Research Original Investigation
The MOSAIC Randomized Controlled Trial
Invited Commentary
An Innovative or Disconcerting Approach to the Psychosocial Care of Your Patient With a Cardiac Condition Are You a Lumper or a Splitter? Karina W. Davidson, PhD; Ian M. Kronish, MD, MPH; Jonathan A. Shaffer, PhD
“Lumpers” and “splitters” were terms originally used to describe scientists who applied centripetal or centrifugal forces, respectively, to the evolving species taxonomy and other nosology debates in the 1800s. The first use of these 2 terms is attributed to Charles DarRelated article page 927 win: “Those who make many species are the ‘splitters,’ and those who make few are the ‘lumpers.’”1(p463) Indeed, evidence from cognitive science suggests that we have individual differences in the way we view information2; some of us process information in a way that leads us to perceive the “whole,” or similarities, in our research, practice, and teaching, whereas others of us process information in a way that leads us to perceive the “parts,” or the distinctions that can inevitably be found. These opposing information-processing and general tendencies are playing out in our approach to entities as different as the medical care that we provide, the medical reimbursement system under which we practice, and the types of research designs, questions, and approaches that we use in our science. For example, the Affordable Care Act seeks to promote the “lumper-friendly” Primary Care Medical Home in which it is intended that 1 team of clinicians will deliver comprehensive care for multiple chronic diseases, conditions, and symptoms rather than split this care among a disparate group of specialists across different health systems. Yet, at the same time, we continue to see “splitting” tendencies in medical care, as subspecialties continue to flourish,3 and the frequency and proportion of medical care that arises from referrals continues to escalate.4 Whereas there may be a normal distribution of lumping to splitting tendencies in the general population, scientists tend as a group to be splitters (as a gross stereotype). The impact of this splitting tendency on the research questions that scientists find interesting and the research designs that they accept as rigorous and worthy of funding is interesting to contemplate. It is also interesting to contemplate how lumpers (think “generalists” here) might view the usefulness and importance of research findings created and funded by splitters. Depending on the manner in which you characteristically process information, you are going to either be enchanted with or have grave concerns about one of the randomized clinical trials reported in this issue of JAMA Internal Medicine.5 In a single-blind, randomized clinical trial of 183 patients hospitalized for acute coronary syndrome, heart failure, or arrhythmia and with symptoms of depression, generalized anxiety, or panic, Huffman and colleagues5 tested whether telephone-based collaborative mental health care treatment, delivered by a social worker and a team of psychiatrists, could 936
improve mental and physical health across 6 months of treatment compared with usual care. They found statistically and clinically significant improvements in mental health–related quality of life—the trial’s primary outcome. Patients who received the treatment also experienced significant improvements in depressive symptoms, physical health–related quality of life, self-reported medication adherence, and functional capacity; improvements in anxiety symptoms or cardiac readmissions were not observed. Strengths of this trial include the low-cost, low-intensity nature of the intervention, the large effect sizes or improvements observed for multiple end points, and the use of cognitive behavioral therapy workbooks that may facilitate dissemination of this intervention. Limitations include the use of a single social worker to deliver the psychotherapy, the absence of cost data or formal cost-effectiveness analyses, and the use of screening measures to provide probabilistic but not definite diagnoses of clinical depression, anxiety disorders, and panic disorders. Such a trial is unusual for a number of reasons. Scientists rarely think that 1 risk marker, or exposure, operates the same way in different diseases and thus often frown on lumping patients with different diseases together in the absence of a priori analytic plans to statistically determine the appropriateness of such lumping. The authors of this study, however, included patients with different forms of cardiac disease. Similarly, scientists rarely lump different risk markers together— even if they are highly comorbid, as is true of depression and anxiety—into 1 treatment focus. When researchers have sought to do so, as was the case with the creation of the “metabolic syndrome” concept, extensive criticism of such a fusing (or lumping) approach is voiced.6 The authors of this study lumped together patients with symptoms of 3 common mental disorders, each of which has been associated with excess cardiovascular risk. Finally, scientists almost never concurrently test whether a single treatment is effective at reducing the adverse health effects of multiple risk factors. This approach is essentially what Huffman and colleagues have attempted. Although cognitive behavioral therapy is an evidence-based intervention for all 3 sets of psychiatric symptoms targeted in this trial, we rarely (if ever) test its effects on multiple conditions concurrently. Finally, to complete their coup d’état of a lumping exercise, Huffman and colleagues employed a generalist social worker with minimal cognitive behavioral therapy training to provide psychotherapy in this trial. It is common in mental health fields to have advanced training in treating only 1 or 2 of the mental conditions targeted in this trial. Of course, most trainees receive basic clinical training in the treatment of all 3, but as in medicine, there has been a distinct split-
