Article

Effects of a Multifaceted Psychiatric Intervention Targeted for the Complex Medically Ill: A Randomized Controlled Trial

May 2008
Psychotherapy and Psychosomatics 77(4):247-56

May 2008
77(4):247-56

DOI:10.1159/000129658

Source
PubMed

Authors:

Friedrich Stiefel

University of Lausanne

Show all 8 authorsHide

This study evaluated a multifaceted psychiatric intervention targeted at the complex medically ill identified by means of the INTERMED, an instrument to assess case complexity. 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). For the majority of the cases the multifaceted intervention consisted of an intervention conducted by a psychiatric liaison nurse and/or of referral to a liaison psychiatrist, followed by advice to the treating physician or organization of a multidisciplinary case conference. Baseline and follow-up at months 3, 6, 9 and 12 measured prevalence of major depression (Mini-International Neuropsychiatric Interview), depressive symptoms (Center for Epidemiological Studies Depression Rating Scale), physical and mental health (SF-36), quality of life (EuroQol), health care utilization and HbA(1c) levels (diabetic patients). Prevalence of major depression was reduced from 61% (T0) to 28% (T4) in the intervention group and remained stable in care as usual (57% at T0 to 50% at T4). Compared to care as usual, significant improvement over time was observed in the intervention group with regard to depressive symptoms (F = 11.9; p = 0.001), perception of physical (F = 5.7; p = 0.018) and mental health (F = 3.9; p = 0.047) and quality of life (F = 21.8; p < 0.001). Effects tended to be stronger in diabetes patients, in patients with baseline major depression and in patients with moderate INTERMED scores. Finally, hospital admissions occurred less often in the intervention group, reaching statistical significance for the period between 6 and 9 months of follow-up (p = 0.02). The results suggest that a psychiatric intervention targeted for complex medical patients can improve health outcomes.

A scoping Review of tools used to assess patient Complexity in rheumatic disease

Article

Full-text available

Feb 2021
HEALTH EXPECT

Objective Patients with rheumatic diseases often have multiple comorbidities which may impact well‐being leading to high psychosocial complexity. This scoping review was undertaken to identify complexity measures/tools used in rheumatology that could help in planning and coordinating care. Methods MEDLINE, EMBASE and CINAHL were searched from database inception to 14 December 2019 using keywords and Medical Subject Headings for “care coordination”, “complexity” and selected rheumatic diseases and known complexity measures/tools. Articles describing the development or use of complexity measures/tools in patients with adult rheumatologic diagnoses were included regardless of study design. Included articles were evaluated for risk of bias where applicable. Results The search yielded 407 articles, 37 underwent full‐text review and 2 were identified during a hand search with 9 included articles. Only 2 complexity tools used in populations of adult patients with rheumatic disease were identified: the SLENQ and the INTERMED. The SLENQ is a 97‐item patient needs questionnaire developed for patients with systemic lupus (n = 1 study describing tool development) and applied in 5 cross‐sectional studies. Three studies (a practice article, trial and a cross‐sectional study) applied the INTERMED, a clinical interview to ascertain complexity and support coordinated care, in patients with rheumatologic diagnoses. Conclusions There is limited information on the use of patient complexity measures/tools in rheumatology. Such tools could be applied to coordinate multidisciplinary care and improve patient experience and outcomes. Patient contribution This scoping review will be presented to patient research partners involved in co‐designing a future study on patient complexity in rheumatic disease.

Evaluation der deutschsprachigen Version des „INTERMED-Self-Assessment“– Fragebogens (IM-SA) zur Erfassung von Patienten mit komplexem Versorgungsbedarf

Article

Jan 2016

Biopsychosocial aspects and the complexity of care of hospitalized elderly

Article

Full-text available

Oct 2014

Objective To investigate the biopsychosocial aspects and aspects of the health system of hospitalized elderly and to classify their degree of care complexity. Methods This was a quantitative study whose convenience sample consisted of 279 elderly. The Interdisciplinary Medicine Instrument (INTERMED) method was used, a tool that identified biopsychosocial aspects and conditions of the health system and classified the complexity of the patient. The data were submitted to descriptive analysis. Results The prevailing profile was of elderly women, retired, white, with low educational levels, married and satisfied with their life conditions. The mean age was 72.3 years. The biological domain was the most compromised. As for the complexity of care, 34.8% of the patients required multiprofessional care. Conclusion The elderly had high care complexity, with the biological and health system domains being the most compromised.

Assessment of biopsychosocial complexity and health care needs: measurement properties of the INTERMED self-assessment version (IMSA)

Article

Dec 2016
PSYCHOSOM MED

Objectives: The INTERMED Self-Assessment questionnaire (IMSA) was developed as an alternative to the observer-rated INTERMED (IM) to assess biopsychosocial complexity and health care needs. We studied feasibility, reliability and validity of the IMSA within a large and heterogeneous international sample of adult hospital in- and outpatients, and its predictive value for health care utilization (HCU) and quality of life (QoL). Methods: 850 participants aged 17 to 90 from 5 countries completed the IMSA and were evaluated with the IM. The following measurement properties were determined: feasibility by percentages of missing values; reliability by Cronbach's alpha; interrater agreement by intraclass correlation coefficients (ICCs); convergent validity of IMSA scores with mental health (SF-36 emotional well-being subscale and HADS), medical health (CIRS) and QoL (EQ-5D) by Spearmans rank correlations; predictive validity of IMSA scores with HCU and QoL by (generalized) linear mixed models. Results: Feasibility, face validity and reliability (Cronbach's alpha 0.80) were satisfactory. ICC between IMSA and IM total scores was .78 (95% CI .75-.81). Correlations of the IMSA with the SF-36, HADS, CIRS and EQ-5D (convergent validity) were -.65, .15, .28 and -.59, respectively. The IMSA significantly predicted QoL and also HCU (emergency room visits, hospitalization, outpatient visits, and diagnostic exams) after 3 and 6 months follow-up. Results were comparable between hospital sites, in- and outpatients, and age groups. Conclusion: The IMSA is a generic and time-efficient method to assess biopsychosocial complexity and to provide guidance for multidisciplinary care trajectories in adult patients, with good reliability and validity across different cultures.

[Evaluation of the German Version of the "INTERMED-Self-Assessment"-Questionnaire (IM-SA) to Assess Case Complexity]

Article

May 2016

Introduction: The INTERMED- interview (IM-CAG=INTERMED complexity assessment grid) is a well validated instrument for the identification of complex patients in need of integrated health care (score ≥21). The IM-SA (INTERMED self-assessment)-questionnaire, derived from the INTERMED- interview, was developed in cooperation with the international INTERMED group in order to facilitate its use in various clinical settings and to foster the patients' perspective on health-care needs. Methods: The German version of the IM-SA was evaluated in a clinical sample (n=136) of psychosomatic outpatients and compared to the IM-CAG. Construct validity was examined by analyzing the correlations of the IM-SA with quality-of-life (SF-36) and anxiety/depression (HADS). Sensitivity and specificity for the identification of complex patients were examined by using ROC (Receiver Operating Characteristic) analysis. Results: The correlations between the total score and the subscales of the IM-SA, compared to the INTERMED, were high (total score r=0.79 (95%-KI: [0.70; 0.85]). Cronbach's α was 0.77, and construct validity was high (SF-36 mental component score: r=-0.57; HADS Depression: r=0.59). The IM-SA total score was significantly lower compared to IM-CAG, mainly because of low IM-SA scores in the somatic domain. According to ROC analysis, the IM-SA-cut-off for identifying complex patients has to be lowered (score ≥17). Discussion: The IM-SA can be used as an instrument to identify complex patients in need of integrated bio-psycho-social care. Conclusion: The IM-SA is a reliable instrument to be used in various clinical settings to identify complex patients and to provide integrated, bio-psycho-social care.

BMI Course Over 10 Years After Bariatric Surgery and Biopsychosocial Complexity Assessed with the INTERMED: a Retrospective Study

Article

Full-text available

Sep 2021
OBES SURG

Background While bariatric surgery is an effective therapy for patients with severe obesity, not all patients benefit equally. An explanation might be that psychosocial risk factors hamper outcome. The study aimed to evaluate if biopsychosocial case complexity predicts evolution of BMI over 10 years after bariatric surgery. Methods Charts of patients ( N = 236) of the Cohort of Obesity Lausanne (COOL) were retrospectively reviewed and rated with the INTERMED, a reliable and validated instrument, which assesses biopsychosocial case complexity and has been proven to predict outcome of medical treatments in different patient populations. The sample was stratified into BMI quartiles, computed from the patients’ baseline BMI. For each quartile, BMI evolution was analyzed using individual growth curve analysis. Results Growth curve analyses showed that in quartiles 1, 2, and 3, none of the INTERMED domain scores significantly predicted the BMI evolution after surgery. However, in the fourth quartile—including patients with the highest pre-surgical BMI—the social domain score of the INTERMED significantly predicted BMI evolution: patients with more social complexity showed higher increase in BMI. Conclusion Effectiveness of interventions targeted at social complexity, especially when patients suffer from severe obesity, may therefore be evaluated in future studies. Graphical abstract

Psychiatric and Psychosomatic Consultation-Liaison Services in General Hospitals: A Systematic Review and Meta-Analysis of Effects on Symptoms of Depression and Anxiety

Article

Jan 2020
PSYCHOTHER PSYCHOSOM

Background: Psychiatric and psychosomatic consultation-liaison services (CL) are important providers of diagnosis and treatment for hospital patients with mental comorbidities and psychological burdens. Objective: To perform a systematic review and meta-analysis investigating the effects of CL on depression and anxiety. Methods: Following PRISMA guidelines, a systematic literature search was conducted until 2017. Included were published randomized controlled trials using CL interventions with adults in general hospitals, treatment as usual as control groups, and depression and/or anxiety as outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Level of integration was assessed using the Standard Framework for Levels of Integrated Healthcare. Meta-analyses were performed using random effects models and meta-regression for moderator effects. Results: We included 38 studies (9,994 patients). Risk of bias was high in 17, unclear in 15, and low in 6 studies. Studies were grouped by type of intervention: brief interventions tailored to the patients (8), interventions based on specific treatment manuals (19), and integrated, collaborative care (11). Studies showed small to medium effects on depression and anxiety. Meta-analyses for depression yielded a small effect (d = -0.19, 95% CI: -0.30 to -0.09) in manual studies and a small effect (d = -0.33, 95% CI: -0.53 to -0.13) in integrated, collaborative care studies, the latter using mostly active control groups with the possibility of traditional consultation. Conclusions: CL can provide a helpful first treatment for symptoms of depression and anxiety. Given that especially depressive symptoms in medically ill patients are long-lasting, the results underline the benefit of integrative approaches that respect the complexity of the illness.

Método INTERMED para pacientes com transtornos mentais

Article

Full-text available

Jul 2019

Modelo do estudo: Revisão integrativa da literatura. Objetivo: Analisar evidências científicas disponíveis na literatura sobre a utilização do método INTERMED pela equipe multidisciplinar em pacientes com transtornos mentais. Metodologia: A seleção de artigos foi realizada nas bases de dados National Library of Medicine (PubMed), American Psychological Association (PsycINFO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) e Scientific Eletronic Library Online (SciELO). Resultados: Ao final, cinco estudos concentrados entre 2000 e 2008, foram selecionados para análise. Os artigos analisados mostraram que o método INTERMED teve resultados positivos na identificação de pacientes que precisam de cuidados complexos, o que direcionou a realização de intervenções psiquiátricas rápidas que diminuíram o tempo de permanência no ambiente hospitalar, o número de internações melhorou a qualidade de vida dos pacientes e, consequentemente, diminuiu custos com a saúde. Conclusão: Os estudos analisados mostraram que há poucas evidências sobre o tema investigado. O método INTERMED tem boa aplicabilidade junto a outros instrumentos e foi eficaz na identificação de pacientes que precisam de cuidados complexos.

