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PSYCHIATRIC INTERVENTIONS IN THE MEDICALLY ILL
CONSULTANT-LIAISON PSYCHIATRY
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PSYCHIATRIC INTERVENTIONS IN THE MEDICALLY ILL Outcome and Effectiveness Research Stephen M. Saravay, MD
As managed care and legislative health care reform radically reshape the practice of medicine, increasing scrutiny will be brought to bear on the clinical, economic, and social consequences of these changes. Although data from outcome research have had limited success to date in influencing policy decisions in comparison with economic and other more current compelling forces, the future promises a more rational process of deliberation and decision making. Legislators and administrators are increasingly likely to turn to data from outcome studies to inform their decisions. Most persuasive to them in the area of inpatient consultation-liaison (CL) psychiatry and outpatient primary care will be studies that demonstrate simultaneous positive outcomes in several domains.I9 Outcomes that contain synchronous positive changes in clinical symptomatology, quality of life, levels of functional disability, and use and costs of general medical services, will provide the strongest basis for effecting policy changes. This article reviews the current status and emerging trends of outcome data from research studies of psychiatric and psychosocial interventions for mental disorders in patients in the general medical sector and suggests promising directions for future research. The success of a psychiatric intervention study in the medically ill depends, among other factors, on the premises on which it is based. Cohen-Cole et a17have delineated the criteria for demonstrating the cost From the Consultation-Liaison Psychiatry Service, Department of Psychiatry, Long Island Jewish Medical Center, New Hyde Park; and Albert Einstein College of Medicine, Bronx, New York
THE PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 19 * NUMBER 3 * SEPTEMBER 1996
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effectiveness of interventions. Because the emphasis of outcome research has broadened to include clinical, functional, and quality-of-life mea44, 65 we can update these criteria by paraphrasing them as folsure~,'~, hWS: 1. The target psychiatric disorder should produce measurable clinical symptoms, functional disability, impaired quality of life, and increased medical use and cost. 2. The intervention must result in demonstrable improvement in psychiatric clinical signs and symptoms. 3. Positive outcomes in function, quality of life, use of medical services, and costs should occur concurrent with or following the clinical changes.
The first step according to the above criteria is to demonstrate the impact of psychiatric disorders and their symptoms on quality of life, functional capacity, use of general medical services, and associated costs. Data of this kind have been gathered for medical and surgical inpatients@and for the primary care outpatient population in large-scale 40, 47 and for patients epidemiologic studies of the general population36* in different health care systems.65These data can then be used to develop the design, select the population sample to be studied, and determine outcome measures to be used. IMPACT OF PSYCHIATRIC DISORDERS IN THE GENERAL MEDICAL INPATIENT SECTOR Outcome studies of the impact of psychiatric disorders on length of stay and use of medical resources on general hospital inpatients in the United States and abroad have recently been critically reviewed.43Studies were divided into three categories or generations: (1)first-generation studies were retrospective; (2) second-generation studies were prospective but did not control for potential confounding variables, such as severity of medical illness or physical impairment; and (3) third-generation studies were prospective and controlled for illness severity or impairment in physical functioning and other potentially confounding variables. Of the total of 26 articles, 80% found a significant correlation between psychiatric or psychologic comorbidity and increased length of stay (LOS) in general hospital inpatients. If studies with the smallest sample sizes (below 110) are eliminated (which might have resulted in a type I1 error), then 89% of the remaining studies had significant findings. If we examine the third generation studies, those with the most rigorous methodologic designs, three of four or 75% demonstrated significant associations between psychiatric comorbidity and LOS, and a fifth study currently being prepared for publication by the author and his co-workers has also demonstrated positive findings. Five of the prospective studies also examined how postdischarge course might be affected by psychiatric comorbidity and all found some significant im-
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pact on such measures as rehospitalization, institutionalization, physical outcome, or mortality. The psychiatric factors that these studies focussed on were affective disorder, mainly depression, and cognitive impairment. A variety of populations were studied, some with homogeneous medical diagnoses, such as stroke, acquired immunodeficiency syndrome (AIDS), orthopedic problems, and so forth, and some with heterogeneous medical diagnoses. Some studies sampled all general hospital patients and some examined patients from specialized inpatient units. Eleven studies looked at geriatric patients and 15 examined general adult populations. The authors conclude that whether one relies on the total results derived from all studies or the conclusions derived from the more recent, rigorously controlled, prospective research, impaired cognition and depressed mood and personality variables contribute to prolonged medical hospital stays and greater use of hospital resources and costs. In addition, psychiatric comorbidity identified within the general hospital was found to be associated with greater use of emergency room visits and rehospitalizations up to 4 years after discharge. These studies, although demonstrating an association between psychiatric comorbidity and increased hospital length of stay, imply but do not prove causality. Nor do they elucidate how associated psychiatric illness might complicate or prolong medical treatment. They do not suggest to the prospective researcher which specific psychiatric intervention to select because the processes by which mental disorders may increase hospital LOS have not been systematically studied. Using delirium or cognitive impairment as an example, the authors review the anecdotal literature describing the ways that delirious symptoms and cognitive impairment might extend hospital stays other than as a result of placement problems. Agitated patients after hip fracture repair have dislocated prostheses or had trochanteric separations or induced hematomas at the surgical site. Restrained agitated patients have developed bed sores, pneumonia, myocardial infarctions, and congestive heart failure. Catheterization for urinary incontinence has been associated with secondary urinary tract infections. Cognitive impairment may require capacity evaluations that delay necessary diagnostic tests and procedures and may negatively affect compliance and impair the cooperation required for successful rehabilitation regimens.43 Similar issues have been described for depression occurring in medical patients, especially in the outpatient sector. Depression and anxiety disorder in patients who somatize may increase general medical use through increased inappropriate use of medical diagnostic services. Depressed phobic-anxious patients may delay treatment resulting in a higher level of medical severity at the time of admission. Compliance with treatment regimens may be impaired and worse medical outcomes have been associated with depression and anxiety.45Future research efforts need to assess systematically the processes by which mental disorders in general medical inpatients increase use and extend length of stay.
