A randomized trial of psychiatric consultation with distressed high utilizers

Psychiatry and Primary Care Editor: Wayne J. Katon, M.D. Recent epidemiologic studies have found that most patients with mental illness are seen exclusively in primary care medicine. These patients often present with medically unexplained somatic symptoms and utilize at least twice as many health care visits as controls. There has been an exponential growth in studies in this interface between primary care and psychiatry in the last 10 years. This special section, edited by Wayne J. Katon, M.D., will publish informative research articles that address primary care-psychiatric issues.

A Randomized Trial of Psychiatric Consultation with Distressed High Utilizers Wayne Katon, M.D., Michael Von Korff, Sc.D., Elizabeth Lin, M.D., M.P.H., Terry Bush, Ph.D., Joan Russo, Ph.D., Patricia Lipscomb, M.D., and Edward Wagner, M.D., M.P.H.

This study reports the results of a randomized trial of a psychiatric consultation intervention with distressed, high utilizing patients of 18 physicians in two primary care clinics. Psychiatric consultation was associated with a significant increase in the use of antidepressants in intervention patients compared with controls in thefirst 6 months after intervention. lnfervenfion patients were also significantly more likely to continue antidepressant treatment than control patients. The primary care physicians receiving psychiatric consultations increased the rate of prescribing antidepressant medications in their practice from 32 prescriptions filled per 1,000 visits before their participation in four consultations to 44 new prescriptions per 2,000 visits in the 12-month period after. There were no significant differences between intervention patients and controls at 6 and 22 months after randomization in psychiatric distress, functional disability, or utilization of health care Cambulafory visits, radiographic and laboratory testing services, admissions to inpatient medical care). Abstract:

From the Department of Psychiatry and Behavioral Sciences University of Washington School of Medicine (WK, JR, PL) and the Center for Health Studies, Group Health Cooperative of Puget Sound (MVK, EL, TB, EW), Seattle, Washington. Address reprint requests to: Wayne Katon, M.D., Department of Psychiatry and Behavioral Sciences, RF-IO, University of Washington, Seattle, WA 98195.

86 ISSN 0163-8343/92/$5.00

Introduction Several large epidemiologic studies have documented high prevalence rates of depressive, anxiety, and substance abuse disorders in the general community in the United States [1,2]. Only a minority of people with these illnesses were shown to be receiving appropriate, accepted treatments [3-51. Patients with depression, anxiety, and substance abuse disorders are more prevalent in primary care practices than in community samples [68]. Further, the common mental disorders of primary care patients have been shown to be associated with 1) a variety of chronic physical diseases and medically unexplained somatic symptoms [911], 2) less favorable global perceptions of health status, 3) significant functional disability [12], and increased utilization rates of health care services [4,51. Despite the high prevalence of mental illness in primary care patients, multiple studies have determined that one-third to one-half of these patients are not accurately diagnosed [7,8,13,14]. These findings have prompted studies in which distress or depression scales were provided to primary care physicians on a randomized basis [1520] on the supposition that improved physician recGeneral Hospital Psychiatry 14,86-98, 1992 0 1992 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010

Randomized Trial of Psychiatric Consultation

ognition of psychological distress would lead to improved diagnosis and treatment. These studies have shown mixed results in terms of increasing accuracy of diagnosis and providing improved mental health treatments to primary care patients, and no study has demonstrated unambiguous positive patient benefits [15-201. A major methodologic critique of these studies is that a distress scale may improve recognition of psychosocial distress, but may not help the physician develop a differential diagnosis and specific treatment plan. A logical next step to improve recognition and treatment of mental illness in primary care is the provision of services to assist the primary care physician in formulating a differential diagnosis and treatment plan. Psychiatric consultation-liaison is a potentially cost-effective method of providing primary care physicians with the knowledge and skills to carry out these three essential steps to improving mental health treatment: 1) increasing the primary care physician’s awareness of psychiatric and social factors in medical utilization and disability, 2) differential diagnosis, and 3) effective treatment protocols. Psychiatric consultation-liaison includes psychiatric evaluation of medical patients within the primary care setting, clinical feedback of specific DSM-III-R diagnosis and psychosocial factors to the primary physician, provision of a pragmatic treatment plan, and ongoing monitoring of patient management. A logical subset of patients on which to focus such a primary care intervention are distressed high utilizers of primary care. Prior research has demonstrated that a small group of primary care patients utilize a disproportionate share of all contacts with health providers relative to their numbers in the population and have a high rate of psychological distress. In a recent analysis at Group Health Cooperative in Seattle, we estimated that the 15% highest cost patients accounted for 64% of total health care costs, whereas the 50% lowest cost patients accounted for only 9.5% of total costs. Thus, it would be difficult to achieve a meaningful “cost offset” effect on total health care costs via psychiatric intervention unless the intervention benefited psychiatrically impaired high utilizers of health care. There has been relatively little controlled research testing the effectiveness of the psychiatric consultation-liaison model in primary care [21]. In one study, Smith et al. [22] identified patients meeting DSM-III criteria for somatization disorder-high utilizing patients with diffuse, medically