Wirksamkeit von psychiatrischen, psychosomatischen und medizinpsychologischen Konsiliar-Liaisondiensten auf die globale, psychische und physische Lebensqualität von Patienten: Systematisches Review und Metaanalyse

Conference Paper

Mar 2019

Einleitung: Ein wesentliches Ziel psychiatrischer, psychosomatischer und medizinpsychologischer Konsiliar-Liaison (C-L) Dienste ist die Verbesserung der Lebensqualität von körperlich kranken Patienten mit psychischen Belastungen und psychischen Komorbiditäten. Mit vorliegendem systematischen Review soll die Wirksamkeit von C-L Diensten auf allgemeine, psychische und physische Lebensqualität metaanalytisch untersucht werden. Methodik: Im Rahmen der Erstellung der S3-Leitlinie fand eine systematische Literaturrecherche zur Wirksamkeit von C-L Diensten statt. Publizierte Arbeiten kamen für das Review infrage, wenn sie Ergebnisse von C-L Interventionen bei erwachsenen Patienten im Allgemeinkrankenhaus anhand von randomisiert kontrollierten oder kontrollierten klinischen Studien berichteten. Effektstärken wurden nach Cohen (1988). Daten zur Lebensqualität sollten aggregiert für globale, psychische oder physische Lebensqualität vorliegen. Die Studien wurden nach Grad der Integration des C-L Dienstes, Intensität der Intervention, Biasrisiko, Berufsgruppen, Setting (sektorenübergreifend oder ausschließlich im Krankenhaus), sowie Art der Kontrollgruppe (übliche Behandlung oder möglicher Kontakt mit C-L Dienst) beurteilt. Die Metaanalysen wurden mit Random-Effects Modellen, die Moderatoranalysen mit Metaregressionen berechnet. Ergebnisse: Die systematische Literatursuche lieferte 2973 Ergebnisse, wovon k = 20 Studien mit 5324 Patienten inkludiert wurden. Von diesen konnten k = 17 in der Metaanalyse verwendet werden. Für alle untersuchten Dimensionen der Lebensqualität fanden sich jeweils kleine Effekte: Global (9 Studien): d = 0.26 (95% CI: 0.10, 0.41); Psychische Dimension (11 Studien): d = 0.33 (95% CI: 0.13, 0.52); Körperliche Dimension (9 Studien): d = 0.24 (95% CI: 0.07, 0.41) bei geringer bis mittlerer Heterogenität. Die Einflüsse der Moderatorvariablen wurden nicht signifikant. Fazit: Das Review belegt die Wirksamkeit von C-L Diensten auf die Lebensqualität von Patienten mit kleinen Effektstärken.

Psychiatric and Psychosomatic Consultation-Liaison Services in General Hospitals: Systematic Review and Meta-Analysis of Effects on Depression and Anxiety

Article

Jun 2018
J PSYCHOSOM RES

Aim: The present systematic review is part of the development of guidelines for psychiatric and psychosomatic consultation-liaison (C-L) services for patients with comorbid medical and mental disorders or psychological burdens in general hospitals. It focuses on one research question: Are C-L services in general hospitals effective for patients concerning symptoms of depression and anxiety at the end of the intervention? Methods: A systematic literature search, screening of all relevant S3-level guidelines, hand searches, and expert surveys were conducted from 2009-2011 with an update in 2016. The following PICOS criteria were used: Population: adults in general hospitals; Intervention: C-L interventions; Comparison: control group design with treatment as usual or attention placebo; Outcomes: depression and anxiety; Studies: randomized controlled trials or controlled clinical trials. Methodological quality was assessed using the Cochrane Risk of Bias Tool. Studies were classified for level of integration of the C-L service using the Standard Framework for Integrated Healthcare (Heath et al., 2013). Random effects models were used to calculate average effect sizes across studies. Moderator analyses were calculated using meta-regression. Results: 43 studies met the inclusion criteria, including 10443 patients. The effect size for depression was d = 0.31 (95% CI: 0.21 to 0.41), and d = 0.19 (95% CI: 0.10 to 0.28) for anxiety. Heterogeneity was very low for anxiety (I² = 0%) and moderate for depression (I² = 63.26%). Level of integration and quality of evidence reduced this heterogeneity, with weaker effect sizes when screening was added to consultation (level 4) as compared to C-L services without screening (level 3) and services with higher levels of integration (level 5, e.g. collaborative care models). The strongest evidence for reduction in depression was found for level 5. Conclusions: The results show that C-L services are effective for reducing symptoms of depression and anxiety in the general hospital, with stronger results for high levels of integration.

Immunosuppressive therapy after solid-organ transplantation: does the INTERMED identify patients at risk of poor adherence?

Article

Full-text available

Dec 2016

Background Lack of adherence to medication is a trigger of graft rejection in solid-organ transplant (SOT) recipients. Objective This exploratory study aimed to assess whether a biopsychosocial evaluation using the INTERMED instrument before transplantation could identify SOT recipients at risk of suboptimal post-transplantation adherence to immunosuppressant drugs. We hypothesized that complex patients (INTERMED>20) might have lower medication adherence than noncomplex patients (INTERMED≤20). Methods Each patient eligible for transplantation at the University Hospital of Lausanne, Switzerland, has to undergo a pre-transplantation psychiatric evaluation. In this context the patient was asked to participate in our study. The INTERMED was completed pre-transplantation, and adherence to immunosuppressive medication was monitored post-transplantation by electronic monitors for 12 months. The main outcome measure was the implementation and persistence to two calcineurin inhibitors, cyclosporine and tacrolimus, according to the dichotomized INTERMED score (>20 or ≤20). Results Among the 50 SOT recipients who completed the INTERMED, 32 entered the study. The complex (N=11) and noncomplex patients (N=21) were similar in terms of age, sex and transplanted organ. Implementation was 94.2% in noncomplex patients versus 87.8% in complex patients (non-significant p-value). Five patients were lost to follow-up: one was non-persistent, and four refused electronic monitoring. Of the four patients who refused monitoring, two were complex and withdrew early, and two were noncomplex and withdrew later in the study. Conclusion Patients identified as complex pre-transplant by the INTERMED tended to deviate from their immunosuppressant regimen, but the findings were not statistically significant. Larger studies are needed to evaluate this association further, as well as the appropriateness of using a nonspecific biopsychosocial instrument such as INTERMED in highly morbid patients who have complex social and psychological characteristics.

An Advocacy for the Academic Underpinning of Psychiatric Liaison

Article

Dec 2023

An Advocacy for the Academic Underpinning of Psychiatric Liaison

Article

Dec 2023

Céline Bourquin

Translation and Cross-Cultural Adaptation of the Japanese Version of the INTERMED Self-Assessment Questionnaire (IMSA) for Patient-Case Complexity Assessment

Article

Full-text available

Dec 2022

Purpose: This study aims to translate and ensure cross-cultural adaptation of a Japanese version of the INTERMED Self-Assessment Questionnaire (IMSA). Methods: A family medicine physician, a medical education specialist, a psychiatrist who prepared the Japanese version of the INTERMED, and two members of the INTERMED consortium were selected as committee members. We used the standard forward and backward translation method to translate the IMSA into Japanese. After translating the original IMSA into Japanese, all committee members discussed and reached a consensus on the proposed translation. The back-translation was performed by an English native professional translator who did not know the original text. We contacted the INTERMED consortium and asked them to review the conceptual equivalence of the back-translated Japanese version with the original version; after two reviews, the members approved the Japanese version. Thereafter, we conducted cognitive debriefings with four patients and nine healthcare professionals to ensure cross-cultural adaptation. Results: The members of the INTERMED consortium approved the use of the Japanese version. We modified some expressions and words, while retaining the original meaning, to make it easier for Japanese patients to understand. Conclusion: We developed a Japanese version of the IMSA. A future study will investigate the construct criterion-related validity and the reliability of the scale.

The impact of Mental Health Nurse Consultants on the care of general hospital patients experiencing concurrent mental health conditions: An integrative literature review

Article

Full-text available

Mar 2022
Int J Ment Health Nurs

Mental Health Nurse Consultants are advanced practice mental health nurses who consult with nurses and other health professionals in a general hospital setting. The aim of this review was to analyse and synthesize the available evidence related to the impact of Mental Health Nurse Consultants on the care of general hospital patients experiencing concurrent mental health conditions. The integrative literature review method was utilized as it allows for the inclusion and integration of quantitative, qualitative, and mixed methods research which produces a synthesized understanding of data to inform practice, policy, and research. The Preferred Reporting Items of Systematic Review and Meta-Analyses guided the search strategy. All published studies examining the impact of clinical consultations provided by Mental Health Nurse Consultants on the mental health care of general hospital patients were included. The 19 selected articles were from North America, Australia, the United Kingdom, and Europe. Fifteen were quantitative, three were qualitative, and one used mixed methods. The findings highlight the role is generally positively received by hospital staff. The results indicate that clinical consultations provided by Mental Health Nurse Consultants (i) may improve patient experiences of mental health conditions, (ii) influence aspects of care delivery, (iii) are valued by staff, particularly nurses, and (iv) increase staff competence and confidence in the provision of mental health care. The review highlighted significant limitations of the available evidence, the need for contemporary discussion and debate of MHNC theory and practice, and further evaluation of the role to inform future service delivery.

The impact of disease severity on the psychological well-being of youth affected by an inborn error of metabolism and their families: A one-year longitudinal study

Article

Full-text available

Dec 2021

Background: Inborn errors of metabolism (IEMs) refer to rare heterogeneous genetic disorders with various clinical manifestations that can cause serious physical and psychological sequelae. Results of previous studies on the impact of an IEM on health-related quality of life (HR-QoL) were incongruent and only few studies considered more broadly the psychological well-being of children with IEM and their families. Our objectives were to examine: (1) the impact of the IEM severity on the HR-QoL and psychological functioning of patients and their parents at baseline; and (2) its evolution over time; and (3) the correlation between parental and children's perspectives. Methods: The sample included 69 pediatric patients (mean age = 7.55 y, SD = 4.59) with evaluations at baseline and after one year. We collected data on HR-QoL, child mental health and emotional regulation as well as on parental mood and stress using different validated questionnaires. IEM severity was rated by a clinician through the biological subdomain of the pediatric INTERMED instrument. Results: Two groups of patients based on IEM severity scores were created (n = 31 with low and n = 38 with moderate/high IEM severity). The two groups differed with respect to age, diet and supplement intake. IEM severity had an impact on HR-QoL and behavioral symptoms in children, as well as on HR-QoL and stress in parents. For patients with moderate/high IEM severity, child and parental HR-QoL improved after 1-year of follow-up. We did not observe any significant difference between evaluations by patients versus parents. Conclusions: Our findings demonstrate that moderate/high IEM severity altered child and parental psychological well-being, but also revealed a significant improvement after one-year follow-up. This observation suggests that patients with a moderate/high IEM severity and their families benefit from the care of an interdisciplinary team including a child psychologist specialized in IEMs. Moreover, in patients with higher IEM severity there may also be more room for improvement compared to patients with low IEM severity. Future studies should focus on observations over a larger time span, particularly during adolescence, and should include objective measurements.

Assessing the perspective of well-being of older patients with multiple morbidities by using the LAVA tool - a person-centered approach

Article

Full-text available

Jul 2021
BMC Geriatr

Background Older patients with multiple morbidities are a particularly vulnerable population that is likely to face complex medical decisions at some time in their lives. A patient-centered medical care fosters the inclusion of the patients’ perspectives, priorities, and complaints into clinical decision making. Methods This article presents a short and non-normative assessment tool to capture the priorities and problems of older patients. The so-called LAVA (“Life and Vitality Assessment”) tool was developed for practical use in seniors in the general population and for residents in nursing homes in order to gain more knowledge about the patients themselves as well as to facilitate access to the patients. The LAVA tool conceptualizes well-being from the perspectives of older individuals themselves rather than from the perspectives of outside individuals. Results The LAVA tool is graphically presented and the assessment is explained in detail. Exemplarily, the outcomes of the assessments with the LAVA of three multimorbid older patients are presented and discussed. In each case, the assessment pointed out resources as well as at least one problem area, rated as very important by the patients themselves. Conclusions The LAVA tool is a short, non-normative, and useful approach that encapsulates the perspectives of well-being of multimorbid patients and gives insights into their resources and problem areas.