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RECOGNITION OF PSYCHIATRIC DISORDERS IN THE GENERAL MEDICAL INPATIENT SECTOR
A hospital admission may be a brief but invaluable window of opportunity for mental health professionals to identify and initiate treatmenP2 for a previously unrecognized mental disorder. Unrecognized comorbid psychiatric disorders may adversely affect both the immediate hospital course and the postdischarge prognosis of the patients' medical disorder? alo* 13, l5 and contribute to higher rehospitalization rates and use of outpatient medical services after di~charge.~", 44,45 A major obstacle to such endeavors has been the stubborn fact that most psychiatric disorders in the general hospital are underrecognized and underreferred.12,32, 50, Whereas 30% to 60% of admitted patients have diagnoseable psychiatric only 1%to 3% of admissions are likely to be referred.& An intervention program in the general hospital cannot, therefore, rely on physicians without specific training in the course of their usual general medical practice to recognize and refer appropriate patients to psychiatric intervention programs. Some combination of screening instruments, physician education on site, and psychiatric liaison will, in all likelihood, be needed to recognize and refer appropriate patients to psychiatric intervention programs in a given hospital setting. PSYCHIATRIC INTERVENTION IN THE GENERAL MEDICAL INPATIENT SECTOR
In a review of prospective intervention studies in elderly hip fracture patients, Strain and c o - ~ o r k e r sfound ~ ~ three studies with significant cost savings that reduced length of stay by using some form of active case finding and providing an integrated liaison presence. One of those studies60 demonstrated synchronous changes in decreased LOS, associated cost savings (Table l),and improvement in clinical symptoms. A reduced level of postdischarge medical use showed that not only were costs savings carried forward by the intervention after discharge,
Table 1. SAVINGS FROM INTERVENTIONSTUDIES IN ELDERLY HIP FRACTURE PATIENTS Authors
Year
Savings ($)
Type of Intervention
Boone et alla 1981 53,762 Early comprehensive social work 1981 183,600 Integrated CL model Levitan and K ~ r n f e l d * ~ ~ 1991 166,926 (Mt. Sinai) Integrated CL model Strain et also 97,361 (Northwestern) Data from Strain JJ, Hammer J, Fulop G: APM task force report on psychosocial interventions in the general hospital inpatient setting: A review of cost-offset studies. Psychosomatics 35:253-262,1994.
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but that cost shifting from the inpatient to the outpatient sector was ruled out as a possible explanation for the inpatient savings. By contrast, an intervention study using a consultation model that was guided only by screening, where the CL psychiatrist was not clinically integrated with the referring and treating medical teams, found poor cooperation of the referring physicians, no measurable clinical improvement, and no reduction in inpatient LOS or follow-up outpatient medical use or associated costs savings.27 Using a still different model, Fuller and JordanI4used a specialized team to treat a specific category of psychiatric disorder referred through a screening program. They demonstrated a cost-offset effect using this approach for substance abusers in the general hospital in which more was generated in revenues for clinical interventions than the salary cost of the treatment team. Outcome of clinical symptoms, function, or quality of life factors, however, were not measured. There are four models in which CL interventions can be attempted in the general hospital. 1. Consultation alone 2. Usual consultation guided by screening 3. Integrated or liaison model in which the CL psychiatrist’s role and function is integrated within the treatment team allowing for collaboration in case finding and treatment 4. Specialized team consultation for specific disorders guided by screening
No prospective, randomized, controlled studies to my knowledge have been reported with the consultation-alone model. The absence of such studies may be owing in part to the ethical dilemma inherent in a design that proposes randomly to withhold psychiatric consultations that have been spontaneously requested for recognized clinical problems. Usual consultation guided by screening without liaison integration was ineffective in the study by Levenson et al,27whereas three liaison models (two CL and one social work) showed positive outcomes (see One study of a specialized team approach guided by screening Table l).59 was found to have a cost-offset effect in patients with substance abuse.I4 IMPACT OF PSYCHIATRIC DISORDERS IN THE GENERAL MEDICAL OUTPATIENT SECTOR
In the outpatient sector, large-scale epidemiologic studies of the general population, like the Epidemiologic Catchment Area and of patients in the general medical sector, such as the World Health Organization Collaborative Project on Psychological Problems in General Health Care36,47 and the Rand Corporation Medical Outcomes Study (MOS)164explored the prevalence of psychiatric disorders, their course, and their impact on functional capacity, quality of life, and use of general medical services. Mental disorders were found to be twice as
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common in the outpatient general medical sector than in the general p o p u l a t i ~ nowing ~ ~ , ~ in ~ part to the fact that patients with mental disorders are higher utilizers of general medical services.16, 23 Between one quarter to one third of patients in primary care have a diagnosable mental disorder in the course of a year39,40 and an additional one fifth have transient stress-induced subsyndromal symptoms. Of those who seek help for their mental disorders, more turn to their primary care physicians than seek help from mental health specialist^.^^ Patients with psychiatric disorders were found to have a surprisingly high degree of disability compared with patients with chronic medical conditions in this country and around the world.2,36, 64, 66 Depression, the most common psychiatric disorder in primary care, has been the most extensively studied. Wells' et al" data on depression as part of the MOS studies of the Rand Corporation and those of others33,56 showed that depressed patients had more sick days, days out of work, days confined in bed, and had more impaired social interpersonal and parenting roles compared with patients with most chronic medical illnesses.33,64 These objective findings applied to patients who met Diagnostic Statistical Manual-111-R (DSM-111-R) criteria, as well as a subsyndromal population of patients with depressive symptoms who did not meet full diagnostic criteria. In another study, patients with major depressive disorder compared with patients without mental disorders had five times more days disabled2 and four times more days spent bedridden.66 The disabilities tended to be pervasive and chronic with most persisting in primary care patients at 2-years follow up.17Furthermore, the functional disability has been shown to vary with the severity of the depression in both crosssectionaP and longitudinal studies'O, 33, 37, 63 and successful clinical results that reduce symptomatology also produce positive changes in the associated functional correlates of d e p r e ~ s i o n . ~ ~ Similar relationships were found for other psychiatric disorders 29, 56 social seen in primary care, such as dysthymia,2O,56 panic phobia@and other anxiety disorders,", 56 as well as full somatization 55, 56 Impairments disorder and subsyndromal somatization dis0rde1-s.~~. in quality of life, functional disabilities in social, work, and parenting roles, and a higher use of general medical services accompany the subjective distress suffered by patients with these disorders. The relationship of psychiatric status and disability is significant after controlling for severity of physical disease and for the number of chronic medical condition^.^^ In addition, when mental disorders coexist with medical 4, 15, 23 illness the outcome of the medical disorder may be wor~ened.~, The economic impact of mental disorders in the general medical sector was found to be substantial. Patients with mental disorders were found to use a disproportionate share of general medical services. They have 50% to 100% higher costs from use of general medical services after controlling for degree of medical morbidity.52Major and minor 52; anxiety dis0rders,2~ including panic disordersz9and social depressionz0, phobia49;and somatization disorders53,55 all have higher rates of use.