unexplained physical symptoms. They forwarded a psychiatric consultation report to their primary care physicians on a randomized basis, explained the diagnosis, and suggested conservative use of medical resources based on objective findings rather than symptom complaints. Provision of a consultation report, in the form of a letter, was associated with reduced health care utilization and costs without worsening the patient’s clinical status or satisfaction with care. The results of that experiment raised issues for further research: whether 1) effects of psychiatric consultation on utilization could be replicated for a broader spectrum of high utilizing patients; 2) psychiatric consultation might improve the patient’s psychiatric and functional status; and 3) consultation might change the psychiatric practice patterns of primary care physicians. The major hypothesis addressed by the current study held that improving physician awareness of psychosocial factors affecting medical utilization and illness behavior via psychiatric consultation would lead to decreased ambulatory and inpatient utilization, decreased medical testing, decreased patient distress, somatization and disability, and improvement in provision of psychiatric services. To address this hypothesis, we conducted a randomized controlled trial of psychiatric consultation for distressed high utilizers of medical care.

Methods Study Population The setting for this study was two primary care clinics of Group Health Cooperative of Puget Sound (GHC), a health maintenance organization (HMO) serving over 300,000 persons in western Washington State. All 18 eligible physicians in the two clinics agreed to participate in the study. All participating physicians were highly experienced, board-certified family physicians or internists. The target population included patients between the ages of 18 and 75 whose utilization in the prior 12 months placed them in the top 10% of the number of ambulatory health care visits for their agesex group. Those patients with the required number of visits who had been continuously enrolled at GHC for at least 2 years were identified using the computerized visit registration data of GHC. In total, 1790 patients were initially identified as high utilizers. Participating physicians reviewed the list of high utilizers among their enrollees. Phy87

W. Katon et al.

ELIQIBLE

HIGH UTILIZERS N91002 I

+ SCREENED N-767 (76.5

I

DISTRESSED

ANXIETY-DEPRESSION N-267 (34.6 %I

N=392

(51.1 K)

SOMATIZATION N=162 (23.7 %I

ELIGIBLE

Figure 1.

K)

I

PHYSICIANASSESSMENT

FOR RANDOMIZATION

N.161 (23.6

%I

N-339

Study design RANDOMIZATION + BASELINE N-251 (74.0 %I

1 CONTROL

N-127

INTERVENTION

6 MONTH

F-U

. N=122 (96.1

%)

6 MONTH

12 MONTH

F-U

N=116 (92.9

%)

12 MONTH

sicians were asked to exclude patients who were pregnant, not known to the physician, suffering from dementia or psychotic illness, terminally ill or too ill to participate, changing physicians, or terminating GHC enrollment within the next year. Those patients not excluded by the physician were mailed a letter describing the study and were contacted by telephone. Upon telephone contact, patients were excluded from further study for the reasons stated above. Among the 1790 high utilizers, 788 (44.0%) were excluded either by the physician or at telephone contact. Further steps in screening, baseline interview, randomization, intervention, and follow-up for 1002 eligible high utilizers are depicted in Figure 1. Among the eligible high utilizers, a screening questionnaire (SQ) was completed by 767 patients (77%). The SQ included the anxiety, depression, somatization, and vegetative symptom scales of the Symptom Checklist Revised (SCL-R) [23], a checklist of chronic medical conditions and disability 88

GROUP

QROUP

N=124

F-U ’ N=120 (96.6

F-U

N=115 (92.7

%I

K)

scale [24], and self-report utilization and sociodemographic items. Patients became eligible for the intervention phase of the study if they met any of three screen criteria for psychiatric distress: 1) the sum of all item scores in the anxiety and depression scales of the SCL was greater than 13, 2) the sum of the somatization item scores was greater than 9, or 3) the patient’s primary care physician referred him/ her for a psychiatric consultation (at the time the initial list of high utilizers was reviewed). SCL cutoffs were about 1 standard deviation (SD) above the population mean based on published SCL norms and SCL data from a survey of a random sample of 1016 adult GHC enrollees [25]. Among the 767 patients completing the SQ, 392 (51.1%) met one or more of the three screening criteria and were eligible for a baseline interview followed by randomization to intervention or control groups. Fifty-three subjects with positive screening criteria were not eligible for the baseline

Randomized Trial of Psychiatric Consultation

interview and randomization because sample size requirements for the randomized trial had already been satisfied.