Title: Health Complexity Assessment in Primary Care: a validity and feasibility study of the INTERMED tool. Short title: Health complexity in PHC assessed by INTERMED

Preprint

Full-text available

Nov 2020

Background While considerable attention has been devoted to patients’ health complexity epidemiology, comparatively less attention has been paid to tools to identify and describe, in a personalized and comprehensive way, “complex patients” in primary health care (PHC). Objective To evaluate INTERMED tool’s validity and feasibility to assess health complexity in PHC. Design Cross-sectional psychometric study. Setting Three Brazilian PHC Units. Participants 230 patients above 18 years of both sexes. Measurements Spearman’s rho assessed concurrent validity between the whole INTERMED and their four domains (biological, psychological, social, health system) with other well-validated instruments. Pearson’s X ² measured associations of the sum of INTERMED “current state” items with use of PHC, other health services and medications. Cronbach’s Alpha assessed internal consistency. INTERMED acceptability was measured through patients’ views on questions and answers’ understanding and application length as well as objective application length. Applicability was measured through patients’ views on its relevance to describe health aspects essential to care and INTERMED’s items-related information already existing in patients’ health records. Results 18.3% of the patients were “complex” (INTERMED’s 20/21 cut-off). Spearman’s correlations located between 0.44 - 0.65. Pearson’s coefficients found were X ² = 26.812 and X ² = 26.883 (both p = 0.020) and X2 = 28.270 (p = 0.013). Cronbach’s Alpha was 0.802. All patients’ views were very favorable. Median application time was 7 minutes and 90% of the INTERMED’s interviews took up to 14 minutes. Only the biological domain had all its items described in more than 50% of the health records. Limitations We utilized the cutoff point used in all previous studies, found in research performed in specialized health services. Conclusion We found good feasibility (acceptability and applicability), and validity measures comparable to those found from specialized health services. Further investigations of INTERMED predictive validity and suitability for routine PHC use are worthwhile.

Psychological morbidity in interstitial lung disease: a study from India

Article

Full-text available

Oct 2020

Evaluation of mental health in chronic lung diseases like interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD) has always been neglected and underrated. The aim of the study was to determine the psychological morbidity in patients of ILD and to determine its various socio-clinical and psychological correlates. A cross-sectional clinic based descriptive study with 50 ILD patients, 30 COPD patients and 30 healthy controls was undertaken. Psychological distress was assessed using different psychological scales, like General Health Questionnaire-12 (GHQ-12), Patient Distress Thermometer (PDT), Coping Strategy Checklist (CSCL), WHO Quality of Life-Brief-26 (WHOQOL-Bref-26) and Depression Anxiety Stress Scale (DASS). The patients with a GHQ-12 score of ≥3 were considered as experiencing psychological distress and additionally referred to consultant psychiatrist for further detailed evaluation and management. Fifty-eight percent of ILD patients and 60% of COPD patients experienced psychological distress after screening with GHQ-12; 40% of all the ILD and COPD patients were ultimately diagnosed with a psychiatric disorder, after evaluation by the psychiatrist. Patients of ILD and COPD had significantly higher scores on GHQ-12, CSCL and DASS, and significantly lower scores on WHOQOL-Bref-26 when compared with healthy controls. However, these scores, including PDT did not differ significantly between ILD and COPD patients. The scores on all these scales in the patients of ILD and COPD who were experiencing psychological distress (GHQ ≥3) were significantly poorer than those without psychological distress (GHQ

The self-assessment INTERMED predicts healthcare and social costs of orthopaedic trauma patients with persistent impairments

Article

Full-text available

Aug 2020

Objective To use the self-assessment INTERMED questionnaire to determine the relationship between biopsychosocial complexity and healthcare and social costs of patients after orthopaedic trauma. Design Secondary prospective analysis based on the validation study cohort of the self-assessment INTERMED questionnaire. Setting Inpatients orthopaedic rehabilitation with vocational aspects. Subjects In total, 136 patients with chronic pain and impairments were included in this study: mean (SD) age, 42.6 (10.7) years; 116 men, with moderate pain intensity (51/100); suffering from upper ( n = 55), lower-limb ( n = 51) or spine ( n = 30) pain after orthopaedic trauma; with minor or moderate injury severity (severe injury for 25). Main measures Biopsychosocial complexity, assessed with the self-assessment INTERMED questionnaire, and other confounding variables collected prospectively during rehabilitation. Outcome measures (healthcare costs, loss of wage costs and time for fitness-to-work) were collected through insurance files after case settlements. Linear multiple regression models adjusted for age, gender, pain, trauma severity, education and employment contract were performed to measure the influence of biopsychosocial complexity on the three outcome variables. Results High-cost patients were older (+3.6 years) and more anxious (9.0 vs 7.3 points at HADS-A), came later to rehabilitation (+105 days), and showed higher biopsychosocial complexity (+3.2 points). After adjustment, biopsychosocial complexity was significantly associated with healthcare (ß = 0.02; P = 0.003; exp ß = 1.02) and social costs (ß = 0.03; P = 0.006, exp ß = 1.03) and duration before fitness-to-work (ß = 0.04; P < 0.001, exp ß = 1.04). Conclusion Biopsychosocial complexity assessed with the self-assessment INTERMED questionnaire is associated with higher healthcare and social costs.

Psychosomatic Psychiatry in Spain: Historical Notes and the State of the Art

Chapter

Jul 2019

This chapter reviews the important historical background of what we call in Spain Psychosomatic Psychiatry (PP), or Psychosomatic and Liaison Psychiatry (PLP). Both medical humanism and empirical, or evidence based science are crucial philosophical ingredients in present day developments. Different theories born in other countries are also apparent, and include the so called “anthropological” medicine, or the “cortico-visceral” medical models. In the approach to medical patients, the Johns Hopkins “perspectives” are prominent. Among the current dominant trends, the influence of the American, consultation-liaison (C-L) model has been crucial. However, the implant of psychiatric services in all general hospitals of the National Health Service (NHS) was decisive to make available the C-L activities. The chapter also reviews some early research movements in the field, the foundation of a specialized journal and the role of national associations. The chapter highlights the notable development of the discipline, since a recent national enquiry shows that close to 60% of NHS hospitals in Spain have a PLP Unit; the advances in education, the crucial one being the mandatory rotation in PLPU’s in the official, national training program in Psychiatry; and the vigorous teaching of psychiatry directed to general physicians in medical schools. Important research initiatives include the organization of National Networks, which have recruited research groups publishing systematically in international, high impact journals. Specific areas of PLP interest in this country are related to Primary Care, Medical Ethics, Psycho-Oncology and Medical Sexology, all of them with qualified representatives. The discipline aims at an eventual, official sub-specialization in Psychiatry. In this background, it has been argued that the future will depend fundamentally on the vision and compromise of the psychiatric Services and Departments; on the commitment and leadership of the psychiatrists; and, certainly, on the advances in research and innovation.

Management of depression in diabetes: A review of psycho-social interventions

Article

Full-text available

Jun 2013

Diabetes and depression are major public health problems associated with significant burden. They share many commonalities. Both the diseases have a very high prevalence, mortality, and disability. The current article reviews the available evidence on psycho-social interventions in management of depression in diabetes. A literature search was performed using MEDLINE, PubMed, PsycINFO, Embase, and Cochrane Review for English language articles published during 1960-2012. There is limited published literature on role of psycho-social interventions in management of depression among diabetics. The available evidence suggests that psycho-social interventions, particularly CBT, are effective in improving depression in patients with diabetes. However, these interventions are not consistently associated with improvement in markers of glycemia control (HbA1c levels).

A short intervention targeting psychosomatic care in older adults with complex health care needs- results of a randomized controlled trial

Article

Oct 2018

Objective The aim of this randomized controlled trial (RCT) was to assess the efficacy of a short intervention targeting psychosomatic care in older adults with complex health care needs. Methods Participants were recruited in the frame of the 11‐year follow‐up of a large population‐based study by means of the INTERMED interview. The INTERMED‐interview is an integrative assessment method to identify bio‐psycho‐social health care needs. Persons with high health care needs (interview score ≥ 17) were invited to take part. Participants were randomized with a 1:1 ratio to a control and an intervention group. The intervention group received a home visit conducted by a doctor trained in psychosomatic medicine. The primary hypothesis stated that the intervention group would have a better outcome with respect to health related quality of life (HRQOL) measured by the 12‐Item Short‐Form Health Survey (mental component score, MCS) six months after randomization (T1). Secondary outcomes were physical HRQOL, health care needs, depression, anxiety, and somatic symptom severity. Results In total, 175 participants were included. At the three‐year follow‐up (T2), 97 participants (55.4 %) were included. At T1, we did not find a difference regarding MCS between the intervention and control groups. At T2, the intervention group showed significantly lower health care needs compared to the control group. Regarding HRQOL, depression, and somatic symptom severity the two groups did not differ at T2. Conclusions The primary hypothesis was not confirmed. However, results indicate that a short intervention with complex patients could lead to reduced bio‐psycho‐social health care needs.

Les déterminants biopsychosociaux de la qualité de vie subjective des patients diabétiques

Article

Apr 2017
ANN MED-PSYCHOL

Résumé La qualité de vie subjective des patients diabétiques peut être déterminée par une interaction des facteurs biologiques, sociaux et psychologiques. Cette conception de l’individu est reconnue dans la pratique clinique, mais peu de travaux ont étudié ses bénéfices de manière quantitative. Dans une approche locale, on examine l’influence de chaque facteur sur la qualité de vie. À l’inverse, dans une approche Bio-Psycho-Sociale ou globale, la qualité de vie est appréhendée au regard de l’interaction de ces différents facteurs. L’étude a inclus 28 patients diabétiques hospitalisés. Pour la qualité de vie, l’évaluation a été réalisée avec l’échelle SF-36. Pour les facteurs qui influencent la qualité de vie, l’outil INTERMED a été utilisé. Il a été démontré que chaque facteur est associé de manière négative, et statistiquement significative, à la qualité de vie subjective. De plus, l’interaction des facteurs permet de mieux expliquer cette qualité de vie que la simple prise en compte de n’importe quel facteur pris isolément. Ces résultats soulignent la nécessité de prendre en charge les éléments psychosociaux auprès des patients afin d’assurer au mieux le vécu subjectif de leur état de santé.

VALIDITY OF THE INTERMED COMPLEXITY ASSESSMENT WITH OLDER PATIENTS IN A JAPANESE GENERAL HOSPITAL

Article

Full-text available

Jan 2016

Objective: The purpose of this study was to investigate the cross-cultural validity of the Japanese version of the INTERMED assessment instrument, designed to evaluate bio-psycho-social complexity of patient populations. Patient complexity is an important variable in relation to effectiveness of treatments and health-related expenses. And in the current investigation, the age variable contributed to complexity. Method: The INTERMED was applied to 56 consecutively admitted patients with a mean age of 73.4 years old. A two-stage cluster analysis was then employed. Results: This revealed three subtypes of patients: (1) males with comparatively low levels of complexity, (2) females mainly with biological indicators of complexity, and (3) multi-domain complex patients. Cluster 3 patients had significantly longer lengths of hospital stay, greater mortality, and the higher medical charges than the other two groups. Conclusions: These findings suggest that at-risk, complex patients in Japan can be validly identified by the INTERMED thus supporting cross-cultural generalizability of the instrument.