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When one approaches the problem from the opposite perspective to look at the prevalence of psychiatric disturbance in high utilizers, 50% of high utilizers of health maintenance organization general medical services were found to be psychologically distressed.23 IDENTIFICATION AND COURSE OF MENTAL DISORDERS IN THE OUTPATIENT GENERAL MEDICAL SECTOR
Studies show that despite the high prevalence and morbidity of mental disorders, primary care physicians missed between 33% to 50% of those that they see'8,23 in this country and throughout the The use of a standardized screening instrument by primary care physicians can result in a 30% increase in referrals for mental health specialty treatment.57When primary care physicians undertake the treatment of the mental disorders they do diagnose, they tend to undertreat them relative to established treatment guidelines and clinical practice patterns of mental health specialists.", 61, 65 Outcome studies have shown how patients with mental disorders fared in outpatient primary care settings. Although there had been an earlier series of studies between 1979 and 1985 that demonstrated a cost offset effect of mental health treatment relative to general medical use costs,', 21, 35 the results need to be confirmed by prospective randomized, controlled studies that include outcome measures of psychiatric symptom severity, functional disability, and quality of life. In a paper on depression in primary care Wellsh5analyzed the data bases of three very large health policy studies: (1)the Health Insurance Experiment, (2) the MOS, and (3) the Prospective Payment Systems Quality of Care Study. He found that outcome and quality of care of depressed patients in the outpatient general medical sector was generally poor. When depressed patients relied on primary care doctors, antidepressants were prescribed only 20% of the time and in these cases 40% received subtherapeutic doses of medications. In addition, primary care physicians provided one tenth the number of visits compared with standard mental health specialist treatment. It has also been found that primary care physicians tend not to prescribe medication for a sufficient durationF1 nor provide adequate longer-term monitoring of antidepressant use.52 Treatment of depression by primary care physicians was found to have the worst outcome and lowest costs compared with two kinds of mental health specialist treatments that had the best outcome and highest cost.61The increase in employment earnings as a result of better clinical and functional outcome and decreased disability, however, was found to offset the additional cost of psychiatric treatment providing evidence of an overall cost benefit of mental health treatment. The authors of this study make the point that mental health treatment provides the best result per dollar spent. According to the authors, however,
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in view of economic constraints some combination of enhanced primary care physician skills and better integration of mental health services in diagnosing, triaging, and treating mental disorders in primary care seems warranted.61 These epidemiologic studies in the outpatient primary care sector catalogue the prevalence, clinical severity, and associated functional disabilities and impaired quality of life in patients with mental disorders, and the higher use of medical services and costs. They show how clinical improvement of psychiatric disorders may result in associated improvements in disability levels, quality of life, and also provide economic gains.61 Yet, primary care physicians who treat more of these patients than mental health specialists do not meet the usual standards of care for mental disorders when compared with accepted clinical treatment guidelines or the usual practice of mental health specialists. Outcome studies suggest these differences result in worse clinical and functional outcomes.6l These findings point to a critical imperative for psychiatry and medicine-the improvement of the treatment of mental disorders in outpatient primary ca~e.6~ Providing patients with mental disorders with more mental health specialty care and enhancing the primary care physician's knowledge and experience in diagnosing, triaging, treating, and referring patients with mental disorders is clearly warranted. Successful educational initiatives in this area have been described.6 PSYCHIATRIC INTERVENTION STUDIES IN THE OUTPATIENT GENERAL MEDICAL SECTOR
The solutions to improving mental health primary care treatment may be different in different settings and for different disorders. The problems defined by large-scale epidemiologic studies need to be addressed by effective intervention strategies. Fortunately, there is a body of methodologically sound research on psychiatric interventions for mental disorders in primary care with outcome data that may suggest likely directions to pursue. Katon and Gonzales" reviewed and analyzed outcomes in three generations of psychiatric CL prospective, randomized, controlled intervention studies in outpatient primary care. In their categorization (Table 2), first-generation studies used standardized instruments to screen patients for psychiatric disorder. Identified patients were then randomly referred to their primary care physicians for treatment. Only one study out of seven demonstrated significant differences in the level of patient distress. Second-generation studies also screened for psychiatric disorders, after which the psychiatrist provided the primary care physician with a specific treatment protocol that the latter used. Two studies fell into this category. In one study, health care use and costs of somatizers were
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Table 2. CONSULTATION-LIAISON INTERVENTION IN PRIMARY CARE Type First generation
Design Screen
Second generation Screen Third generation
No. of Studies 7
+ collaborative plan
Screen + collaborative + direct and indirect CL involvement
2 2
% of Studies with Positive Outcomes
14% change in patient distress 50% change in health care use; 50% change in prescribing practice 100% change in patient distress
Data from Katon W, Gonzales JJ: A review of randomized trials of psychiatric consultation-liaison studies in primary care. Psychosomatics 35:268-278,1994.
reduced in the intervention group without clinical impr~vernent.~~ The second, a study of distressed high users of medical carez6found increased use of psychotropic drugs by primary care physicians in the intervention group, but no change in health care use or patient distress was observed. Third-generation studies, in addition to prospective screening, provided higher intensity interventions by mental health specialists compared with the second-generation studies. The two studies completed at the time of the review5,51 demonstrated significantly reduced psychological distress in the experimental groups compared with the patients receiving usual treatment by the primary care physician. The authors conclude that positive outcomes from psychiatric intervention programs are more likely when the CL psychiatrist’s efforts are more integrated with those of the primary care physician and include more direct involvement with the patient. Five subsequent reports expand on these conclusions. Three recent papers of patients with somatization disorder and subsyndromal somatization patients amplify and expand on Smith et a l ’ original ~ ~ ~ study.22* 41, 55 For patients with somatization disorder, a second-generation design was again used. Seventy patients with somatization disorder were randomized to experimental and control groups. The intervention consisted of a letter outlining the diagnosis and recommended treatment plan for the patients with a description of somatization disorder, its course, low physical morbidity, and mortality. The treatment plan consisted of scheduled brief appointments every 4 to 6 weeks with brief concentration on the physical complaints, avoidance of tests and procedures unless clearly indicated, and instructions to avoid telling patients “it’s all in your heads.” Results showed improved mental health measures over 12 months, a decrease of 45% in medical costs owing to decreased hospitalizations, and an improvement in capacity to carry out everyday tasks. Smith et a155using the same approach for subsyndromal somatizers showed a 33% decrease in general medical care costs and improved physical health. When structured short-term group therapy by a mental
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health specialist was added, additional gains were demonstrated in the capacity to carry out daily tasks and in overall mental health with an added 52% net savings in health care charges.22 Also using a group approach, Miranda and M u n o P used a cognitive-behavioral intervention in a randomized, controlled, intervention study for 150 inner city primary care patients with minor depression. They showed significant symptomatic improvement in depression, decreased somatization, and improved compliance at 6-month and 1-year follow up.34In a carefully designed, prospective, randomized, controlled study of patients in primary care with major depression, Katon et alZ5 found that outcome was better in a model that integrated psychiatric and primary care treatment compared with usual care by the primary care physician. Compliance and patient satisfaction improved; clinical improvement was noted as well. These findings from intervention studies in the outpatient general medical sector complement the results of large-scale epidemiologic studies. The naturalistic epidemiologic studies showed primary care physicians’ treatment of mental disorders to be less effective than treatment rendered by mental health specialists. The prospective, randomized, and controlled intervention studies suggest that positive outcomes are associated with higher-intensity involvement of the psychiatrist within the medical setting, with close collaboration with the primary care physician, and with greater opportunity for direct patient contact.24,25
