Psychosomatics 2014:]:]]]–]]]
& 2014 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Review Article Integrated Models of Care for Medical Inpatients With Psychiatric Disorders: A Systematic Review Maria Hussain, M.D., FRCPC, Dallas Seitz, M.D., FRCPC
Objective: Psychiatric disorders are common among medical inpatient settings and management of psychiatric disorders can be challenging in this setting. Integrated models of care (IMCs) combining psychiatric and medical specialties within a single service may improve psychiatric and medical outcomes, although evidence for IMCs in medical inpatient settings has not been well described. Method: We searched MEDLINE, Embase, and Google scholar for relevant articles. We included all randomized controlled trials or quasiexperimental studies in English that evaluated IMCs for medical inpatients with psychiatric disorders when compared with usual care. We defined IMCs as models of care where psychiatric and medical providers had joint responsibility for all patients within a given service. We extracted information on the characteristics of IMCs and on the effects of IMCs on psychiatric, medical, and
health service outcomes. Results: Four studies met the inclusion criteria, thereby including 716 participants overall. All studies differed in the study design, models of IMCs, and outcomes reported. In 2 studies, IMCs improved psychiatric symptoms compared with those admitted to a general medical service. Two studies demonstrated reductions in length of stay with IMCs compared with usual care. One study reported an improvement in functional outcomes and a decreased likelihood of long-term care admission associated with IMCs when compared with usual care. Conclusions: There is preliminary evidence that IMCs may improve a number of outcomes for medical inpatients with psychiatric disorders. Additional well-designed studies of IMCs are required to further evaluate the effect of IMCs on patient outcomes and costs of care. (Psychosomatics 2014; ]:]]]–]]])
INTRODUCTION
higher, with up to 60% of hospitalized patients aged 65 years and older diagnosed with dementia, delirium, or depression.8 Psychiatric disorders significantly increase both length of stay (LOS) and postdischarge health services utilization. Studies show that psychiatric disorders are often unrecognized by non–mental health physicians.9
Medical conditions are common among adults with psychiatric disorders, which places the individuals at risk of medical complications due to poor health behaviors and inadequate preventative health care. The prevalence of psychiatric disorders in general medical inpatient settings has been estimated to be between 20% and 40%,1–5 with certain medical conditions placing patients at higher risk. Up to 50% of patients with coronary artery disease have depressive symptoms,6 and 42% of hospitalized patients with cancer are affected with major depression.7 Data from older adults in medical settings demonstrate that the burden of psychiatric illness in this population is even Psychosomatics ]:], ] 2014
Received July 25, 2013; revised July 25, 2013; accepted August 5, 2013. From Department of Psychiatry, Queen's University, Kingston, Ontario, Canada. Send correspondence and reprint requests to Maria Hussain, M.D., Kingston Geriatric Psychiatry Outreach Team, 640 Cataraqui Woods Drive, Unit 2, Kingston, Ontario, Canada K7P 2Y5; e-mail: [email protected] & 2014 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
www.psychosomaticsjournal.org
1
Integrated Care for Medical Inpatients Collaborative or integrated mental health care has been defined as care delivered by general medical physicians working with psychiatrists and other allied health professionals to provide complementary services, patient education, and management to improve mental health outcomes.10 Integrated models of care (IMCs) are patient-centered, and they not only involve the psychiatrist as a consultant with co-location of psychiatric and medical services, but also involve a shared responsibility for the care of all patients within a service.11 IMCs involving mental health providers and other health care professionals have demonstrated improved medical and mental health outcomes in primary care settings.12 In addition, mental health case managers in primary care settings have demonstrated positive outcomes.13,14 IMCs have also been linked to functional improvement,15 reduced disability days,16 increased quality-adjusted life years,17 and increased compliance with medication16 when compared with other models of care. IMCs combining psychiatric services within medical inpatient settings have been investigated as a potential method to improve both psychiatric and medical outcomes for medical inpatients with psychiatric disorders (MIPD). Descriptions of these models have included “medical-psychiatric units”18 and “joint care wards,”19 both of which integrate psychiatrists, general medical physicians, and allied health staff into a single inpatient service. To date, there have been no systematic reviews evaluating the effectiveness of IMCs for MIPD. Therefore, the aim of this systematic review is to review the different models of IMCs for MIPD and to examine the effects of IMCs on mental health, medical, and health service outcomes when compared with standard models of care.
to identify additional articles of relevance. The key words and medical subject headings included “hospital unit,” “psychiatry,” “liaison psychiatry,” “gerontopsychiatry,” “hospital,” “general hospital,” “geriatric hospital,” “medical psychiatric unit,” “co-morbidity,” “referral and consultation,” and “combined modality therapy,” The search strategy for MEDLINE and Embase has been included in Appendix 1.
METHODS
Inclusion Criteria
Search Strategy
We included all English language publications that evaluated the effects of IMCs for MIPD when compared with either usual medical care or another model of psychiatric care (e.g., psychiatric consultation) for medical inpatients. Both randomized controlled trials and other quasi-experimental (e.g., controlled beforeand-after studies) studies were included. Descriptive studies of IMC that did not have a comparison group were excluded. We also excluded studies where the subjects were younger than 18 years.
We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for conducting systematic reviews to guide our review process.20 We searched the electronic databases MEDLINE and Embase from inception until May 2012 using free-text search terms and medical subject headings. Google scholar was also searched for additional relevant articles. We conducted a further handsearch 2
www.psychosomaticsjournal.org
Definition of IMCs We defined IMCs for MIPD as models of care where psychiatrists and general medical physicians, either in isolation or in combination with other allied health staff, were integrated within a single team to provide care to an entire inpatient population. In this model, the psychiatrists, along with the general medical physicians, are jointly responsible for the care of all patients admitted to the inpatient medical service. An evidence-based model of care and management plan is implemented in a collaborative fashion. An example of an IMC is a medical-psychiatric unit with a coattending model such that both specialists have shared responsibility for all patients on a service.21 Typically, there are specific criteria for admission of patients to such a ward and the acuity of both medical and psychiatric symptomatology is taken into consideration.22 We also included models of care that incorporated psychiatric nurse practitioners or mental health case managers who could implement mental health care as part of the general medical service. We did not include studies that only examined consultation or liaison models of psychiatric care, as this model of care did not meet our definition of IMCs.
Psychosomatics ]:], ] 2014
Hussain and Seitz Data Extraction Each abstract and article was reviewed independently by the 2 authors. We extracted information on study characteristics, patient characteristics, and outcomes. For study characteristics, we extracted information on study setting, description of the IMCs, and comparison model of care, and the study design. Patient characteristics included mean age, gender distribution, psychiatric diagnoses, and admitting medical diagnoses. We also extracted information on psychiatric outcomes (e.g., change in depression symptoms and cognition), medical outcomes (e.g., mortality and physical functioning) and health service outcomes (e.g., LOS and inpatient costs) where these were reported. Assessment of Study Quality The Cochrane Effective Practice and Organisation of Care risk of bias tool was utilized to describe the potential risk of bias with various aspects of study design,23 which included method of sequence generation, concealment of allocation, similarity of outcome measures, similarity of baseline characteristics, incomplete outcome data, blinding, protection against contamination, selective outcome reporting, and other potential sources of bias. Each item was rated as being at “low,” “high,” or “unclear” risk of bias. Data Synthesis We summarized participant demographic data and diagnoses in tables. We planned to conduct a metaanalysis of outcomes if the studies meeting the inclusion criteria were homogeneous in study design and outcomes measured. However, the heterogeneity of the included studies precluded a meta-analysis of outcomes. RESULTS Study Selection The flow of studies through the review process is illustrated in the Figure. A total of 959 citations were obtained by an electronic search, of which, 867 articles were excluded after reviewing titles and abstracts; 68 citations were identified through handsearches and 157-full text articles were retrieved and reviewed for Psychosomatics ]:], ] 2014
eligibility. After reviewing full-text articles, 4 studies met the inclusion criteria,24–27 which included 2 randomized controlled trials,24,26 one interrupted time series study,25 and one controlled before-andafter study.27 Characteristics of Included Studies Characteristics of Participants in Included Studies The characteristics of participants in the included studies are summarized in Table 1. There were a total of 716 individuals included in the studies with a mean study sample size of 179.0 (standard deviation [SD] ¼ 53.9). The characteristics of the patients in the individual studies varied; the mean age of participants ranged from 52.8 years27 to 82.5 years.24 The gender distribution reflected the proportion of female participants ranging between 41.9%25 and 70.1%.26 Mood disorders were one of the most common psychiatric diagnoses in most studies, at 51%25 and 45%,27 with anxiety disorders (54%)27 and substance-related disorders (31%)25 also being commonly reported. Cardiovascular disorders were the most common medical diagnoses in 3 studies,24,26,27 with other diagnostic categories, such as respiratory, gastrointestinal, and neurologic disorders, being less common. Description of IMCs The IMCs identified in these 4 studies used different models of care (Table 2). In the study by Slaets et al., patients randomized to the IMC received care from a specialized multidisciplinary geriatric medicine team consisting of a geriatrician trained in geriatric psychiatry, a geriatric liaison nurse, and a physiotherapist, as well as additional medical nursing staff.24 The IMC provided integrated multidisciplinary assessments and treatment plans, discharge planning, and postdischarge follow-up. There was regular communication between the members of the IMC, nursing staff, and patients. The IMC had weekly multidisciplinary meetings with the health care providers responsible for the patients in addition to having their own weekly rounds. Kishi and Kathol described an IMC as part of an internal medicine service that integrated general internists and psychiatrists in a co-attending model.25 This IMC model consisted of a psychiatrist, general internist, nursing staff with training in both medical www.psychosomaticsjournal.org
3
Integrated Care for Medical Inpatients
FIGURE.
