Disease management and depression

1
Disease management and depression

• Aart H. Schene
• Adri Peters
• Bonn january 11, 2007

2
Educational objectives of the conference

• to share experiences with DM programmes in Europe
  
• to share knowledge about DM programmes in Europe
• to stimulate opinions and concepts about DM
  programmes
• to brainstorm on policy that stimulates DM
  programmes in Europe

3
Workshops will address the following issues (1)

• Primary process
• clearly defining the patient populations and
  sub-populations
• methodological education and the advancement of
  self management
• orientation on the integration of the various
  parts of the care processes, including preventive
  interventions
• protocols based on evidence-based diagnostics and
  treatment
• classification of patients in clinical pathways
  based on sub-characteristics
• treatment of multimorbidity in disease management
  

4
Workshops will address the following issues (1)

• Primary process
• clearly defining the patient populations and
  sub-populations
• methodological education and the advancement of
  self management
• orientation on the integration of the various
  parts of the care processes, including preventive
  interventions
• protocols based on evidence-based diagnostics and
  treatment
• classification of patients in clinical pathways
  based on sub-characteristics
• treatment of multimorbidity in disease management
  

5
Workshops will address the following issues (2)

• Support of primary process
• ?? substitution of care from physicians to nurses
  
• ?? use of information and communication
  technology
• Financing and management
• ?? using a range of management instruments such
  as benchmarking and feedback
• ?? large-scale and robust organizational
  structures
• ?? direction and funding from a centralized point

6
Disease management and depression

• Aart H. Schene
• Adri Peters
• Bonn january 11, 2007

7
Content of the workshop (part 1)

• 13.00-13.10 introduction to the workshop (AS)
• 13.10-13.40 introduction of the participants
  (AP)
• 13.40-14.00 depression (AS)
• 14.00-14.15 protocols, programmes, DM (AS)
• 14.15-14.30 discussion (AP)
• 14.30-15.00 tea break

8
Content of the workshop (part 2)

• 15.00-15.30 mental health care programmes and
  depression in the Netherlands an overview (AP)
• 15.30-15.40 discussion
• 15.40-16.00 disease management effectiveness
  (AS)
• 16.00-16.10 break
• 16.10-16.45 experiences of participants with
  care programmes and disease management (AP)
• 16.45-17.00 an agenda for the near future (AP)

9
Content of the workshop (part 1)

• 13.00-13.10 introduction to the workshop (AS)
• 13.10-13.40 introduction of the participants
  (AP)
• 13.40-14.00 depression (AS)
• 14.00-14.15 protocols, programmes, DM (AS)
• 14.15-14.30 discussion (AP)
• 14.30-15.00 tea break

10
Content of the workshop (part 1)

• 13.00-13.10 introduction to the workshop (AS)
• 13.10-13.40 introduction of the participants
  (AP)
• 13.40-14.00 depression (AS)
• 14.00-14.15 protocols, programmes, DM (AS)
• 14.15-14.30 discussion (AP)
• 14.30-15.00 tea break

11
Major depressive disorderor depression

• depressed mood
• diminished interest or pleasure
• weight (loss or gain)
• sleep (insomnia or hypersomnia)
• agitation or retardation
• fatigue or loss of energy
• worthlessness, guilt
• thinking and concentration
• thoughts on death

12
DEPRES II 6 European countriessymptoms during
latest depressive episode ()

• low mood 76
• no energy 73
• broken sleep 63
• emotional 59
• anxious 57
• poor memory 51
• irritable 50
• change appetite 40

• felt worthless 40
• no motivation 39
• constant worry 38
• reduced interest 37
• intrusive thougths 37
• life not worth liv. 34
• palpitations 34

(N1884)
13
Depression epidemiology

• year-prevalence
• men 4.1
• women 7.5
• life-time-prevalence
• men 10.9
• women 20.1

14
Depression epidemiology service use (per 1000
per year)
65-70
55-60
Prevalence in the community
25-30
Visiting GP
5-6
Detected by GP
0.5-0.7
Mental health care
In day
15
Burden of disease - disability adjusted life
years -

• DALY expresses years of life lost to premature
  death and years lived with a disability, adjusted
  for the severity of the disability
• one DALY is one year lost for healthy life

16
Global Burden of Disease Major depression will
have worldwide second rank order among the
15 leading causes of disability (DALYs) in
2020 Murray CJL Lopez AD WHO, Harvard SPH
Worldbank (1996)
17
Depression main consequences

• personal suffering and disfunctioning
• suicide and suicide attempts
• burden on partners, children and others
• loss of productivity
• work cut back days (presenteism)
• work loss days (absenteism)
• treatment costs
• medical care
• mental health care

18
WHO World Health Report 1999- making a
difference -

• Improving Health Outcomes key priorities
• we will work to see that mental health
• - and particularly the neglected scourge of
  depression - is given the attention it deserves.