CONCLUSIONS The data from these epidemiologic and outcome studies bring into focus a pressing need to improve the treatment of mental disorders in the general medical sector. First, they show that mental disorders are more common in the general medical sector-both in hospitals and in the outpatient primary care sector-than in the general population. Second, they are shown to be serious disorders attended by significant, measurable, functional disabilities and impaired quality of life in addition to the personal suffering they cause. These findings hold true for mental disorders that meet standard criteria for diagnosis and for their subsyndromal variants. Third, patients with mental disorders in the general medical sector are high utilizers of medical services resulting in higher health care costs in the hospital and in outpatient primary care. Fourth, they show that in hospitals and in the outpatient sector primary care physicians miss a major proportion of the psychiatric disorders they see. Fifth, patients with mental disorders who are diagnosed and treated by their primary care physicians receive less effective care and have worse outcomes on a variety of measures when compared with treatment outcomes with mental health specialists. Approaches that may address the unmet needs of patients with mental disorders in primary care are suggested by outcome data from intervention studies. The data show that psychiatric treatment interven-
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tions in the general hospital and in the outpatient primary care sector can be clinically effective and cost effective, reduce overuse of general medical services, and in some cases provide cost offset. More recent studies increasingly show that clinical improvement is accompanied by synchronous improvement in function, in quality of life, and in decreases in disability and use of general medical services. Psychiatric intervention programs with successful outcomes share common features whether they are used in the outpatient or inpatient general medical sector. A psychiatric intervention program integrated within a designated health care system increases the likelihood of better outcomes.25A model that has an on-site psychiatrist who, through training, can enhance the skills of the primary care physicians, who can collaborate in screening, diagnosis, and treatment and have direct patient contact where indicated will have demonstrably better outcomes. By comparison, those models that lack an integrated medical-psychiatric collaboration will be less likely to demonstrate significant positive outcomes both in the hospital and in outpatient primary care. All these results point to the need for a more organized and structured collaboration between psychiatrists and primary care physicians to improve the mental health care of patients in the general medical sector. The question is no longer whether an improved collaboration is required to address the unmet needs of patients with mental disorders in the general medical setting, but rather which model of collaboration is most effective in which clinical setting and for which The data from outcome studies have provided some promising suggestions for effective models. These data and those from future studies are likely to be increasingly relied on by clinicians and administrators in their attempts to improve the mental health care of patients in the general medical sector in an economically responsible fashion. ACKNOWLEDGMENTS The author would like to acknowledge the assistance of Barbara Federlein and Jonathan Schor in the preparation of the reference list.
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toward psychiatry, rate of consultation, and psychosocial documentation. Gen Hosp Psychiatry 11:77-87, 1989 51. Scott ATF, Freeman CPL: Edinburgh primary care depression study: Treatment outcome patient satisfaction, and cost after 16 weeks. BMJ 304883-887, 1992 52. Simon G, Ormel J, Von Korff, et al: Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry 152353-357, 1993 53. Smith GR: The course of somatization and its effects on utilization of health care resources. Psychosomatics 35263-267, 1994 54. Smith GR, Monson RA, Ray DC: Psychiatric consultation in somatization disorder. N Engl J Med 344:1407-1413, 1986 55. Smith GR, Rost, Kashner TM: A trial of the effect of a standardized consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 52:238-243, 1995 56. Spitzer RL, Kroenke K, Linzer M, et al: Health-related quality of life in primary care patients with mental disorders. Results from the PRIME-MD 1,000 study. JAMA 274:1511-1517, 1995 57. Spitzer RL, Williams JBW, Kroenke K, et al: Utility of a new procedure for diagnosing mental disorders in primary care: The PRIME-MD 1,000 study. JAMA 27217491756, 1994 58. Steinberg H, Torem M, Saravay SM: An analysis of physician resistance to psychiatric consultations. Arch Gen Psychiatry 371007-1012, 1980 59. Strain JJ, Hammer JS, Fulop G: APM task force report on psychosocial interventions in the general hospital inpatient setting: A review of cost-offset studies. Psychosomatics 35253-262, 1994 60. Strain JJ, Lyons JS, Hammer JS, et al: Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients. Am J Psychiatry 148:8:1044-1049, 1991 61. Sturm R, Wells KB: How can care for depression become more cost effective. JAMA 273~51-58,1995 62. Torem M, Saravay SM, Steinberg H: Psychiatric liaison: Benefits of an "active" approach. Psychosomatics 20:598-611, 1979 63. Von Korff M, Ormel J, Katon W, et al: Disability and depression among high utilizers of health care. Arch Gen Psychiatry 49:91-100, 1992 64. Wells EB, Stewart A, Hays R, et al: The functioning and well-being of depressed patients. Results from the medical outcomes study. JAMA 262:914-919, 1989 65. Wells KB: Depression in general medical settings: Review of three health policy studies for consultation-liaison psychiatry. Psychosomatics 35:279-296, 1994 66. Wells KB, Golding JM, Burnam MA: Psychiatric disorders and limitations in physical functioning in a sample of the Los Angeles general population. Am J Psychiatry 145:712-717, 1988 Address reprint requests to Stephen M. Saravay, MD Consultation-Liaison Psychiatry Long Island Jewish Medical Center 270-05 76th Avenue New Hyde Park, NY 11042
0193-953>(/96 $0.00
+ .20
PSYCHIATRIC INTERVENTIONS IN THE MEDICALLY ILL Outcome and Effectiveness Research Stephen M. Saravay, MD
As managed care and legislative health care reform radically reshape the practice of medicine, increasing scrutiny will be brought to bear on the clinical, economic, and social consequences of these changes. Although data from outcome research have had limited success to date in influencing policy decisions in comparison with economic and other more current compelling forces, the future promises a more rational process of deliberation and decision making. Legislators and administrators are increasingly likely to turn to data from outcome studies to inform their decisions. Most persuasive to them in the area of inpatient consultation-liaison (CL) psychiatry and outpatient primary care will be studies that demonstrate simultaneous positive outcomes in several domains.I9 Outcomes that contain synchronous positive changes in clinical symptomatology, quality of life, levels of functional disability, and use and costs of general medical services, will provide the strongest basis for effecting policy changes. This article reviews the current status and emerging trends of outcome data from research studies of psychiatric and psychosocial interventions for mental disorders in patients in the general medical sector and suggests promising directions for future research. The success of a psychiatric intervention study in the medically ill depends, among other factors, on the premises on which it is based. Cohen-Cole et a17have delineated the criteria for demonstrating the cost From the Consultation-Liaison Psychiatry Service, Department of Psychiatry, Long Island Jewish Medical Center, New Hyde Park; and Albert Einstein College of Medicine, Bronx, New York
THE PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 19 * NUMBER 3 * SEPTEMBER 1996
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effectiveness of interventions. Because the emphasis of outcome research has broadened to include clinical, functional, and quality-of-life mea44, 65 we can update these criteria by paraphrasing them as folsure~,'~, hWS: 1. The target psychiatric disorder should produce measurable clinical symptoms, functional disability, impaired quality of life, and increased medical use and cost. 2. The intervention must result in demonstrable improvement in psychiatric clinical signs and symptoms. 3. Positive outcomes in function, quality of life, use of medical services, and costs should occur concurrent with or following the clinical changes.