Randomization The consent

procedure explained that 1) one-half of all subjects would be assigned by chance to psychiatric intervention and one-half would continue usual care, and 2) the intervention group would participate in an extended visit with its physician in which the physician would be assisted by “a psychiatrist who has been specially trained to help family practitioners understand how illness affects how a person feels emotionally and physically, how illness produces stress in a person’s life, and how stress can worsen physical illness.” Among the 339 subjects eligible for randomization, 251 (74.0%) accepted randomization. Patients accepting randomization did not differ from those who declined in terms of age, gender, marital status, race, household income, SCL-90-R Anxiety or Somatization, or self-rated health status. Patients who accepted the intervention had higher SCL90-R depression scores (0.99 vs 0.78; t = 2.54, p = 0.01); had more visits in the prior year (15.3 vs 13.6, t = 2.08, p = 0.04); had higher disability scores (1.49 vs 1.16, t = 1.92, p = 0.06); and were more likely to have attended college (76.5% vs 59.1%, X = 9.8, p = 0.002). Thus, patients choosing to enter the study were more likely to be depressed and disabled than the distressed high utilizers declining participation. A baseline questionnaire (BQ) was administered in person to all subjects who agreed to participate. Randomization was stratified by physician and blocked so that an equal number of subjects were assigned to intervention and control groups within physician every fourth assignment. Among the 251 subjects randomized, 124 were assigned to the psychiatric intervention and 127 were assigned to a control group. Among the patients assigned to the intervention, 119 (96.0%) completed the in-clinic study examination procedure. Most interventions were completed within 1 month of the date of randomization.

Intervention During the psychiatric examination, the patient first received a l-hour interview in which the National Institute of Mental Health Diagnostic Inter-

view Schedule, Version 3A, (DIS) [26] was administered by one of the two study boardcertified psychiatrists (WK or PL). Both were experienced in administering the DIS to medical patients. Minor changes were made in the DIS panic and generalized anxiety disorder sections in accordance with DSM-III-R criteria [27]. The DIS was also modified to inquire about current symptoms of major depression [28]. Psychiatric diagnoses were made for a current disorder if symptoms were present in the prior month. We also reported lifetime diagnoses. Over the course of the study, 10% of the examinations were completed with both psychiatrists present. The DIS was independently scored by both psychiatrists, and there was complete agreement in psychiatric diagnoses for all but one of these patients. In addition, clinical information about the patient’s most recent life stresses, the family and social support system, current medications, the relationship with the primary care physician, health problems, work history, developmental history, and family history of mental illness were elicited by semistructured interview. After the DIS was completed, the patient received a half-hour interview conducted by the psychiatrist with the primary cure physician present. In this phase of the examination, the psychiatrist reviewed the salient points in the social and developmental history and key aspects of the clinical psychiatric status. After the interview the physicians jointly formulated a treatment plan and negotiated a mutually acceptable course of action with the patient. Typical elements of treatment plans included initiating or adjusting psychopharmacologic treatment, referral to the mental health service, placing the patient on a fixed-interval visit schedule to alter symptom-contingent visit patterns; and conservative use of testing, specialty, and hospital care to work up nonspecific symptoms. We hypothesized that intervention patients would have increased quality of psychiatric care compared with controls as evidenced by increased prescriptions for antidepressants, decreased prescriptions for opiates and benzodiazepines, and increased successful referral to outpatient mental health counseling. The primary care physician was provided with a written psychiatric consultation, a brief written protocol of treatment, and an article on treatment of the specific mental disorder the patient suffered (i.e., major depression [14], panic disorder [29], somatization disorder [30], and alcohol abuse [31]).

W. Katon et al.

Over the course of the study, the study psychiatrists held one conference with each participating physician to review the management of each intervention patient.