19
Depression highly recurrent

• General population 50 over 20 years
• (Eaton et al., 1997)
• General practice 40 over 10 years
• (van Weel-Baumgarten, 2000)
• Psychiatric outpatients 40 over 5 years
• (Van London, 1998)
• Psychiatric inpatients 30 in one year
• (Piccinelli Wilkinson, 1994)

20
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21
Recovery from depression- collaborative program
on the psychobiology of depression -

• Duration of episode chance on recovery
• first episode 22 weeks 92
• second episode 20 weeks 88
• third episode 21 weeks 90
• fourth episode 19 weeks
• fifth episode 14 weeks
• (Solomon et al, Am J Psychiatry 2000157229)

22
Depression a chronic disorder

• 15 of patients will become chronic depressive
  patients (gt 2 years)
• each new episode of depression chance on
  chronicity increases by 10 to 15
• each GP has about 5 of his population with long
  term depression

23
(No Transcript)
24
Evidence based therapies (1)

• Biological therapies
• antidepressants
• light therapy
• electro convulsive therapy
• Psychological therapies
• problem solving therapy
• counseling
• cognitive behavioral therapy (CBT)
• interpersonal psychotherapy (IPT)

25
Evidence based therapies (2)

• Biological psychological therapy
• Bibliotherapy
• Psychoeducation
• Exercize walking, running etc
• Vocational rehabilitation
• Combined therapies
• day treatment
• inpatient treatment

26
Depression the main issues

• high prevalence high chronicity
• stigmatising disabeling
• underdiagnosed undertreated
• not treated adequately
• consequences underestimated
• comorbidity psychiatric, somatic, addiction
• high health care utilization costs

27
Content of the workshop (part 1)

• 13.00-13.10 introduction to the workshop (AS)
• 13.10-13.40 introduction of the participants
  (AP)
• 13.40-14.00 depression (AS)
• 14.00-14.15 protocols, programmes, DM (AS)
• 14.15-14.30 discussion (AP)
• 14.30-15.00 tea break

28
Quality improvement- a set of popular approaches
-

• Evidence based mental health
• Treatment protocols
• Clinical guidelines
• Programmes
• Disease management

How are these interconnected ?
29
Management of depression- how to improve it ? -

• Evidence based mental health care, protocols
  guidelines
• EBMHC what
• protocols what when
• guidelines what when why

30
Management of depression- how to improve it ? -

• evidence based mental health care, protocols and
  guidelines say
• what, when why
• remaining questions
• by whom ?
• for how long ?
• in what order ?
• in what combination ?
• where ?

31
Management of depression- mental health
programme (I) -

• target population
• symptoms, functioning, demands, needs,
  personality characteristics, social
  circumstances, recidivism, chronicity, etc
• specific sub-populations
• psychiatric and somatic co-morbidity
• diagnostic procedures
• biological
• psychological
• social

32
Management of depression- mental health
programme (II) -

• goals for each particular sub-population
• detailed description of content
• treatments modules
• protocols guidelines
• stepped care principle
• pathways through the programme
• relationship with other programmes
• personnel, budget material circumstances

33
Management of depression- how to improve it ? -

• evidence based mental health care
• what
• protocols
• what when
• guidelines
• what when why
• programmes
• what when why by whom, for how long, in
  what order, in what combination where
• disease management
• ibid. for what outcome and what costs

34
Disease management

• one health problem, clearly defined patient
  populations
• methodological education and self management
• integration of various parts of the care process
  including preventive interventions
• DM protocols based on evidence based diagnostics
  and treatment
• classification of patients in clinical pathways
  based on sub-characteristics
• reshufling of duties from doctors to nurses
• use of information and communication technology
• range of management instruments benchmarking,
  feedback
• robust and large scale organizational structure
• direction funding from one central point