The first step according to the above criteria is to demonstrate the impact of psychiatric disorders and their symptoms on quality of life, functional capacity, use of general medical services, and associated costs. Data of this kind have been gathered for medical and surgical inpatients@and for the primary care outpatient population in large-scale 40, 47 and for patients epidemiologic studies of the general population36* in different health care systems.65These data can then be used to develop the design, select the population sample to be studied, and determine outcome measures to be used. IMPACT OF PSYCHIATRIC DISORDERS IN THE GENERAL MEDICAL INPATIENT SECTOR Outcome studies of the impact of psychiatric disorders on length of stay and use of medical resources on general hospital inpatients in the United States and abroad have recently been critically reviewed.43Studies were divided into three categories or generations: (1)first-generation studies were retrospective; (2) second-generation studies were prospective but did not control for potential confounding variables, such as severity of medical illness or physical impairment; and (3) third-generation studies were prospective and controlled for illness severity or impairment in physical functioning and other potentially confounding variables. Of the total of 26 articles, 80% found a significant correlation between psychiatric or psychologic comorbidity and increased length of stay (LOS) in general hospital inpatients. If studies with the smallest sample sizes (below 110) are eliminated (which might have resulted in a type I1 error), then 89% of the remaining studies had significant findings. If we examine the third generation studies, those with the most rigorous methodologic designs, three of four or 75% demonstrated significant associations between psychiatric comorbidity and LOS, and a fifth study currently being prepared for publication by the author and his co-workers has also demonstrated positive findings. Five of the prospective studies also examined how postdischarge course might be affected by psychiatric comorbidity and all found some significant im-
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pact on such measures as rehospitalization, institutionalization, physical outcome, or mortality. The psychiatric factors that these studies focussed on were affective disorder, mainly depression, and cognitive impairment. A variety of populations were studied, some with homogeneous medical diagnoses, such as stroke, acquired immunodeficiency syndrome (AIDS), orthopedic problems, and so forth, and some with heterogeneous medical diagnoses. Some studies sampled all general hospital patients and some examined patients from specialized inpatient units. Eleven studies looked at geriatric patients and 15 examined general adult populations. The authors conclude that whether one relies on the total results derived from all studies or the conclusions derived from the more recent, rigorously controlled, prospective research, impaired cognition and depressed mood and personality variables contribute to prolonged medical hospital stays and greater use of hospital resources and costs. In addition, psychiatric comorbidity identified within the general hospital was found to be associated with greater use of emergency room visits and rehospitalizations up to 4 years after discharge. These studies, although demonstrating an association between psychiatric comorbidity and increased hospital length of stay, imply but do not prove causality. Nor do they elucidate how associated psychiatric illness might complicate or prolong medical treatment. They do not suggest to the prospective researcher which specific psychiatric intervention to select because the processes by which mental disorders may increase hospital LOS have not been systematically studied. Using delirium or cognitive impairment as an example, the authors review the anecdotal literature describing the ways that delirious symptoms and cognitive impairment might extend hospital stays other than as a result of placement problems. Agitated patients after hip fracture repair have dislocated prostheses or had trochanteric separations or induced hematomas at the surgical site. Restrained agitated patients have developed bed sores, pneumonia, myocardial infarctions, and congestive heart failure. Catheterization for urinary incontinence has been associated with secondary urinary tract infections. Cognitive impairment may require capacity evaluations that delay necessary diagnostic tests and procedures and may negatively affect compliance and impair the cooperation required for successful rehabilitation regimens.43 Similar issues have been described for depression occurring in medical patients, especially in the outpatient sector. Depression and anxiety disorder in patients who somatize may increase general medical use through increased inappropriate use of medical diagnostic services. Depressed phobic-anxious patients may delay treatment resulting in a higher level of medical severity at the time of admission. Compliance with treatment regimens may be impaired and worse medical outcomes have been associated with depression and anxiety.45Future research efforts need to assess systematically the processes by which mental disorders in general medical inpatients increase use and extend length of stay.
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RECOGNITION OF PSYCHIATRIC DISORDERS IN THE GENERAL MEDICAL INPATIENT SECTOR
A hospital admission may be a brief but invaluable window of opportunity for mental health professionals to identify and initiate treatmenP2 for a previously unrecognized mental disorder. Unrecognized comorbid psychiatric disorders may adversely affect both the immediate hospital course and the postdischarge prognosis of the patients' medical disorder? alo* 13, l5 and contribute to higher rehospitalization rates and use of outpatient medical services after di~charge.~", 44,45 A major obstacle to such endeavors has been the stubborn fact that most psychiatric disorders in the general hospital are underrecognized and underreferred.12,32, 50, Whereas 30% to 60% of admitted patients have diagnoseable psychiatric only 1%to 3% of admissions are likely to be referred.& An intervention program in the general hospital cannot, therefore, rely on physicians without specific training in the course of their usual general medical practice to recognize and refer appropriate patients to psychiatric intervention programs. Some combination of screening instruments, physician education on site, and psychiatric liaison will, in all likelihood, be needed to recognize and refer appropriate patients to psychiatric intervention programs in a given hospital setting. PSYCHIATRIC INTERVENTION IN THE GENERAL MEDICAL INPATIENT SECTOR
In a review of prospective intervention studies in elderly hip fracture patients, Strain and c o - ~ o r k e r sfound ~ ~ three studies with significant cost savings that reduced length of stay by using some form of active case finding and providing an integrated liaison presence. One of those studies60 demonstrated synchronous changes in decreased LOS, associated cost savings (Table l),and improvement in clinical symptoms. A reduced level of postdischarge medical use showed that not only were costs savings carried forward by the intervention after discharge,
Table 1. SAVINGS FROM INTERVENTIONSTUDIES IN ELDERLY HIP FRACTURE PATIENTS Authors
Year
Savings ($)
Type of Intervention
Boone et alla 1981 53,762 Early comprehensive social work 1981 183,600 Integrated CL model Levitan and K ~ r n f e l d * ~ ~ 1991 166,926 (Mt. Sinai) Integrated CL model Strain et also 97,361 (Northwestern) Data from Strain JJ, Hammer J, Fulop G: APM task force report on psychosocial interventions in the general hospital inpatient setting: A review of cost-offset studies. Psychosomatics 35:253-262,1994.