The biopsychosocial screening of transplant patients by means of the INTERMED

Article

Jul 2005
J PSYCHOSOM RES

ASSESSING PSYCHOSOCIAL VULNERABILITY AND CARE NEEDS OF TRANSPLANT PATIENTS BY MEANS OF THE INTERMED

Data

Full-text available

Dec 2015

Identification of components of health complexity on internal medicine units by means of the INTERMED method

Article

Aug 2015
INT J CLIN PRACT

The INTERMED was developed for the early identification of biological, psychological, social and health system factors considered interacting in health complexity. This is defined as the interference with the achievement of expected or desired health and service use outcomes when patients are exposed to standard care. The aim of this study was to test the INTERMED's ability to identify 'case' and 'care' complexity, identifying patients that would especially benefit from integrated care. Observational longitudinal study of Internal medicine in patients in two National Health System hospitals in Spain using the INTERMED (patients scoring ≥ 21 were considered to be 'complex'); the Cumulative Illness Rating Scale (CIRS), a severity of illness assessment; and standard clinical variables. Six hundred and fifteen consecutives were included, and the prevalence of health complexity was 27.6%. The greatest differences between patients with and without health complexity were observed in the non-biological domains. Eighty-five per cent of patients with health complexity had non-biological items considered to require timely (immediately or soon) assistance or intervention compared to 30% of those without, nearly a threefold difference. Complex patients had a significantly higher number of medical diagnoses (p = 0.002) and number of psychiatric referrals (p = 0.041), but there were no differences in CIRS scores or lengths of stay. The INTERMED has the potential to identify a considerable subset of complex internal medicine inpatients for which timely corrective action related to non-biological risk factors not typically uncovered during standard medical evaluations would be considered beneficial. © 2015 John Wiley & Sons Ltd.

Management of depression in diabetes: A review of psycho-social interventions

Article

Full-text available

Jan 2013

Complexity in palliative care inpatients: prevalence and relationship with provision of care, a retrospective study

Preprint

Full-text available

Mar 2024

Context: Palliative car aims to provide comprehensive care, since end of life can be marked by somatic, psycho-social and spiritual distress, requiring interdisciplinary care. However, interdiscoplinary care is costly, and palliative care services, as all other medical services, get under pressure to be as cost-effective as possible. Objectives To describe the case complexity of palliative care inpatients, to evaluate possible correlations between complexity and provision of care and to identifycomplexity subgroups. Methods Patients (N = 222) hospitalized in a specialized palliative care unit (Switzerland) were assessed regarding their biopsychosocial case complexity by means of the INTERMED. Based on a chart review, INTERMED scores were determined at admission and the end of hospitalization/death. Descriptive statistics and Pearson correlation coefficients were estimated for the association between biopsychosocial case complexity and amount and type of care provided. A principal component analysis (PCA) was conducted to explain variance and to identify patient subgroups. Results Almost all patients (98.7 %) qualified as complex as indicated by the INTERMED. Provision of care correlated positively (r=0.23, p=0.0008) with the INTERMED scores upon admission. The change of INTERMED score during stay correlated negatively with provided care (r=-0.27, p=0.0001). PCA performed with two factors explained 49% of the total variance and identified two subgroups which differed regarding the psychosocial item scores of the INTERMED. Conclusion Specialized palliative care inpatients show the highest complexity score of all populations assessed up to now with the INTERMED. Correlations between biopsychosocial complexity and care provided, and between care and decrease of complexity scores, can be considered as an indicator for care efficiency. Patient subgroups with specific needs (psychosocial burden) suggest that palliative care teams need specialized staff. Trial registration The study was accepted August 24, 2023 by the ethics committee of the Canton of Vaud (CER-VD 2023-01200).

Consultation-Liaison Psychiatry: Four International Perspectives

Chapter

Dec 2023

Consultation-liaison psychiatry has evolved rapidly in the last decade, with significant expansion of services across the UK. Now in its third edition, Seminars in Consultation-Liaison Psychiatry provides a current, comprehensive, practically orientated guide that covers clinical topics, education, service development, audit and research. New and updated chapter topics cover the presentation, diagnosis, and management of common conditions, and chapters on organisational topics provide insights into developing and managing the context within which practice takes place. Each chapter is informed by the latest research while remaining hands-on in its focus, structured around common clinical scenarios that liaison staff encounter in hospital settings. A practical guide, this book is packed with essential reading for clinicians working at the interface between mental and physical healthcare.

Diabetes mellitus

Chapter

Jan 2023

Hans-Peter Kapfhammer

Diabetes mellitus zählt zu den Krankheitsgruppen mit den höchsten Risiken einer vorzeitigen Mortalität. Vor allem für den Typ-2 Diabetes ist weltweit ein Anstieg der Inzidenzraten zu beobachten. Ätiopathogenese und Pathophysiologie von Typ-1 und Typ-2 Diabetes unterscheiden sich wesentlich. Beide teilen sich aber gemeinsame Spätkomplikationen im Krankheitsverlauf. Koexistente affektive und Stress-bezogene Störungen sind bei beiden Formen des Diabetes mellitus erhöht und mit je bedeutsamen negativen Effekten auf den Krankheitsverlauf assoziiert. Vorausgehende psychische Störungen und Stressfaktoren nehmen einen differentiellen Einfluss auf das jeweilige somatische Erkrankungsrisiko. Zu den Interaktionen zwischen psychischer und somatischer Komorbidität existieren detaillierte biopsychosoziale Erkenntnisse. Trotz einiger ermutigender Resultate erweisen sich sowohl Psychotherapien als auch Pharmakotherapien in der Behandlung von koexistenten affektiven und Stress-bezogenen Störungen bei Diabetes mellitus als weniger wirksam als ohne diesen somatische Krankheitskontext. Um den biologischen Krankheitsverlauf nachhaltig zu beeinflussen, genügen beide psychologischen und medikamentösen Verfahren je alleine nicht. Eine Änderung langfristig etablierter ungesunder Verhaltensweisen ist am ehesten durch gezielte gesundheitspsychologische Ansätze im Rahmen integrativer Versorgungsmodelle zu erreichen.

Definition of patient complexity in adults: A narrative review

Article

Full-text available

Feb 2022

Background Better identification of complex patients could help to improve their care. However, the definition of patient complexity itself is far from obvious. We conducted a narrative review to identify, describe, and synthesize the definitions of patient complexity used in the last 25 years. Methods We searched PubMed for articles published in English between January 1995 and September 2020, defining patient complexity. We extended the search to the references of the included articles. We assessed the domains presented in the definitions, and classified the definitions as based on (1) medical aspects (e.g., number of conditions) or (2) medical and/or non-medical aspects (e.g., socio-economic status). We assessed whether the definition was based on a tool (e.g., index) or conceptual model. Results Among 83 articles, there was marked heterogeneity in the patient complexity definitions. Domains contributing to complexity included health, demographics, behavior, socio-economic factors, healthcare system, medical decision-making, and environment. Patient complexity was defined according to medical aspects in 30 (36.1%) articles, and to medical and/or non-medical aspects in 53 (63.9%) articles. A tool was used in 36 (43.4%) articles, and a conceptual model in seven (8.4%) articles. Conclusion A consensus concerning the definition of patient complexity was lacking. Most definitions incorporated non-medical factors in the definition, underlining the importance of accounting not only for medical but also for non-medical aspects, as well as for their interrelationship.

Prevention of depression in adults with long-term physical conditions

Article

Mar 2021

Background: Major depression is one of the world's leading causes of disability in adults with long-term physical conditions compared to those without physical illness. This co-morbidity is associated with a negative prognosis in terms of increased morbidity and mortality rates, increased healthcare costs, decreased adherence to treatment regimens, and a substantial decline in quality of life. Therefore, preventing the onset of depressive episodes in adults with long-term physical conditions should be a global healthcare aim. In this review, primary or tertiary (in cases of preventing recurrences in those with a history of depression) prevention are the focus. While primary prevention aims at preventing the onset of depression, tertiary prevention comprises both preventing recurrences and prohibiting relapses. Tertiary prevention aims to address a depressive episode that might still be present, is about to subside, or has recently resolved. We included tertiary prevention in the case where the focus was preventing the onset of depression in those with a history of depression (preventing recurrences) but excluded it if it specifically focused on maintaining an condition or implementing rehabilitation services (relapse prevention). Secondary prevention of depression seeks to prevent the progression of depressive symptoms by early detection and treatment and may therefore be considered a 'treatment,' rather than prevention. We therefore exclude the whole spectrum of secondary prevention. Objectives: To assess the effectiveness, acceptability and tolerability of psychological or pharmacological interventions, in comparison to control conditions, in preventing depression in adults with long-term physical conditions; either before first ever onset of depressive symptoms (i.e. primary prevention) or before first onset of depressive symptoms in patients with a history of depression (i.e. tertiary prevention). Search methods: We searched the Cochrane Common Mental Disorders Controlled Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO and two trials registries, up to 6 February 2020. Selection criteria: We included randomised controlled trials (RCTs) of preventive psychological or pharmacological interventions, specifically targeting incidence of depression in comparison to treatment as usual (TAU), waiting list, attention/psychological placebo, or placebo. Participants had to be age 18 years or older, with at least one long-term physical condition, and no diagnosis of major depression at baseline (primary prevention). In addition, we included studies comprising mixed samples of patients with and without a history of depression, which explored tertiary prevention of recurrent depression. We excluded other tertiary prevention studies. We also excluded secondary preventive interventions. Primary outcomes included incidence of depression, tolerability, and acceptability. Secondary outcomes included severity of depression, cost-effectiveness and cost-utility. Data collection and analysis: We used standard methodological procedures expected by Cochrane. Main results: We included 11 RCTs, with one trial on psychological interventions, and 10 trials on pharmacological interventions. Data analyses on the psychological intervention (problem-solving therapy compared to TAU) included 194 participants with age-related macular degeneration. Data analyses on pharmacological interventions included 837 participants comparing citalopram (one trial), escitalopram (three trials), a mixed sample of fluoxetine/nortriptyline (one trial), melatonin (one trial), milnacipran (one trial), and sertraline (three trials), each to placebo. Included types of long-term physical conditions were acute coronary syndrome (one trial), breast cancer (one trial), head and neck cancer (two trials), stroke (five trials), and traumatic brain injury (one trial). Psychological interventions Very low-certainty evidence of one study suggests that problem solving therapy may be slightly more effective than TAU in preventing the incidence of depression, immediately post-intervention (odds ratio (OR) 0.43, 95% confidence interval (CI) 0.20 to 0.95; 194 participants). However, there may be little to no difference between groups at six months follow-up (OR 0.71, 95% CI 0.36 to 1.38; 190 participants; one study; very low-certainty evidence). No data were available regarding incidence of depression after six months. Regarding acceptability (drop-outs due to any cause), slightly fewer drop-outs occurred in the TAU group immediately post-intervention (OR 5.21, 95% CI 1.11 to 24.40; 206 participants; low-certainty evidence). After six months, however, the groups did not differ (OR 1.67, 95% CI 0.58 to 4.77; 206 participants; low-certainty evidence). This study did not measure tolerability. Pharmacological interventions Post-intervention, compared to placebo, antidepressants may be beneficial in preventing depression in adults with different types of long-term physical conditions, but the evidence is very uncertain (OR 0.31, 95% CI 0.20 to 0.49; 814 participants; nine studies; I2 =0%; very low-certainty evidence). There may be little to no difference between groups both immediately and at six months follow-up (OR 0.44, 95% CI 0.08 to 2.46; 23 participants; one study; very low-certainty evidence) as well as at six to 12 months follow-up (OR 0.81, 95% CI 0.23 to 2.82; 233 participants; three studies; I2 = 49%; very low-certainty evidence). There was very low-certainty evidence from five studies regarding the tolerability of the pharmacological intervention. A total of 669 adverse events were observed in 316 participants from the pharmacological intervention group, and 610 adverse events from 311 participants in the placebo group. There was very low-certainty evidence that drop-outs due to adverse events may be less frequent in the placebo group (OR 2.05, 95% CI 1.07 to 3.89; 561 participants; five studies; I2 = 0%). There was also very low-certainty evidence that drop-outs due to any cause may not differ between groups either post-intervention (OR 1.13, 95% CI 0.73 to 1.73; 962 participants; nine studies; I2 = 28%), or at six to 12 months (OR 1.13, 95% CI 0.69 to 1.86; 327 participants; three studies; I2 = 0%). Authors' conclusions: Based on evidence of very low certainty, our results may indicate the benefit of pharmacological interventions, during or directly after preventive treatment. Few trials examined short-term outcomes up to six months, nor the follow-up effects at six to 12 months, with studies suffering from great numbers of drop-outs and inconclusive results. Generalisation of results is limited as study populations and treatment regimes were very heterogeneous. Based on the results of this review, we conclude that for adults with long-term physical conditions, there is only very uncertain evidence regarding the implementation of any primary preventive interventions (psychological/pharmacological) for depression.