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a SUNY Binghamton User on 05/14/2015
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The MOSAIC Randomized Controlled Trial
Original Investigation Research
ting tendency within behavioral health care to specialize in only 1 patient population or treatment modality and to receive referrals for that 1 presenting problem. Now comes the self-reflective quiz part of this commentary. Are you bothered by the indiscriminant lumping of important distinctions that occurred in the design of this trial, such that you cannot conceive of how this study advances either our scientific knowledge or our approach to managing patients? Or, are you impressed by the disruptive thinking imbued in the logic of the trial’s design, and do you believe that this innovative approach to science may open up new avenues for how we combine symptoms, patient groups, treatments, and outcomes, to more holistically treat patients? Your answer to these questions may cause you to pause to reflect on your preferred information-processing style and to examine the ways in which that style influences your approach to science and patient care. If such a pause just occurred, then this commentary has achieved its educational goal. Behavior follows financial incentives, often regardless of intention.7 For decades, our health care system has reinARTICLE INFORMATION Author Affiliations: Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University, New York, New York (Davidson, Kronish, Shaffer); Department of Psychiatry, Columbia University, New York, New York (Davidson, Shaffer). Corresponding Author: Karina W. Davidson, PhD, Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University, 622 W 168th St, PH9 West, Room 314, New York, NY 10032 ([email protected]). Published Online: April 14, 2014. doi:10.1001/jamainternmed.2014.86. Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported by grants HL-115941, HL-084034, and 3R01HL115941-01S1 from the National Heart, Lung, and Blood Institute. Drs Kronish and Shaffer
forced separate systems for rewarding the care of patients, for example, by providing higher reimbursements for time spent performing procedures as compared with counseling patients with complex medical conditions. This approach has contributed to splintered and uncoordinated care. Arguably, this predilection for splitting has been most apparent in the way that physical and mental health care services are reimbursed. As a result of the changes in financing health care in the Affordable Care Act, we may be witnessing a paradigm shift that ripples through not only our health care delivery systems but also our science. Lumping together co-occurring risk factors, conditions, patient groups, and management strategies, particularly when 1 treatment may be an appropriate solution for many problems, may mark a new wave of science that emerges from our changing medical care reimbursement landscape. Ironically, this unintended consequence of a political compromise (the Affordable Care Act) may be a welcome one that leads us to be more efficient in caring for patients facing complex, intertwined problems.
received funding from the National Heart, Lung, and Blood Institute (grants K23 HL-098359 and K23 HL-11285, respectively).
4. Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, 1999-2009. Arch Intern Med. 2012;172(2):163-170.
Role of the Sponsor: The National Heart, Lung, and Blood Institute had no role in the preparation, review, or approval of the manuscript, and the decision to submit the manuscript for publication.
5. Huffman JC, Mastromauro CA, Beach SR, et al. Collaborative care for depression and anxiety disorders in patients with recent cardiac events: the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized clinical trial [published online April 14, 2014]. JAMA Intern Med. doi:10.1001 /jamainternmed.2014.739.
REFERENCES 1. Darwin C. The Life and Letters of Charles Darwin. New York, NY: D Appleton and Co; 1919. 2. Peterson ER, Deary IJ. Examining wholistic–analytic style using preferences in early information processing. Pers Individ Dif. 2006;41 (1):3-14. 3. West CP, Dupras DM. General medicine vs subspecialty career plans among internal medicine residents. JAMA. 2012;308(21):2241-2247.
jamainternalmedicine.com
6. Després JP, Lemieux I. Abdominal obesity and metabolic syndrome. Nature. 2006;444 (7121):881-887. 7. Lynagh MC, Sanson-Fisher RW, Bonevski B. What’s good for the goose is good for the gander: guiding principles for the use of financial incentives in health behaviour change. Int J Behav Med. 2013; 20(1):114-120.