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but that cost shifting from the inpatient to the outpatient sector was ruled out as a possible explanation for the inpatient savings. By contrast, an intervention study using a consultation model that was guided only by screening, where the CL psychiatrist was not clinically integrated with the referring and treating medical teams, found poor cooperation of the referring physicians, no measurable clinical improvement, and no reduction in inpatient LOS or follow-up outpatient medical use or associated costs savings.27 Using a still different model, Fuller and JordanI4used a specialized team to treat a specific category of psychiatric disorder referred through a screening program. They demonstrated a cost-offset effect using this approach for substance abusers in the general hospital in which more was generated in revenues for clinical interventions than the salary cost of the treatment team. Outcome of clinical symptoms, function, or quality of life factors, however, were not measured. There are four models in which CL interventions can be attempted in the general hospital. 1. Consultation alone 2. Usual consultation guided by screening 3. Integrated or liaison model in which the CL psychiatrist’s role and function is integrated within the treatment team allowing for collaboration in case finding and treatment 4. Specialized team consultation for specific disorders guided by screening
No prospective, randomized, controlled studies to my knowledge have been reported with the consultation-alone model. The absence of such studies may be owing in part to the ethical dilemma inherent in a design that proposes randomly to withhold psychiatric consultations that have been spontaneously requested for recognized clinical problems. Usual consultation guided by screening without liaison integration was ineffective in the study by Levenson et al,27whereas three liaison models (two CL and one social work) showed positive outcomes (see One study of a specialized team approach guided by screening Table l).59 was found to have a cost-offset effect in patients with substance abuse.I4 IMPACT OF PSYCHIATRIC DISORDERS IN THE GENERAL MEDICAL OUTPATIENT SECTOR
In the outpatient sector, large-scale epidemiologic studies of the general population, like the Epidemiologic Catchment Area and of patients in the general medical sector, such as the World Health Organization Collaborative Project on Psychological Problems in General Health Care36,47 and the Rand Corporation Medical Outcomes Study (MOS)164explored the prevalence of psychiatric disorders, their course, and their impact on functional capacity, quality of life, and use of general medical services. Mental disorders were found to be twice as
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common in the outpatient general medical sector than in the general p o p u l a t i ~ nowing ~ ~ , ~ in ~ part to the fact that patients with mental disorders are higher utilizers of general medical services.16, 23 Between one quarter to one third of patients in primary care have a diagnosable mental disorder in the course of a year39,40 and an additional one fifth have transient stress-induced subsyndromal symptoms. Of those who seek help for their mental disorders, more turn to their primary care physicians than seek help from mental health specialist^.^^ Patients with psychiatric disorders were found to have a surprisingly high degree of disability compared with patients with chronic medical conditions in this country and around the world.2,36, 64, 66 Depression, the most common psychiatric disorder in primary care, has been the most extensively studied. Wells' et al" data on depression as part of the MOS studies of the Rand Corporation and those of others33,56 showed that depressed patients had more sick days, days out of work, days confined in bed, and had more impaired social interpersonal and parenting roles compared with patients with most chronic medical illnesses.33,64 These objective findings applied to patients who met Diagnostic Statistical Manual-111-R (DSM-111-R) criteria, as well as a subsyndromal population of patients with depressive symptoms who did not meet full diagnostic criteria. In another study, patients with major depressive disorder compared with patients without mental disorders had five times more days disabled2 and four times more days spent bedridden.66 The disabilities tended to be pervasive and chronic with most persisting in primary care patients at 2-years follow up.17Furthermore, the functional disability has been shown to vary with the severity of the depression in both crosssectionaP and longitudinal studies'O, 33, 37, 63 and successful clinical results that reduce symptomatology also produce positive changes in the associated functional correlates of d e p r e ~ s i o n . ~ ~ Similar relationships were found for other psychiatric disorders 29, 56 social seen in primary care, such as dysthymia,2O,56 panic phobia@and other anxiety disorders,", 56 as well as full somatization 55, 56 Impairments disorder and subsyndromal somatization dis0rde1-s.~~. in quality of life, functional disabilities in social, work, and parenting roles, and a higher use of general medical services accompany the subjective distress suffered by patients with these disorders. The relationship of psychiatric status and disability is significant after controlling for severity of physical disease and for the number of chronic medical condition^.^^ In addition, when mental disorders coexist with medical 4, 15, 23 illness the outcome of the medical disorder may be wor~ened.~, The economic impact of mental disorders in the general medical sector was found to be substantial. Patients with mental disorders were found to use a disproportionate share of general medical services. They have 50% to 100% higher costs from use of general medical services after controlling for degree of medical morbidity.52Major and minor 52; anxiety dis0rders,2~ including panic disordersz9and social depressionz0, phobia49;and somatization disorders53,55 all have higher rates of use.
