the question is not whether to integrate, but how eric goplerud, ph.d. the 17th annual commemoration...
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“The question is not whether to integrate, but how”
Eric Goplerud, Ph.D.
The 17th Annual Commemoration of World Mental Health Day The World Federation for Mental Health and the Pan American
Health Organization
Thursday, October 8, 2009
Center for Integrated Behavioral Health Policy
Department of Health Policy, The George Washington University Medical Center
•Prince et al, Lancet, 2007
Contribution by different non-communicable diseases to disability-adjusted life-years worldwide in 2005
Leading Causes of Disease Burden
by Select World Bank Region, 2001
Rank
East Asia/
Pacific
Europe/
Central Asia
Latin America/
CaribbeanHigh-income
Countries
1Cerebrovascular diseases
Ischemic
heart diseasePerinatal Conditions
Ischemic heart disease
2 Perinatal conditionsCerebrovascular diseases
Unipolar depressive disorders
Cerebrovascular
disease
3Chronic obstructive pulmonary disease
Unipolar depressive disorders
Homicide and violence
Unipolar depressive disorders
4Ischemic
heart diseaseSelf-inflicted injuries
Ischemic heart disease
Alzheimer’s disease and other dementias
5Unipolar depressive disorders
Chronic obstructive pulmonary disease
Cerebrovascular disease
Tracheal and lung cancer
Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 4.2
WHO, mhGAP, 2006
Proportion of specified budget allocated for mental health out of total health budget in each country
Redrawn from WHO Mental Health Atlas
Burden of mental disorders and budget for mental health
* Proportion of disability-adjusted life-years (DALYs), defined as the sum of the years of life lost due to premature mortality in the population and the years lost due to disability for incident cases of mental disorders.36† Median values for proportion of total health budget allocated to mental health.5 Sexenar et al, Lancet, 2007)
Years of Potential Life Lost to Persons Years of Potential Life Lost to Persons with Serious Mental Illnesseswith Serious Mental Illnesses
• Compared to the general population, persons with major mental illness typically lose more than 25 years of normal life span. Premature mortality among addicts up to 18 years.
• In DC, average age of death of DMH patients – 54 years, average life expectancy in DC – 72 years
Colton CW, Manderscheid RW. Prev Chronic Dis] 2006 Apr ; Hser et al, 2003Colton CW, Manderscheid RW. Prev Chronic Dis] 2006 Apr ; Hser et al, 2003
Year AZ MO OK RI TX UT VA
1997 26.3 25.1 28.5
1998 27.3 25.1 28.8 29.3 15.5
1999 32.2 26.8 26.3 29.3 26.9 14.0
2000 31.8 27.9 24.9 13.5
Causes of Morbidity and Mortality in Causes of Morbidity and Mortality in People with Serious Mental IllnessPeople with Serious Mental Illness
• Suicide and injury account for about 30-40% of excess mortality
• About 60% of premature deaths are due to “natural causes”– Cardiovascular disease– Diabetes– Respiratory diseases– Infectious diseases
Colton CW, Manderscheid RW. Prev Chronic Dis] 2006 ; Lutterman et al, 2003; Apr ; Hser et al, 2003Colton CW, Manderscheid RW. Prev Chronic Dis] 2006 ; Lutterman et al, 2003; Apr ; Hser et al, 2003
Smoking, Serious Mental Illness and Smoking, Serious Mental Illness and AddictionAddiction
• Prevalence=75% to 85%
• Consume 44% of all cigarettes nationally
• Smoke heavier
• Smoke more efficiently
Ziedonis et al, 2003
Co-occurrence of Mental Illness and Addiction: US
SAMHSA, 2003
WHO, mhGAP, 2006
Cost-effectiveness of Interventions for Mental Disorders in Low- and Middle-Income
Countries
Source: Disease Control Priorities in Developing Countries, second edition, 2006, Figures 2.2 and 2.3
Condition Intervention
Cost-effectiveness
($ per DALY averted)
SchizophreniaAntipsychotic drugs with optional psychosocial treatment (hospital-based) 4,105-19,736
SchizophreniaAntipsychotic drugs with optional psychosocial treatment (community-based) 2,472-17,197
Bipolar DisorderMood-stabilizing drugs with optional psychosocial treatment (hospital-based) 3,590-5,244
Bipolar DisorderMood-stabilizing drugs with optional psychosocial treatment (community-based) 2,498-3,728
Depression Drugs with optional psychosocial treatment 657-2,741
Panic Disorder Drugs with optional psychosocial treatment 384-1,084
Costs of a Mental Health Care PackageBy Region
Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 31.7