Flow of Studies Through the Review Process. Records identified through database search: MEDLINE: 766 Embase: 981 Total N= 1747
Screened after duplicates removed N= 959
Records excluded after reviewing titles and abstracts: N = 867 Full text articles reviewed from database search: N = 92 Full text hand searched articles identified and reviewed: N = 69 Total full text articles reviewed N= 161 Full text articles excluded: N = 157 Included articles N=4
and psychiatric care, and other allied health staff. The ward for the IMC was modified to accommodate the needs of patients with any degree of medical or psychiatric symptomatology. Baldwin et al.26 conducted a randomized controlled trial comparing a nurse-led mental health liaison intervention with usual care for patients aged 65 years and older who were admitted to 4 general medical wards. The patients assigned to the IMC received mental health assessments, nonpharmacologic interventions, and liaison support from a mental health nurse. The mental health nurse also assisted in identifying individuals with psychiatric disorders on the medical inpatient unit and communicated with medical staff to initiate management. 4
www.psychosomaticsjournal.org
Leue et al.27 conducted a controlled before-andafter study of patients admitted to an IMC that was provided in an internal medicine ward. The ward was capable of treating patients of moderate to severe psychiatric and medical acuity. The IMC consisted of a psychiatrist, gastroenterologist, and cardiologist, as well as a psychologist, occupational therapist, and medical and psychiatric nursing staff. Effects of IMCs on Outcomes Psychiatric Outcomes The outcomes associated with IMCs are summarized in Table 3. One study reported the change in Psychosomatics ]:], ] 2014
Hussain and Seitz
TABLE 1.
Characteristics of Participants in Studies Included in Review
Study
Number Mean Age (SD)
Female Sex, Psychiatric Diagnosis (%) n (%)
Medical Diagnosis (%)
140
82.5 (4.9)
94 (67.1)
NR
97
83.2 (5.1)
73 (75.3)
NR
Congestive heart failure (41.4) Endocrine disorders (28.6) Gastrointestinal disorders (20.0) Congestive heart failure (41.2) Endocrine disorders (26.8) Gastrointestinal disorders (16.5)
Kishi and Kathol25 IMC 105
47 (17)
44 (41.9)
Medication adjustment/adverse drug effects (30.5) Intoxication/poisoning (24.8) Neurologic disorders (19.0)
Control group 105
54 (19)
55 (52.3)
Mood disorders (20.0) Psychosis (9.5) Delirium (9.5) Substance-related disorders (13.3) Substance-related disorders (37.1) Delirium (18.1) Mood disorders (9.5) Dementia (9.5)
Cardiovascular disorders (36.1) CNS disorders (20.8) Respiratory disorder (13.9) Endocrine/metabolic disorders (13.9) Cardiovascular disorders (25.0) Respiratory disorders (20.8) CNS disorders (19.4)
Slaets et al.24 IMC
Control group
Baldwin et al.26 IMC
59
80.6 (7.2)
54 (70.1)
NR
61
80.0 (7.5)
44 (57.9)
NR
32*
52.8 (15.1)
17 (53.1)
Anxiety disorders (54) Mood disorders (45) Somatoform disorders (36)
Control group 117†
52.8 (15.1)
57 (48.7)
Mood disorders (3) Anxiety disorders (2) Psychotic disorders (1) Substance-use disorder (1)
Control group
Leue et al.27 IMC
Gastrointestinal disorders (21.9) Medication adjustment/adverse drug effects (17.1) Pulmonary disorder (14.9)
Circulatory disorders (15) Gastrointestinal disorders (14) Genitourinary disorders (8) Circulatory system (27) Gastrointestinal disorders (7) Genitourinary disorders (7) Respiratory disorders (5)
CNS ¼ central nervous system; IMC ¼ integrated model of care; MPU ¼ medical-psychiatric unit; n ¼ number; NR ¼ not reported, SD ¼ standard deviation. n
†
Patient admitted to MPU only Patients admitted to both IMC and Medical wards.
psychiatric symptom severity using the Global Assessment of Functioning score, which demonstrated a significant improvement in the Global Assessment of Functioning score for patients in the IMC compared with the control group (19.5 vs 11.2 point improvement; P ¼ 0.003).25 Another study used a global measure of psychiatric morbidity, the Health of the Nations Outcome Scales for Elderly People, which showed no significant improvement in the IMC patients compared with the control group on the total score, although patients in the IMC showed more Psychosomatics ]:], ] 2014
improvement on the mood subscore of the Health of the Nations Outcome Scales for Elderly People.26 One of the studies used the Mini-Mental Status Examination to identify patients with cognitive impairment, with no significant changes in cognition noted. This study also examined change in depressive symptoms using the Geriatric Depression Scale.26 At the end of 8 weeks, mean Geriatric Depression Scale scores were lower in the IMC patients as compared with the usual care group (12.2 [SD ¼ 6.2] vs 14.0 [SD ¼ 6.6]; P ¼ 0.043). One study reported on the detection of www.psychosomaticsjournal.org
5
Integrated Care for Medical Inpatients
TABLE 2.
Characterisitics of Integrated Models of Care for Studies Included in Review Country
Study Design
Integrated Model of IMC Health Care Care (IMC) Providers
Slaets et al.24 Netherlands
Randomized controlled trial
Kishi and Kathol25
USA
Interrupted time series
Baldwin et al.26
UK
Randomized controlled trial
Leue et al.27
Netherlands
Controlled beforeand after-study
Multidisciplinary joint treatment by a geriatric team in addition to the usual care on a general medicine ward. “Type IV” integrated medicine and psychiatry treatment program with the provisions of an acute medicine as well as a psychiatric ward. Administered through the department of internal medicine. Nurse-led mental health liaison service in addition to usual care on internal medicine wards. Medical-psychiatric unit located on an internal medicine ward in the gastroenterology section.
Intervention Group Comparison Group
Geriatrician trained Patients aged 75 y in geriatric and older admitted psychiatry, geriatric to an IMC. liaison nurse, and physiotherapist.
Patients aged 75 y and older admitted to a general medicine ward.
Co-attending model with internist, psychiatrist, and nurses trained in medical and psychiatric management.
Mental health Patients aged 65 y liaison nurse in and older admitted addition to the usual to an IMC. care team.
Patients admitted to the general internal medicine, gastroenterology, endocrinology, cardiology, and pulmonary wards identified by nursing supervisors as requiring psychiatric evaluation. Patients aged 65 y and older admitted to a general medicine ward.
Psychiatrist, cardiologist, gastroenterologist, medical and psychiatric nursing staff, psychologist, and occupational therapist.
Similar patient population requiring psychiatric and medical management, but admitted to general medicine wards.
Patients with concurrent active psychiatric and medical comorbidity admitted to the IMC.
Patients admitted to the IMC, having concurrent moderate to severe psychiatric and medical co-morbidity.
