Effects of a Multifaceted Psychiatric Intervention Targeted for the Complex Medically Ill: A Randomized Controlled Trial

Abstract

Background: This study evaluated a multifaceted psychiatric intervention targeted at the complex medically ill identified by means of the INTERMED, an instrument to assess case complexity. Methods: Of 885 rheumatology inpatients and diabetes outpatients who were assessed for eligibility, 247 were identified as complex (INTERMED score >20) and randomized to the intervention (n = 125, 84 rheumatology and 41 diabetes patients) or care as usual (n = 122, 78 rheumatology and 44 diabetes patients). For the majority of the cases the multifaceted intervention consisted of an intervention conducted by a psychiatric liaison nurse and/or of referral to a liaison psychiatrist, followed by advice to the treating physician or organization of a multidisciplinary case conference. Baseline and follow-up at months 3, 6, 9 and 12 measured prevalence of major depression (Mini-International Neuropsychiatric Interview), depressive symptoms (Center for Epidemiological Studies Depression Rating Scale), physical and mental health (SF-36), quality of life (EuroQol), health care utilization and HbA_1c levels (diabetic patients). Results: Prevalence of major depression was reduced from 61% (T0) to 28% (T4) in the intervention group and remained stable in care as usual (57% at T0 to 50% at T4). Compared to care as usual, significant improvement over time was observed in the intervention group with regard to depressive symptoms (F = 11.9; p = 0.001), perception of physical (F = 5.7; p = 0.018) and mental health (F = 3.9; p = 0.047) and quality of life (F = 21.8; p < 0.001). Effects tended to be stronger in diabetes patients, in patients with baseline major depression and in patients with moderate INTERMED scores. Finally, hospital admissions occurred less often in the intervention group, reaching statistical significance for the period between 6 and 9 months of follow-up (p = 0.02). Conclusions: The results suggest that a psychiatric intervention targeted for complex medical patients can improve health outcomes.

Biopsychosocial aspects and the complexity of care of hospitalized elderly

“…(8)(9)(10)(11) The profile of the elderly investigated in this study showed a mean age of 72.3 years, females predominated, with a socioeconomic income in the range of three times the minimum wage, a profile that was similar to that observed in the literature. (12)(13)(14)(15) The increase in longevity was a response to the evolution of medical science, however, the quality of life of the elderly was one of the greatest challenges in developing countries, where poverty and social inequality were highlighted.…”

“…(7) The validity of this instrument is documented for the care of several types of patients. (8)(9)(10) Compared with usual care, targeted nursing interventions based on the INTERMED scores resulted in improvements in quality of life, at the time of admission and discharge in patients in general practice and in elderly patients requiring interdisciplinary care. (6,(8)(9)(10)(11) Assuming the importance of providing comprehensive care to the hospitalized elderly, this study aims to investigate biopsychosocial aspects of hospitalized elderly, and aspects of the health system, and to classify their degree of care complexity.…”

Identifying Risk for Attrition during Treatment for Depression

“…These interventions may have modified patient beliefs or their intent to continue, or both. Studies of collaborative care or educational interventions indicate that the provision of educational or supportive interventions that can address topics such as what to do about side effects or the time expected to reach remission may be useful in improving adherence or persistence in taking medications as well as outcomes [4, 6,43,44,45,46]. Personalized responses to each patient’s own expressed concerns may be even more useful in retaining less committed, at-risk patients in treatment for a sufficient time to maximize the chances of reaching and sustaining remission with this often chronic or recurrent illness.…”

Prevention of Major Depression in Complex Medically Ill Patients: Preliminary Results From a Randomized, Controlled Trial

“…Elsewhere, we have applied this intervention to a sample of 247 high-risk patients recruited at a rheumatology department and a diabetes outpatient clinic, and found that it was successful in reducing the prevalence of major depression, as compared with usual care. 21 Because a substantial proportion of the randomized sample did not suffer from major depression at baseline, we had the opportunity to determine whether the intervention was also capable of preventing incident major depression, and because so few studies have actually looked at this possibility, we performed this subgroup analysis in the present study.…”