Psychiatr News January 6, 2006
Volume 41, Number 1, page 30
© 2006 American Psychiatric Association
Primary Care Patients Dial Up Effective Mental Health Intervention
Mark Moran
Patients who received a telephone-based intervention were significantly
less likely to report two or more trips to the emergency room at the 12-month
follow-up.
A "collaborative care" model that includes telephone-based
monitoring and follow-up significantly reduced symptoms of anxiety and
depression in primary care patients with panic and generalized anxiety
disorder.
Patients who were randomly assigned to a telephone-based, care-management
intervention reported reduced anxiety and depression at 12-months, improved
mental health related quality of life, and greater improvements over baseline
in hours worked per week, compared with patients who received usual care in
the primary care setting.
They also had fewer work days absent, according to a study in the December
2005 Archives of General Psychiatry. Lead author Bruce Rollman, M.D.,
M.P.H., told Psychiatric News that the study also found that the
intervention resulted in fewer trips to the emergency room. "It doesn't
take a lot of visits to the emergency room to pay for this
intervention," he said.
Rollman is an associate professor of medicine and psychiatry at the
University of Pittsburgh School of Medicine.
"The study is the first to report the impact of treating anxiety on
work outcome and health-services utilization," he said. "This is
important because we have an employer-based health care system, and employers
want to know if their employees are productive.
"With our collaborative care intervention we found a reduction in
anxiety and an improvement of quality of life," he said. "We also
found that patients randomized to the intervention were significantly more
likely to be working at 12-month followup, had missed fewer days of work, and
had worked more hours per week than patients randomized to usual
care."
In the study, investigators used the brief, self-administered Patient
Questionnaire portion of the PRIME-MD instrument to screen patients aged 18-64
at four primary care sites for the presence of anxiety symptoms between July
2000 and April 2002. The four sites were all affiliated with the University of
Pittsburgh Medical Center and were connected by an electronic medical
record-keeping system.
Those who screened positive were then administered the PRIME-MD Anxiety
Module to determine if they met DSM-IV criteria for panic disorder or
generalized anxiety disorder.
Finally, those patients who met these criteria were given the Hamilton
Anxiety Rating Scale and the seven-item Panic Disorder Severity Scale (PDSS).
All study-eligible patients with panic disorder scored 7 or higher on the PDSS
or had generalized anxiety disorder alone or comorbid with panic disorder and
scored 14 or higher on the Hamilton Anxiety Rating Scale.
A total of 191 patients were recruited. Of those, 116 were randomly
assigned to the telephone-based care-management intervention, and 75 were
assigned to usual care. "Usual care" entailed only notifying the
patient and primary care physician of the diagnosis.
The intervention, not unlike the "disease management"
strategies used by some health insurance plans, employed nonspecialist
"care managers" who telephoned patients to conduct a detailed
mental health assessment, provide basic psychoeducation about panic disorder
and generalized anxiety disorder, and ascertain patients' treatment
preferences.
Patients could choose one or any combination of the following three
treatment options: a workbook with self-management skills and follow-up by
care managers to review lesson plans; a guideline-based trial of anxiolytic
pharmacotherapy to be prescribed by the primary care physician; or referral to
a community mental health specialist.
Based on those preferences, a treatment recommendation was made to the
primary care physician, who was free to accept or reject recommendations.
Eighty percent of the intervention patients chose the self-management
workbook. And approximately 80 percent of intervention patients used an
SSRI/SNRI, with no significant difference at 12 months in use of
pharmacotherapy between the intervention group and the usual care group.
Approximately 18 percent of intervention patients saw a mental health
specialist, compared to 26 percent in the usual care group.
"Patients in the intervention used both the workbook and meds, and
some also accepted referral to a mental health specialist," Rollman
said.
Throughout the follow-up period, care managers telephoned patients in the
intervention group at regular intervals to promote adherence to whatever
treatment they were receiving and monitor progress.
At the 12-month follow-up, intervention patients also experienced greater
reductions in depression scores on the Hamilton Rating Scale for Depression
and were more likely to experience a 40 percent or greater reduction in
depressive symptoms. Usual care patients were significantly more likely to
report two or more visits to the emergency room than were intervention
patients.
Rollman told Psychiatric News that the collaborative care model
used in the study can be used in primary care settings that do not have
electronic medical record keeping, though communication with primary care
physicians will require faxing and telephone calling.
"These models are spreading," he said. "We believe these
results are meaningful, especially with regard to utilization of health
services, and we need to make the case to the people who are paying the bills
as to why these conditions are important to treat."
An abstract of "A Randomized Trial to Improve the Quality of
Treatment for Panic and Generalized Anxiety Disorders in Primary Care"
is posted at
<http://archpsyc.ama-assn.org/cgi/content/abstract/62/2/1332>.
Arch Gen Psychiatry 2005 62 1332[Abstract/Free Full Text]
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