For decades medicine’s divide between psychiatrists who cared for the mind and primary care physicians (PCPs), who treated “from the neck down,” worked against both patients and the healthcare system. The arrival of the Affordable Care Act (ACA), coupled with a federal parity law for mental health coverage, offers hope for those with multiple chronic conditions.
Persons with diabetes mellitus, either type 1 (T1DM) or type 2 (T2DM), stand to gain, if the offerings at recent medical meetings are any sign. Both, the May gathering of the American Psychiatric Association (APA) in New York City,1 and the June Scientific Sessions of the American Diabetes Association (ADA) in San Francisco,2 featured sessions on the link between diabetes and depression.
The message at both meetings: coordinating care between PCPs and mental health providers is an idea whose time has come. Not only does this approach work better for patients, but evidence shows it saves money, too. Both meetings and several studies published in recent years have explored the connections between diabetes and depression. Among the observations:
persons with depression account for more healthcare spending on diabetes and cardiovascular disease than those without mental health problems; depression that starts during adolescence causes sufferers to eat poorly, be less active, or smoke and drink, contributing to obesity and other comorbidities; and, managing diabetes over a lifetime is stressful and time-consuming, which wears patients down.3,4
“Depression raises the risk 60% that the patient will develop type 2 diabetes, Wayne J. Katon, MD, of the University of Washington, said in an interview with Evidence-Based Diabetes Management. Once a patient has T2DM, untreated depression can make it hard to follow diets or stick with medication, he said. Many of these connections have been known for years. In 2001, a study in Diabetes Care, the ADA’s flagship journal, concluded that the presence of diabetes doubled the odds of comorbid depression.5 The difference now is the push to coordinate care for the constellation of diseases, rather than treat mental health in a silo.
What’s driving the shift? There are many factors, but the most important one is the ACA, which requires providers and health plans, as well as new entities called accountable care organizations (ACOs), to deliver better care while cutting costs. This has forced the healthcare system to confront how inattention to mental health drives up spending on the medical side. The 2014 report prepared for APA by the actuarial firm Milliman, Inc, got a full airing in New York City, including the finding that better integration of primary and mental health care could save $26 billion a year.6
In 2012, 14% of the enrollees on commercial plans had mental health claims, but these patients accounted for 28.7% of the medical spending.6 Taxpayers pay for lack of coordination too.
Mental health patients make up 9% and 20% of the enrollees in Medicare and Medicaid, respectively, but these enrollees accounted for 26.3% of the medical spending in those plans.3 At the APA session, “Levering Psychiatric Expertise: Integrated Care and Healthcare Reform,” panelists agreed that psychiatrists and PCPs who fail to embrace integrated delivery models will suffer financial consequences.3
Washington’s TEAMcare Approach
The pioneers integrating primary and mental health care, particularly for patients with T2DM, are at the University of Washington, where the TEAMcare design was developed and studied in a clinical trial.7 Patients were randomly assigned to receive usual care or collaborative care; patients in the second group had their care across multiple diseases—including depression, T2DM, and cardiovascular disease, managed by a specially trained nurse who ensured that cases were reviewed at weekly sessions with the care team.
The University of Washington group reported its results in the New England Journal of Medicine in 2010.7 Patients receiving collaborative care for 12 months had 58% improvement in glycated hemoglobin (A1C) levels relative to the control group. Low-density lipoprotein measures and blood pressures improved by wider margins (Table), as did scores on the Symptoms Checklist (SCL-20) depression screen. Patients receiving collaborative care were more likely to have adjustments to insulin or to antihypertensive and antidepressant medications.
Patients who received the intervention also reported higher levels of satisfaction with their care.5 The cost of care for this group was lower—an average of $594 per patient for the year.4 The Washington results have gained notice. Katon, who was the lead author on the NEJM article, took part in both panel discussions at APA and gave a workshop on practical ways to bring collaborative care to a practice.3,8 Co-author Paul Ciechanowski, MD, MPH, presented the TEAMcare approach at the ADA symposium, “Bending the Curve: Behavioral Health Efforts in Diabetes and Healthcare Reform.”4 Katon and his University of Washington colleagues are now bringing TEAMcare concepts to practices around the country.9
As Ciechanowski and others explained at the ADA session, the key ingredient in collaborative care is the weekly case review, where PCPs, mental health professionals, care coordinators, and diabetes educators track who has missed an appointment, whose A1C levels should be taken, and whose unexplained physical symptoms could be a sign of a stress.4
Another component is better use of electronic health records, although some state regulations constrain mergers of medical and mental health records.
A Long Time Coming
The need for collaborative approaches to diabetes and mental healthcare seems so obvious—so why has it taken so long?
In an interview, Katon listed many challenges: Acute versus chronic conditions. Primary care has historically meant “acute care,” such as treatment of a symptom or injury, while mental health services work best over time.
Confronting stigma. Most patients will show up at a PCP when stress manifests itself as a physical symptom, but the stigma of mental healthcare often means they won’t follow up on a referral to a psychiatrist. It’s easier to get past this when the mental health provider is part of the PCP’s team.
Adherence. Getting patients to take medications is a problem across chronic conditions, but it’s especially troublesome in the mental health arena. And the divide between primary care and mental health care has often meant that needed adjustments to antidepressants never occur. When medication doesn’t work or side effects appear, patients may stop taking it.
Coverage. Historically, the biggest barrier to coordination of primary and mental health care has been the separation of coverage by payers. Limits on mental health visits and restrictions to higher-cost medications have made continuity of care and affordability difficult for many patients. ACA’s enshrinement of mental health parity should help change this, although enforcement is just beginning.
