Disclosures. Learning Objectives. Consultant, National Council for Behavioral Health

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1 Disclosures Consultant, National Council for Behavioral Health Lori Raney, MD Medical Director, Axis Health System Chair, American Psychiatric Association s Workgroup on Integrated Care Durango, CO Learning Objectives Depression Describe the co morbid physical illnesses in patients with severe and persistent mental illness (SPMI). Discuss difficulties with this population physicians and providers have when working with SPMI populations Describe different options for providing primary health care to patients with SPMI. Describe rationale and models for providing primary care services in a mental health setting Pa Etoh/Drugs Medical Bipolar Disorder Schizophrenia Panic WHO Global Burden of Disease 2004 report

2 Comorbidity of Mental Disorders and Medical Conditions Primary Care is the De Facto Mental Health System National Comorbidity Survey Replication Provision of Behavioral Health Care: Setting of Service General Medical 56% No Treatment 59% 41% Receiving Care MH Professional 44% Mental Disorders and Medical Comorbidity by Druss BG and Reisinger Walker E:( Original data from National Comorbidity Survey Replication, Wang P, et al., Twelve-Month Use of Mental Health Services in the United States, Arch Gen Psychiatry, 62, June % people with mental health issues are treated in primary care settings 210,000 to 800,000 Increase from 1998 to 2003 in the # patients receiving MH/SU care in Community Health Centers. Increase of mental health services in general medical settings even greater in public sector compared to private sector. Chronic Physical Pain 25 50% Smoking, Obesity, Physical Inactivity 40 70% Mental Health / Substance Abuse Heart Disease 10 30% Cancer 10 20% Diabetes Neurologic Disorders 10 30% 10 20% Mauer BJ & Druss BG. J Behav Health Serv & Res.2009

3 Definition: Serious & Persistent Mental Illness (SPMI) A mental, behavioral or emotional disorder (excluding substance & developmental disorders) Functional disability in areas of social and occupational functioning. Serious functional impairment, which substantially interferes with or limits one or more major life activities GAF <50 60 Spollen JJ.Perspectives in Serious Mental Illness. GAF: Global Assessment of Functioning No symptoms. Superior functioning in a wide range of activities Mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, ) OR any serious impairment in social, occupational, or school functioning Some impairment in reality testing or communication (e.g., speech is at times illogical, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood Behavior is considerably influenced by delusions or hallucinations OR serious impairment, in communication or judgment (e.g., sometimes incoherent, acts inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed, no job, home, or friends) Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene, OR gross impairment in communication (e.g., largely incoherent or mute) Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death. 0 (Not currently defined ) 56 70% 20 34% 10% Schizophrenia or Non Affective Psychosis Bipolar Disorder Major depression, OCD or borderline Personality disorder McDevitt J et al. Clinical practice recommendations Evidenced based guidelines for integrated care.2002 Schizophrenia Diagnostic Criteria Two or more of the following: Positive Symptoms Hallucinations auditory most common Delusions paranoid, somatic, grandiose Disorganized Speech Grossly Disorganized or Catatonic Behavior Negative Symptoms Flat affect blank look, lack of expression Lack of motivation/drive/desire to pursue goals Lack of additional, unprompted content seen in normal speech patterns monotone, monosyllabic Social/Occupational Dysfunction

4 Serious Mental Illness in the Past Year Among Adults, 18 and Over Multi State Study Mortality Data: Years of Potential Life Lost Year AZ MO OK RI TX UT VA (IP only) and Older Male Female Compared to the general population, persons with major mental illness typically lose more than 25 years of normal life span Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited]. Data courtesy of SAMHSA Percentage of deaths Cardiovascular Disease Is Primary Cause of Death in Persons with Mental Illness How This Looks World Wide *Average data from Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited].

5 SMI Population Cardiovascular Disease # 1 problem Causes of Increased Mortality Obesity, Hypertension, NIDDM, lipids many with metabolic syndrome Smoking 45% of all cigarettes in US sold to MI pop, approx 85% with schizophrenia smoke Modifiable Risk Factors: Smoking, Weight and Inactivity Social isolation/ Homeless Unemployment/ Poverty Limited access to primary care Lack of access to care Medications/ Polypharmacy Separation of medical and mental health Non Treatment of Medical Comorbidity: CATIE data Annual Cost of Care Total Population Common Chronic Medical Illnesses Common Chronic Medical Illnesses with Comorbid Mental Condition Patient Groups Annual Cost of Care Illness % with Comorbid Prevalence Mental Condition* Annual Cost with Mental Condition % Increase with Mental Condition All Insured $2,920 10% 15% Arthritis $5, % 36% $10,710 94% Asthma $3, % 35% $10, % Cancer $11, % 37% $18,870 62% Diabetes $5, % 30% $12, % CHF $9, % 40% $17,200 76% Migraine $4, % 43% $10, % COPD $3, % 38% $10, % Cartesian Solutions, Inc. --consolidated health plan claims data *Approximately 10% receive evidence-based mental condition treatment Nasrallah HA et al, 2006 Cartesian Solutions, Inc.

