Volume 15, Issue 2
Spring 2003
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Feature Article
Profile: Greg Simon, MD, MPH
CHS psychiatrist and researcher pursues evidence to improve care for
depression, bipolar disorder, obesity, and more
By Katie Saunders
Greg Simon says he was "bitten by the public health bug"
while a medical resident at the University of Washington in the early
1980s. Intrigued with concepts such as evidence-based medicine, Simon
followed up his residency training with a two-year stint as a Robert Wood
Johnson Clinical Scholar from 1988 to 1990. Seeking the best of both
worlds, Simon came to Group Health in 1990 as a half-time researcher at
Group Health Center for Health Studies (CHS) and a part-time practicing psychiatrist in the delivery system.
Even though his role at CHS is only part-time, Simon has enjoyed
remarkable success in his field. In 2002 he won two national awards for
outstanding mental health research—one from the American Psychiatric
Association and the other from Eli Lilly and Company.
Asked about common themes in his research, Simon doesn’t hesitate
with his first answer—the epidemiology of mental disorders. Simon has
studied the prevalence, co-morbidities, treatments, and health care costs
associated with several common mental conditions including depression,
anxiety, insomnia, bipolar disorder, and somatization. Such studies
contribute to the "evidence-base" and help patients, providers,
insurers, and policy-makers make informed decisions about treatments and
resource allocation.
For example, after fielding many questions from pregnant patients,
Simon conducted a study looking at the effects on offspring of selective
serotonin reuptake inhibitor (SSRI)
antidepressant use by pregnant women. The study showed that SSRI use
during pregnancy was associated with an increased rate of premature
births. Simon concluded that women with mild forms of depression might
consider discontinuing SSRI use during pregnancy. At the same time, he
said the benefits of SSRIs probably outweigh the risks for pregnant women
with more severe forms of depression. Some experts took issue with this
message, questioning how Simon could say anything negative about
antidepressants given their overwhelming benefit. Simon counters that
people need to know the truth. "People ask what the facts are and you
need to present the facts," he added.
It’s not the first time Simon’s epidemiological studies have shaken
previously accepted "truths" in the field. For example, clinical
textbooks have consistently stated that 15 percent of patients treated for
depression will eventually die by suicide. Simon points out that these
estimates came from studies conducted in inpatient and specialty mental
health settings, whereas nearly half of patients treated for depression
are managed solely by general medical providers. In an observational study
conducted at Group Health among all patients treated for depression in a
three-year period, Simon found that the suicide rate among the total
population of depressed patients (4 percent) was only about one-fourth of
the rate obtained from inpatient samples.
In another methodological article related to the epidemiology of
depression, Simon challenged high profile reports that the U.S. was
experiencing a depression epidemic. Such reports claimed that younger
people’s lifetime depression rates were higher than those of their older
counterparts, with earlier ages of onset. Simon argued that
cross-sectional studies (the source of these reports) were inadequate to
answer questions about generational shifts in depression prevalence.
"The field goofed," he said, adding that it is now increasingly
accepted that depression rates are not rising at the rate suggested by
cross-sectional studies.
Simon recently reported on the epidemiology and treatment of bipolar
disorder at Group Health as well. This condition, characterized by periods
of depression and mania, is a severe mental disorder estimated to affect 1
percent to 1.5 percent of adults in the U.S. There has been debate as to
whether prepaid health plans were willing to enroll patients with severe
mental disorders such as bipolar disorder. Simon and colleagues found that
the prevalence of bipolar disorder at Group Health was 0.7 percent, only
somewhat lower than population estimates and higher than prior estimates
from other prepaid health plans.
Simon is currently involved in two more epidemiological studies at
Group Health examining the association between depression and obesity and
diabetes (see below).
Studying the design of mental health care
Although epidemiology has been a mainstay of his research program,
Simon points to an increased emphasis on intervention studies in recent
years. Much of his focus has been on interventions for depressed patients,
largely because, with a prevalence of 6 percent to 10 percent, major
depression is the most common mental disorder in the U.S. It is second
only to hypertension as the most common chronic condition seen by general
practitioners. Depression exacts an enormous toll, not only on the
individual’s mood and functioning, but also on the person’s family,
and society, in terms of lost work productivity and increased health care
costs.