Annual Cost ($ millions) per One Million Population
Intervention
Sub-Saharan
Africa
Latin America/
CaribbeanMiddle East/ North Africa
Europe/ Central
AsiaSouth Asia
East Asia/
Pacific
Schizophrenia: older antipsychotic drugs plus psychosocial treatment 0.47 1.81 1.61 1.32 0.52 0.75
Bipolar disorder: older mood-stabilizing drugs plus psychosocial treatment 0.48 1.80 1.23 1.39 0.62 0.95
Depression: proactive care with newer antidepressant drugs 1.80 4.80 3.99 3.56 2.81 2.59
Panic disorder: newer antidepressant drugs 0.15 0.27 0.21 0.23 0.16 0.20
Total cost of interventions 2.9 8.7 7.0 6.5 4.1 4.5
Cost-effectiveness of Interventions for Alcohol Abuse in Low- and Middle-
Income Countries
Source: Disease Control Priorities in Developing Countries, second edition, 2006, Figure 2.2
Intervention
Cost-effectiveness Ratio
($ per DALY averted)
Increased taxation on alcohol 1,249-1,504
Brief advice by primary health care doctor about alcohol abuse 642
Increased taxation, advertising ban, and brief advice by primary health care doctor 601-661
Advertising ban and restrictions on alcohol sales 367-441
Estimated Impact of Interventions to Reduce High-Risk Drinking
Notes: Coverage (modeled percentage of all high-risk drinkers exposed to the intervention): *95%, **80%, ***50%.
Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 47.6
DALYs Averted per Million Population per Year
InterventionEurope/ Central
AsiaLatin America/
CaribbeanSub-Saharan
Africa
Excise tax (current situation)* 685 586 697
Excise tax (25% increase)* 756 654 724
Excise tax (50% increase)* 828 719 764
Reduced access to retail outlets* 441 287 386
Comprehensive advertising ban* 395 243 406
Random breath testing of drivers** 284 307 197
Brief advice to heavy drinkers by primary care physician*** 1,328 713 539
For schizophrenia, bipolar disorder, depression and hazardous use of alcohol
--- over a 10-year period US$ 1.85 to US$ 2.60 per capita in low-income countries
US$ 3.20 to US$ 6.25 per capita in lower-middle income countries
-- US$ 0.20 per capita per year in low-income countries US$ 0.30 per capita per year in lower-middle-income countries
National Institute for Health and Clinical Excellence. Depression: management of depression in primary and secondary care. British Psychological Society, Gaskell, 2004. National Institute for Health and Clinical Excellence. Schizophrenia: full national clinical guidelines on core interventions in primary and secondary care. British Psychological Society, Gaskell, 2003.
What would a primary care-led MH/SA package cost?
WHO, mhGAP, 2006
WHO, mhGAP, 2006
Care Model: Integration is the Expectation
California Primary Care,2009
Lessons learned – Culture change
• Primary care culture: Acute focus
• Mental health culture: Individual (not population) focus
• Adjusting to a public health approach can be challenging, especially for experienced mental health professionals
• Examples of chronic disease management (e.g., for diabetes) can help make it clear for PCPs
Lessons learned – Staff buy-in
• Most providers understand why this is needed, but feasibility must be demonstrated
• Administrative support and PCP champions are critical
• Psychiatrist and care managers need to establish trust with PCPs – Takes time
• Once implemented, PCPs see the benefits, and late adopters come on board
Lessons learned – Workforce
• Even with collaborative care, workforce issues have impact:
• Limited availability of psychiatrists & care managers, especially in rural areas
• Child mental health providers particularly hard to find
• Care managers’ personality or orientation may be more
important than credentials
• For partnerships across distances, a web-based registry facilitates communication
Lessons learned – Clinical issues
• Collaborative care approach can reduce stigma as barrier to treatment seeking in populations of color
• Severity of mental health problems in CHCs is high
• Co-morbid conditions (especially SU & chronic pain) must be addressed
• Demand is great – Have to be creative
• Specialty mental health partners are critical – Can’t do this alone
Lessons learned – Sustainability
• Policy piece is critical to address state and federal barriers
• Financial solutions require state and local problem-solving
• Creative partnerships facilitate model
• Need to promote collaborations between primary care provider organization, hospitals / hospital districts, mental health partners, and others