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a SUNY Binghamton User on 05/14/2015
937
The MOSAIC Randomized Controlled Trial
Invited Commentary
An Innovative or Disconcerting Approach to the Psychosocial Care of Your Patient With a Cardiac Condition Are You a Lumper or a Splitter? Karina W. Davidson, PhD; Ian M. Kronish, MD, MPH; Jonathan A. Shaffer, PhD
“Lumpers” and “splitters” were terms originally used to describe scientists who applied centripetal or centrifugal forces, respectively, to the evolving species taxonomy and other nosology debates in the 1800s. The first use of these 2 terms is attributed to Charles DarRelated article page 927 win: “Those who make many species are the ‘splitters,’ and those who make few are the ‘lumpers.’”1(p463) Indeed, evidence from cognitive science suggests that we have individual differences in the way we view information2; some of us process information in a way that leads us to perceive the “whole,” or similarities, in our research, practice, and teaching, whereas others of us process information in a way that leads us to perceive the “parts,” or the distinctions that can inevitably be found. These opposing information-processing and general tendencies are playing out in our approach to entities as different as the medical care that we provide, the medical reimbursement system under which we practice, and the types of research designs, questions, and approaches that we use in our science. For example, the Affordable Care Act seeks to promote the “lumper-friendly” Primary Care Medical Home in which it is intended that 1 team of clinicians will deliver comprehensive care for multiple chronic diseases, conditions, and symptoms rather than split this care among a disparate group of specialists across different health systems. Yet, at the same time, we continue to see “splitting” tendencies in medical care, as subspecialties continue to flourish,3 and the frequency and proportion of medical care that arises from referrals continues to escalate.4 Whereas there may be a normal distribution of lumping to splitting tendencies in the general population, scientists tend as a group to be splitters (as a gross stereotype). The impact of this splitting tendency on the research questions that scientists find interesting and the research designs that they accept as rigorous and worthy of funding is interesting to contemplate. It is also interesting to contemplate how lumpers (think “generalists” here) might view the usefulness and importance of research findings created and funded by splitters. Depending on the manner in which you characteristically process information, you are going to either be enchanted with or have grave concerns about one of the randomized clinical trials reported in this issue of JAMA Internal Medicine.5 In a single-blind, randomized clinical trial of 183 patients hospitalized for acute coronary syndrome, heart failure, or arrhythmia and with symptoms of depression, generalized anxiety, or panic, Huffman and colleagues5 tested whether telephone-based collaborative mental health care treatment, delivered by a social worker and a team of psychiatrists, could 936
improve mental and physical health across 6 months of treatment compared with usual care. They found statistically and clinically significant improvements in mental health–related quality of life—the trial’s primary outcome. Patients who received the treatment also experienced significant improvements in depressive symptoms, physical health–related quality of life, self-reported medication adherence, and functional capacity; improvements in anxiety symptoms or cardiac readmissions were not observed. Strengths of this trial include the low-cost, low-intensity nature of the intervention, the large effect sizes or improvements observed for multiple end points, and the use of cognitive behavioral therapy workbooks that may facilitate dissemination of this intervention. Limitations include the use of a single social worker to deliver the psychotherapy, the absence of cost data or formal cost-effectiveness analyses, and the use of screening measures to provide probabilistic but not definite diagnoses of clinical depression, anxiety disorders, and panic disorders. Such a trial is unusual for a number of reasons. Scientists rarely think that 1 risk marker, or exposure, operates the same way in different diseases and thus often frown on lumping patients with different diseases together in the absence of a priori analytic plans to statistically determine the appropriateness of such lumping. The authors of this study, however, included patients with different forms of cardiac disease. Similarly, scientists rarely lump different risk markers together— even if they are highly comorbid, as is true of depression and anxiety—into 1 treatment focus. When researchers have sought to do so, as was the case with the creation of the “metabolic syndrome” concept, extensive criticism of such a fusing (or lumping) approach is voiced.6 The authors of this study lumped together patients with symptoms of 3 common mental disorders, each of which has been associated with excess cardiovascular risk. Finally, scientists almost never concurrently test whether a single treatment is effective at reducing the adverse health effects of multiple risk factors. This approach is essentially what Huffman and colleagues have attempted. Although cognitive behavioral therapy is an evidence-based intervention for all 3 sets of psychiatric symptoms targeted in this trial, we rarely (if ever) test its effects on multiple conditions concurrently. Finally, to complete their coup d’état of a lumping exercise, Huffman and colleagues employed a generalist social worker with minimal cognitive behavioral therapy training to provide psychotherapy in this trial. It is common in mental health fields to have advanced training in treating only 1 or 2 of the mental conditions targeted in this trial. Of course, most trainees receive basic clinical training in the treatment of all 3, but as in medicine, there has been a distinct split-