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When one approaches the problem from the opposite perspective to look at the prevalence of psychiatric disturbance in high utilizers, 50% of high utilizers of health maintenance organization general medical services were found to be psychologically distressed.23 IDENTIFICATION AND COURSE OF MENTAL DISORDERS IN THE OUTPATIENT GENERAL MEDICAL SECTOR
Studies show that despite the high prevalence and morbidity of mental disorders, primary care physicians missed between 33% to 50% of those that they see'8,23 in this country and throughout the The use of a standardized screening instrument by primary care physicians can result in a 30% increase in referrals for mental health specialty treatment.57When primary care physicians undertake the treatment of the mental disorders they do diagnose, they tend to undertreat them relative to established treatment guidelines and clinical practice patterns of mental health specialists.", 61, 65 Outcome studies have shown how patients with mental disorders fared in outpatient primary care settings. Although there had been an earlier series of studies between 1979 and 1985 that demonstrated a cost offset effect of mental health treatment relative to general medical use costs,', 21, 35 the results need to be confirmed by prospective randomized, controlled studies that include outcome measures of psychiatric symptom severity, functional disability, and quality of life. In a paper on depression in primary care Wellsh5analyzed the data bases of three very large health policy studies: (1)the Health Insurance Experiment, (2) the MOS, and (3) the Prospective Payment Systems Quality of Care Study. He found that outcome and quality of care of depressed patients in the outpatient general medical sector was generally poor. When depressed patients relied on primary care doctors, antidepressants were prescribed only 20% of the time and in these cases 40% received subtherapeutic doses of medications. In addition, primary care physicians provided one tenth the number of visits compared with standard mental health specialist treatment. It has also been found that primary care physicians tend not to prescribe medication for a sufficient durationF1 nor provide adequate longer-term monitoring of antidepressant use.52 Treatment of depression by primary care physicians was found to have the worst outcome and lowest costs compared with two kinds of mental health specialist treatments that had the best outcome and highest cost.61The increase in employment earnings as a result of better clinical and functional outcome and decreased disability, however, was found to offset the additional cost of psychiatric treatment providing evidence of an overall cost benefit of mental health treatment. The authors of this study make the point that mental health treatment provides the best result per dollar spent. According to the authors, however,
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in view of economic constraints some combination of enhanced primary care physician skills and better integration of mental health services in diagnosing, triaging, and treating mental disorders in primary care seems warranted.61 These epidemiologic studies in the outpatient primary care sector catalogue the prevalence, clinical severity, and associated functional disabilities and impaired quality of life in patients with mental disorders, and the higher use of medical services and costs. They show how clinical improvement of psychiatric disorders may result in associated improvements in disability levels, quality of life, and also provide economic gains.61 Yet, primary care physicians who treat more of these patients than mental health specialists do not meet the usual standards of care for mental disorders when compared with accepted clinical treatment guidelines or the usual practice of mental health specialists. Outcome studies suggest these differences result in worse clinical and functional outcomes.6l These findings point to a critical imperative for psychiatry and medicine-the improvement of the treatment of mental disorders in outpatient primary ca~e.6~ Providing patients with mental disorders with more mental health specialty care and enhancing the primary care physician's knowledge and experience in diagnosing, triaging, treating, and referring patients with mental disorders is clearly warranted. Successful educational initiatives in this area have been described.6 PSYCHIATRIC INTERVENTION STUDIES IN THE OUTPATIENT GENERAL MEDICAL SECTOR
The solutions to improving mental health primary care treatment may be different in different settings and for different disorders. The problems defined by large-scale epidemiologic studies need to be addressed by effective intervention strategies. Fortunately, there is a body of methodologically sound research on psychiatric interventions for mental disorders in primary care with outcome data that may suggest likely directions to pursue. Katon and Gonzales" reviewed and analyzed outcomes in three generations of psychiatric CL prospective, randomized, controlled intervention studies in outpatient primary care. In their categorization (Table 2), first-generation studies used standardized instruments to screen patients for psychiatric disorder. Identified patients were then randomly referred to their primary care physicians for treatment. Only one study out of seven demonstrated significant differences in the level of patient distress. Second-generation studies also screened for psychiatric disorders, after which the psychiatrist provided the primary care physician with a specific treatment protocol that the latter used. Two studies fell into this category. In one study, health care use and costs of somatizers were
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Table 2. CONSULTATION-LIAISON INTERVENTION IN PRIMARY CARE Type First generation
Design Screen
Second generation Screen Third generation
No. of Studies 7
+ collaborative plan
Screen + collaborative + direct and indirect CL involvement
2 2
% of Studies with Positive Outcomes
14% change in patient distress 50% change in health care use; 50% change in prescribing practice 100% change in patient distress
Data from Katon W, Gonzales JJ: A review of randomized trials of psychiatric consultation-liaison studies in primary care. Psychosomatics 35:268-278,1994.
reduced in the intervention group without clinical impr~vernent.~~ The second, a study of distressed high users of medical carez6found increased use of psychotropic drugs by primary care physicians in the intervention group, but no change in health care use or patient distress was observed. Third-generation studies, in addition to prospective screening, provided higher intensity interventions by mental health specialists compared with the second-generation studies. The two studies completed at the time of the review5,51 demonstrated significantly reduced psychological distress in the experimental groups compared with the patients receiving usual treatment by the primary care physician. The authors conclude that positive outcomes from psychiatric intervention programs are more likely when the CL psychiatrist’s efforts are more integrated with those of the primary care physician and include more direct involvement with the patient. Five subsequent reports expand on these conclusions. Three recent papers of patients with somatization disorder and subsyndromal somatization patients amplify and expand on Smith et a l ’ original ~ ~ ~ study.22* 41, 55 For patients with somatization disorder, a second-generation design was again used. Seventy patients with somatization disorder were randomized to experimental and control groups. The intervention consisted of a letter outlining the diagnosis and recommended treatment plan for the patients with a description of somatization disorder, its course, low physical morbidity, and mortality. The treatment plan consisted of scheduled brief appointments every 4 to 6 weeks with brief concentration on the physical complaints, avoidance of tests and procedures unless clearly indicated, and instructions to avoid telling patients “it’s all in your heads.” Results showed improved mental health measures over 12 months, a decrease of 45% in medical costs owing to decreased hospitalizations, and an improvement in capacity to carry out everyday tasks. Smith et a155using the same approach for subsyndromal somatizers showed a 33% decrease in general medical care costs and improved physical health. When structured short-term group therapy by a mental
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health specialist was added, additional gains were demonstrated in the capacity to carry out daily tasks and in overall mental health with an added 52% net savings in health care charges.22 Also using a group approach, Miranda and M u n o P used a cognitive-behavioral intervention in a randomized, controlled, intervention study for 150 inner city primary care patients with minor depression. They showed significant symptomatic improvement in depression, decreased somatization, and improved compliance at 6-month and 1-year follow up.34In a carefully designed, prospective, randomized, controlled study of patients in primary care with major depression, Katon et alZ5 found that outcome was better in a model that integrated psychiatric and primary care treatment compared with usual care by the primary care physician. Compliance and patient satisfaction improved; clinical improvement was noted as well. These findings from intervention studies in the outpatient general medical sector complement the results of large-scale epidemiologic studies. The naturalistic epidemiologic studies showed primary care physicians’ treatment of mental disorders to be less effective than treatment rendered by mental health specialists. The prospective, randomized, and controlled intervention studies suggest that positive outcomes are associated with higher-intensity involvement of the psychiatrist within the medical setting, with close collaboration with the primary care physician, and with greater opportunity for direct patient contact.24,25
CONCLUSIONS The data from these epidemiologic and outcome studies bring into focus a pressing need to improve the treatment of mental disorders in the general medical sector. First, they show that mental disorders are more common in the general medical sector-both in hospitals and in the outpatient primary care sector-than in the general population. Second, they are shown to be serious disorders attended by significant, measurable, functional disabilities and impaired quality of life in addition to the personal suffering they cause. These findings hold true for mental disorders that meet standard criteria for diagnosis and for their subsyndromal variants. Third, patients with mental disorders in the general medical sector are high utilizers of medical services resulting in higher health care costs in the hospital and in outpatient primary care. Fourth, they show that in hospitals and in the outpatient sector primary care physicians miss a major proportion of the psychiatric disorders they see. Fifth, patients with mental disorders who are diagnosed and treated by their primary care physicians receive less effective care and have worse outcomes on a variety of measures when compared with treatment outcomes with mental health specialists. Approaches that may address the unmet needs of patients with mental disorders in primary care are suggested by outcome data from intervention studies. The data show that psychiatric treatment interven-
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tions in the general hospital and in the outpatient primary care sector can be clinically effective and cost effective, reduce overuse of general medical services, and in some cases provide cost offset. More recent studies increasingly show that clinical improvement is accompanied by synchronous improvement in function, in quality of life, and in decreases in disability and use of general medical services. Psychiatric intervention programs with successful outcomes share common features whether they are used in the outpatient or inpatient general medical sector. A psychiatric intervention program integrated within a designated health care system increases the likelihood of better outcomes.25A model that has an on-site psychiatrist who, through training, can enhance the skills of the primary care physicians, who can collaborate in screening, diagnosis, and treatment and have direct patient contact where indicated will have demonstrably better outcomes. By comparison, those models that lack an integrated medical-psychiatric collaboration will be less likely to demonstrate significant positive outcomes both in the hospital and in outpatient primary care. All these results point to the need for a more organized and structured collaboration between psychiatrists and primary care physicians to improve the mental health care of patients in the general medical sector. The question is no longer whether an improved collaboration is required to address the unmet needs of patients with mental disorders in the general medical setting, but rather which model of collaboration is most effective in which clinical setting and for which The data from outcome studies have provided some promising suggestions for effective models. These data and those from future studies are likely to be increasingly relied on by clinicians and administrators in their attempts to improve the mental health care of patients in the general medical sector in an economically responsible fashion. ACKNOWLEDGMENTS The author would like to acknowledge the assistance of Barbara Federlein and Jonathan Schor in the preparation of the reference list.