Psychiatric Comorbidity and Complex Regional Pain Syndrome Through the Lens of the Biopsychosocial Model: A Comparative Study

Article

Full-text available

Dec 2020

Purpose: To compare the prevalence of psychiatric comorbidity between patients with complex regional pain syndrome (CRPS) of the hand and non-CRPS patients and to assess the association between biopsychosocial (BPS) complexity profiles and psychiatric comorbidity in a comparative study. Patients and methods: We included a total of 103 patients with CRPS of the hand and 290 patients with chronic hand impairments but without CRPS. Psychiatric comorbidities were diagnosed by a psychiatrist, and BPS complexity was measured by means of the INTERMED. The odds ratios (OR) of having psychiatric comorbidities according to BPS complexity were calculated with multiple logistic regression (adjusted for age, sex, and pain). Results: Prevalence of psychiatric comorbidity was 29% in CRPS patients, which was not significantly higher than in non-CRPS patients (21%, relative risk=1.38, 95% CI: 0.95 to 2.01 p=0.10). The median total scores of the INTERMED were the same in both groups (23 points). INTERMED total scores (0-60 points) were related to an increased risk of having psychiatric comorbidity in CRPS patients (OR=1.46; 95% CI: 1.23-1.73) and in non-CRPS patients (OR=1.21; 95% CI: 1.13-1.30). The four INTERMED subscales (biological, psychological, social, and health care) were correlated with a higher risk of having psychiatric comorbidity in both groups. The differences in the OR of having psychiatric comorbidity in relation to INTERMED total and subscale scores were not statistically different between the two groups. Conclusion: The total scores, as well as all four dimensions of BPS complexity measured by the INTERMED, were associated with psychiatric comorbidity, with comparable magnitudes of association between the CRPS and non-CRPS groups. The INTERMED was useful in screening for psychological vulnerability in the two groups.

The development of pathways for responding to patient complexity in a liaison psychiatry setting

Article

Jul 2020

Objectives The aims were to develop and operationalise a method of identifying patients at increased risk of adverse outcomes due to clinical and systems complexity within consultation-liaison psychiatry (CLP), and to formalise escalation processes for enhanced input with targeted clinical and organisational support. Methods The literature pertaining to methods for identifying and responding to complexity in general hospital settings was reviewed. An Escalation Tool operationalising the identification of complexity and response pathways was devised and tested. Feedback on the face validity and utility guided refinement. Results Two established tools that assess complexity, INTERMED and the Patient-Centred Accreditation method (PCAM) and a novel ‘episode complexity’ screening method, were identified and informed the development of a tool for identifying and responding to complexity, which was then piloted. The tool was deemed useful, notwithstanding variability in scoring. Conclusions The Escalation Tool combined elements of existing measures to identify complexity in general hospital inpatients and guide pathways for action. It was well received and considered feasible for implementation, with local adaptation according to available resources.

Psychosomatic Features, Compliance, and Complementary Therapies in Rheumatoid Arthritis

Article

Dec 2019
Curr Rheumatol Rev

This review highlights the issue of psychosomatic conditions in rheumatoid arthritis, paying a special attention to new researches and trends in this field. Emerging concepts in all the major parts of the problem are covered consecutively, from the impact of chronic musculoskeletal pain on emotional state to disease influence over quality of life, socio-psychological, and interpersonal relationships. Chronic pain is closely related to emotional responses and coping ability, with pronounced positive effect of psychotherapeutic interventions, family and social support on it. Psychosexual disorders, anxiety, depression also commonly coexist with rheumatoid arthritis, leading to further decrease of quality of life, low compliance, and high suicide risk. Influence of psychosomatic conditions on overall treatment effect is usually underestimated by rheumatologists and general practitioners. Psychosomatic considerations are of great importance for up-to-date management of rheumatoid arthritis, as they strongly influence quality of life, compliance, and thereby disease outcomes. Two major approaches of psychological rehabilitation exist, both coping with pain through regulation of emotion and psychotherapeutic intervention, which not only helps patients in coping with the disease, but also aimed at improving the overall adaptation of the patient. It includes techniques of relaxation, cognitive-behavioral therapy, and biofeedback therapy. Current data about efficacy of the additional correcting therapies for patients with rheumatoid arthritis, both emerging and common ones, are discussed in the review.

Psychische Störungen bei somatischen Krankheiten

Chapter

Jan 2017

Hans-Peter Kapfhammer

Unique Characteristics of High-Cost Users of Medical Care With Comorbid Mental Illness or Addiction in a Population-Based Cohort

Article

Oct 2017
PSYCHOSOMATICS

Objective: To understand whether high-cost users of medical care with and without comorbid mental illness or addiction differ in terms of their sociodemographic and health characteristics. Unique characteristics would warrant different considerations for interventions and service design aimed at reducing unnecessary health care utilization and associated costs. Methods: From the top 10% of Ontarians ranked by total medical care costs during fiscal year 2011/2012 (N = 314,936), prior 2-year mental illness or addiction diagnoses were determined from administrative data. Sociodemographics, medical illness characteristics, medical costs, and utilization were compared between those high-cost users of medical care with and without comorbid mental illness or addiction. Odds of being a frequent user of inpatient (≥3 admissions) and emergency (≥5 visits) services were compared between groups, adjusting for age, sex, socioeconomic status and medical illness characteristics. Results: High-cost users of medical care with comorbid mental illness or addiction were younger, had a lower socioeconomic status, had greater historical medical morbidity, and had higher total medical care costs (mean excess of $2,031/user) than those without. They were more likely to be frequent users of inpatient (12.8% vs 10.2%; adjusted OR, 1.14; 95% CI: 1.12-1.17) and emergency (8.4% vs 4.8%; adjusted OR, 1.55; 95% CI: 1.50-1.59) services. Effect sizes were larger in major mood, psychotic, and substance use disorder subgroups. Conclusions: High-cost medical care users with mental illness or addiction have unique characteristics with respect to sociodemographics and service utilization patterns to consider in interventions and policies for this patient group.

Mood disorders

Chapter

Mar 2017

This chapter reviews the prevalence and management of mood disorders in older people with diabetes. Patients suffering from depression are likely to be physically inactive and less likely to comply with healthcare recommendations such as diet, exercise, and medications, which may lead to poor glycemic control and increased risk of diabetes complications, with reduced function and increased mortality. Diabetes and depression are inter-related. Hyperglycemia reduces hippocampal integrity, neurogenesis, and neuroplasticity, leading to hippocampal atrophy and contributing to mood symptoms. The Patient Health Questionnaire (PHQ-9) is a brief tool that provides a two-step process to assess the presence of depressive symptoms. In high-income countries (HIC) depression affects around 25% of older people with diabetes, but in low- and middle-income countries (LMIC) the prevalence of depression appears to be higher, averaging around 35.7%. Depression tends to be associated with cognitive dysfunction, which may further compromise patients’ ability to look after themselves.

Psychische Störungen bei somatischen Krankheiten

Chapter

Jan 2015

Hans-Peter Kapfhammer

Psychische Störungen bei somatischen Krankheiten definieren einen Kernsektor der psychosomatischen Medizin. Kognitive wie affektive Veränderungen können gleichermaßen als mögliche komorbide psychopathologische Syndrome im Kontext körperlicher Erkrankungen auftreten. In einer pathogenetischen Perspektive sind sowohl psychosomatische als auch somatopsychische Prozesse zu beachten. Unter den kognitiven Syndromen imponieren in erster Linie Delire. Sie werden zusammen mit weiteren organisch bedingten psychischen Störungen andernorts näher ausgeführt (Kap. Delir, Kap. Organische Psychosyndrome) und hier nur kurz skizziert. Depressiv-ängstliche Störungen stellen die wichtigsten komorbiden affektiven Störungen bei körperlichen Krankheiten dar. Sie sind nicht nur als psychologische Reaktionen auf die Situation der jeweiligen Erkrankung zu verstehen, sondern in ein komplexes psychosomatisches bzw. somatopsychisches Bedingungsgefüge eingebettet. Sie sind besonders häufig bei Erkrankungen des Zentralnervensystems oder mit Beteiligung endokriner und inflammatorisch-immunologischer Systeme, die entscheidend auf die Regulation von Affekten und Stimmung einwirken. Es besteht ein enger Zusammenhang von somatischer und depressiv-ängstlicher Komorbidität im Hinblick auf Chronizität, Schwere und Prognose der Erkrankung. Eigenständige Effekte von diversen pharmakologischen Substanzgruppen sind wahrscheinlich. Beim Verlauf somatischer Erkrankungen sind negative Auswirkungen koexistenter depressiv-ängstlicher Störungen auf die psychosoziale Adaptation, das medizinische Inanspruchnahmeverhalten, die Morbidität und Mortalität zu beachten. Psychotherapeutische Verfahren besitzen einen wichtigen Stellenwert im Gesamtbehandlungsplan. Differenzierte psychoparmakologische Strategien sind für die einzelnen somatischen Erkrankungen unter Kenntnis wichtiger Nebenwirkungen, der Interaktionen mit Internistika und der pathophysiologischen Grundbedingungen der somatischen Erkrankung verfügbar. Kontrollierte empirische Studien zur Wirksamkeit psychotherapeutischer und psychopharmakologischer Behandlungen depressiv-ängstlicher Syndrome bei somatischen Erkrankungen sowie zu Effekten auf den weiteren Krankheitsverlauf erlauben eine erste Orientierung.

Self management interventions for type 2 diabetes in adult people with severe mental illness

Article

Full-text available

Apr 2016

Background: People with severe mental illness are twice as likely to develop type 2 diabetes as those without severe mental illness. Treatment guidelines for type 2 diabetes recommend that structured education should be integrated into routine care and should be offered to all. However, for people with severe mental illness, physical health may be a low priority, and motivation to change may be limited. These additional challenges mean that the findings reported in previous systematic reviews of diabetes self management interventions may not be generalised to those with severe mental illness, and that tailored approaches to effective diabetes education may be required for this population. Objectives: To assess the effects of diabetes self management interventions specifically tailored for people with type 2 diabetes and severe mental illness. Search methods: We searched the Cochrane Library, MEDLINE, EMBASE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the International Clinical Trials Registry Platform (ICTRP) Search Portal, ClinicalTrials.gov and grey literature. The date of the last search of all databases was 07 March 2016. Selection criteria: Randomised controlled trials of diabetes self management interventions for people with type 2 diabetes and severe mental illness. Data collection and analysis: Two review authors independently screened abstracts and full-text articles, extracted data and conducted the risk of bias assessment. We used a taxonomy of behaviour change techniques and the framework for behaviour change theory to describe the theoretical basis of the interventions and active ingredients. We used the GRADE method (Grades of Recommendation, Assessment, Development and Evaluation Working Group) to assess trials for overall quality of evidence. Main results: We included one randomised controlled trial involving 64 participants with schizophrenia or schizoaffective disorder. The average age of participants was 54 years; participants had been living with type 2 diabetes for on average nine years, and with their psychiatric diagnosis since they were on average 28 years of age. Investigators evaluated the 24-week Diabetes Awareness and Rehabilitation Training (DART) programme in comparison with usual care plus information (UCI). Follow-up after trial completion was six months. Risk of bias was mostly unclear but was high for selective reporting. Trial authors did not report on diabetes-related complications, all-cause mortality, adverse events, health-related quality of life nor socioeconomic effects. Twelve months of data on self care behaviours as measured by total energy expenditure showed a mean of 2148 kcal for DART and 1496 kcal for UCI (52 participants; very low-quality evidence), indicating no substantial improvement. The intervention did not have a substantial effect on glycosylated haemoglobin A1c (HbA1c) at 6 or 12 months of follow-up (12-month HbA1c data 7.9% for DART vs 6.9% for UCI; 52 participants; very low-quality evidence). Researchers noted small improvements in body mass index immediately after the intervention was provided and at six months, along with improved weight post intervention. Diabetes knowledge and self efficacy improved immediately following receipt of the intervention, and knowledge also at six months. The intervention did not improve blood pressure. Authors' conclusions: Evidence is insufficient to show whether type 2 diabetes self management interventions for people with severe mental illness are effective in improving outcomes. Researchers must conduct additional trials to establish efficacy, and to identify the active ingredients in these interventions and the people most likely to benefit from them.