Data Intervention and control group patients were interviewed 6 and 12 months after the date of randomization by an interviewer blind to the randomization status. These follow-up interviews had response rates exceeding 90% (see Figure 1). The follow-up interviews included measures of anxiety, depression, somatization [23], and disability [24]. A Physician Review Form (PRF) was completed by the primary care physician for each randomized patient before the intervention and at 6-month follow-up. The PRFs included physician ratings of severity of physical illness, tendency to amplify physiologic sensations, and severity of psychiatric illness. Baseline PRFs were completed by study physicians for 97% of the randomized patients. Use of ambulatory health care, prescription medicines, radiographic and laboratory tests, and in-patient care were measured for the year before and after randomization using automated data of the HMO.

Data Analyses Evaluation of differences between intervention and control groups for mental health treatment, psychologic status, and utilization variables was based on comparisons of repeated measures data. For continuous variables (e.g., number of services received), a general linear model repeated measures analysis was used to test intervention effects, with age entered as a covariate and the level of psychologic distress (moderate or severe) as a classification variable. These analyses examined the utilization trends for four time periods: 6-12 months before randomization, O-6 months before randomization, O-6 months after randomization, 6-12 months after randomization. Intervention effects were evaluated by the F-test for the time x group interaction-testing the null hypothesis that the trend lines were parallel. Analysis of transformed (square root and logarithmic) and untransformed utilization data yielded comparable results. In the case of dichotomous treatment and utilization variables (e.g., percent using an antidepressant) the trends were examined, stratified by level 90

of psychiatric distress, over the four time periods. A test statistic was estimated for each time period using a Mantel-Haenszel Chi-square test to evaluate the overall effect. For psychologic status, disability, and self-rated health status, measurements were made at baseline (or screening) 6 months after randomization and 12 months after randomization. The same approach to general linear models described above was used to test intervention-control group differences for the variables measured by interview. The stratified data for key process and outcome variables are presented graphically to permit inspection of trends for intervention and control groups.

Results Baseline Characteristics The sociodemographic profile of the distressed high utilizers who accepted randomization is shown for the intervention and control groups in Table 1. Most were under the age of 65 because utilization norms used in selecting high utilizers were age and sex specific. The intervention group was somewhat younger than the, control group (i = 2.25, p = 0.03), but the two groups were similar on all other sociodemographic variables examined. As shown in Table I, over 40% of these patients rated their health status as fair to poor (compared with 14% of a random sample of GHC adults [2532]. Their physicians agreed with this evaluation: over one-half were rated as having moderate or severe physical health problems. Not shown in Table 1, two-thirds of patients reported one or more chronic disorders (e.g., hypertension, asthma, diabetes). Mean rates of disability were high: the study patients reported about 14 days in the prior year when they were in bed all or most of the day, and an additional 65 days when they had to cut down on activities because of illness or injury. The distressed high utilizers made an average of about 15 medical visits in the prior year to GHC facilities (compared with an average of about four visits per year for a random sample of adult GHC enrollees) 125, 321. At baseline, the intervention and control groups were balanced on all physical health status, disability, and medical care utilization variables examined. The intervention group had significantly higher mean SCL anxiety and depression scores than the

Randomized

Table

1. Baseline characteristics

of intervention and control groups: randomized distressed high utilizers of medical care Control Intervention (N = 127) (N = 124)

Demographics Mean age (SD) Female (%) College educated (W) Unemployed (%) Earning $15,000 or less (%) Health and mental health status Physician rating of Physical pathology (% moderate-severe) Psychological distress (% marked-severe) (W moderate) Self-rated health status (% fair-poor) SCL anxiety (mean) (SD) SCL depression (mean) (SD) SCL somatization (mean) (SD) Utilization Health care visits/year (mean) (SD)

48.9 (14.1) 60.6 75.6 8.7 29.8

45.1” (12.6) 62.1 77.4 8.9 21.9

Trial of Psychiatric Consultation

Table 2. Comparison of intervention and control groups stratified by severity of anxiety-depression: SCL standard scores, age-sex adjusted Control Severe distress Number of subjects SCL anxiety (mean) (SD) SCL depression (mean) (SD) SCL somatization (mean) (SD)

50.0

54.0

43.5 30.6

40.7 30.6

41.1 0.64

48.4 0.78’

(.61) 0.88 (.65)

(W 1.11” (.77)

0.78

0.81 (.59)

(.53)

15.2 (6.6)

15.4 (8.9)

‘>p< 0.10;“p < 0.05.