(Schrijvers et al, 2006)
35
Content of the workshop (part 1)

• 13.00-13.10 introduction to the workshop (AS)
• 13.10-13.40 introduction of the participants
  (AP)
• 13.40-14.00 depression (AS)
• 14.00-14.15 protocols, programmes, DM (AS)
• 14.15-14.30 discussion (AP)
• 14.30-15.00 tea break

36
Content of the workshop (part 2)

• 15.00-15.30 mental health care programmes and
  depression in the Netherlands an overview (AP)
• 15.30-15.40 discussion
• 15.40-16.00 disease management effectiveness
  (AS)
• 16.00-16.10 break
• 16.10-16.45 experiences of participants with
  care programmes and disease management (AP)
• 16.45-17.00 an agenda for the near future (AP)

37
Content of the workshop (part 2)

• 15.00-15.30 mental health care programmes and
  depression in the Netherlands an overview (AP)
• 15.30-15.40 discussion
• 15.40-16.00 disease management effectiveness
  (AS)
• 16.00-16.10 break
• 16.10-16.45 experiences of participants with
  care programmes and disease management (AP)
• 16.45-17.00 an agenda for the near future (AP)

38
Content of the workshop (part 2)

• 15.00-15.30 mental health care programmes and
  depression in the Netherlands an overview (AP)
• 15.30-15.40 discussion
• 15.40-16.00 disease management effectiveness
  (AS)
• 16.00-16.10 break
• 16.10-16.45 experiences of participants with
  care programmes and disease management (AP)
• 16.45-17.00 an agenda for the near future (AP)

39
Disease management depression

• Three approaches
• prevention
• primary care
• secondary care

40
Depression prevention
65-70
55-60
Prevalence in the community
25-30
Visiting GP
5-6
Detected by GP
0.5-0.7
Mental health care
In day
41
Depression primary care
65-70
55-60
Prevalence in the community
25-30
Visiting GP
5-6
Detected by GP
0.5-0.7
Mental health care
In day
42
Depression secondary care
65-70
55-60
Prevalence in the community
25-30
Visiting GP
5-6
Detected by GP
0.5-0.7
Mental health care
In day
43
Depression prevention
65-70
55-60
Prevalence in the community
25-30
Visiting GP
5-6
Detected by GP
0.5-0.7
Mental health care
In day
44
Prevention of depression -12-18 years -

• Indicated pervention groups at risk with minimal
  levels of symptoms
• Adolescent coping with depression course
• Risk on depression over 24 months
• Control group 0.29
• Intervention group 0.09
• Number needed to treat 5.1
• Total reduction 440 DALYs/jaar

45
Prevention of depression - 18-64 years -

• Selective prevention
• People with chronic somatic disease
• reduction of incidence of depression (Kühler,
  2003)
• Indicated prevention effective strategies
• Coping with depression
• reduction of depression severity
• reduction of depression incidence
• Exercize
• reduction of depression severity
• Total reduction 1830 DALYs/jaar

46
Prevention of depression - gt 64 years -

• Selective prevention
• People with chronic somatic disease
• reduction of incidence of depression (Kühler,
  2003)
• Indicated prevention effective strategies
• Coping with depression (group)
• reduction of depression risk status
• reduction of depression incidence
• total reduction 1830 DALYs/jaar
• Life review (group)
• reduction of depression severity
• CGT on internet
• reduction of depression risk status

47
Depression primary care
65-70
55-60
Prevalence in the community
25-30
Visiting GP
5-6
Detected by GP
0.5-0.7
Mental health care
In day
48
Depression primary care models

• GP is the one who treats depression
• Quality improvement of GP post academic training
  in diagnosis and treatment and the use of
  guidelines and protocols
• Consultation to GP
• telephone consultation with a psychiatrist
• GP and psychiatrist case conference on paper
  patients
• GP and psychiatrist see and diagnose patients
• psychiatrist consultation /- referral

49
Depression primary care models

• GP refers patient within primary care
• Collaborative care treatment within primary care
  team by other non medical specialists social
  worker, nurses, psychologist etc
• Transferred (secondary mental health) care
  secondary care professionals are executing
  treatments within the primary care setting