IMC ¼ integrated model of care.
psychiatric illness and found that psychiatric disorders were detected more frequently in the IMC compared with the control wards.27 Medical Outcomes Medical outcomes were reported using different methods in the studies. Only one study reported differences in change in medical symptoms, it demonstrated equal improvement in medical symptoms of the IMC patients when compared with the control group using the Karnofsky score.25 Functional outcomes were reported in one study.24 IMC patients showed significantly greater functional improvement across all domains in the measure used, compared with the control group. The authors of one study reported that the rate of detection of medical illnesses on the IMC was the same as on other wards.27 6
www.psychosomaticsjournal.org
Health Service Outcomes Health service outcomes were reported in all studies. One study showed that the LOS was significantly reduced in the IMC (19.7 vs 24.8 d) as compared with the control group.24 This study also investigated the 6-month rehospitalization rate, which was lower for IMC patients when compared with the control group (17.4% vs 29.9%; P ¼ 0.05). One study demonstrated that total LOS was increased in IMC when compared with the control wards (17.5 vs 12.5 d; P ¼ 0.01). However, when the number of days spent on the index ward before transfer to IMC was adjusted, the LOS for the IMC patients was 13.5 (SD ¼ 12.9) compared with 10.5 (SD ¼ 9.7) for the control group, which the authors reported as not being a significant difference.25 The third study showed that the average LOS of IMC patients was comparable to the control group (27.8 vs Psychosomatics ]:], ] 2014
Hussain and Seitz
TABLE 3. Study
Outcomes Associated With Integrated Models of Care Psychiatric Outcomes
Slaets et al.24 IMC NR
Control group Kishi and Kathol25 IMC
Control group
Medical Outcomes
Health Service Outcomes
Global Improvement
Activities of Daily Living
Length of Stay
Medical Costs
Nursing Home Placement
NR
Great improvement across activities of daily living, continence, and mobility.* –
NR
NR
NR
NR
Probability of being placed in a nursing home at 12 mo was 2.5times lower. –
NR
NR
NR
NR
GAF score improvement 19.5 (SD ¼ 20.9)* GAF score improvement 11.2 (SD ¼ 16.3)*
Karnofsky score improvement 24.3 (SD ¼ 19.5)† Karnofsky score improvement 22.4 (SD ¼ 21.4)†
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR NR
NR NR
Baldwin et al.26 IMC Decrease in depression per GDS scores* and mood subscore of HoNOS65þ* No difference in MMSE scores. Control Less improvement in group depression. No difference in MMSE scores. Leue et al.27 IMC NR Control NR group
Increased Decreased
Decreased Increased
NR NR
GAF ¼ global assessment of functioning; GDS ¼ geriatric depression scale; HoNOS65þ ¼ Health of the Nations Outcome Scales for Elderly People; IMC ¼ integrated model of care; MMSE ¼ mini-mental state examination; NR ¼ not reported; SD ¼ standard deviation. n
†
Statistically significant (P r 0.05). Not statistically significant.
29.5; P ¼ 0.76).26 The last study included in the review showed a significantly increased LOS for patients admitted to the IMC compared with the control group (24.1 vs 8.2)27 The authors in this study also reported that costs associated with psychiatric illness were higher on the IMC compared with the control wards, whereas medical costs were lower on the IMC. One study reported that patients admitted to the control wards had a 2.5times greater likelihood of nursing home admission when compared with those admitted to the IMC.24 Quality of Included Studies The risk of bias in the individual studies using the Cochrane Effective Practice and Organisation of Care Psychosomatics ]:], ] 2014
risk of bias tool is summarized in Table 4. The randomized controlled trials24,26 included in the study were at a lower risk of bias for most of the quality assessment parameters, whereas the other 2 studies were at higher potential risk of bias. DISCUSSION Our review identified that there are only a few studies that have evaluated the effect of IMCs for MIPD. The models of care described in the studies included in our review were diverse in terms of the organization of IMCs, patient characteristics, and outcomes examined. IMCs appear to be associated with www.psychosomaticsjournal.org
7
Integrated Care for Medical Inpatients
TABLE 4.
Slaets et al.24 Kishi and Kathol25 Baldwin et al.26 Leue et al.27
Quality of Studies Included in the Review According to the EPOC Criteria23 Allocation Allocation Baseline Sequence Concealment Outcome Measurements
Similar Incomplete Baseline Outcome Characteristics Data
Blinding of Outcome Assessment
Protection against Contamination
Selective Outcome Reporting
Unclear
Unclear
Low
Low
Low
Unclear
Low
Low
High
High
Unclear
High
Low
Low
Low
High
Low
High
Low
Low
Low
High
Low
Low
High
High
High
High
High
Low
Low
Low
EPOC ¼ Effective Practice and Organisation of Care.
improvements in psychiatric symptoms when compared with usual care, however, the effect on medical symptoms was less clear. Health service outcomes associated with IMC demonstrated that LOS, readmissions, and rates of long-term care placement may be reduced by IMCs, although not all studies provided information on these outcomes. There are several ways in which psychiatric care can be delivered to patients in medical inpatient services. In most general medical inpatient settings in the United States and Europe, psychiatric consultation or consultation-liaison models are the most common models of care.28,29 Psychiatric consultation models involve a referral being generated by the general medical service under which the patient is admitted for medical care. The psychiatric service assesses the patient and provides written suggestions to the general medical service. In contrast, liaison psychiatry involves the psychiatric service being more proactive in identifying patients with psychiatric morbidity within a general medical setting.30 Education and regular attendance of rounds is a part of the liaison model.31 Studies show that psychiatric consultations are requested more frequently by specialities that have an established psychiatric liaison service, as compared with those specialties that do not have these services.32 Consultation-liaison psychiatry services incorporate both consultation and liaison. This model has been associated with an increase in accurate diagnoses, reduction in mortality, and reductions in LOS and health service utilization as compared with those patients receiving usual general medical care.33–35 However, there are limitations with the consultation-liaison model of psychiatric care in general 8
www.psychosomaticsjournal.org
hospitals, highlighting the need for more effective models of psychiatric care. Barriers to liaison activities, an integral component of consultation-liaison psychiatry, have been identified.36 A barrier to engagement of psychiatrists in liaison activities may be limited remuneration for these services.37 Other challenges may also be that general medical physicians may be less amenable to some of the psychosocial aspects of psychiatric care. Studies have identified that the concordance with suggestions made by consultation-liaison psychiatry services overall is low, with only 61% of recommendations being followed.38 In addition, referring medical providers are more receptive to pharmacologic recommendations as compared with recommendations involving diagnostic evaluation or nonpharmacologic management.38 An IMC may be one way of improving communication and psychiatric care for patients in medical settings compared with more typical consultation-liaison models. Although there is limited literature on IMCs in medical inpatient settings, IMCs have an extensive evidence base for the delivery of mental health care in primary care settings. Collaborative or integrated psychiatric care, usually involves a psychiatrist or other mental health providers being colocated in primary care settings. There are several psychiatric conditions in which IMCs in primary care settings have been shown to be efficacious. Evidence shows that IMCs for dementia lead to significant improvement in behavioral and psychologic symptoms39 and improved quality of life for older adults in primary care.40 These models have also been demonstrated to improve psychiatric outcomes in patients with late-life depression13; concurrent depression; and diabetes mellitus,41 bipolar Psychosomatics ]:], ] 2014
Hussain and Seitz disorder,42 anxiety disorders,43 and substance-use disorders.44 IMCs in primary care have been shown to be cost-effective45 and to improve medical symptoms.46 Literature from geriatric psychiatry has described joint geriatric psychiatry and geriatric medicine units,47 which have been demonstrated to decrease the use of physical restraints and antipsychotics and can be both clinically effective and cost-effective.47 Therefore, IMCs are increasingly being recognized as effective models of mental health care in primary care outpatient settings and would be expected to demonstrate similar benefits in medical inpatient settings. There are some strengths of our study. To our knowledge, this is the first systematic review of this topic. We used a rigorous and sensitive search strategy to identify as many studies as possible. Our review also provided a detailed description of studies and an assessment of study quality. However, there are some limitations to our review. The first limitation is the small number of studies included in this review. In addition, the study designs and outcome measures were heterogeneous, precluding a meta-analysis of outcomes. We only included English language articles for the ease of review and may have overlooked some studies published in other languages. Finally, patient and health care providers' experience and satisfaction with IMCs were not evaluated in the studies and therefore could not be evaluated. In conclusion, there is some preliminary evidence to support IMCs for MIPD and these models appear to be a promising way to improve care for this complex population. Given the high prevalence of psychiatric disorders in many general medical inpatient settings, IMCs may be feasible in many general medical inpatient environments. Further well-designed studies are needed to investigate their effectiveness on improving psychiatric, medical, and economic outcomes. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
