Disclosure: Wayne Katon, MD Lilly Wyeth Forest Pfizer I I I I I I Company Employment Management Independent Contractor Consulting Speaking & Teaching Board, Panel or Committee Membership
Dec 24, 2015
Disclosure: Wayne Katon, MD Lilly Wyeth Forest Pfizer
I I I I
I I
Company
Employment
Management
Independent Contractor
Consulting
Speaking & Teaching
Board, Panelor CommitteeMembership
Enhancing Treatment for Patients with Comorbid Depression, Diabetes
and Heart DiseaseWayne Katon, MD1
Mike VonKorff, ScD2
Elizabeth Lin, MD, MPH2
Paul Ciechanowski, MD, MPH1
Greg Simon, MD, MPH2
Evette Ludman, PhD2
Joan Russo, PhD1
Carolyn Rutter, PhD2
Bessie Young, MD, MPH1
1 University of Washington School of Medicine2 Center for Health Studies, Group Health Cooperative NIMH Grants MH 4-1739 and MH 01643 (Dr. Katon)
Mrs. K is a 45-year-old female computer programmer with a 5-year history of type 2 diabetes. She started the study in Sept. 2007 based on the following eligibility criteria: PHQ-9 of 20, HbA1c 9.6.
Patient has a history of childhood sexual abuse, has had recurrent depressive episodes and obesity with a BMI of 51 (>30 meets obesity criteria). Prior history of smoking and has sleep apnea Rxed with CPAP.
Adverse Bidirectional Interaction
Major Depression
• Smoking
• Sedentary lifestyle
• Obesity
• Lack of adherence to medical regimens
• Psychophysiologic
Insulin sensitivity Autonomic NS Inflammatory markers
• Medical illness at earlier age
• Poor symptom control
functional impairment
complications of medical illness
mortality
Katon et al. Biol Psychiatry 2003
Premature Mortality and Chronic Mental Illness
Schizophrenia: 20-25 years Bipolar: 10-15 years Major Depression: 5 to 10 years
Medical Morbidity Chronic stress: effects on HPA axis,
autonomic nervous system, immune system
Health risk behaviors: smoking, sedentary lifestyle, diet/obesity, alcohol/drugs
Lack of self care: adherence to medication, diet, exercise, cessation of smoking
Psychiatric medications: obesity, metabolic syndrome, diabetes, CAD
Behavioral Risk Factors: Depression
Behavioral risk factors (smoking, obesity, sedentary lifestyle) account for approximately 40% of all deaths in the U.S.
Depression is linked to all 3 Wassertheil-Smoller (2004) have shown in
98,000 women that depression was associated with higher rates of smoking, lack of exercise, obesity, diabetes, high cholesterol levels and rates of hypertension compared to non-depressed populations
Meta-Analysis of the Effect of Depression on Patient Adherence
Compared to nondepressed patients, the odds are 3 times greater that depressed patients would be nonadherent with medical treatment recommendations
DiMatteo MR et al. Arch Intern Med 2000
02468
1012141618
None Minor Major
Depression Group
% S
mok
ing
% Smoking by Depression Level
Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type and duration, treatment type , HbA1c and clinic
N = 4,225p<0.001; Major > Nonep<0.01; Minor > None
Katon et al. Diabetes Care 2004
% BMI > 30 kg/m2 by Depression
01020304050607080
None Minor Major
Depression Group
BM
I >
30
kg/
m2 (%
)
N = 4,225p<0.001; Major > Nonep<0.01; Minor > None
Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type and duration, treatment type, HbA1c and clinic
Katon et al. Diabetes Care 2004
HbA1c > 8% by Depression Level
0
10
20
30
40
50
60
None Minor Major
Depression Group
Hb
A1c >
8%
(%
)
Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type and duration, treatment type and clinic
N = 4,225p<0.001; Major > Nonep<0.01; Minor > None
Katon et al. Diabetes Care 2004
18.8 19.321.6
24.527.2 27.9
0
10
20
30
40Non DepressedDepressed
Medication Adherence in Patients with Diabetes
Oral Hypoglycemic
Lipid LoweringMeds
ACEInhibitors
No