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a SUNY Binghamton User on 05/14/2015
jamainternalmedicine.com
The MOSAIC Randomized Controlled Trial
Original Investigation Research
ting tendency within behavioral health care to specialize in only 1 patient population or treatment modality and to receive referrals for that 1 presenting problem. Now comes the self-reflective quiz part of this commentary. Are you bothered by the indiscriminant lumping of important distinctions that occurred in the design of this trial, such that you cannot conceive of how this study advances either our scientific knowledge or our approach to managing patients? Or, are you impressed by the disruptive thinking imbued in the logic of the trial’s design, and do you believe that this innovative approach to science may open up new avenues for how we combine symptoms, patient groups, treatments, and outcomes, to more holistically treat patients? Your answer to these questions may cause you to pause to reflect on your preferred information-processing style and to examine the ways in which that style influences your approach to science and patient care. If such a pause just occurred, then this commentary has achieved its educational goal. Behavior follows financial incentives, often regardless of intention.7 For decades, our health care system has reinARTICLE INFORMATION Author Affiliations: Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University, New York, New York (Davidson, Kronish, Shaffer); Department of Psychiatry, Columbia University, New York, New York (Davidson, Shaffer). Corresponding Author: Karina W. Davidson, PhD, Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University, 622 W 168th St, PH9 West, Room 314, New York, NY 10032 ([email protected]). Published Online: April 14, 2014. doi:10.1001/jamainternmed.2014.86. Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported by grants HL-115941, HL-084034, and 3R01HL115941-01S1 from the National Heart, Lung, and Blood Institute. Drs Kronish and Shaffer
forced separate systems for rewarding the care of patients, for example, by providing higher reimbursements for time spent performing procedures as compared with counseling patients with complex medical conditions. This approach has contributed to splintered and uncoordinated care. Arguably, this predilection for splitting has been most apparent in the way that physical and mental health care services are reimbursed. As a result of the changes in financing health care in the Affordable Care Act, we may be witnessing a paradigm shift that ripples through not only our health care delivery systems but also our science. Lumping together co-occurring risk factors, conditions, patient groups, and management strategies, particularly when 1 treatment may be an appropriate solution for many problems, may mark a new wave of science that emerges from our changing medical care reimbursement landscape. Ironically, this unintended consequence of a political compromise (the Affordable Care Act) may be a welcome one that leads us to be more efficient in caring for patients facing complex, intertwined problems.
received funding from the National Heart, Lung, and Blood Institute (grants K23 HL-098359 and K23 HL-11285, respectively).
4. Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, 1999-2009. Arch Intern Med. 2012;172(2):163-170.
Role of the Sponsor: The National Heart, Lung, and Blood Institute had no role in the preparation, review, or approval of the manuscript, and the decision to submit the manuscript for publication.
5. Huffman JC, Mastromauro CA, Beach SR, et al. Collaborative care for depression and anxiety disorders in patients with recent cardiac events: the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized clinical trial [published online April 14, 2014]. JAMA Intern Med. doi:10.1001 /jamainternmed.2014.739.
REFERENCES 1. Darwin C. The Life and Letters of Charles Darwin. New York, NY: D Appleton and Co; 1919. 2. Peterson ER, Deary IJ. Examining wholistic–analytic style using preferences in early information processing. Pers Individ Dif. 2006;41 (1):3-14. 3. West CP, Dupras DM. General medicine vs subspecialty career plans among internal medicine residents. JAMA. 2012;308(21):2241-2247.
jamainternalmedicine.com
6. Després JP, Lemieux I. Abdominal obesity and metabolic syndrome. Nature. 2006;444 (7121):881-887. 7. Lynagh MC, Sanson-Fisher RW, Bonevski B. What’s good for the goose is good for the gander: guiding principles for the use of financial incentives in health behaviour change. Int J Behav Med. 2013; 20(1):114-120.
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a SUNY Binghamton User on 05/14/2015
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