50
Collaborative care for depression- the evidence -

• Chronic disease management principles
• Mostly within US managed health care settings
• Great role for nonmedical specialists
• Range of interventions of varying intensity
• Simple telephone interventions
• Adherence supervision
• Intensive follow up
• Structured psychosocial interventions

Gilbody et al, Arch Intern Med 20061662314-2321
51
Collaborative care for depression- the evidence -

• In comparison to standard care
• positive effect on depression at 6, 12, 18, 24
  and 60 months
• Effectivieness was greater if
• case manager had a mental health background
• case manager got regular supervision usually from
  a psychiatrist

Gilbody et al, Arch Intern Med 20061662314-2321
52
Collaborative care for depression- the evidence -

• Depression outcome
• related to fidelity to collaborative care (case
  manager, primary care physician, access to
  specialist input)
• related to compliance with mediaction
• effect of addition of specified forms of
  psychotherapy to medication was not clear
• not related to number of case management sessions
• Collaborative care
• likely to be cost-effective
• potential to substantially reduce global burden
  of illness associated with depression
• results are only valid for United States

Gilbody et al, Arch Intern Med 20061662314-2321
53
Disease management for depression

• A systematic review
• Badamgarav et al,
• Am J Psychiatry 20031602080-2090
• A meta-analysis
• Neumeyer-Gromen et al,
• Medical Care 2004421211

54
Effectiveness of disease management programs in
Depression a systematic review

• Disease management programs
• Needs of chronically ill patients
• Patient education
• Multidisciplinary care
• Multiple treatment modalities
• Evidence based guidelines
• Expert systems systematically developed
  statements to assist decisions about appropriate
  care in specific clinical circumstances

Badamgarav et al, Am J Psychiatry 20031602080
55
Effectiveness of disease management programs in
Depression a systematic review

• Results
• 19 studies (15 US, 2 UK, 1 Australia, 1 Canada)
• Process of care
• Detection of depression by screening (EZ 0.18,
  s)
• Referral to psychiatrist (EZ 0.13, ns)
• Adequacy of prescribed treatment (EZ 0.44, s)
• Adherence with treatment regimen (EZ 0.36, s)

Badamgarav et al, Am J Psychiatry 20031602080
56
Effectiveness of disease management programs in
Depression a systematic review

• Results outcomes of care
• Symptoms of depression (EZ 0.33, s)
• Physical functioning (EZ -0.05, ns)
• Social and health status (EZ 0.06, ns)
• Satisfaction with treatment (EZ 0.51, s)
• Health care utilization (EZ -0.10, s)
• Hospitalization (EZ -0.20, ns)
• Health care costs (EZ -1.-3, ns)

Badamgarav et al, Am J Psychiatry 20031602080
57
Disease management Programs for Depression a
systematic review and meta-analysis of RCTs

• Disease management programs
• Population identification processes (eg
  screening)
• Patient self management education
• Provider education
• Evidence based/guideline driven
• Good communication between all care providers
• Interdisciplinary discussions of treatment
  options
• Regular reassessment
• Routine reporting and regular feedback
• Monitoring of compliance
• Evaluation of outcome

Neumeyer-Gromen et al, Medical Care 2004421211
58
Disease management Programs for Depression a
systematic review and meta-analysis of RCTs

• 10 RCTs for meta-analysis
• DMP significant effect on
• Depression severity
• Satisfaction with service
• Adherence to treatment regimen
• Cost effectiveness (costs per QALY
  9,051-49.500)
• Limitations
• All studies from US
• Limited intervention duration (4-12 months)
• Unclear which elements are most effective

Neumeyer-Gromen et al, Medical Care 2004421211
59
Content of the workshop (part 2)

• 15.00-15.30 mental healthcare programmes and
  depression in the Netherlands an overview (AP)
• 15.30-15.40 discussion
• 15.40-16.00 disease management effectiveness
  (AS)
• 16.00-16.10 break
• 16.10-16.45 experiences of participants with
  care programmes and disease management (AP)
• 16.45-17.00 an agenda for the near future (AP)

60
Content of the workshop (part 2)

• 15.00-15.30 mental healthcare programmes and
  depression in the Netherlands an overview (AP)
• 15.30-15.40 discussion
• 15.40-16.00 disease management effectiveness
  (AS)
• 16.00-16.10 break
• 16.10-16.45 experiences of participants with
  care programmes and disease management (AP)
• 16.45-17.00 an agenda for the near future (AP)