Many of Simon’s and colleagues’ depression interventions have
focused on improving the intensity of treatment (either antidepressants or
psychotherapy) and active follow-up. One-third of patients beginning
treatment with antidepressant medications discontinue treatment after the
first month, and among those continuing treatment, only a few receive
optimal dosages. Ideally, antidepressants should be taken at adequate
dosages for at least 6 months—and even longer for patients at high risk
for relapse. In the acute phase of depression treatment (the first 12
weeks), patients should have at least three follow-up visits, either
in-person or by telephone. This rarely happens. In addition to improving
treatment intensity and follow-up, the depression interventions focus on
patient education, with the goal of making the patient an active
participant in his or her care.
These intervention components are similar to those espoused for the
care of other chronic conditions, such as diabetes or heart disease. They
conform to the chronic care model, developed at CHS by the MacColl
Institute’s Ed Wagner, MD. In essence, the chronic care model embodies
an organized system of care for a wide range of chronic conditions,
including mental disorders. This organized delivery of care often involves
a restructuring to achieve "collaborative" care between the
patient’s primary care physician and a "care manager." The
care manager, often a nurse or other allied health professional, monitors
treatment, ensures follow-up, helps with patient education and support,
and optimizes self-management. In this model, consultation from mental
health specialists is available as needed.
Simon put many of these principles to the test in a recently-published
randomized trial among depressed patients starting antidepressant
treatment. The trial included a control arm and two interventions—"feedback
only" and "feedback plus care management." "Feedback
only" consisted of feedback and algorithm based recommendations to
providers from computerized records of medications and visits.
"Feedback plus care management" included the feedback component
as well as systematic telephone follow-up—two 10–15 minute calls over a
16-week period—delivered by a care manager. The care manager also
assisted with arranging follow-up visits and referrals. The study found
that the "feedback alone" intervention did not have an effect on
depressive outcomes but that the feedback combined with care management
improved antidepressant treatment intensity and depressive symptoms
relative to controls The extra cost of the feedback plus care management
intervention was about $80 per patient.
Simon and colleagues are currently extending this trial by adding an
eight-session cognitive-behavioral telephone counseling intervention to
the already-proven phone monitoring. The counseling, provided by a master’s
level psychotherapist, focuses on behavioral activation (pursuing
rewarding activities), brief cognitive therapy (reducing negative
thoughts), and development of a self-care plan.
In addition, data analysis is currently underway on a large trial to
improve care for bipolar disorder. Similar to unipolar depression, a
substantial gap exists between what is known and what is done for the
treatment of bipolar disorder. For example, although several medications,
including lithium, have been shown to effectively treat this condition,
continuity of use is problematic for many patients. The trial’s
intervention arm consisted of telephone monitoring as well as structured
group sessions facilitated by a nurse. Preliminary analyses from the first
half of the study indicate that the intervention significantly reduced
risk of mania and suggest a growing effect on depression over time. Given
the positive findings, Simon hopes to extend this research beyond Group
Health to reach greater numbers of patients.
Simon is participating in a study that explicitly acknowledges the
connection between mental and physical disease. Led by UW's Wayne Katon
and CHS' Michael Von Korff, the randomized trial is looking at the effect
of a systematic depression treatment in people with diabetes. This trial
gives intervention subjects the option of choosing their treatment—either
antidepressant medications or psychotherapy. The researchers are
interested in how the intervention affects both the patients’ depression
and diabetes. With rates of depression in diabetics 1.5 to 2 times higher
than in the general population, Simon notes there’s been a lot of
interest in the question of how depression affects diabetes in terms of
glucose control, complications, and adherence to treatment.
Simon and colleagues are also just beginning a large study of obesity
and depression. First, an epidemiological survey will examine the
association between obesity and depression in women aged 40 to 65. It is
estimated that depression rates in this age group of obese women are as
much as 50 percent higher than those in comparably aged non-obese women.