Psychische Störungen bei somatischen Krankheiten

Chapter

Jan 2011

Hans-Peter Kapfhammer

Psychische Störungen bei somatischen Krankheiten definieren einen Kernsektor der psychosomatischen Medizin . Kognitive wie affektive Veränderungen können gleichermaßen als mögliche komorbide psychopathologische Syndrome im Kontext körperlicher Erkrankungen auftreten. In einer pathogenetischen Perspektive sind sowohl psychosomatische als auch somatopsychische Prozesse zu beachten. Unter den kognitiven Syndromen imponieren in erster Linie Delire. Sie werden zusammen mit weiteren organisch bedingten psychischen Störungen andernorts näher ausgeführt (► Kap. 46, 48) und hier nur kurz skizziert. Depressiv-ängstliche Störungen stellen die wichtigsten komorbiden affektiven Störungen bei körperlichen Krankheiten dar. Sie sind nicht nur als psychologische Reaktionen auf die Situation der jeweiligen Erkrankung zu verstehen, sondern in ein komplexes psychosomatisches bzw. somatopsychisches Bedingungsgefüge eingebettet. Sie sind besonders häufig bei Erkrankungen des Zentralnervensystems oder endokriner Systeme, die unmittelbar die Regulation von Affekten und Stimmung betreffen. Es besteht ein enger Zusammenhang zur Chronizität, Schwere und Prognose der Erkrankung. Eigenständige Effekte von diversen pharmakologischen Substanzgruppen sind wahrscheinlich. Beim Verlauf somatischer Erkrankungen sind negative Auswirkungen koexistenter depressiv-ängstlicher Störungen auf die psychosoziale Adaptation, das medizinische Inanspruchnahmeverhalt en, die Morbidität und Mortalität zu beachten. Psychotherapeutische Verfahren besitzen einen wichtigen Stellenwert im Gesamtbehandlungs plan. Differenzierte psychopharmakologische Strategien sind für die einzelnen somatischen Erkrankungen unter Kenntnis wichtiger Nebenwirkungen, der Interaktionen mit Internistika und der pathophysiologischen Grundbedingungen der somatischen Erkrankung verfügbar. Kontrollierte empirische Studien zur Wirksamkeit psychotherapeutischer und psychopharmakologischer Behandlungen depressiv-ängstlicher Syndrome bei somatischen Erkrankungen sowie zu Effekten auf den weiteren Krankheitsverlauf erlauben eine erste Orientierung.

Depression and Dementia in Diabetes A dangerous Combination is the Focus of DECODIA grouping in Competence of Diabetes mellitus

Article

Jul 2011
DIABETES STOFFWECH H

Integrated care concepts for patients with diabetes and psychosocial stress

Article

Jan 2011

Despite of extensive efforts to improve the care of patients with diabetes and reducing the costs, the situation still seems to be unsatisfactory: About one third of patients with diabetes are poorly controlled with a HbA1c above 7.5% and have an elevated blood pressure (Icks, Rathmann, Haastert, Mielck, Holle, Löwel, Giani, & Meisinger, 2006). Different investigations demonstrate the high importance of psychosocial stress with regard to the course of treatment as well as to the effects of psychotherapeutic interventions in patients with diabetes and psychosocial stress. Afterwards, an integrated cooperative care model for patients with diabetes and psychosocial stress (psy-PAD) will be presented. The care model is currently being tested and evaluated in cooperation with specialized diabetic outpatient clinics. The intervention includes a manualized coaching and treatment program based on elements of the self-management therapy and problem-oriented psychotherapy within a psychodynamic view. The procedure is illustrated by a case study.

Depression and dementia in patients with diabetes

Article

Jul 2011
DIABETES STOFFWECH H

Consultation liaison in primary care for people with mental disorders

Article

Full-text available

Sep 2015

Background: Approximately 25% of people will be affected by a mental disorder at some stage in their life. Despite the prevalence and negative impacts of mental disorders, many people are not diagnosed or do not receive adequate treatment. Therefore primary health care has been identified as essential to improving the delivery of mental health care. Consultation liaison is a model of mental health care where the primary care provider maintains the central role in the delivery of mental health care with a mental health specialist providing consultative support. Consultation liaison has the potential to enhance the delivery of mental health care in the primary care setting and in turn improve outcomes for people with a mental disorder. Objectives: To identify whether consultation liaison can have beneficial effects for people with a mental disorder by improving the ability of primary care providers to provide mental health care. Search methods: We searched the EPOC Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), and bibliographic databases: MEDLINE, EMBASE, CINAHL and PsycINFO, in March 2014. We also searched reference lists of relevant studies and reviews to identify any potentially relevant studies. Selection criteria: We included randomised controlled trials (RCTs) which compared consultation liaison to standard care or other service models of mental health care in the primary setting. Included participants were people attending primary care practices who required mental health care or had a mental disorder, and primary care providers who had direct contact with people in need of mental health care. Data collection and analysis: Two review authors independently screened the titles and abstracts of identified studies against the inclusion criteria and extracted details including the study design, participants and setting, intervention, outcomes and any risk of bias. We resolved any disagreements by discussion or referral to a third author. We contacted trial authors to obtain any missing information.We collected and analysed data for all follow-up periods: up to and including three months following the start of treatment; between three and 12 months; and more than 12 months following the start of therapy.We used a random-effects model to calculate the risk difference (RD) for binary data and number needed to treat for an additional beneficial outcome (NNTB), if differences between groups were significant. The mean difference (MD) or standardised mean difference (SMD) was calculated for continuous data. Main results: There were 8203 citations identified from database searches and reference lists. We included 12 trials with 2605 consumer participants and more than 905 primary care practitioner participants. Eleven trials compared consultation liaison to standard care and one compared consultation liaison to collaborative care, with a case manager co-ordinating mental health care. People with depression were included in eight trials; and one trial each included people with a variety of disorders: depression, anxiety and somatoform disorders; medically unexplained symptoms; and drinking problems. None of the included trials reported separate data for children or older people.There was some evidence that consultation liaison improved mental health up to three months following the start of treatment (two trials, n = 445, NNTB 8, 95% CI 5 to 25) but there was no evidence of its effectiveness between three and 12 months. Consultation liaison also appeared to improve consumer satisfaction (up to three months: one trial, n = 228, NNTB 3, 95% CI 3 to 5; 3 to 12 months: two trials, n = 445, NNTB 8, 95% CI 5 to 17) and adherence (3 to 12 months: seven trials, n = 1251, NNTB 6, 95% CI 4 to 13) up to 12 months. There was also an improvement in the primary care provider outcomes of providing adequate treatment between three to 12 months (three trials, n = 797, NNTB 7, 95% CI 4 to 17) and prescribing pharmacological treatment up to 12 months (four trials, n = 796, NNTB 13, 95% CI 7 to 50). There was also some evidence that consultation liaison may not be as effective as collaborative care in regards to symptoms of mental disorder, disability, general health status, and provision of treatment.The quality of these findings were low for all outcomes however, apart from consumer adherence from three to 12 months, which was of moderate quality. Eight trials were rated a high risk of performance bias because consumer participants were likely to have known whether or not they were allocated to the intervention group and most outcomes were self reported. Bias due to attrition was rated high in eight trials and reporting bias was rated high in six. Authors' conclusions: There is evidence that consultation liaison improves mental health for up to three months; and satisfaction and adherence for up to 12 months in people with mental disorders, particularly those who are depressed. Primary care providers were also more likely to provide adequate treatment and prescribe pharmacological therapy for up to 12 months. There was also some evidence that consultation liaison may not be as effective as collaborative care in terms of mental disorder symptoms, disability, general health status, and provision of treatment. However, the overall quality of trials was low particularly in regards to performance and attrition bias and may have resulted in an overestimation of effectiveness. More evidence is needed to determine the effectiveness of consultation liaison for people with mental disorders particularly for those with mental disorders other than depression.

Rheumatoid arthritis: Psychosomatic aspects

Article

Mar 2013

The review considers the results of studies of the psychosomatic aspects of rheumatoid arthritis (RA), which have been published in the past 5 years. In particular, there is evidence for the impact of chronic pain on the psychological status of patients with RA, for that of the disease on quality of life in the patients, their sociopsychological and interpersonal relationships; trials of the efficiency of additional treatment options for RA are given.

L’outil : INTERMED et la complexité bio-psycho-sociale

Article

Nov 2014

Marie Guitteny

La plupart des outils utilisés en psychiatrie générale présentent des limites dans l’évaluation des troubles ou symptômes présentés par les patients rencontrés en psychiatrie de liaison. Le concept de « complexité de cas » se montre souvent plus pertinent pour décrire les populations hospitalisées en soins généraux. L’instrument INTERMED, issu du travail de collaboration de psychiatres de liaison et de médecins somaticiens européens, permet d’évaluer les patients dans une perspective bio-psycho-sociale et d’identifier des patients dits complexes, avec un haut degré de comorbidité somatique et psycho-sociale. Ces sous-groupes de patients seraient caractérisés par une réponse diminuée aux traitements et une augmentation de l’utilisation des soins. Se référant à la médecine intégrée, INTERMED est composé de vingt variables, évaluées de manière quantitative sur la base d’un entretien semi-structuré. Le score total définit le degré de complexité du cas et fournit des indications pour l’orientation de la prise en charge, notamment des interventions ciblées sur les patients identifiés comme complexes. Une revue de la littérature permettra de décrire l’outil et de préciser ses différents domaines d’application, qui peuvent concerner les champs de la clinique, de la recherche, de l’enseignement et de l’organisation des systèmes de soins, notamment dans ses aspects médico-économiques. Une population de 91 patients diabétiques hospitalisés en service d’endocrinologie sera décrite en termes de complexité de cas (INTERMED-Complexity Assessment Grid) et une recherche de corrélation avec les symptômes anxieux et dépressifs (Hospital Anxiety and Depression Scale) sera discutée. La prise en compte du malade dans sa complexité permet de tendre vers une approche globale, intégrée, et contribue à renforcer les liens entre intervenants de psychiatrie de liaison et services de soins somatiques.

Société de psychologie médicale et de psychiatrie de liaison (avec le soutien de la FTLSU) – Le malade complexe en psychiatrie de liaison : évaluation, stratégies thérapeutiques et aspects médico-économiques

Article

Nov 2014

La Société de psychologie médicale et de psychiatrie de liaison de langue française souhaite consacrer un symposium à la place grandissante des « malades complexes » en psychiatrie de liaison, situations exigeant plus que toute autre, une intervention multidisciplinaire coordonnée, basée sur des expertises complémentaires, telles qu’elles sont réunies tout particulièrement dans les Centres Hospitalo-Universitaires. Ces situations sont également exemplaires pour aborder les aspects médico-économiques et proposer des pistes pour une valorisation des activités de psychiatrie de liaison. La complexité bio-psycho-sociale des cas rencontrés sera déclinée et approchée : – à l’aide d’outils évaluatifs, comme INTERMED, en cours de validation dans différents pays européens sous sa forme d’auto-questionnaire ; – au travers d’exemples de patients pris en charge dans des secteurs d’excellence comme la chirurgie bariatrique, les greffes cardiaques ou le cœur artificiel, à l’Assistance Publique–Hôpitaux de Paris ou dans d’autres Centres Hospitalo-Universitaires, comme le CHU d’Angers ; – en précisant les rôles respectifs des psychiatres, psychologues, infirmiers de liaison ; – en brossant la diversité des approches thérapeutiques initiées ou envisagées ; – enfin en réfléchissant à l’impact médico-économique de la complexité et des interventions menées pour rendre plus efficient le parcours de soins de ces patients et mieux préserver leur qualité de vie.