6 100 Cost of Health Complexity Patient Type Acute Illness Self-resolving illness Low grade acute illness Serious Chronic Illness Chronic diseases Moderate to severe acute illness Health Complexity Multiple diagnoses Physical & mental health comorbidity High health service use Impairment and disability Personal, social, financial upheaval Health system issues % of Patients % of Costs Low 1/3 Medium 1/3 High 1/3 Decade of the Brain ( ) Antidepressants 1987 Prozac 1989 Celexa 1989 Wellbutrin 1992 Zoloft 1992 Paxil 1993 Effexor 1993 Luvox 2 nd Generation Antipsychotics (SGAs) 1991 Clozapine 1994 Risperdal 1994 Zyprexa 1995 Seroquel 2001 GeoDon 2002 Abilify x adapted from Meier DE, J Pall Med, 7: , 2004 Cartesian Solutions, Inc. 14 Olanzapine ( mg) Olanzapine ( mg) Quetiapine Risperidone Ziprasidone Aripiprazole 24 ADA/APA Screening Guidelines for Second Generation Antipsychotics Change From Baseline Weight (kg) Olanzapine ( mg) Olanzapine ( mg) Quetiapine Weeks Change From Baseline Weight (lb) American Association of Clinical Endocrinologists, North American Association for the Study of Obesity: Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004; 27: Jones M et al. Poster. 2003; Marder SR. J Clin Psychiatry. 2003;64: ; Nemeroff CB. J Clin Psychiatry. 1997;58(suppl 10):45-49; Sussman N. J Clin Psych. 2001;62:5-12.

7 Typical Day Barriers to Providing Primary Health Care to Psychiatric Populations PRIMARY CARE A B C + D A1c Blood Pressure Cholesterol Depression MENTAL HEALTH SMI + C H O D S CHOLESTEROL HYPERTENSION OBESITY DIABETES SMOKING 26 Beneficial Effects of Interventions to Reduce Risks of CVD Blood cholesterol 10% = 30% in CVD ( ) High blood pressure (> 140 SBP or 90 DBP) ~ 6 mm Hg = 16% in CVD; 42% in stroke Diabetes (HbA1c > 7) 1% point HbA1c = 21% dec in DM related deaths, 14% decrease in MI, 37% dec in microvascular complications Cigarette smoking cessation ~ 50% in CVD Maintenance of ideal body weight (BMI = ) 35% 55% in CVD Maintenance of active lifestyle (~30 min walk daily) 35% 55% in CVD Stratton, et al, BMJ 2000 Hennekens CH. Circulation 1998;97: Rich Edwards JW, et al. N Engl J Med 1995;332: Bassuk SS, Manson JE. J Appl Physiol 2005;99: Patient Factors Often suffer significant cognitive and social impairment. Poor communication Poor motivation and difficulty in follow through with tasks. Fearfulness and distrust High percentage of psychiatric and medical comorbidity esp TRAUMA and Substance Abuse.

8 Health Professionals Views on Treating Patients with SPMI Discomfort with treating persons with SPMI Feeling that treatment of SPMI patients is too specialized for PCPs Lack of knowledge about specific psychiatric illnesses. Time constraints/competing demands Lester HE. BMJ, doi.1136/bmj f 2005 Approach to the Exam Tips Trauma considerations Little at a time bombardment Calm demeanor don t challenge delusions reassurance and understanding Longer appointment time ** Collaborate and coordinate care with your psychiatric and embedded PCP colleagues

9 Recovery Movement Recovery is often defined conservatively as returning to a stable baseline or former level of functioning. A job, a roof over my head and someone to come home to at night. 42 % Recovery Recovery Rates 35% Intermediate Outcome Hope Secure Base Durable sense of self Meaning Supportive Relationships Empowerment and Inclusion Coping Strategies 27% Poor Outcome

10 Primary Care Setting Facilitated referral from MHC Site of Care Delivery Co location PCP Consultant How Care Delivered Mental Health Setting On site PCP provider Primary care by psychiatrists Experimenting: Some Developing Models PCARE study (Druss et al, 2010) 10 to 7% drop Framingham score Care Management Hot Spotters New Yorker Jeff Brenner Missouri Medicaid Health Homes PC and CMHC s VA Programs Three Efforts: enhanced care coordination, care manager to SMI patients and PC presence within SMI SAMHSA/HRSA PCBHI 92 Grantees PBHCI: Models developed so far Primary Care access at the Mental Health site. Care management / coordination with outside primary care. Use of registry [not widespread use of computerized registry] Wellness activities training Behavior change! Working Together: A Team Approach PCP Care Manager Patient Case Manager Psychiatrist Core Team Other Behavioral Health Clinicians Substance Treatment Vocational Rehabilitation Other Community Resources Other Resources 40

11 Different models must be tested the cost and suffering of doing nothing is unacceptable. Vieweg, et al., American Journal of Medicine. March 2012