controls and thus all subsequent analyses were stratified into two groups: those with scores on a combined anxiety-depression scale of the SCL of 0.75 or greater (severe distress), and those with scores below that threshold (moderate distress). This stratification resulted in the intervention and control groups being balanced on depression, anxiety, and somatization at baseline (Table 2). The DSM-III-R psychiatric diagnoses of distressed high utilizers are reported in Table 3. Over two-thirds had a history of major depression, usually recurrent, with a median of four episodes. Almost one-third of patients had a history of dysthymic disorder and all of these dysthymic patients also had experienced one or more major depressive episodes. Panic disorder, generalized anxiety disorder, and somatization disorder were also common. A tendency toward amplification of

Moderate distress Number of subjects SCL anxiety (mean) (SD) SCL depression (mean) (SD) SCL somatization (mean) (SD)

Intervention

49 1.67 (1.5) 1.60

67 1.67

(0.9) 0.96 (1.1)

(1.4) 1.03 (1.6)

68

-0.19 (0.6) -0.09 (0.6) 0.67 (I.21

(1.2) 1.78

48 -0.15 (0.6) - 0.07 (0.6) 0.80 (1.1)

symptoms was also suggested by intervention patients reporting a mean of 8.7 (5.6 SD) medically unexplained somatic symptoms on the 37-item somatization disorder section of the DE.

intervention

Effects: Psychiatric Treatments

In a Mantel-Haenszel analysis stratified by use of mental health services in the year before randomization, the consultation was not associated with a significant increase in the utilization of the mental health service of the HMO by intervention patients relative to controls (X2 = 2.28, p = 0.13) in the 6and 12-month periods postrandomization. There was a significant increase in the percentage of patients filling a prescription for an antidepressant medication in the first 6-month period postrandomization (see Figure 2, X2 = 6.30, p = 0.01). The difference was 38.3% vs 25.3% in the moderate distress group, and 50.0% vs 31.4% in the severe distress group. Although the severe distress group had much higher levels of depression than the moderate distress group, there was little difference in the rates of antidepressant use by level of distress among the control group subjects. The percentages filling a prescription for antidepressant medications remained higher in the intervention group than in the controls in the second 6-month period postrandomization as well, but

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W. Katon et al.

We also examined whether intervention patients were more likely to utilize antidepressant medications for a sufficient period of time to experience therapeutic benefit. Nine percent of controls and 8% of intervention subjects filled only one prescription for antidepressants in the year after intervention. However, in the first 6-month period postintervention, the intervention group patients were significantly more likely to fill three or more antidepressant prescriptions (25.6% vs 15.6%, p = 3.7, p = 0.05). This difference was sustained in the second 6-month period as well (24.1% vs 13.5%, X2 = 4.3, p = 0.04). These results suggest that the psychiatric consultation resulted in increased adherence to antidepressant medications by intervention patients. We examined whether a physician training effect may have occurred by examining the trends in the number of new prescriptions written for antidepressant medications for all patients seen by the participating physicians. A new prescription is one written for an adult patient with no prescription for the same medication in the prior year. We compared the study physicians to nonstudy physicians from another GHC clinic not participating in this research. A priori, we set the date of the fourth consultation as the point in time at which we would expect to begin to observe a training effect. In the

Table 3. DSM-III mental disorder diagnoses: intervention subjects only Major depression Current Lifetime (including current) Dysthymic disorder Current Lifetime Somatization disorder Panic disorder Current Lifetime (including current) Generalized anxiety disorder Current Lifetime Alcohol abuse and dependence Current Lifetime None of the above Current Lifetime

Percent

(N)

23.5 68.1

(28) (81)

16.8 38.0 20.2

(20)

11.8 21.8

(14) (26)

21.8 40.3

(26)

(32) (24)

(48)

5.0 24.3

(29)

47.9 16.7

(57) (20)

(6)

these differences were no longer statistically significant. The psychiatrists noted in their consultations that 47% (N = 56) of the intervention group subjects were in need of antidepressant medications. Eighty-four percent of these patients filled a prescription for an antidepressant medication in the year after randomization compared with 45% (N = 25) in the year before randomization.

Figure 2. Filled antidepressant Rx-6 months (%)

+

60%

INTERVENTION

*CONTROL

MODERATE DISTRESS

SEVERE DISTRESS

;O%: L 40% 30% 20%

;:c::: 10% -

0%’

I

BEFORE

92

I

I

I

AFTER

I

I

BEFORE

I

I

I

AFTER

Randomized

prescriptions Table 4. New antidepressant filled/l,000 visits: study physicians participating in four or more consultations compared with nonstudy physicians 18 Months before consultations Study physicians Rxil,OOO visits (AI visits)

12 Months after consultations

tided with participation sultations.