APPENDIX 1. SEARCH STRATEGY FOR MEDLINE AND EMBASE 1. psychiatry/ or gerontopsychiatry/ or liaison psychiatry/ or psychosomatics/ 2. mental disease/ or exp addiction/ or exp adjustment disorder/ or alexithymia/ or exp anxiety disorder/ or autism/ or behavior disorder/ or confusion/ or exp delirium/ or exp dementia/ or exp dissociative disorder/ or emotional disorder/ or learning disorder/ or memory disorder/ or mental instability/ or exp mood disorder/ or neurosis/ or organic brain syndrome/ or organic psychosyndrome/ or exp personality disorder/ or exp psychosexual disorder/ or exp psychosis/ or exp psychosomatic disorder/ or psychotrauma/ or thought disorder/ psychophysiologic disorders. mp. or psychosomatic disorder/ 3. psychiatric department, hospital.mp. or exp psychiatric department/ 4. exp HOSPITALIZATION/ 5. hospital unit.mp. or "hospital subdivisions and components"/ 6. hospital patient/ 7. hospital/ or community hospital/ or general hospital/ or geriatric hospital/ or non profit hospital/ or pediatric hospital/ or private hospital/ or public hospital/ or exp teaching hospital/ 8. COMORBIDITY/ 9. combined modality therapy.mp./ "medical psychiatric unit".mp. [mp¼title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] 10. exp patient referral/ 11. 1 or 2 or 3 12. 4 or 5 or 6 or 7 13. 8 or 9 or 10 14. 11, 12, and 13
References 1. Mayou R, Hawton K: Psychiatric disorder in the general hospital. Br J Psychiatry 1986; 149:172–190 2. Seltzer A: Prevalence, detection and referral of psychiatric morbidity in general medical patients. J R Soc Med 1989; 82:410
Psychosomatics ]:], ] 2014
3. Silverstone PH: Prevalence of psychiatric disorders in medical inpatients. J Ner Ment Dis 1996; 184:43–45 4. Arolt V, Driessen M, Dilling H: The Luebeck General Hospital study. I: prevalence of psychiatric disorders in medical and surgical inpatients. Int J Psychiatry Clin Pract 1997; 1:207–216
www.psychosomaticsjournal.org
9
Integrated Care for Medical Inpatients 5. Martucci M, Balestrieri M, Bisoffi G, et al: Evaluating psychiatric morbidity in a general hospital: a two-phase epidemiological survey. Psychol Med 1999; 29:823–831 6. Freedland KE, Rich MW, Skala JA, Carney RM, DavilaRoman VG, Jaffe AS: Prevalence of depression in hospitalized patients with congestive heart failure. Psychosom Med 2003; 65:119–128 [Research Support, Non-U.S. Gov't Research Support, U.S. Gov't, P.H.S.] 7. Bukberg J, Penman D, Holland JC: Depression in hospitalized cancer patients. Psychosom Med 1984; 46:199–212 8. Royal College of Psychiatrists: Who Cares Wins. London: Royal College of Psychiatry 2005 9. Wancata J, Windhaber J, Bach M, Meise U: Recognition of psychiatric disorders in nonpsychiatric hospital wards. J Psychosom Res 2000; 48:149–155 10. Katon W, Von Korff M, Lin E, et al: Collaborative management to achieve treatment guidelines Impact on depression in primary care. J Am Med Assoc 1995; 273:1026–1031 11. Druss BG, Rohrbaugh RM, Levinson CM, Rosenheck RA: Integrated medical care for patients with serious psychiatric illness: a randomized trial. Arch Gen Psychiatry 2001; 58:861 12. Dobscha SK, Corson K, Perrin NA, et al: Collaborative care for chronic pain in primary care. J Am Med Assoc 2009; 301:1242–1251 13. Unützer J, Katon W, Callahan CM, et al: Collaborative care management of late-life depression in the primary care setting. J Am Med Assoc 2002; 288:2836–2845 14. Bower P, Gilbody S: Managing common mental health disorders in primary care: conceptual models and evidence base. Br Med J 2005; 330:839–842 15. Katon WJ, Seelig M: Population-based care of depression: team care approaches to improving outcomes. J Occup Environ Med 2008; 50:459–467 16. Simon GE, Katon WJ, Lin EHB, et al: Cost-effectiveness of systematic depression treatment among people with diabetes mellitus. Arch Gen Psychiatry 2007; 64:65 17. Wang PS, Patrick A, Avorn J, et al: The costs and benefits of enhanced depression care to employers. Arch Gen Psychiatry 2006; 63:1345 18. Kathol RG, Harsch HH, Hall RC, Shakespeare A: Categorization of types of medical/psychiatry units based on level of acuity. Psychosomatics 1992; 33:376–386 19. Pitt B, Silver C: The combined approach to geriatrics and psychiatry: evaluation of a joint unit in a teaching hospital district. Age Ageing 1980; 9:33–37 20. Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6:e1000097 21. Fogel BS, Stoudemire A: Organization and development of combined medical-psychiatric units: part 2. Psychosomatics 1986; 27:417–428 22. Stoudemire A, Fogel BS: Organization and development of combined medical-psychiatric units: part 1. Psychosomatics 1986; 27:341–345 23. 〈http://epoc.cochrane.org〉
10
www.psychosomaticsjournal.org
24. Slaets J, Kauffmann R, Duivenvoorden H, Pelemans W, Schudel WJ: A randomized trial of geriatric liaison intervention in elderly medical inpatients. Psychosom Med 1997; 59:585–591 25. Kishi Y, Kathol RG: Integrating medical and psychiatric treatment in an inpatient medical setting: the type IV program. Psychosomatics 1999; 40:345–355 26. Baldwin R, Pratt H, Goring H, Marriott A, Roberts C: Does a nurse-led mental health liaison service for older people reduce psychiatric morbidity in acute general medical wards? A randomised controlled trial. Age ageing 2004; 33:472–478 27. Leue C, Driessen G, Strik JJ, et al: Managing complex patients on a medical psychiatric unit: an observational study of university hospital costs associated with medical service use, length of stay, and psychiatric intervention. J Psychosom Res 2010; 68:295–302 28. Lipowski Z: Consultation-liaison psychiatry: the first half century. Gen Hosp Psychiatry 1986; 8:305–315 29. Mayou R, Huyse F: Consultation-liaison psychiatry in Western Europe. Gen Hosp Psychiatry 1991; 13:188–208 30. Strain J: Liaison psychiatry. In: Wise M, Rundell JR, (eds). The American Psychiatric Publishing Text Book of Consultation—Liaison Psychiatry: Psychiatry in the medically ill. 2nd ed. Washington DC: American Psychiatric Publishing; 2002. p. 33–48 31. Malhotra S, Padhy KS: Consultation-liaison psychiatry: conceptual issues. J Ment Health Hum Behav 2012; 17(3 Suppl):S4–S13 32. Schubert DS, Billowitz A, Gabinet L, Friedson W: Effect of liaison psychiatry on attitudes toward psychiatry, rate of consultation, and psychosocial documentation. Gen Hosp Psychiatry 1989; 11:77–87 33. Bourgeois JA, Hilty DM, Servis ME, Hales RE: Consultation-liaison psychiatry: advantages for healthcare systems. Dis Manage Health Outcomes 2005; 13:93–106 34. Hales RE: The benefits of a psychiatric consultation-liaison service in a general hospital. Gen Hosp Psychiatry 1985; 7:214–218 35. Friedman RS, Molay F: A history of psychiatric consultation in America. Psychiatr Clin North Am 1994; 17:667–681 36. Lipowski Z: Consultation-liaison psychiatry: past failures and new opportunities. Gen Hosp Psychiatry 1979; 1:3–10 37. Fenton BJ, Guggenheim FG: Consultation-liaison psychiatry and funding: why can't alice find wonderland? Gen Hosp Psychiatry 1981; 3:255–260 38. Huyse FJ, Strain JJ, Hammer JS: Interventions in consultation/liaison psychiatry: part II: concordance. Gen Hosp Psychiatry 1990; 12:221–231 39. Callahan CM, Boustani MA, Unverzagt FW, et al: Effectiveness of collaborative care for older adults with Alzheimer disease in primary care. J Am Med Assoc 2006; 295:2148–2157 40. Vickrey BG, Mittman BS, Connor KI, et al: The effect of a disease management intervention on quality and outcomes
Psychosomatics ]:], ] 2014
Hussain and Seitz of dementia care. A randomized, controlled trial. Ann Intern Med 2006; 145:713–726 41. Katon WJ, Von Korff M, Lin EH, et al: The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry 2004; 61:1042 42. Bauer M, McBride L, Williford W, et al: Collaborative care for bipolar disorder: part II. Impact on clinical outcome, function, and costs. Psychiatric Serv 2006; 57:937–945 43. Katon WJ, Roy-Byrne P, Russo J, Cowley D: Costeffectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder. Arch Gen Psychiatry 2002; 59:1098
Psychosomatics ]:], ] 2014
44. Bartels SJ, Coakley EH, Zubritsky C, et al: Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. Am J Psychiatry 2004; 161:1455–1462 45. Unutzer J, Katon WJ, Fan M-Y, et al: Long-term cost effects of collaborative care for late-life depression. Am J Manag Care 2008; 14:95–100 [page 2] 46. Katon WJ, Lin EH, Von Korff M, et al: Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010; 363:2611–2620 47. George J, Adamson J, Woodford H: Joint geriatric and psychiatric wards: a review of the literature. Age ageing 2011; 40:543–548
www.psychosomaticsjournal.org
11
& 2014 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Review Article Integrated Models of Care for Medical Inpatients With Psychiatric Disorders: A Systematic Review Maria Hussain, M.D., FRCPC, Dallas Seitz, M.D., FRCPC
Objective: Psychiatric disorders are common among medical inpatient settings and management of psychiatric disorders can be challenging in this setting. Integrated models of care (IMCs) combining psychiatric and medical specialties within a single service may improve psychiatric and medical outcomes, although evidence for IMCs in medical inpatient settings has not been well described. Method: We searched MEDLINE, Embase, and Google scholar for relevant articles. We included all randomized controlled trials or quasiexperimental studies in English that evaluated IMCs for medical inpatients with psychiatric disorders when compared with usual care. We defined IMCs as models of care where psychiatric and medical providers had joint responsibility for all patients within a given service. We extracted information on the characteristics of IMCs and on the effects of IMCs on psychiatric, medical, and
health service outcomes. Results: Four studies met the inclusion criteria, thereby including 716 participants overall. All studies differed in the study design, models of IMCs, and outcomes reported. In 2 studies, IMCs improved psychiatric symptoms compared with those admitted to a general medical service. Two studies demonstrated reductions in length of stay with IMCs compared with usual care. One study reported an improvement in functional outcomes and a decreased likelihood of long-term care admission associated with IMCs when compared with usual care. Conclusions: There is preliminary evidence that IMCs may improve a number of outcomes for medical inpatients with psychiatric disorders. Additional well-designed studies of IMCs are required to further evaluate the effect of IMCs on patient outcomes and costs of care. (Psychosomatics 2014; ]:]]]–]]])