References 1. Borus JF, Olendzki MC, Kessler L, et al: The “offset effect” of mental health treatment on ambulatory medical care utilization and charges. Arch Gen Psychiatry 42573580, 1985 la. Boone CR, Coulton CJ, Keller SM: The impact of early and comprehensive social work services on length of stay. SOCWork Health Care 71-9, 1981 2. Broadhead WE, Blazer DG, George LK, et al: Depression, disability days, and days lost from work in a prospective epidemiologic survey. JAMA 2642524-2528, 1990 3. Bruce ML, Leaf PJ, Rozal GPM, et al: Psychiatric status and 9-year mortality data in the New Haven epidemiologic catchment care study. Am J Psychiatry 151:5, 1994 4. Carney RM, Freedland KE, Jaffe AS: Insomnia and depression prior to myocardial infarction. Psychosom Med 52:603409, 1990
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5. Catalan J, Gath DH, Anastiades P, et al: Evaluation of a brief psychological treatment for emotional disorders in primary care. Psycho1 Med 21:1013-1018,1991 6. Cohen-Cole SA, Boker J, Bird J, et al: Psychiatric education improves internists’ knowledge: A three-year randomized controlled evaluation. Psychosom Med 55:212, 1993 7. Cohen-Cole SA, Howell EF, Barret JE, et al: Consultation-liaison research: Four selected topics. In Judd FK, Burrows GD, Lipsitt DR (eds): Handbook of Studies on General Hospital Psychiatry. New York, Elsevier BV (Biomedical Division), 1991, pp 79-98 8. Dalack GW, Roose SP: Perspectives on the relationship between cardiovascular disease and affective disorder. J Clin Psychiatry 5l(suppl 7):4-9, 1990 9. Depression Guideline Panel: Depression in Primary Care, vol 1. Detection and Diagnosis. Clinical Practice Guideline, Number 5. Rockville, MD, US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 93-0550, 1993 10. Depression Guideline Panel: Depression in Primary Care, vol 2. Treatment of Major Depression. Clinical Practice Guideline Number 5. Rockville, MD, US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Pub. No. 93-0551, 1993 11. Fifer SK, Mathias SD, Patrick DL, et al: Untreated anxiety among adult primary care patients in a health maintenance organization. Arch Gen Psychiatry 51:740-750,1994 12. Francis J, Martin D, Kapoor WN: A prospective study of delirium in hospitalized elderly. JAMA 2631097-1101, 1990 13. Frasure-Smith N, Lesperance F, Talajic M: Depression following myocardial infarction: Impact on 6 month survival. JAMA 270:1819-1825, 1993 14. Fuller MG, Jordan M L The Substance Abuse Team. Addressing the problem of hospitalized substance abusers. Gen Hosp Psychiatry 16:73-77, 1994 15. Goodnick PJ, Henry JH, Buki VMV: Treatment of depression in patients with diabetes mellitus. J Clin Psychiatry 56:128-136, 1995 16. Hankin J, Oktay JS Mental disorder and primary medical care. An analytic review of the literature. In NIMH Series D, No. 7, DHEW Pub. No. (ADM) 78461, Rockville, MD, Government Printing Office, 1979 17. Hays RD, Wells KB, Sherboume CD, et al: Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. Arch Gen Psychiatry 5211-19, 1995 18. Higgins E S A review of unrecognized mental illness in primary care: Prevalence, natural history, and efforts to change the course. Arch Fam Med 3:908-917, 1994 19. Hill DR, Kelleher K, Shumaker SA: Psychosocial interventions in adult patients with coronary heart disease and cancer: A literature review. Gen Hosp Psychiatry 14S28%42S, 1992 20. Howland RH: General health, health care utilization and medical comorbidity in dysthymia. Int J Psychiatry Med 23211-238,1993 21. Jones KR, Vischi RT Impact of alcohol, drug abuse and mental health treatment on medical care utilization: A review of the research literature. Med Care 17(suppl):l82, 1979 22. Kashner MT, Rost K, Cohen B, et al: Enhancing the health of somatization disorder patients: Effectiveness of short-term group therapy. Psychosomatics 36:462470, 1995 23. Katon W Panic disorder in the medical setting. National Institute of Mental Health (DHHS Pub. No. ADM-89-1629), Washington, DC, US Government Printing Office, 1989 24. Katon W, Gonzales J: A review of randomized trials of psychiatric consultationliaison studies in primary care. Psychosomatics 35268-278, 1994 25. Katon W, Von Korff M, Lin E, et a1 Collaborative management to achieve treatment guidelines: Impact on depression in primary care. JAMA 273:1026-1031,1995 26. Katon W, Von Korff M, Lin EH, et al: A randomized trial of psychiatric consultation with distressed high-utilizers. Gen Hosp Psychiatry 14:86-98, 1992 27. Levenson JL, Hamer RM, Rossiter LF A randomized controlled trial of psychiatric
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