Intervention

p-value” co.01

32 (47,182)

(32:73)

Nonstudy physicians Rx/l,000 visits (N visits)

NS (39::74)

“Based on Poisson t-test

18 months prior to this date, the study physicians wrote 32 prescriptions (that were filled) for antidepressant medications for every 1,000 visits provided to adult patients (Table 4). This ratio increased to 44/1,000 visits during the 12 months after the date of the fourth consultation. This difference was statistically significant as assessed by a Poisson test (t = 7.94, p < 0.001). For the nonstudy physicians, an index date was selected which was at the midpoint of the interval of the dates for the study physicians. The nonstudy physicians wrote 39 antidepressant prescriptions for every 1,000 visits in the before period and 41/1,000 in the after period, a difference that was not statistically significant. When monthly trends in prescribing rates were examined, the change in antidepressant prescribing rates among study physicians coin-

Figure 3. Trends

in SCL depression

Trial of Psychiatric

and somatization

Consultation

in the psychiatric

con-

Effects: Patient Oufcomes

Next, we examined whether provision of a psychiatric consultation was associated with differences in psychiatric status, self-rated health, or disability at 6- and 12-month follow-up. Controlling for age, the time by group interaction revealed no significant differences between the intervention and control groups in level of SCL depression (F = 0.85, p = 0.43) or anxiety measures (F = 0.41, p = 0.66) at 6- or 12-month follow-up. Figure 3 shows the trends in SCL depression and somatization scores. Both intervention and control patients had a significant decrease at 6 and 12 months for SCL depression and SCL anxiety. No consistent differences between the intervention and control groups were found in disability (F = 2.49, p = 0.08) or self-rated health status (F = 2.21, p = 0.11) at follow-up. Similarly, there were no consistently significant differences in any of the following utilization measures between the two groups: primary care (F = 2.12, p = 0.097) and medical specialty visits (F = 2.21, p = O.lll), radiography (F = 0.62, p = 0.61) and laboratory testing services (F = 2.34, p = 0.072), and admission to inpatient medical care (F = 1.72, p = 0.16). Primary care visits for intervention patients included the consultation visit. Utilization rates that approached statistical significance generally showed higher rates in the intervention group. Despite the fact that patients were stratified by baseline level of distress, the observed trends may have been due to residual group differences in overall health status.

scores SCL Depression

(Standard

SCL Somatization

Scores) 2

Pop”l.,lon

Scores)

-rk- INTERVENTION

-@ CONTROL

SEVERE DISTRESS

1.6

0

(Standard

MODERATE DISTRESS

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=

wi -0.5

’ 3:

SMO

12 MO

YE

S MO

32 MO

93

W. Katon et al.

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YonthS

(Mean)

4 Medical

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Monlho

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0;

INTERVENTION

+

CONTROL

SEVERE DISTRESS

S3

MODERATE DISTRESS

I

0' BEFORE

AFTER

BEFORE

AFTER

Mean rates of ambulatory visits are shown for two 6-month periods before randomization and two 6-month periods after randomization (Figure 4) (the utilization rates are not annualized). There was a significant decline in total ambulatory medical visit rates over the follow-up period for both groups (log transformed total visits F = 4.03, p = 0.007), but the rate of ambulatory visits was still well above the population norms. Utilization of inpatient and testing services remained high during the l-year follow-up period, suggesting that high utilization among distressed high utilizers is not an entirely transient phenomenon.

Discussion A large body of research has now shown that common mental disorders of primary care patients are often unidentified or receive less than optimal therapy [13,14,29,30,33,34]; have important health consequences in terms of suffering and disability [14,29,30,33]; and are associated with chronic, medically unexplained symptoms [ 10, 11,14,29, 30,341, chronic disease [9,10,12,14], high utilization of health care, and high health care costs [4,5,11,12,14,29,30]. Innovative changes in delivery of mental health services in primary care are needed to address these problems. The major objectives of this experiment were to focus on psychiatrically impaired high utilizers of health care and to evaluate the effects psychiatric consultation services might have in terms of 1) changing psychiatric treatment practices of primary care physicians, 2) improving the psychiatric status of distressed high utilizers, and 3) bringing about a more effective and less costly pattern of health care for these patients. In each instance, our results suggest that simple solutions may not be at hand. 94

0’ BEFORE

Figure 4.

