Preliminary Findings from PROSPECT An NIMH supported study on Prevention of Suicide in Primary Care Elderly: Collaborative Trial
THE TWO PREMISES OF PROSPECT’S INTERVENTION
2. Guidelines alone do not ensure both correct physician
decisions and patient adherence to treatment.
PROSPECT has added a “ depression specialist ” to:
assist the physician by providing timely and targeted
patient-specific clinical strategies
encourage patient adherence to treatment through
education and support.
1. Effective treatments for depression exist:
PROSPECT has operationalized AHCPR guidelines for use in primary care with the elderly
PROSPECT Percent with > 50% reduction in HDRS/24 Scores Among Patients with MDD P=.001 P=0.01 P=0.2
Telephone Based Interventions
Telephone Disease Management is algorithm driven care delivered by a Behavioral Health Specialist.
Enhanced Usual care. The PCP can monitor, treat, and/or refer. The PCP is provided a diagnosis and references for treatment options.
Baseline Characteristics 0.834 58.7 60.8 Cases from Primary Care (%) 0.571 34.8 29.4 Cases of at-risk drinking (%) 0.206 73.9 84.3 Cases of depression (%) 0.552 39.1 45.1 Currently smokes (%) 0.328 39.1 49.0 Marital Status (% married) 0.085 58.7 41.2 Race (% Caucasian) 0.916 95.7 96.1 Gender (% Male) 0.775 61.3 (10.3) 61.9 (11.3) Age (n=46) (n=51) p TDM Subjects Usual Care Subjects
Improvements with TDM Oslin, et. al. 2003
VA Performance Measures for 2004
Mental Health Performance Measures for 2004
VA Measures are modeled after HEDIS measures
Apply to patients with
New diagnosis of depression
New treatment with antidepressant medication
Measures probe the quality of acute phase (12 wk) tx
% with > 3 clinical follow-up visits
Only 1 visit can be by telephone
At least 1 must be with the prescribing MD
% who receive adequate medication for 84 days
Depression Care Monitoring
Diagnosis and decision to treat
Baseline assessment (from BHL)
Prescription of antidepressant
Follow-up assessment in 1-2 weeks
With provider or designate
Check on adherence
Check on side effects
Follow-up assessments at 6 and 10 weeks by BHL
Follow-up in-person assessments with MD at the conclusion of an episode of care
If remission, discuss continuation treatment
If no response by 6 weeks, modify treatment
If residual symptoms at 12 weeks, modify treatment.
Motivational based brief intervention for enhancing adherence and retention
Pilot of 20 patients – 70% treatment engagement
Telephone Disease Management VISN 4 MIRECC VA Philadelphia University of Pennsylvania
To develop a method for delivering high quality depression and alcoholism treatment in Primary Care, CBOCs, and other clinics in which there are significant transportation, staff resource, or other impediments to the delivery of face-to-face MH/SA care.
To develop methods for translating effects demonstrated in randomized clinical trials to clinic populations.
Who is Appropriate?
DSM-IV Major Depression
MMSE > 18
Hearing and language adequate for participation
Other substance abuse
History of primary psychosis
History of (hypo)mania
The Role of the Behavioral Health Specialist
The role of Behavioral Health Specialist (BHS) is to influence adherence to guidelines by providing "on-time, on‑target" information to primary care physicians and collaboratively make appropriate care decisions.
Integration of Care with the Supervising Psychiatrist
1. Review of physician progress notes
2. History of psychiatric and medical conditions
3. List of current medications
4. History of use of psychotropic medications
5. Recent laboratory and neuroimaging reports
6. Record information on initial progress note
Initial contact - Goals
Begin to establish rapport in order to build a supportive and therapeutic relationship.
Review the purpose of the phone call and the reasons for the referral.
Conduct a semi-structured clinical interview in order to learn the patient’s perception of his or her problem and the clinician’s assessment of the presenting problem. (PHQ-9, Beck Anxiety Scale (if warranted), alcohol/substance use and the UKU for side effects)
Begin to develop a hypothesis of the patient’s diagnosis
Complete a Choose a treatment algorithm based on the outcome of the interview
Consult with the primary physician regarding the proposed treatment plan.
Consult with the psychiatrist if needed.
Discuss the proposed treatment plan with the patient, using motivational techniques
Educate the patient regarding medications, if any, that are ordered.
Set up a follow-up phone call with the patient and the BHS for one week later.
Schedule a follow-up visit
Complete a baseline progress note.
Motivating the Patient for Treatment
Assist the individual in recognizing their symptoms and developing an interest in addressing the symptoms.
Motivational Interviewing helps to resolve ambivalence so that the patient can make a decision to accept and adhere to treatment suggestions.
It is a supportive, respectful approach
Avoid arguments with the Patient
Roll with Resistance
Develop Discrepancy (help the patient identify where they are now and where they want to be in the future)
Determining a Treatment Plan
1. Monitoring (but not treating) some patients.
2. Treatment by the physician and BHS within protocol guidelines.
3. Delay initiation of treatment algorithms pending further medical stabilization, patient/family approval, or further diagnostic assessment or consultation.
4. Referral for a consultation and/or treatment of patients with complicated diagnostic presentations, chronic benzodiazepine use, severe cognitive impairment, need for hospitalization, or primary psychotic illnesses.
Acute Phase of Treatment for Depressive Disorders X X X Substance abuse X X X X X X Clinical Note X X X X X X Medication profile X X X X X X UKU X X X X X X PHQ-9 Week 12 Week 9 Week 6 Week 3 Week 1 Baseline
Asymptomatic or minimally symptomatic (PHQ-9 score of 10 or less) - continuing pharmacotherapy of six months duration.
During maintenance therapy, meet once a month to obtain clinical ratings.
During the maintenance phase, if a patient scores 10 or greater on the PHQ-9, s/he should be reassessed one week later. If the PHQ-9 score remains at 10 or greater, the patient may be relapsing; therefore, the BHS should consult with the physician and/or supervising psychiatrist. The patient may need to restart the acute phase of the study.
End of Treatment Procedure for Maintenance Therapy
Siscuss with the patient her/his interest in continuing to take medication for relapse prevention.
Patients who continue taking it are less likely to have a relapse than those who discontinue it.
Adverse Event Documentation
During each phone contact, the BHS will initially ask patients if they are having any problems with their medication in an open-ended fashion.
The BHS will proceed with administration of the UKU Side Effects Rating Scale.
Psychotherapy may be used as alternative to pharmacotherapy (Psychotherapy alone) or be combined with antidepressants (augmentation).
Drugs that are simpler to implement in primary care are favored over drugs of known efficacy, but which require special procedures,
Treatments that are often poorly tolerated are given lower priority than treatments that are more likely to be tolerated, even when the efficacy of the latter treatments may be less well-established, e.g., bupropion augmentation of SSRI's was favored over lithium augmentation of SSRI's,
Venlafaxine/Bupropion will be the preferred treatment for patients who appear to be refractory.
When following each algorithm, clinical judgment can override the algorithm.
BHS clinicians are encouraged to discuss these cases with the supervising psychiatrist.