Doctors themselves can be a barrier to better coordination, even in settings like the TEAMcare project in Washington. But if they can be won over, Katon explained at APA, these one-time doubters can be the strongest supporters. He described a colleague, a former athlete-turned-PCP who would not make a mental health referral for 2 years. Then this doctor spent months working to alleviate his patient’s unexplained back pain, without success. Katon, the psychiatrist on the team, interviewed the patient and learned of multiple family problems in the home, including addiction, unemployment, and money woes among the patient’s adult children. Katon treated the woman’s depression and helped her learn to set limits, which rid her of pain. In the process, Katon won over her primary care doctor.
Changing Incentives Opens Doors
Katon has high hopes for the movement toward the Patient-Centered Medical Home (PCMH), which should mean better coordination of care. Standards revised this spring by the National Committee on Quality Assurance (NCQA), which offers PCMH accreditation, call for better integration of behavioral health services into primary care.10 In June, NCQA took comment on revisions that will boost accountability for antidepressant medication management and proactive assessment of drug and alcohol abuse, as well as numerous measurements in diabetes care.11
“The ACO movement, the vertical organization with medical specialty care, and the focus on keeping people out of the hospital will all help,” Katon said. Healthcare reform is forcing practices and health systems to scrutinize where patients with psychiatric disorders are overrepresented in treatment of comorbid conditions. The movement promises to tackle what has been a hurdle in promoting collaborative care: how to pay for the care coordinators or diabetes educators who make these models hum. Too often, Katon said, practices that did the right thing saved money, but the savings flowed to the payer, not to those delivering better care.
The arrival of ACOs and shared savings means “there’s an incentive to get that money back,” he said. He expects that Medicare’s tracking of 30-day hospital readmission rates to be especially powerful in ensuring that mental health patients with comorbid conditions get not only care but also support services upon discharge. Research into the connections is advancing as well, looking beyond the behavioral associations to biochemical roots. An article published last month, based on preclinical work on mice, suggests that decreased serotonin transporter function may be the common thread between depression and insulin resistance.12 Better coordination of care may help doctors distinguish between true depression and “fatigue” from dealing with symptoms. Preliminary results presented in San Francisco found that measures of depression dissipated among many patients who received interventions aimed at helping them manage their disease.13
“What’s important about this,” said Lawrence Fisher, PhD, ABPP, of the University of California San Francisco and lead author of the study, “is that many of the depressive symptoms reported by people with type 2 diabetes are really related to their diabetes, and don’t have to be considered psychopathology. So they can be addressed as part of the spectrum of the experience of diabetes and dealt with by their diabetes care team.”14
1. American Psychiatric Association. 167th Annual Meeting website. http://annualmeeting.psychiatry. org/. Accessed June 20, 2014.
2. American Diabetes Association. 74th Scientific Sessions website. http://professional.diabetes.org/Congress_Display.aspx?TYP=9&CID=93229.Accessed June 20, 2014.
3. Caffrey MK. Integrated care no longer an afterthought at APA: conference coverage, AJMC.com. http://www.ajmc.com/conferences/APA2014/Integrated-Care-No-Longer-an-Afterthought-at-APA. Published May 4, 2014.Accessed June 24, 2014.
4. Caffrey MK. Behavioral health session tackles diabetic burnout, mental health delivery: conference coverage, AJMC.com. http://www.ajmc.com/conferences/ada-2014/Behavioral-Health-Session-Tackles-Diabetic-Burnout-Mental-Health-Delivery-Published June 15, 2014. Accessed June 24, 2014.
5. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes. Diabetes Care. 2001;24(6):1069-1078.
6. American Psychiatric Association. APA unveils report on cost-effectiveness of integrated care. Psychiatric News Alert. http://alert.psychiatricnews.org/2014/04/apa-unveils-report-on-cost.html.Published April 4, 2014. Accessed June 24, 2014.
7. Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363:2611-2620.
8. Caffrey MK. Practical ideas for implementing collaborative care: conference coverage, AJMC.com. http://www.ajmc.com/conferences/APA2014/Practical-Ideas-for-Implementing-Collaborative-Care.Published May 4, 2014. Accessed June 24, 2014.
9. TEAMcare website. http://www.teamcarehealth .org/. Accessed June 24, 2014.
10. New NCQA patient-centered medical home standards raise the bar [press release]. Washington, DC: National Committee for Quality Assurance; March 24, 2014. http://www.ncqa.org/Newsroom/NewsArchive/2014NewsArchive/NewsReleaseMarch242014.aspx.
11. Public invited to help shape new measures on physical health, comorbid conditions and care transitions for people with serious mental illness and alcohol or other drug use disorders [press release]. Washington, DC: National Committee for Quality Assurance; June 3, 2014. http://www.ncqa .org/Newsroom/NewsArchive/2014NewsArchive/NewsReleaseJune32014.aspx.
12. Pomytkin IA, Cline BH, Anthony DC, Steinbusch HW, Lesch KP, Strekalova T. Endotoxaemia resulting from serotonin transporter (5-HTT) function: a reciprocal risk factor for depression and insulin resistance [published online May 4, 2014]? Behav Brain Res. doi:10.1016/j.bbr.2014.04.049.
13. Fisher L, Polonsky W, Hessler D. A new validated measure of diabetes distress for adults with type 1 diabetes. Diabetes. 2014;63(suppl 1):Abstract 67-LB.
14. Diabetes distress v. depression: are people with type 2 being misdiagnosed [press release]? San Francisco, CA: American Diabetes Association; June 16, 2014. http://www.diabetes.org/newsroom/press-releases/2014/diabetes-distress-vsdepression. html.