Second, obese women with depression will be invited to participate in a
randomized trial consisting of a usual care arm and two different
intervention arms. One intervention will focus solely on weight loss. The
second targets both weight loss and depression, in light of evidence
suggesting that depression is associated with reduced success both in
losing weight and maintaining weight loss.
Examining the cost of better treatment
When designing and evaluating interventions, Simon keeps an eye toward
the "real world." "I’m interested in how to take what we
know about treatments that work under ideal conditions and how to
implement them under the conditions of real-world practice," he says.
Cost is obviously one of these conditions. "Better treatment costs
more money," says Simon. This has been borne out by several
cost-effectiveness studies conducted by Simon and colleagues showing that
successful depression treatments involve modest to significant treatment
costs—many on the order of about $15 per patient per extra
depression-free day. To date, these extra costs have not been shown to be
offset by other reductions in health care costs—that is, the argument
that successfully treating depression will result in lower costs, at least
in the health care system, has not yet been proven.
But Simon points out that the greatest savings achieved through
successful mental health treatment might actually occur in the workplace.
Estimates show that depressed workers have 1.5 to 3.2 more "sick
days" in a 30-day period than do non-depressed workers. These
additional sick days result in salary-equivalent production costs of $182
to $359—about equal to the costs of many successful mental health
treatments. In light of this promising cost-benefit ratio, Simon and
Evette Ludman, PhD, of CHS are collaborating with researchers at Harvard
and United Behavioral Health to evaluate an organized system of treating
depression in terms of its effect on work productivity and work
performance, not just depressive symptoms.
Returning to the issue of health care costs, Simon argues that the
extra costs associated with successful depression treatments are often
modest. Further, the added costs are not commensurately more than those
deemed acceptable for the treatment of other chronic conditions. But, at
the same time, he acknowledges that price is a dominant factor in today’s
health care marketplace.
This raises some interesting research questions for Simon—namely, how
to implement care improvements less expensively. He notes that the Center’s
mental health research has already moved in this direction. For example,
in early studies psychiatrists performed the medication monitoring. Now,
monitoring is computerized, with "less expensive personnel"
acting as the front-line or primary contacts. Psychiatrists are more
involved in back-up or supervisory roles.
In the telephone counseling trial described above, psychotherapy is
provided over the phone in eight sessions. This is another
"real-world" attempt to address what Simon describes as a very
important question—how to provide psychotherapy that is affordable,
accessible, and available to the patient.
Although cost of treatments is a legitimate concern, Simon is quick to
point out that some people with more severe depression will need more
expensive treatment—and they should be able to get it. For example, in
an editorial in The Journal of the American Medical Association, he
says it makes sense for health care systems to select the cheapest SSRI as
the first-line antidepressant. But he takes issue with placing
restrictions on second- or third-line treatment agents based on cost
concerns. Many patients do not respond to the first-line treatment, but do
ultimately benefit after switching medications, Simon notes. Similarly,
low-cost interventions such as telephone monitoring may benefit some
patients, but others will require higher cost treatments. The bottom line
is that providing quality health care for mental health problems is the right
thing to do. "The health care system in our society is a cost center,
it’s not a revenue center. We spend money on the health care system
because we believe it produces things of value," Simon says.
Simon describes the impact that his and colleagues’ research has had
on the mental health field as incremental. "It’s not that you can
point to any one study and say there was something earth-shattering. It’s
more of an accumulation of things over time, in terms of depression being
an important public health problem and demonstrating that organized care
programs can improve quality and outcomes for people with depression. I
think a lot of the efforts to improve depression care at Group Health have
to do with things we’ve done," he says.
"Fun" is probably the word Simon uses most often to describe
his research. And it fits. Coming up with future ideas for research is no
problem for Simon, who says there are an unlimited number of interesting
areas to pursue. Extending his work on bipolar disorder and developing
long-term interventions for depression are just a few. And he’s happy to
be able to do this work at CHS and Group Health. "I can’t imagine a
better place for me to do the kinds of things that I want to do," he
says, "both in terms of the intellectual culture of the place—the
kind of freedom you have here—and the ability to work within a large
health care system that places a value on research and is willing to
innovate."
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