nad
her
ent
Day
s (%
)
Lin et al. Diabetes Care 2004
Pathways Epidemiology Study
Baseline
Mail Survey1 2 3 4
5-YearTelephone
Survey
Disease control (HbA1c, LDLs, blood pressure)
Pharmacy refills (adherence)ICD-9 diagnosisMacrovascular/microvascular complications (chart
review)Mortality (Washington State mortality data)
Depression: Association with Complications and Mortality
Minor Depression
Major Depression
Microvascular Complications
1.05 (0.83, 1.33) 1.33 (1.08, 1.65)
Macrovascular Complications
1.32 (0.99, 1.75) 1.38 (1.08, 1.78)
Mortality
(All cause)1.23 (0.94, 1.61) 1.53 (1.19, 196)
Foot Ulcers 1.50 (0.82, 2.60) 2.30 (1.50, 3.70)
Pathways Randomized Controlled Trial Participants randomly assigned to
Pathways nurse collaborative care intervention (N = 165) vs. usual care (N = 164)
Usual Care Primary care or referral to specialty MH care
as available Pathways Care
Collaborative/stepped care disease management program for depression in primary care
Katon et al. Arch Gen Psych 2004
Treatment Protocol
Behavioral activation/pleasant events scheduling Antidepressant medication
Usually an SSRI or other newer antidepressantOR
Problem Solving Treatment in Primary Care (PST-PC)
6-8 individual sessions followed by monthly group
maintenance sessions
Maintenance and Relapse Prevention Plan For patients in remission
Katon et al. Arch Gen Psych 2004
Intervention vs Control Differences on Mean SCL Depression Scores (Range 0 – 4)
0.5
1
1.5
2
I UC
Baseline 3 mos 6 mos 12 mos
Mea
n S
CL
-20
Dep
ress
ion
Sco
re
Katon et al. Arch Gen Psych 2004
6
6.5
7
7.5
8
Intervention vs Control Differences on Mean HbA1c
I UC
Baseline 6 mos 12 mos
Mea
n H
bA
1C %
Katon et al. Arch Gen Psych 2004
Intervention vs. Usual Care Differences in Health Risk Behaviors No significant I vs. UC differences in
exercise, diet, smoking or checking blood glucose
Intervention patients had a significantly lower mean BMI level compared to UC at 12 months
Lin et al. Arch Fam Med 2006
Depression: Diabetes Lower Total Health Care Costs Over 2 Years
Usu
al C
are
Inte
rven
tio
n
Sav
ing
s
Usu
al C
are
Inte
rven
tio
n
Sav
ing
s$0
$5,000
$10,000
$15,000
$20,000
$25,000
Pathways IMPACT
$22,258
$21,148 $18,932$18,035
$1,110$897
Treating depression and other mental Illness is a necessary
first step, but not sufficient alone to improve health risk
behaviors and chronic medical disease control
Health Services Models
TeamCare Approaches have been shown to improve quality of care and outcomes of patients with depression, diabetes, asthma and CHF
The most complex and medical costly patients often have multiple comorbidities including at least one mental health diagnosis
Medicare Patients Depression, diabetes and heart disease are
among the most common illnesses in aging populations but fewer than 4% of Medicare beneficiaries with any of these three illnesses have no other chronic medical conditions
80% of those with CHF, 71% with depression and 56% with diabetes have 4 or more chronic conditions
Partnership for Solutions 2001
Diabetes: Achieve Recommended Risk Factor Targets
Less than 10% of diabetes patients attain
recommended goals for: HbA1c < 7.0%, Systolic
BP < 130 and LDL < 100mg Poor Adherence found in 20% of patients No evidence of poor adherence but lack of Rx
intensification found in 30% of hyperglycemia patients, 47% of hyperlipidemia patients and 36% of hypertensive patients
Schmittdiel J et al. JGIM 23:588-94, 2008
Challenge: Development of Health Services Models for
“Natural” Clusters of Illness
Examples: Diabetes, CAD, depression Depression, chronic pain, substance
abuse
Definition: Illnesses with high prevalence, high comorbidity and bidirectional adverse interactions
New NIMH-Funded Study: TeamCare Inclusion Criteria
