10.4%)

Pulmonary Conditions 49.2 (16.9%)

The US Economic Impact of Chronic Disease

Annual Costs in Billions

Treatment Expenditures $277.0

Lost Productivity $1,046.7

Total Costs $1,323.7

Milken Institute, 2003

Percentage of Adults with Mental Disorders and/or Medical Conditions 2001-2003

Adapted from the National Comorbidity Survey Replication 2001-2003

General Assistance-Unemployable (GA-U) Program in Washington State

Comorbid Behavioral Health and Chronic Medical Conditions

Chronic Medical Condition % with depression/anxiety % treated for depression/anxiety

Arthritis 32.3% 7.1%

Hypertension 30.5% 5.5%

Chronic Pain 61.2% 5.9%

Diabetes Mellitus 30.8% 5.2%

Asthma 60.5% 6.8%

Coronary Artery Disease 48.2% 5.7%

Cancer 39.8% 5.7%

2006 Milliman, Inc US Health Care Study

Why Are Rates of Comorbidity So High?

• High prevalence of mental disorders and chronic conditions

• Having a mental health disorder is a risk factor for developing a chronic condition (and vice versa)

• The pathways causing comorbidity are complex and bidirectional

Goodell, Druss, and Reisinger Walker. Mental disorders and Medical Comorbidity. Policy Brief. 2011.

Mental and Physical Disorder Interactions – Complex and Bidirectional

Katon WJ. Clinical and health services relationships between major depression, depressive symptoms and general medical illness. Biological Psychiatry. 2003.

The Risk Factors

• They are the same…and modifiable– Tobacco Use– Alcohol Consumption– Poor Nutrition/Obesity– Lack of Exercise– Unsafe Sexual Behavior– Substance Use and Misuse– Inadequate Medical Care

The Complex Patient

• Gone are the days of patients with one chronic condition (although research still tries to preserve this model)

• Co-morbidity is the rule, not the exception• Complexity involves unique challenges:– Prioritizing treatment– Polypharmacy– Coordinating care

The Origins of Complex Patients

• People are living with one or more chronic conditions longer

• Increased, long-term demands on health care systems

• Lack of emphasis on prevention

The Complex Patient

• Treating patients with several chronic conditions can cost as much as seven times more than treating patients with only one chronic illness

• Among Medicare patients, 66% of spending is for those with five or more chronic conditions

Agency for Healthcare Research and Quality. The Challenge of Prioritizing Care for Complex Patients. 2011.

The Challenges of Treating Complex Patients

The Hypothetical Patient• 79 year old woman with COPD, diabetes, osteoporosis, HTN, and

osteoarthritis• Aggregated the evidence-based recommendations of clinical practice

guidelines– Most CPGs did not discuss how their recommendations apply to older patients

with multiple comorbidities– Most CPGs did not comment on short and long term goals

• If recommendations were followed, the hypothetical patient would be prescribed 12 medications ($406/month) and complicated non-pharmacological interventions

• Drug and disease interactions could occur• Adhering to current CPGs could lead to poorer quality of care in complex

patientsBoyd et al Clinical Practice Guidelines and Quality of Care for Older Patients with Multiple Comorbid Diseases. JAMA 2005.

Mental Health Disparities

• People with serious mental illnesses die 25 years earlier than the rest of the population

• Among individuals with serious mental illnesses, nearly half have at least one chronic illness severe enough to limit daily functioning

• People with mental illnesses are more likely to have multiple physical disorders

Average Life Expectancies (Worldwide)

The “Natural Causes” of Death among Individuals with Serious Mental Illness

• Cardiovascular disease• Diabetes (and related conditions)• Respiratory disease• Infectious disease

Challenges in Co-Managing Chronic Disease in Primary Care Settings

• Half of the care for common mental disorders is delivered in general medical setting• Primary care providers prescribe the majority of

psychotropic drugs for children and adults• However, mental disorders often go undiagnosed,

untreated, of under-treated in primary care• When mental illness is recognized, it is not always

adequately treated in the primary care setting, and referrals from primary care to specialty mental health are often not completed

Challenges in Co-Managing Chronic Disease in Behavioral Health Settings

• Specialty mental health providers often have difficulty providing adequate medical care to consumers with co-existing mental and physical illnesses

• Individuals with serious mental illness have high levels of non-psychiatric medical illnesses and excess medical mortality

Case Presentation

• 52 year old African American female veteran with a past history of schizophrenia presented to the Atlanta VAMC with suicidal ideations secondary to chronic pain.

• History of Present Illness: pan-positive symptoms of depression, suicidal ideations with no specific plan, increased level of anxiety and distress, no current auditory hallucinations or overt delusions, no current or previous evidence of manic symptoms

Past Medical History

• Diabetes – poorly controlled symptoms• Complications associated with diabetes

include diabetic neuropathy chronic pain and high suspicion for diabetic retinopathy (decreased visual acuity for the past few months)

• Uncontrolled hypertension• Overweight

Past Medical History(Healthcare Access)

• Was receiving psychiatric care until 6 months ago, when her psychiatrist went on maternity leave – states has not seen anyone since then, but that she continues to get her medication in the mail

• Has been prescribed multiple narcotic pain medications, neuropathic pain medicines, antihypertensives, and insulin in the past, but denies taking any of these medications regularly (but has more than 15 prescription bottles at home, and takes these medications on a PRN basis)

• Denies seeing a regular primary care provider

Substance Use History

• History of crack cocaine use for many years• States her last use was 3 years ago• Occasional alcohol use, but denies

problematic drinking• Smokes cigarettes – 34 pack-year history• UDS was positive for cocaine on admission

Social History

• Less than high school education• Unstable housing – lives with sister, who does

not assist patient with her healthcare• Never married, one adult daughter• No social support• Unemployed• On disability – service connected through the

VAMC

Treating Complex Consumers

• What are her chronic conditions?• What are barriers to her effective treatment?– Patient level– Provider level– Systems level

• How do we go about providing effective care for this consumer?

DISCUSSION