INTRODUCTION
higher, with up to 60% of hospitalized patients aged 65 years and older diagnosed with dementia, delirium, or depression.8 Psychiatric disorders significantly increase both length of stay (LOS) and postdischarge health services utilization. Studies show that psychiatric disorders are often unrecognized by non–mental health physicians.9
Medical conditions are common among adults with psychiatric disorders, which places the individuals at risk of medical complications due to poor health behaviors and inadequate preventative health care. The prevalence of psychiatric disorders in general medical inpatient settings has been estimated to be between 20% and 40%,1–5 with certain medical conditions placing patients at higher risk. Up to 50% of patients with coronary artery disease have depressive symptoms,6 and 42% of hospitalized patients with cancer are affected with major depression.7 Data from older adults in medical settings demonstrate that the burden of psychiatric illness in this population is even Psychosomatics ]:], ] 2014
Received July 25, 2013; revised July 25, 2013; accepted August 5, 2013. From Department of Psychiatry, Queen's University, Kingston, Ontario, Canada. Send correspondence and reprint requests to Maria Hussain, M.D., Kingston Geriatric Psychiatry Outreach Team, 640 Cataraqui Woods Drive, Unit 2, Kingston, Ontario, Canada K7P 2Y5; e-mail: [email protected] & 2014 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
www.psychosomaticsjournal.org
1
Integrated Care for Medical Inpatients Collaborative or integrated mental health care has been defined as care delivered by general medical physicians working with psychiatrists and other allied health professionals to provide complementary services, patient education, and management to improve mental health outcomes.10 Integrated models of care (IMCs) are patient-centered, and they not only involve the psychiatrist as a consultant with co-location of psychiatric and medical services, but also involve a shared responsibility for the care of all patients within a service.11 IMCs involving mental health providers and other health care professionals have demonstrated improved medical and mental health outcomes in primary care settings.12 In addition, mental health case managers in primary care settings have demonstrated positive outcomes.13,14 IMCs have also been linked to functional improvement,15 reduced disability days,16 increased quality-adjusted life years,17 and increased compliance with medication16 when compared with other models of care. IMCs combining psychiatric services within medical inpatient settings have been investigated as a potential method to improve both psychiatric and medical outcomes for medical inpatients with psychiatric disorders (MIPD). Descriptions of these models have included “medical-psychiatric units”18 and “joint care wards,”19 both of which integrate psychiatrists, general medical physicians, and allied health staff into a single inpatient service. To date, there have been no systematic reviews evaluating the effectiveness of IMCs for MIPD. Therefore, the aim of this systematic review is to review the different models of IMCs for MIPD and to examine the effects of IMCs on mental health, medical, and health service outcomes when compared with standard models of care.
to identify additional articles of relevance. The key words and medical subject headings included “hospital unit,” “psychiatry,” “liaison psychiatry,” “gerontopsychiatry,” “hospital,” “general hospital,” “geriatric hospital,” “medical psychiatric unit,” “co-morbidity,” “referral and consultation,” and “combined modality therapy,” The search strategy for MEDLINE and Embase has been included in Appendix 1.
METHODS
Inclusion Criteria
Search Strategy
We included all English language publications that evaluated the effects of IMCs for MIPD when compared with either usual medical care or another model of psychiatric care (e.g., psychiatric consultation) for medical inpatients. Both randomized controlled trials and other quasi-experimental (e.g., controlled beforeand-after studies) studies were included. Descriptive studies of IMC that did not have a comparison group were excluded. We also excluded studies where the subjects were younger than 18 years.
We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for conducting systematic reviews to guide our review process.20 We searched the electronic databases MEDLINE and Embase from inception until May 2012 using free-text search terms and medical subject headings. Google scholar was also searched for additional relevant articles. We conducted a further handsearch 2
www.psychosomaticsjournal.org
Definition of IMCs We defined IMCs for MIPD as models of care where psychiatrists and general medical physicians, either in isolation or in combination with other allied health staff, were integrated within a single team to provide care to an entire inpatient population. In this model, the psychiatrists, along with the general medical physicians, are jointly responsible for the care of all patients admitted to the inpatient medical service. An evidence-based model of care and management plan is implemented in a collaborative fashion. An example of an IMC is a medical-psychiatric unit with a coattending model such that both specialists have shared responsibility for all patients on a service.21 Typically, there are specific criteria for admission of patients to such a ward and the acuity of both medical and psychiatric symptomatology is taken into consideration.22 We also included models of care that incorporated psychiatric nurse practitioners or mental health case managers who could implement mental health care as part of the general medical service. We did not include studies that only examined consultation or liaison models of psychiatric care, as this model of care did not meet our definition of IMCs.
Psychosomatics ]:], ] 2014
Hussain and Seitz Data Extraction Each abstract and article was reviewed independently by the 2 authors. We extracted information on study characteristics, patient characteristics, and outcomes. For study characteristics, we extracted information on study setting, description of the IMCs, and comparison model of care, and the study design. Patient characteristics included mean age, gender distribution, psychiatric diagnoses, and admitting medical diagnoses. We also extracted information on psychiatric outcomes (e.g., change in depression symptoms and cognition), medical outcomes (e.g., mortality and physical functioning) and health service outcomes (e.g., LOS and inpatient costs) where these were reported. Assessment of Study Quality The Cochrane Effective Practice and Organisation of Care risk of bias tool was utilized to describe the potential risk of bias with various aspects of study design,23 which included method of sequence generation, concealment of allocation, similarity of outcome measures, similarity of baseline characteristics, incomplete outcome data, blinding, protection against contamination, selective outcome reporting, and other potential sources of bias. Each item was rated as being at “low,” “high,” or “unclear” risk of bias. Data Synthesis We summarized participant demographic data and diagnoses in tables. We planned to conduct a metaanalysis of outcomes if the studies meeting the inclusion criteria were homogeneous in study design and outcomes measured. However, the heterogeneity of the included studies precluded a meta-analysis of outcomes. RESULTS Study Selection The flow of studies through the review process is illustrated in the Figure. A total of 959 citations were obtained by an electronic search, of which, 867 articles were excluded after reviewing titles and abstracts; 68 citations were identified through handsearches and 157-full text articles were retrieved and reviewed for Psychosomatics ]:], ] 2014
eligibility. After reviewing full-text articles, 4 studies met the inclusion criteria,24–27 which included 2 randomized controlled trials,24,26 one interrupted time series study,25 and one controlled before-andafter study.27 Characteristics of Included Studies Characteristics of Participants in Included Studies The characteristics of participants in the included studies are summarized in Table 1. There were a total of 716 individuals included in the studies with a mean study sample size of 179.0 (standard deviation [SD] ¼ 53.9). The characteristics of the patients in the individual studies varied; the mean age of participants ranged from 52.8 years27 to 82.5 years.24 The gender distribution reflected the proportion of female participants ranging between 41.9%25 and 70.1%.26 Mood disorders were one of the most common psychiatric diagnoses in most studies, at 51%25 and 45%,27 with anxiety disorders (54%)27 and substance-related disorders (31%)25 also being commonly reported. Cardiovascular disorders were the most common medical diagnoses in 3 studies,24,26,27 with other diagnostic categories, such as respiratory, gastrointestinal, and neurologic disorders, being less common. Description of IMCs The IMCs identified in these 4 studies used different models of care (Table 2). In the study by Slaets et al., patients randomized to the IMC received care from a specialized multidisciplinary geriatric medicine team consisting of a geriatrician trained in geriatric psychiatry, a geriatric liaison nurse, and a physiotherapist, as well as additional medical nursing staff.24 The IMC provided integrated multidisciplinary assessments and treatment plans, discharge planning, and postdischarge follow-up. There was regular communication between the members of the IMC, nursing staff, and patients. The IMC had weekly multidisciplinary meetings with the health care providers responsible for the patients in addition to having their own weekly rounds. Kishi and Kathol described an IMC as part of an internal medicine service that integrated general internists and psychiatrists in a co-attending model.25 This IMC model consisted of a psychiatrist, general internist, nursing staff with training in both medical www.psychosomaticsjournal.org
3
Integrated Care for Medical Inpatients
FIGURE.
