Effects of a Multi-Faceted Psychiatric Intervention Targeted at the Complex Medically Ill: a Randomized Controlled Trial
Condition: Rheumatoid Arthritis; Diabetes
MeSH terms: Arthritis; Arthritis, Rheumatoid
Study type: Interventional
Phase: Phase 4

Summary: 
      Background: somatic patients with psychiatric co-morbidities are a major challenge for the
      health care system. This study evaluated a psychiatric intervention targeted at the complex
      medically ill identified by means of the INTERMED, an instrument to assess case complexity.

      Methods: of 885 rheumatology inpatients and diabetes outpatients who were assessed for
      eligibility, 247 were identified as complex (INTERMED score > 20) and randomized to the
      intervention (N=125, 84 rheumatology and 41 diabetes patients) or care as usual (N=122, 78
      rheumatology and 44 diabetes patients). Intervention consisted of counseling by a psychiatric
      nurse, referral to a liaison psychiatrist, or a multidisciplinary case conference. Baseline
      and follow up at months 3, 6, 9 and 12 measured prevalence of major depression (MINI),
      depressive symptoms (CES-D), physical and mental health (SF-36), quality of life (EuroQol),
      hospitalizations (rheumatology patients) and HbA1c levels (diabetic patients).
    

Detailed description: 
      Of the 885 that assessed for eligibility (see Figure 2), 184 (20.8%) met exclusion criteria,
      such as not speaking French (N=43), severe cognitive disturbances (N=27) or hospitalization
      for less than 3 days (N=28); 6.2% refused to participate (N=55). Of the remaining patients
      (N= 701), 64.8% (N=454) did not qualify as complex patients (INTERMED score < 20). The
      remaining 247 patients were randomized, 125 (84 rheumatology inpatients and 41 diabetes
      outpatients) to the intervention and 122 to care as usual (78 rheumatology inpatients and 44
      diabetes outpatients). With regard to sociodemographics and baseline measurements (including
      the above mentioned strata of the rheumatology patients and the different types of diabetes),
      intervention and care as usual group did not differ at baseline (see Table 1). More than half
      of the sample (61% of the intervention group and 56% of the care as usual group) suffered
      from major depression.

      In the intervention arm, most patients (N = 107) received an intervention conducted by the
      psychiatric liaison nurse; the interventions, effectuated as single interventions or
      combined, consisted of "facilitating emotional expression" (73%), "giving practical advice"
      (71%), "promoting life narrative" (48%) and "providing psycho-educational interventions"
      (44%). For about half of the patients in the intervention group (N = 76) also other types of
      interventions were proposed, such as referral to a liaison psychiatrist (N = 36), psychiatric
      advice to the treating physician (N = 32) or interdisciplinary case conferences (N = 8). A
      minority of patients (N=13) did not receive any treatment (due to no indication for a
      psycho-social intervention or patients lacking motivation) (N=13). The liaison nurses, who
      effectuated the intervention and organized psychiatric referral, psychiatric advice to the
      treating physician and interdisciplinary case conferences, were supervised weekly for an hour
      by a senior psychiatrist (FS) or an experienced psychiatric liaison nurse (YD).

      Between 62% and 70% of the patients of the intervention arm and between 57% to 69% of
      patients of the usual care arm provided complete follow up data at the four time points (see
      Figure 2). Patients with missing data did not differ from patients with complete data with
      regard to age, sex, educational and professional status, baseline quality of life and
      depression on each of the four follow up assessments.

      Effects of intervention

      In Table 2 and Figures 3-7, comparisons between patients in the intervention arm on and usual
      care arm on the main outcomes are presented. Overall, the intervention was associated with
      less depression and higher levels of quality of life during follow up. Using statistical
      tests to evaluate differences at each of the separate follow up points, statistically
      significant differences are observed with regard to the prevalence of major depression at 12
      months, physical health at 3 months and quality of life at 3, 6, and 12 months (see Table 2).
    

Intervention name(s): Multi-faceted psychiatric intervention
Intervention type(s): Behavioral
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single
Primary purpose: Treatment
Keywords: Case complexity; INTERMED; Consultation liaison psychiatry; depression