AFTER

EEFORE

AFTER

Mean rates of ambulatoryvisits

The consultation interventions placed major emphasis on assisting the primary care physicians in identifying and treating patients who were likely to benefit from pharmacologic treatment of depression and anxiety. From a public health perspective, improved delivery of antidepressants is generally regarded as potentially one of the most costeffective ways of improving the psychiatric status of primary care patients [5,14,29,33]. Our results focused on antidepressants because over twothirds of distressed high utilizers had recurrent major depression, which has been shown to be most effectively treated with aggressive antidepressant therapy. Also, less than 5% of distressed high utilizers were treated with benzodiazepines or opiates prior to consultation. The consultation intervention appeared to increase 1) the percent of intervention patients who used an antidepressant (relative to controls), 2) the percent of intervention patients with longer-term use of antidepressants, and 3) the rate of prescribing antidepressants by the study physicians in their practices overall. Among intervention patients for whom the psychiatric consultant recommended antidepressant therapy, 85% filled a prescription for antidepressant medication. This suggests that patients are willing to initiate antidepressant treatment when it is recommended by their physician with conviction. The study physicians who participated in four or more consultations showed a 38% increase in their rate of prescribing antidepressant medications per visit (3.2% of visits before consultation services were initiated and 4.4% of visits after). These results suggest that the provision of consultation services may be an efficient and clin-

Randomized Trial of Psychiatric Consultation

ically relevant approach to altering psychiatric prescribing patterns of primary care physicians. At the patient level, the pattern of antidepressant use raised issues with significant implications for how pharmacotherapy might be improved in primary care. Of the 56 (47%) intervention patients deemed by the psychiatrist to need an antidepressant medication only about 50% filled three or more prescriptions in the year after intervention and over one-quarter of patients in need of antidepressant treatment either did not fill one prescription or filled only one prescription. Moreover, in the prior year, primary care physicians had prescribed antidepressants in 45% of the intervention patients, yet these patients were still quite distressed at screening. These data suggest that increasing the initiation of antidepressant therapy may be too narrow a focus for efforts to improve mental health treatment in primary care. Informal observations in this study, and data of other research groups, suggest that other aspects of the prescribing of antidepressant medications may be crucial to achieving therapeutic benefit: achieving therapeutic dosage levels [33], improving adherence to medication regimens, improving early identification of relapse so that pharmacotherapy can be re-initiated on a timely basis [35-371, and adjunctive interventions directed at acute and chronic psychologic and social problems [35,36]. Efforts to increase initiation of antidepressant treatment in primary care in the absence of attention to the above may not yield expected benefits for the patients. Future research may need to integrate behavioral and pharmacologic interventions to achieve significant improvements in outcome of primary care services for depression, especially patients with recurrent affective episodes. For instance, educational interventions such as those used in patients with a new diagnosis of diabetes mellitus (38,391 or hypertension [40,41] might help increase patient adherence to treatment. The changes in physician prescribing patterns were not accompanied by identifiable improvement in the psychiatric status of intervention patients relative to controls. Several factors may have contributed to the lack of demonstrable therapeutic benefit of psychiatric consultation for distressed high utilizers of health care: 1) Specific changes in the process of care (e.g., increased delivery of antidepressant medications) affected a minority of intervention group patients, diluting the potential for observing intervention effects. 2) Distressed high