Flow of Studies Through the Review Process. Records identified through database search: MEDLINE: 766 Embase: 981 Total N= 1747
Screened after duplicates removed N= 959
Records excluded after reviewing titles and abstracts: N = 867 Full text articles reviewed from database search: N = 92 Full text hand searched articles identified and reviewed: N = 69 Total full text articles reviewed N= 161 Full text articles excluded: N = 157 Included articles N=4
and psychiatric care, and other allied health staff. The ward for the IMC was modified to accommodate the needs of patients with any degree of medical or psychiatric symptomatology. Baldwin et al.26 conducted a randomized controlled trial comparing a nurse-led mental health liaison intervention with usual care for patients aged 65 years and older who were admitted to 4 general medical wards. The patients assigned to the IMC received mental health assessments, nonpharmacologic interventions, and liaison support from a mental health nurse. The mental health nurse also assisted in identifying individuals with psychiatric disorders on the medical inpatient unit and communicated with medical staff to initiate management. 4
www.psychosomaticsjournal.org
Leue et al.27 conducted a controlled before-andafter study of patients admitted to an IMC that was provided in an internal medicine ward. The ward was capable of treating patients of moderate to severe psychiatric and medical acuity. The IMC consisted of a psychiatrist, gastroenterologist, and cardiologist, as well as a psychologist, occupational therapist, and medical and psychiatric nursing staff. Effects of IMCs on Outcomes Psychiatric Outcomes The outcomes associated with IMCs are summarized in Table 3. One study reported the change in Psychosomatics ]:], ] 2014
Hussain and Seitz
TABLE 1.
Characteristics of Participants in Studies Included in Review
Study
Number Mean Age (SD)
Female Sex, Psychiatric Diagnosis (%) n (%)
Medical Diagnosis (%)
140
82.5 (4.9)
94 (67.1)
NR
97
83.2 (5.1)
73 (75.3)
NR
Congestive heart failure (41.4) Endocrine disorders (28.6) Gastrointestinal disorders (20.0) Congestive heart failure (41.2) Endocrine disorders (26.8) Gastrointestinal disorders (16.5)
Kishi and Kathol25 IMC 105
47 (17)
44 (41.9)
Medication adjustment/adverse drug effects (30.5) Intoxication/poisoning (24.8) Neurologic disorders (19.0)
Control group 105
54 (19)
55 (52.3)
Mood disorders (20.0) Psychosis (9.5) Delirium (9.5) Substance-related disorders (13.3) Substance-related disorders (37.1) Delirium (18.1) Mood disorders (9.5) Dementia (9.5)
Cardiovascular disorders (36.1) CNS disorders (20.8) Respiratory disorder (13.9) Endocrine/metabolic disorders (13.9) Cardiovascular disorders (25.0) Respiratory disorders (20.8) CNS disorders (19.4)
Slaets et al.24 IMC
Control group
Baldwin et al.26 IMC
59
80.6 (7.2)
54 (70.1)
NR
61
80.0 (7.5)
44 (57.9)
NR
32*
52.8 (15.1)
17 (53.1)
Anxiety disorders (54) Mood disorders (45) Somatoform disorders (36)
Control group 117†
52.8 (15.1)
57 (48.7)
Mood disorders (3) Anxiety disorders (2) Psychotic disorders (1) Substance-use disorder (1)
Control group
Leue et al.27 IMC
Gastrointestinal disorders (21.9) Medication adjustment/adverse drug effects (17.1) Pulmonary disorder (14.9)
Circulatory disorders (15) Gastrointestinal disorders (14) Genitourinary disorders (8) Circulatory system (27) Gastrointestinal disorders (7) Genitourinary disorders (7) Respiratory disorders (5)
CNS ¼ central nervous system; IMC ¼ integrated model of care; MPU ¼ medical-psychiatric unit; n ¼ number; NR ¼ not reported, SD ¼ standard deviation. n
†
Patient admitted to MPU only Patients admitted to both IMC and Medical wards.
psychiatric symptom severity using the Global Assessment of Functioning score, which demonstrated a significant improvement in the Global Assessment of Functioning score for patients in the IMC compared with the control group (19.5 vs 11.2 point improvement; P ¼ 0.003).25 Another study used a global measure of psychiatric morbidity, the Health of the Nations Outcome Scales for Elderly People, which showed no significant improvement in the IMC patients compared with the control group on the total score, although patients in the IMC showed more Psychosomatics ]:], ] 2014
improvement on the mood subscore of the Health of the Nations Outcome Scales for Elderly People.26 One of the studies used the Mini-Mental Status Examination to identify patients with cognitive impairment, with no significant changes in cognition noted. This study also examined change in depressive symptoms using the Geriatric Depression Scale.26 At the end of 8 weeks, mean Geriatric Depression Scale scores were lower in the IMC patients as compared with the usual care group (12.2 [SD ¼ 6.2] vs 14.0 [SD ¼ 6.6]; P ¼ 0.043). One study reported on the detection of www.psychosomaticsjournal.org
5
Integrated Care for Medical Inpatients
TABLE 2.
Characterisitics of Integrated Models of Care for Studies Included in Review Country
Study Design
Integrated Model of IMC Health Care Care (IMC) Providers
Slaets et al.24 Netherlands
Randomized controlled trial
Kishi and Kathol25
USA
Interrupted time series
Baldwin et al.26
UK
Randomized controlled trial
Leue et al.27
Netherlands
Controlled beforeand after-study
Multidisciplinary joint treatment by a geriatric team in addition to the usual care on a general medicine ward. “Type IV” integrated medicine and psychiatry treatment program with the provisions of an acute medicine as well as a psychiatric ward. Administered through the department of internal medicine. Nurse-led mental health liaison service in addition to usual care on internal medicine wards. Medical-psychiatric unit located on an internal medicine ward in the gastroenterology section.
Intervention Group Comparison Group
Geriatrician trained Patients aged 75 y in geriatric and older admitted psychiatry, geriatric to an IMC. liaison nurse, and physiotherapist.
Patients aged 75 y and older admitted to a general medicine ward.
Co-attending model with internist, psychiatrist, and nurses trained in medical and psychiatric management.
Mental health Patients aged 65 y liaison nurse in and older admitted addition to the usual to an IMC. care team.
Patients admitted to the general internal medicine, gastroenterology, endocrinology, cardiology, and pulmonary wards identified by nursing supervisors as requiring psychiatric evaluation. Patients aged 65 y and older admitted to a general medicine ward.
Psychiatrist, cardiologist, gastroenterologist, medical and psychiatric nursing staff, psychologist, and occupational therapist.
Similar patient population requiring psychiatric and medical management, but admitted to general medicine wards.
Patients with concurrent active psychiatric and medical comorbidity admitted to the IMC.
Patients admitted to the IMC, having concurrent moderate to severe psychiatric and medical co-morbidity.