Evidence via automated date (ICD-9) of having diabetes and/or coronary artery disease (CAD)
Evidence of poor disease control (HbA1c > 8.5, blood pressure >140/90, LDL >130)
PHQ-9 > 10
10,000 Group Health patients with diabetes and/or CAD & poor disease control
Screen 1: PHQ-2 (response rate 82.6%)
14.8% positive (>3 on PHQ-2)
Screen 2: 1066 eligible for SQ-2 with PHQ-9
268 with PHQ-9 >10 completed baseline
>200 randomized
TeamCare Intervention Goals
Improve depression care: behavioral activation and antidepressants
Improve medical disease control: HbA1c, HTN, LDL
Improve self-care (diet, exercise, cessation of smoking, glucose checks)
TeamCare Interventionists
3 diabetes nurse educators Caseload supervision
Depression: 2 psychiatrists Diabetes and CAD: nephrologist, family
doctor E-Mail to diabetologist for complex
cases
Nurse Training
Motivational interviewing Problem solving Behavioral activation Antidepressants TREAT-to-TARGET: blood glucose,
HTN, LDLS
Initially, the case manager increased the patient’s Celexa from 20 to 60 mg and also began working with the patient on monitoring blood sugars more frequently and increasing NPH insulin. Trazadone was also added to help with sleep. Her HbA1c decreased by December to 8.4%. PHQ score initially decreased from 20 to 12 on Celexa 60 mg. and Trazodone 50 mg and Wellbutrin was added at 100 SR with gradually increasing dosages. By mid-November, her PHQ had decreased to a 5 on Celexa 40 mg, Wellbutrin SR 200 mg BID, Trazodone 50 mg.
TeamCare Summary Report
Initial Clinic Enroll DatePHQ
BL Now
BP
BL Now
HbA1c
BL Now
LDL
BL Now
NSH 5/19/08 19 19141/69
127/77
7.3 6.8 168 138
NSH 1/9/08 15 2118/80
130/80
9.2 8.3 138 124
EVM 11/12/07 14 9160/98
150/85
6.4 6.8 108 67
EVM 10/30/07 13 2209/119
126/76
7.3 7.7 119 103
LYN 8/23/07 14 3149/71
111/58
8.1 7.7 85 82
Improving Adherence
Patient self-care materials: book and video on depression, patient manual (Tools for Managing Your Chronic Disease)
Nurse support/education/motivational interviewing
Medisets Simplifying medication regimen $4 generics to avoid $10 co-pays
Self-Care Enhancements
Glucometers: Group Health provides Home blood pressure monitors Pedometers to increase exercise Medisets to improve adherence
Phases of Treatment
Intervene on depression initially Behavioral activation Antidepressant medication
Medical Disease Control Is patient adhering to medication regimen? If adhering and in poor control, is patient
on optimal dosage? If maximum dosage has been reached
should a new medication be tried instead or augmentation of initial medication?
Team recommendations of medication changes are reviewed with primary care physician for approval
Behavioral Goals
Behavioral activation/exercise Dietary changes Checking blood glucose/altering
insulin Cessation of smoking
The nurse worked with the patient in January/February 2008 on increasing exercise and weight reduction. Patient also began to gather information about gastric bypass surgery. She began to watch food proportion sizes, worked out on a treadmill and joined a pregastric bypass group. Her PHQ-9 in June was a 7, HbA1c 7.4%, blood pressure 113/82 (had decreased from 132/80) and LDL was 77 (had decreased from 101).
.
Conclusions Patients with common psychiatric illnesses
have significantly shorter life spans due to premature development of medical illnesses.
Economies of scale: New health services interventions are needed for patients with multiple comorbidities (one of which is a psychiatric disorder).
Integration of evidence-based mental health interventions into primary care and preventative medical interventions into community mental health care are needed to enhance outcomes of patients with comorbidities.