The Structure of Self-Reported Health in Chronic Disease Patients

Article

Full-text available

Mar 1990

A multidimensional model of self-reported health status in 1,980 patients with 1 or more chronic medical conditions was evaluated. Two dimensions of health were hypothesized: Physical health was defined by measures of physical functioning, role limitations, satisfaction with physical ability, and mobility; mental health was defined by depression, positive affect, anxiety, and feelings of belonging. Physical and mental health were correlated but distinct, sharing about 20% of variance in common. Correlations of 11 other indicators of health with the physical and mental health constructs corresponded to a priori hypotheses. It is concluded that self-reports of physical and mental health are distinguishable and that both constructs need to be represented for comprehensive assessment of health status. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Application of Hierarchical Linear Models to Assess Change

Article

Full-text available

Jan 1987

Recent advances in the statistical theory of hierarchical linear models should enable important breakthroughs in the measurement of psychological change and the study of correlates of change. A two-stage model of change is proposed here. At the first, or within-subject stage, an individual's status on some trait is modeled as a function of an individual growth trajectory plus random error. At the second, or between-subjects stage, the parameters of the individual growth trajectories vary as a function of differences between subjects in background characteristics, instructional experiences, and possible experimental treatments. This two-stage conceptualization, illustrated with data on Head Start children, allows investigators to model individual change, predict future development, assess the quality of measurement instruments for distinguishing among growth trajectories, and study systematic variation in growth trajectories as a function of background characteristics and experimental treatments. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Validating the SF-36 Health Survey Questionnaire: New Outcome Measure for Primary Care

Article

Full-text available

Aug 1992

To test the acceptability, validity, and reliability of the short form 36 health survey questionnaire (SF-36) and to compare it with the Nottingham health profile. Postal survey using a questionnaire booklet together with a letter from the general practitioner. Non-respondents received two reminders at two week intervals. The SF-36 questionnaire was retested on a subsample of respondents two weeks after the first mailing. Two general practices in Sheffield. 1980 patients aged 16-74 years randomly selected from the two practice lists. Scores for each health dimension on the SF-36 questionnaire and the Nottingham health profile. Response to questions on recent use of health services and sociodemographic characteristics. The response rate for the SF-36 questionnaire was high (83%) and the rate of completion for each dimension was over 95%. Considerable evidence was found for the reliability of the SF-36 (Cronbach's alpha greater than 0.85, reliability coefficient greater than 0.75 for all dimensions except social functioning) and for construct validity in terms of distinguishing between groups with expected health differences. The SF-36 was able to detect low levels of ill health in patients who had scored 0 (good health) on the Nottingham health profile. The SF-36 is a promising new instrument for measuring health perception in a general population. It is easy to use, acceptable to patients, and fulfils stringent criteria of reliability and validity. Its use in other contexts and with different disease groups requires further research.

The Functioning and Well-being of Depressed Patients: Results From the Medical Outcomes Study

Article

Full-text available

Sep 1989

We describe the functioning and well-being of patients with depression, relative to patients with chronic medical conditions or no chronic conditions. Data are from 11,242 outpatients in three health care provision systems in three US sites. Patients with either current depressive disorder or depressive symptoms in the absence of disorder tended to have worse physical, social, and role functioning, worse perceived current health, and greater bodily pain than did patients with no chronic conditions. The poor functioning uniquely associated with depressive symptoms, with or without depressive disorder, was comparable with or worse than that uniquely associated with eight major chronic medical conditions. For example, the unique association of days in bed with depressive symptoms was significantly greater than the comparable association with hypertension, diabetes, and arthritis. Depression and chronic medical conditions had unique and additive effects on patient functioning.

The effects of psychological intervention on recovery from surgery and heart attacks: An analysis of the literature

Article

Full-text available

Mar 1982

A quantitative review of 34 controlled studies demonstrates that, on the average, surgical or coronary patients who are provided information or emotional support to help them master the medical crisis do better than patients who receive only ordinary care. A review of 13 studies that used hospital days post-surgery or post-heart attack as outcome indicators showed that on the average psychological intervention reduced hospitalization approximately two days below the control group's average of 9.92 days. Most of the interventions were modest and, in most studies, were not matched in any way to the needs of particular patients or their coping styles. Beyond the intrinsic value of offering humane and considerate care, the evidence is that psychological care can be cost-effective.

Measuring health status in British patients with rheumatoid arthritis: Reliability, validity and responsiveness of the Short Form 36-Item Health Survey (SF-36)

Article

Full-text available

May 1998

The objective was to assess the performance of the SF-36 health survey (SF-36) in a sample of patients with rheumatoid arthritis (RA) stratified by functional class. The eight SF-36 subscales and the two summary scales (the physical and mental component scales) were assessed for test retest reliability, construct validity and responsiveness to self-reported change in health. In 233 patients with RA, the SF-36 scales were: reliable (intra-class correlation coefficients 0.76-0.93); correlated with American College of Rheumatology (ACR) core disease activity measures [Spearman r = -0.12 (erythrocyte sedimentation rate) to -0.89 (Modified Health Assessment Questionnaire)]; and responsive to improvements in health (standardized response means 0.27-0.9). The distribution of scores on four of the eight subscales (physical function, role limitations physical, role limitations emotional and social function) was clearly non-Gaussian. Very marked floor effects were noted with the physical function scale, and both ceiling and floor effects with the other three subscales. The two SF-36 physical and mental component summary scales are reliable, valid and responsive measures of health status in patients with RA. Six of the eight subscales meet standards required for comparing groups of patients, and the physical function and general health scales may be suitable for monitoring individuals. The two scales measuring role limitations have poor measurement characteristics. The SF-36 pain and physical function scales may be suitable for use as patient self-assessed measures of pain and physical function within the ACR core disease activity set.

Risk Factors for Complex Care Needs in General Medical Inpatients: Results From a European Study

Article

Full-text available

May 2001
PSYCHOSOMATICS

The authors linked admission risk factors to a series of indicators for complex care delivery to enable detection of patients in need of care coordination at the moment of admission to the general hospital. The authors found 13 risk factors to be predictive of more than one indicator of care complexity. An admission risk screening procedure to detect patients in need of care coordination should focus on these risk factors and should include predictions made by doctors and nurses at admission and information collected from the patient and the medical chart.

Care Complexity in the General Hospital Results From a European Study

Article

Full-text available

May 2001
PSYCHOSOMATICS

There is increasing pressure to effectively treat patients with complex care needs from the moment of admission to the general hospital. In this study, the authors developed a measurement strategy for hospital-based care complexity. The authors' four-factor model describes the interrelations between complexity indicators, highlighting differences between length of stay (LOS), objective complexity (such as medications or consultations), complexity ratings by the nurse, and complexity ratings by the doctor. Their findings illustrate limitations in the use of LOS as a sole indicator for care complexity. The authors show how objective and subjective complexity indicators can be used for early and valid detection of patients needing interdisciplinary care.

Article

Full-text available

Apr 2002
DIABETES CARE

To estimate the health-related quality of life (HRQOL) and treatment satisfaction for patients with type 2 diabetes in the Netherlands and to examine which patient characteristics are associated with quality of life and treatment satisfaction. For a sample of 1,348 type 2 diabetes patients, recruited by 29 general practitioners, we collected data regarding HRQOL. This study was performed as part of a larger European study (Cost of Diabetes in Europe - Type 2 [CODE-2]). We used a generic instrument (Euroqol 5D) to measure HRQOL. Treatment satisfaction was assessed using the Diabetes Treatment Satisfaction Questionnaire. Patients without complications had an HRQOL (0.74) only slightly lower than similarly aged persons in the general population. Insulin therapy, obesity, and complications were associated with a lower HRQOL, independent of age and sex. Although higher fasting blood glucose and HbA1c levels were negatively associated with HRQOL, these factors were not significant after adjustment for other factors using multivariate analysis. Overall treatment satisfaction was very high. Younger patients, patients using insulin, and patients with higher HbA1c levels were less satisfied with the treatment than other patients. Obesity and the presence of complications are important determinants of HRQOL in patients with type 2 diabetes.

Diabetes, Depression, and Quality of Life A population study

Article

Full-text available

May 2004
DIABETES CARE

The aim of the study was to assess the prevalence of diabetes and depression and their associations with quality of life using a representative population sample. The study consisted of a representative population sample of individuals aged > or = 15 years living in South Australia comprising 3,010 personal interviews conducted by trained health interviewers. The prevalence of depression in those suffering doctor-diagnosed diabetes and comparative effects of diabetic status and depression on quality-of-life dimensions were measured. The prevalence of depression in the diabetic population was 24% compared with 17% in the nondiabetic population. Those with diabetes and depression experienced an impact with a large effect size on every dimension of the Short Form Health-Related Quality-of-Life Questionnaire (SF-36) as compared with those who suffered diabetes and who were not depressed. A supplementary analysis comparing both depressed diabetic and depressed nondiabetic groups showed there were statistically significant differences in the quality-of-life effects between the two depressed populations in the physical and mental component summaries of the SF-36. Depression for those with diabetes is an important comorbidity that requires careful management because of its severe impact on quality of life.

Integrated Care Programmes for Chronically Ill Patients: A Review of Systematic Reviews

Article

Full-text available

May 2005

To investigate effectiveness, definitions, and components of integrated care programmes for chronically ill patients on the basis of systematic reviews. Literature review from January 1996 to May 2004. Definitions and components of integrated care programmes and all effects reported on the quality of care. Searches in the Medline and Cochrane databases identified 13 systematic reviews of integrated care programmes for chronically ill patients. Despite considerable heterogeneity in interventions, patient populations, and processes and outcomes of care, integrated care programmes seemed to have positive effects on the quality of patient care. No consistent definitions were present for the management of patients with chronic illnesses. In all the reviews the aims of integrated care programmes were very similar, namely reducing fragmentation and improving continuity and coordination of care, but the focus and content of the programmes differed widely. The most common components of integrated care programmes were self-management support and patient education, often combined with structured clinical follow-up and case management; a multidisciplinary patient care team; multidisciplinary clinical pathways and feedback, reminders, and education for professionals. Integrated care programmes seemed to have positive effects on the quality of care. However, integrated care programmes have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programmes and to inappropriate application of research results. To compare programmes and better understand the (cost) effectiveness of the programmes, consistent definitions must be used and component interventions must be well described.

Meta-review of high-quality systematic reviews of interventions in key areas of liaison psychiatry

Article

Full-text available

Sep 2005

When planning and delivering a liaison psychiatry service it is important to have an understanding of the research evidence supporting the use of interventions likely to be delivered by the service. To identify high-quality systematic reviews for all interventions in three defined areas of liaison psychiatry, to summarise their clinical implications and to highlight areas where more research is needed. The three areas were the psychological effects of physical illness or treatment, somatoform disorders and self-harming behaviour. Computerised database searching, secondary reference searching, hand-searching and expert consultation were used to identify relevant systematic reviews. Studies were reliably selected, and quality-assessed, and data were extracted and interpreted by two reviewers. We found 64 high-quality systematic reviews. Only 14 reviews included meta-analyses. Many areas of liaison psychiatry practice are not based on high-quality evidence. More research in this area would help inform development and planning of liaison psychiatry services.

Timing of Psychiatric Consultations

Article

Nov 2000
PSYCHOSOMATICS

The authors examined the timing of patient referrals to a psychiatric consultation-liaison service in relation to the patient's social vulnerability and level of psychiatric dysfunction. One hundred consecutive patients were assessed with the INTERMED, a method to document biopsychosocial and health care-related aspects of disease. Although 30% of patients were referred within the first day of admission, 19% of requests for referrals were made after 2 weeks. Late referral was associated with high social vulnerability and early referral with severe psychiatric dysfunction. The authors illustrate the disadvantages of a psychiatric liaison model focusing on psychopathology alone and demonstrate the need for an integrated patient assessment in the general hospital, focusing on detecting frail elderly patients.