IMC ¼ integrated model of care.
psychiatric illness and found that psychiatric disorders were detected more frequently in the IMC compared with the control wards.27 Medical Outcomes Medical outcomes were reported using different methods in the studies. Only one study reported differences in change in medical symptoms, it demonstrated equal improvement in medical symptoms of the IMC patients when compared with the control group using the Karnofsky score.25 Functional outcomes were reported in one study.24 IMC patients showed significantly greater functional improvement across all domains in the measure used, compared with the control group. The authors of one study reported that the rate of detection of medical illnesses on the IMC was the same as on other wards.27 6
www.psychosomaticsjournal.org
Health Service Outcomes Health service outcomes were reported in all studies. One study showed that the LOS was significantly reduced in the IMC (19.7 vs 24.8 d) as compared with the control group.24 This study also investigated the 6-month rehospitalization rate, which was lower for IMC patients when compared with the control group (17.4% vs 29.9%; P ¼ 0.05). One study demonstrated that total LOS was increased in IMC when compared with the control wards (17.5 vs 12.5 d; P ¼ 0.01). However, when the number of days spent on the index ward before transfer to IMC was adjusted, the LOS for the IMC patients was 13.5 (SD ¼ 12.9) compared with 10.5 (SD ¼ 9.7) for the control group, which the authors reported as not being a significant difference.25 The third study showed that the average LOS of IMC patients was comparable to the control group (27.8 vs Psychosomatics ]:], ] 2014
Hussain and Seitz
TABLE 3. Study
Outcomes Associated With Integrated Models of Care Psychiatric Outcomes
Slaets et al.24 IMC NR
Control group Kishi and Kathol25 IMC
Control group
Medical Outcomes
Health Service Outcomes
Global Improvement
Activities of Daily Living
Length of Stay
Medical Costs
Nursing Home Placement
NR
Great improvement across activities of daily living, continence, and mobility.* –
NR
NR
NR
NR
Probability of being placed in a nursing home at 12 mo was 2.5times lower. –
NR
NR
NR
NR
GAF score improvement 19.5 (SD ¼ 20.9)* GAF score improvement 11.2 (SD ¼ 16.3)*
Karnofsky score improvement 24.3 (SD ¼ 19.5)† Karnofsky score improvement 22.4 (SD ¼ 21.4)†
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR NR
NR NR
Baldwin et al.26 IMC Decrease in depression per GDS scores* and mood subscore of HoNOS65þ* No difference in MMSE scores. Control Less improvement in group depression. No difference in MMSE scores. Leue et al.27 IMC NR Control NR group
Increased Decreased
Decreased Increased
NR NR
GAF ¼ global assessment of functioning; GDS ¼ geriatric depression scale; HoNOS65þ ¼ Health of the Nations Outcome Scales for Elderly People; IMC ¼ integrated model of care; MMSE ¼ mini-mental state examination; NR ¼ not reported; SD ¼ standard deviation. n
†
Statistically significant (P r 0.05). Not statistically significant.
29.5; P ¼ 0.76).26 The last study included in the review showed a significantly increased LOS for patients admitted to the IMC compared with the control group (24.1 vs 8.2)27 The authors in this study also reported that costs associated with psychiatric illness were higher on the IMC compared with the control wards, whereas medical costs were lower on the IMC. One study reported that patients admitted to the control wards had a 2.5times greater likelihood of nursing home admission when compared with those admitted to the IMC.24 Quality of Included Studies The risk of bias in the individual studies using the Cochrane Effective Practice and Organisation of Care Psychosomatics ]:], ] 2014
risk of bias tool is summarized in Table 4. The randomized controlled trials24,26 included in the study were at a lower risk of bias for most of the quality assessment parameters, whereas the other 2 studies were at higher potential risk of bias. DISCUSSION Our review identified that there are only a few studies that have evaluated the effect of IMCs for MIPD. The models of care described in the studies included in our review were diverse in terms of the organization of IMCs, patient characteristics, and outcomes examined. IMCs appear to be associated with www.psychosomaticsjournal.org
7
Integrated Care for Medical Inpatients
TABLE 4.
Slaets et al.24 Kishi and Kathol25 Baldwin et al.26 Leue et al.27
Quality of Studies Included in the Review According to the EPOC Criteria23 Allocation Allocation Baseline Sequence Concealment Outcome Measurements
Similar Incomplete Baseline Outcome Characteristics Data
Blinding of Outcome Assessment
Protection against Contamination
Selective Outcome Reporting
Unclear
Unclear
Low
Low
Low
Unclear
Low
Low
High
High
Unclear
High
Low
Low
Low
High
Low
High
Low
Low
Low
High
Low
Low
High
High
High
High
High
Low
Low
Low
EPOC ¼ Effective Practice and Organisation of Care.
improvements in psychiatric symptoms when compared with usual care, however, the effect on medical symptoms was less clear. Health service outcomes associated with IMC demonstrated that LOS, readmissions, and rates of long-term care placement may be reduced by IMCs, although not all studies provided information on these outcomes. There are several ways in which psychiatric care can be delivered to patients in medical inpatient services. In most general medical inpatient settings in the United States and Europe, psychiatric consultation or consultation-liaison models are the most common models of care.28,29 Psychiatric consultation models involve a referral being generated by the general medical service under which the patient is admitted for medical care. The psychiatric service assesses the patient and provides written suggestions to the general medical service. In contrast, liaison psychiatry involves the psychiatric service being more proactive in identifying patients with psychiatric morbidity within a general medical setting.30 Education and regular attendance of rounds is a part of the liaison model.31 Studies show that psychiatric consultations are requested more frequently by specialities that have an established psychiatric liaison service, as compared with those specialties that do not have these services.32 Consultation-liaison psychiatry services incorporate both consultation and liaison. This model has been associated with an increase in accurate diagnoses, reduction in mortality, and reductions in LOS and health service utilization as compared with those patients receiving usual general medical care.33–35 However, there are limitations with the consultation-liaison model of psychiatric care in general 8
www.psychosomaticsjournal.org
hospitals, highlighting the need for more effective models of psychiatric care. Barriers to liaison activities, an integral component of consultation-liaison psychiatry, have been identified.36 A barrier to engagement of psychiatrists in liaison activities may be limited remuneration for these services.37 Other challenges may also be that general medical physicians may be less amenable to some of the psychosocial aspects of psychiatric care. Studies have identified that the concordance with suggestions made by consultation-liaison psychiatry services overall is low, with only 61% of recommendations being followed.38 In addition, referring medical providers are more receptive to pharmacologic recommendations as compared with recommendations involving diagnostic evaluation or nonpharmacologic management.38 An IMC may be one way of improving communication and psychiatric care for patients in medical settings compared with more typical consultation-liaison models. Although there is limited literature on IMCs in medical inpatient settings, IMCs have an extensive evidence base for the delivery of mental health care in primary care settings. Collaborative or integrated psychiatric care, usually involves a psychiatrist or other mental health providers being colocated in primary care settings. There are several psychiatric conditions in which IMCs in primary care settings have been shown to be efficacious. Evidence shows that IMCs for dementia lead to significant improvement in behavioral and psychologic symptoms39 and improved quality of life for older adults in primary care.40 These models have also been demonstrated to improve psychiatric outcomes in patients with late-life depression13; concurrent depression; and diabetes mellitus,41 bipolar Psychosomatics ]:], ] 2014
Hussain and Seitz disorder,42 anxiety disorders,43 and substance-use disorders.44 IMCs in primary care have been shown to be cost-effective45 and to improve medical symptoms.46 Literature from geriatric psychiatry has described joint geriatric psychiatry and geriatric medicine units,47 which have been demonstrated to decrease the use of physical restraints and antipsychotics and can be both clinically effective and cost-effective.47 Therefore, IMCs are increasingly being recognized as effective models of mental health care in primary care outpatient settings and would be expected to demonstrate similar benefits in medical inpatient settings. There are some strengths of our study. To our knowledge, this is the first systematic review of this topic. We used a rigorous and sensitive search strategy to identify as many studies as possible. Our review also provided a detailed description of studies and an assessment of study quality. However, there are some limitations to our review. The first limitation is the small number of studies included in this review. In addition, the study designs and outcome measures were heterogeneous, precluding a meta-analysis of outcomes. We only included English language articles for the ease of review and may have overlooked some studies published in other languages. Finally, patient and health care providers' experience and satisfaction with IMCs were not evaluated in the studies and therefore could not be evaluated. In conclusion, there is some preliminary evidence to support IMCs for MIPD and these models appear to be a promising way to improve care for this complex population. Given the high prevalence of psychiatric disorders in many general medical inpatient settings, IMCs may be feasible in many general medical inpatient environments. Further well-designed studies are needed to investigate their effectiveness on improving psychiatric, medical, and economic outcomes. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