utilizers were often found to have chronic psychologic illness accompanied by diffuse, medically unexplained somatic symptoms and chronic illness behaviors. These characteristics portend reduced likelihood of benefit from pharmacologic and psychotherapeutic intervention [9,30]. 3) Two-thirds of the study patients had one or more chronic physical diseases. Thus, the physician’s ability to attend to psychiatric illness was complicated by coexisting problems in management of physical disease [9,10,42]. Additionally, any improvement in psychologic status may be overshadowed by the multiplicity of distress from chronic physical disorders. 4) Educational effects of the consultation interventions on physicians may have generalized to their practice as a whole, affording some benefit to control patients, as evidenced by the increased number of tricyclic antidepressant prescriptions for the overall practice of intervention physicians. Our impression was that the chronicity of medical and psychiatric problems of distressed high utilizers, and the small magnitude of change in the process of care resulting from one psychiatric consultation, were the most significant factors undermining the potential for intervention effects on psychiatric status, health perceptions, and disability. The chronicity of psychiatric illness among distressed high utilizers deserves special comment. Because high utilizers consume one-third to onehalf of all primary care services and one-half are psychologically distressed, distressed high utilizers represent a large component of the primary care physician’s practice experience. Most of the study patients had a history of recurrent major depressive illness, accompanied by diffuse, medically unexplained physical symptoms. Although many of these patients were between episodes of major depression when examined and didn’t meet diagnostic criteria for a current major depression, many evidenced high levels of depressive symptoms at the time of examination. This ongoing depression often appeared to be a stable trait of these patients rather than an acute psychologic illness that could be expected to respond to either short-term pharmaco- or psychotherapies feasible in primary care. Most teaching of primary care physicians about depression emphasizes acute treatment strategies. However, for the distressed high utilizers in this study, major depression was usually a relapsing-remitting illness with persistent manifestations (e.g., insomnia and fatigue, dysthymic disorder, chronic pain, decreased selfconfidence, reduced vocational and social role per95

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formance) that remained after the subsidence of acute major depressive episodes. Many also showed characteristics associated with poor prognosis for psychotherapeutic treatments, that is, chronic medical illness [9,35], double depression (chronic dysthymic disorder and major depression) [37], and somatization disorder [30]. We believe that prior research reporting low recognition and management rates for depressed primary care patients may need to be reevaluated, taking into account both the diagnostic and prognostic status of the depressed patients identified. Clinical research is needed that evaluates methods of managing chronic affective illness below the threshold of DSM-III-R criteria for major depression; that research should be practical for use with primary care patients with (and without) co-existing physical disease [7,43]. Finally, the psychiatric consultation, consisting mainly of a single in-depth evaluation session accompanied by written treatment protocols to be carried out by the primary care physician, did not reduce health care utilization or costs over a l-year follow-up period. We hypothesized that more accurate psychosocial diagnosis and formulation of a plan of management with a psychiatrist might decrease utilization of testing services, specialty care, and inpatient care. Utilization of ambulatory services decreased from the prestudy to the poststudy period for both intervention and control patients, as might be expected due to the phenomenon of regression to the mean. But overall utilization rates remained high for both intervention and control patients. There were no differences in utilization rates for ambulatory, testing, or inpatient services comparing both patient groups. We believe there are several possible explanations for these results: 1) Chronic medical conditions of distressed highutilizers were more substantial than expected. 2) Practice patterns of the HMO physicians participating in this research were conservative at baseline compared with fee-for-service physicians [44], reducing the potential for reductions in unwarranted testing, inpatient care, and specialty care. 3) The psychiatric and dysfunctional illness problem (e.g., chronic pain) of these patients had become chronic and typically progressed to an advanced stage. Strategies for multimodal treatment as used in pain clinics (e.g., behavioral management, tapering habituating medicines) may be necessary for high utilizing patients with chronic psychosocial problems. In conclusion, the single-session psychiatric con96

sultation intervention increased the physician rates of antidepressant prescribing (both in intervention patients and the physician’s overall clinic), but did not decrease utilization or result in significant improvement in psychiatric status in distressed high users of health care services. However, we believe that attention to psychiatric and behavioral strategies of managing psychiatric illness and associated dysfunctional illness behaviors remains an important area for future research. Both the primary care physicians and the psychiatric consultants believed that psychiatric and behavioral factors made an important contribution to the patterns of health care utilization of these patients [45]. Clinically, it appeared that psychiatrically ill patients with coexisting chronic physical disease presented great difficulties to primary care physicians in management of physical, psychiatric, and dysfunctional illness behaviors. Special thanks to Ms. Ellie Polk for her invaluable role in carrying out this project and to Dr. Bill Barlow for biostatistical assistance. Dr. Michael Stuart provided helpful critique. This project was made possible by the enthusiastic participation of the following physicians: Gregory 1. Allen, Michael D. Evans, john G. Geyman, Fred E. Heidrich, Arthur C. Israel, Ann L. McKee, William F. Stanley, Sara D. Thompson, Michael 1. Wanderer, Kathleen G. Boulware, Allen L. Fine, Geraldine A. Hashisaki, Michael A. Howard, Muriel E. fones, Peter S. Seyl, Janice G. Suyehira, Frank 1. Tubridy, and Charles L. Wischman. This study was supported by Grant MH41739-03 from the National Institute of Mental Health, Rockville, Md.

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