APPENDIX 1. SEARCH STRATEGY FOR MEDLINE AND EMBASE 1. psychiatry/ or gerontopsychiatry/ or liaison psychiatry/ or psychosomatics/ 2. mental disease/ or exp addiction/ or exp adjustment disorder/ or alexithymia/ or exp anxiety disorder/ or autism/ or behavior disorder/ or confusion/ or exp delirium/ or exp dementia/ or exp dissociative disorder/ or emotional disorder/ or learning disorder/ or memory disorder/ or mental instability/ or exp mood disorder/ or neurosis/ or organic brain syndrome/ or organic psychosyndrome/ or exp personality disorder/ or exp psychosexual disorder/ or exp psychosis/ or exp psychosomatic disorder/ or psychotrauma/ or thought disorder/ psychophysiologic disorders. mp. or psychosomatic disorder/ 3. psychiatric department, hospital.mp. or exp psychiatric department/ 4. exp HOSPITALIZATION/ 5. hospital unit.mp. or "hospital subdivisions and components"/ 6. hospital patient/ 7. hospital/ or community hospital/ or general hospital/ or geriatric hospital/ or non profit hospital/ or pediatric hospital/ or private hospital/ or public hospital/ or exp teaching hospital/ 8. COMORBIDITY/ 9. combined modality therapy.mp./ "medical psychiatric unit".mp. [mp¼title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] 10. exp patient referral/ 11. 1 or 2 or 3 12. 4 or 5 or 6 or 7 13. 8 or 9 or 10 14. 11, 12, and 13
References 1. Mayou R, Hawton K: Psychiatric disorder in the general hospital. Br J Psychiatry 1986; 149:172–190 2. Seltzer A: Prevalence, detection and referral of psychiatric morbidity in general medical patients. J R Soc Med 1989; 82:410
Psychosomatics ]:], ] 2014
3. Silverstone PH: Prevalence of psychiatric disorders in medical inpatients. J Ner Ment Dis 1996; 184:43–45 4. Arolt V, Driessen M, Dilling H: The Luebeck General Hospital study. I: prevalence of psychiatric disorders in medical and surgical inpatients. Int J Psychiatry Clin Pract 1997; 1:207–216
www.psychosomaticsjournal.org
9
Integrated Care for Medical Inpatients 5. Martucci M, Balestrieri M, Bisoffi G, et al: Evaluating psychiatric morbidity in a general hospital: a two-phase epidemiological survey. Psychol Med 1999; 29:823–831 6. Freedland KE, Rich MW, Skala JA, Carney RM, DavilaRoman VG, Jaffe AS: Prevalence of depression in hospitalized patients with congestive heart failure. Psychosom Med 2003; 65:119–128 [Research Support, Non-U.S. Gov't Research Support, U.S. Gov't, P.H.S.] 7. Bukberg J, Penman D, Holland JC: Depression in hospitalized cancer patients. Psychosom Med 1984; 46:199–212 8. Royal College of Psychiatrists: Who Cares Wins. London: Royal College of Psychiatry 2005 9. Wancata J, Windhaber J, Bach M, Meise U: Recognition of psychiatric disorders in nonpsychiatric hospital wards. J Psychosom Res 2000; 48:149–155 10. Katon W, Von Korff M, Lin E, et al: Collaborative management to achieve treatment guidelines Impact on depression in primary care. J Am Med Assoc 1995; 273:1026–1031 11. Druss BG, Rohrbaugh RM, Levinson CM, Rosenheck RA: Integrated medical care for patients with serious psychiatric illness: a randomized trial. Arch Gen Psychiatry 2001; 58:861 12. Dobscha SK, Corson K, Perrin NA, et al: Collaborative care for chronic pain in primary care. J Am Med Assoc 2009; 301:1242–1251 13. Unützer J, Katon W, Callahan CM, et al: Collaborative care management of late-life depression in the primary care setting. J Am Med Assoc 2002; 288:2836–2845 14. Bower P, Gilbody S: Managing common mental health disorders in primary care: conceptual models and evidence base. Br Med J 2005; 330:839–842 15. Katon WJ, Seelig M: Population-based care of depression: team care approaches to improving outcomes. J Occup Environ Med 2008; 50:459–467 16. Simon GE, Katon WJ, Lin EHB, et al: Cost-effectiveness of systematic depression treatment among people with diabetes mellitus. Arch Gen Psychiatry 2007; 64:65 17. Wang PS, Patrick A, Avorn J, et al: The costs and benefits of enhanced depression care to employers. Arch Gen Psychiatry 2006; 63:1345 18. Kathol RG, Harsch HH, Hall RC, Shakespeare A: Categorization of types of medical/psychiatry units based on level of acuity. Psychosomatics 1992; 33:376–386 19. Pitt B, Silver C: The combined approach to geriatrics and psychiatry: evaluation of a joint unit in a teaching hospital district. Age Ageing 1980; 9:33–37 20. Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6:e1000097 21. Fogel BS, Stoudemire A: Organization and development of combined medical-psychiatric units: part 2. Psychosomatics 1986; 27:417–428 22. Stoudemire A, Fogel BS: Organization and development of combined medical-psychiatric units: part 1. Psychosomatics 1986; 27:341–345 23. 〈http://epoc.cochrane.org〉
10
www.psychosomaticsjournal.org
24. Slaets J, Kauffmann R, Duivenvoorden H, Pelemans W, Schudel WJ: A randomized trial of geriatric liaison intervention in elderly medical inpatients. Psychosom Med 1997; 59:585–591 25. Kishi Y, Kathol RG: Integrating medical and psychiatric treatment in an inpatient medical setting: the type IV program. Psychosomatics 1999; 40:345–355 26. Baldwin R, Pratt H, Goring H, Marriott A, Roberts C: Does a nurse-led mental health liaison service for older people reduce psychiatric morbidity in acute general medical wards? A randomised controlled trial. Age ageing 2004; 33:472–478 27. Leue C, Driessen G, Strik JJ, et al: Managing complex patients on a medical psychiatric unit: an observational study of university hospital costs associated with medical service use, length of stay, and psychiatric intervention. J Psychosom Res 2010; 68:295–302 28. Lipowski Z: Consultation-liaison psychiatry: the first half century. Gen Hosp Psychiatry 1986; 8:305–315 29. Mayou R, Huyse F: Consultation-liaison psychiatry in Western Europe. Gen Hosp Psychiatry 1991; 13:188–208 30. Strain J: Liaison psychiatry. In: Wise M, Rundell JR, (eds). The American Psychiatric Publishing Text Book of Consultation—Liaison Psychiatry: Psychiatry in the medically ill. 2nd ed. Washington DC: American Psychiatric Publishing; 2002. p. 33–48 31. Malhotra S, Padhy KS: Consultation-liaison psychiatry: conceptual issues. J Ment Health Hum Behav 2012; 17(3 Suppl):S4–S13 32. Schubert DS, Billowitz A, Gabinet L, Friedson W: Effect of liaison psychiatry on attitudes toward psychiatry, rate of consultation, and psychosocial documentation. Gen Hosp Psychiatry 1989; 11:77–87 33. Bourgeois JA, Hilty DM, Servis ME, Hales RE: Consultation-liaison psychiatry: advantages for healthcare systems. Dis Manage Health Outcomes 2005; 13:93–106 34. Hales RE: The benefits of a psychiatric consultation-liaison service in a general hospital. Gen Hosp Psychiatry 1985; 7:214–218 35. Friedman RS, Molay F: A history of psychiatric consultation in America. Psychiatr Clin North Am 1994; 17:667–681 36. Lipowski Z: Consultation-liaison psychiatry: past failures and new opportunities. Gen Hosp Psychiatry 1979; 1:3–10 37. Fenton BJ, Guggenheim FG: Consultation-liaison psychiatry and funding: why can't alice find wonderland? Gen Hosp Psychiatry 1981; 3:255–260 38. Huyse FJ, Strain JJ, Hammer JS: Interventions in consultation/liaison psychiatry: part II: concordance. Gen Hosp Psychiatry 1990; 12:221–231 39. Callahan CM, Boustani MA, Unverzagt FW, et al: Effectiveness of collaborative care for older adults with Alzheimer disease in primary care. J Am Med Assoc 2006; 295:2148–2157 40. Vickrey BG, Mittman BS, Connor KI, et al: The effect of a disease management intervention on quality and outcomes
Psychosomatics ]:], ] 2014
Hussain and Seitz of dementia care. A randomized, controlled trial. Ann Intern Med 2006; 145:713–726 41. Katon WJ, Von Korff M, Lin EH, et al: The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry 2004; 61:1042 42. Bauer M, McBride L, Williford W, et al: Collaborative care for bipolar disorder: part II. Impact on clinical outcome, function, and costs. Psychiatric Serv 2006; 57:937–945 43. Katon WJ, Roy-Byrne P, Russo J, Cowley D: Costeffectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder. Arch Gen Psychiatry 2002; 59:1098
Psychosomatics ]:], ] 2014
44. Bartels SJ, Coakley EH, Zubritsky C, et al: Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. Am J Psychiatry 2004; 161:1455–1462 45. Unutzer J, Katon WJ, Fan M-Y, et al: Long-term cost effects of collaborative care for late-life depression. Am J Manag Care 2008; 14:95–100 [page 2] 46. Katon WJ, Lin EH, Von Korff M, et al: Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010; 363:2611–2620 47. George J, Adamson J, Woodford H: Joint geriatric and psychiatric wards: a review of the literature. Age ageing 2011; 40:543–548
www.psychosomaticsjournal.org
11