The functioning and well-being of depressed patients. Results from the Medical Outcomes Study

Article

Aug 1989

K. B. Wells

Depression following myocardial infarction. Impact on 6-month survival

Article

Oct 1993

N. Frasure-Smith

Depression Following Myocardial Infarction

Article

Oct 1993

Nancy Frasure-Smith

Objective. —To determine if the diagnosis of major depression in patients hospitalized following myocardial infarction (Ml) would have an independent impact on cardiac mortality over the first 6 months after discharge.Design. —Prospective evaluation of the impact of depression assessed using a modified version of the National Institute of Mental Health Diagnostic Interview Schedule for major depressive episode. Cox proportional hazards regression was used to evaluate the independent impact of depression after control for significant clinical predictors in the data set.Setting. —A large, university-affiliated hospital specializing in cardiac care, located in Montreal, Quebec.Patients. —All consenting patients (N=222) who met established criteria for Ml between August 1991 and July 1992 and who survived to be discharged from the hospital. Patients were interviewed between 5 and 15 days following the MI and were followed up for 6 months. There were no age limits (range, 24 to 88 years; mean, 60 years). The sample was 78% male.Primary Outcome Measure. —Survival status at 6 months.Results. —By 6 months, 12 patients had died. All deaths were due to cardiac causes. Depression was a significant predictor of mortality (hazard ratio, 5.74; 95% confidence interval, 4.61 to 6.87; P=.0006). The impact of depression remained after control for left ventricular dysfunction (Killip class) and previous Ml, the multivariate significant predictors of mortality in the data set (adjusted hazard ratio, 4.29; 95% confidence interval, 3.14 to 5.44; P=.013).Conclusion. —Major depression in patients hospitalized following an Ml is an independent risk factor for mortality at 6 months. Its impact is at least equivalent to that of left ventricular dysfunction (Killip class) and history of previous Ml. Additional study is needed to determine whether treatment of depression can influence post-MI survival and to assess possible underlying mechanisms.(JAMA. 1993;270:1819-1825)

Detection and treatment of psychiatric illness in a general medical ward - I. Consultant-consultee interaction

Article

Nov 1998
J PSYCHOSOM RES

This article describes a prospective, randomized, controlled trial of screening and treatment for psychiatric disorder in medical in-patients. The study has assessed whether increased recognition of psychiatric disorder among medical in-patients improves clinical outcome and reduces the costs of care, and whether routine involvement of a psychiatrist in the assessment and care of medical in-patients with probable psychiatric disorder is superior to the efforts of the physicians alone. A total of 218 medical in-patients who scored over the screening threshold for psychiatric disorder on the General Health Questionnaire were randomly allocated to one of two intervention groups or a control group. Six months later their mental health, subjective health status, quality of life, and costs of care was reassessed. Mental health and quality of life at 6 months were similar in the two intervention groups and the control group. Patients whose physicians were told the results of the screening test had lower costs for subsequent admissions, but this was probably due to differences between the groups in terms of employment status. Treatments recommended by psychiatrists broke down when patients were discharged home, leading to inadequate treatment of psychiatric disorders. We have not been able to show that routine screening for psychiatric disorder produces any benefit, either in better outcome for patients or reduced costs for the NHS. Further research should: consider examining a more homogeneous group in terms of costs of care; screen only for disorders likely to respond to a specific treatment; and ensure that treatment recommendations are carried out.

Detection and Treatment of Mental Disorders in General Health Care

Article

Dec 1997

Mental health service delivery in the general health care sector is restricted with regard to understanding the magnitude and impact of mental illness in the medically ill (co-morbidity), as well as the significance of current mental health service delivery. A new model in development in the framework of a Biomed2 grant is presented. It consists of case-finding through complexity of hospital care prediction (COMPRI) followed by an integral health service needs assessment (INTERMED). It might serve to develop a more structural relation with the general health care sector for the management of mentally co-morbid high utilizing patients.

21ASSESSMENT OF CASE COMPLEXITY BY MEANS OF THE INTERMED: THE USERS' POINT OF VIEW

Article

Jun 2004
J PSYCHOSOM RES

54-A RANDOMIZED PSYCHIATRIC INTERVENTION IN COMPLEX MEDICAL PATIENTS: EFFECTS ON DEPRESSION

Article

Jun 2004
J PSYCHOSOM RES

“INTERMED”: a method to assess health service needs

Article

Feb 1999
GEN HOSP PSYCHIAT

The validity and clinical use of a recently developed instrument to assess health care needs of patients with a physical illness, called INTERMED, is investigated. The INTERMED combines data reflecting patients’ biological, psychological, and social characteristics with information on health care utilization characteristics. An example of a patient population in which such an integral assessment can contribute to the appropriateness of care, are patients with low back pain of degenerative or unknown origin. It supports the validity and the clinical usefulness of the INTERMED when clinically relevant subgroups in this heterogeneous population can be identified and described based on their INTERMED scores. The INTERMED was utilized in a group of patients (N = 108) having low back pain who vary on the chronicity of complaints, functional status, and associated disability. All patients underwent a medical examination and responded to a battery of validated questionnaires assessing biological, psychological, and social aspects of their life. In addition, the patients were assessed by the INTERMED. It was studied whether it proved to be possible to form clinically meaningful groups of patients based on their INTERMED scores; for this, a hierarchical cluster analysis was performed. In order to clinically describe them, the groups of patients were compared with the data from the questionnaires. The cluster analysis on the INTERMED scores revealed three distinguishable groups of patients. Comparison with the questionnaires assessing biological, psychological, and social aspects of disease showed that one group can be characterized as complex patients with chronic complaints and reduced capacity to work who apply for a disability compensation. The other groups differed explicitly with regard to chronicity, but also on other variables. By means of the INTERMED, clinically relevant groups of patients can be identified, which supports its use in clinical practice and its use as a method to describe case mix for scientific or health care policy purposes. In addition, the INTERMED is easy to implement in daily clinical practice and can be of help to ease the operationalization of the biopychosocial model of disease. More information on its validity in different patient populations is necessary.

The CES-D Scale: A Self-Report Depression Scale for Research in the General Population

Article

Jun 1977
APPL PSYCH MEAS

Lenore Sawyer Radloff

The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.

INTERMED-An Assessment and Classification System for Case Complexity: Results in Patients With Low Back Pain

Article

Feb 1999

Study Design. Cross-sectional investigation and follow-up of patients with low back pain. Objectives. To evaluate the capacity of the INTERMED-a biopsychosocial assessment and classification system for case complexity-to identify patients with a chronic, disabling course of low back pain and to predict treatment outcome. Summary of Background Data. An impressive number of biologic and nonbiologic factors influencing the course of low back pain have been identified. However, the lack of a concise, comprehensive, reliable and validated classification system of this heterogeneous patient population hampers preventive and therapeutic progress. Methods. The INTERMED was used to assess patients with low back pain, who participated in a functional rehabilitation program (n = 50) and patients with low back pain who applied for disability compensation (n = 50). Patients of the rehabilitation program were observed to assess the effects of treatments. Results. The INTERMED distinguished between patients in different phases of disability and provided meaningful information about the biopsychosocial aspects of low back pain. In hierarchical cluster analysis two distinct clusters emerged that differed in the degree of case complexity and treatment outcomes. Conclusions. This first application of the INTERMED indicates its potential utility as a classification system for patients with low back pain.

Identification of case complexity and increased health care utilization in patients with rheumatoid arthritis

Article

Jun 2001
ARTHRIT RHEUM-ARTHR

Objectives To document biopsychosocial profiles of patients with rheumatoid arthritis (RA) by means of the INTERMED and to correlate the results with conventional methods of disease assessment and health care utilization.Methods Patients with RA (n = 75) were evaluated with the INTERMED, an instrument for assessing case complexity and care needs. Based on their INTERMED scores, patients were compared with regard to severity of illness, functional status, and health care utilization.ResultsIn cluster analysis, a 2-cluster solution emerged, with about half of the patients characterized as complex. Complex patients scoring especially high in the psychosocial domain of the INTERMED were disabled significantly more often and took more psychotropic drugs. Although the 2 patient groups did not differ in severity of illness and functional status, complex patients rated their illness as more severe on subjective measures and on most items of the Medical Outcomes Study Short Form 36. Complex patients showed increased health care utilization despite a similar biologic profile.Conclusions The INTERMED identified complex patients with increased health care utilization, provided meaningful and comprehensive patient information, and proved to be easy to implement and advantageous compared with conventional methods of disease assessment. Intervention studies will have to demonstrate whether management strategies based on INTERMED profiles can improve treatment response and outcome of complex patients.

Psychosocial interventions in chronic medical illness. An overview of outcome research

Article

Dec 1992
GEN HOSP PSYCHIAT

James L. Levenson

Previous studies have shown that psychopathology is common in the medically ill, affects the course of medical illness, and is associated with increased health care costs. Recent controlled trials have demonstrated that psychosocial interventions in the medically ill can improve both psychosocial and medical outcomes. Although an important aim of current research is to assess the cost effectiveness of such interventions, the meaning and significance of "cost effectiveness," "cost benefit," and "cost offset" are frequently misunderstood. An overview of outcome research will be used to illuminate the promise and the limitations of such studies, with special attention to bias in research design.

Psychosocial interventions in adult patients with coronary heart disease and cancer. A literature review

Article

Dec 1992
GEN HOSP PSYCHIAT

A growing body of evidence suggests that chronic medical illness is associated with an increased prevalence and incidence of psychiatric and psychological disturbances. The present literature review is based on two theses: first, that chronic illness is viewed as a stressor and is associated with increased psychological distress, and secondly, that interventions can minimize the distress. A review of the studies conducted with adult patients diagnosed either with coronary heart disease or cancer suggests that psychosocial interventions are, in general, efficacious in relieving self-reported psychological distress. The review also recommends psychosocial interventions for high-risk patients rather than all patients, and that researchers need to identify other outcomes such as health care costs, disability, days in hospital, morbidity, and mortality in order to convince policy makers that these interventions are worthwhile. Recommendations for future research are also discussed.

A randomized controlled study of psychiatric consultation guided by screening in general medical inpatients

Article

Jun 1992

The purpose of the study was to test the hypothesis that psychiatric consultation would reduce health care utilization during and after medical hospitalization. A randomized, double-controlled clinical trial of psychiatric consultation was conducted on the general medical inpatient services of a university hospital. After meeting inclusion criteria, 1,541 patients were screened for depression, anxiety, confusion, and pain over a period of 21 months. The 741 patients with high levels of psychopathology or pain were subdivided into baseline control subjects (N = 232), contemporaneous control subjects (N = 253), and an experimental consultation group (N = 256). The major outcome measures were length of hospital stay and hospital costs. Secondary outcome measures were posthospital health status, rehospitalization rates, and use of outpatient medical care. This study did not demonstrate an effect of experimental psychiatric consultation on hospital resource use or posthospital medical care utilization after adjustment was made for disease severity. Hospital resource use decreased in the entire sample over the 21-month duration of the study. The brief, efficient screen for anxiety, depression, confusion, and pain identified a group of patients who also used more hospital resources, but a single experimental psychiatric consultation did not reduce costs. The double-controlled nature of the design proved essential to avoid being misled by background changes in hospital resource use.

Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs

Article

Dec 1990
GEN HOSP PSYCHIAT

Among a sample of 767 high utilizers of health care, 51% were identified as distressed by an elevated score on the SCL anxiety and depression scales, the SCL somatization scale, or by their primary-care physician. These distressed high utilizers were found to have a high prevalence of chronic medical problems and significant limitation of activities caused by illness. In the prior year, they made an average of 15 medical visits and 15 telephone calls to the clinic. The Diagnostic Interview Schedule was completed on 119 distressed high utilizers randomly assigned to an intervention group in a controlled trial of psychiatric consultation. The following DSM-III-R disorders were most common: major depression 23.5%, dysthymic disorder 16.8%, generalized anxiety disorder 21.8%, and somatization disorder 20.2%. Two thirds had a lifetime history of major depression. The examination resulted in an improved diagnostic assessment for 40% of intervention patients and a revised treatment plan for 67%.

Meta-analysis of the Effects of Educational and Psychosocial Interventions on Management of Diabetes Mellitus

Article

Feb 1988
J CLIN EPIDEMIOL

A meta-analysis of the literature of controlled studies of educational and psychosocial interventions in the treatment of diabetes mellitus yielded 93 studies of 7451 patients testing the effects of eight intervention types: (1) didactic education, (2) enhanced education, (3) diet instruction, (4) exercise instruction, (5) self-monitoring instruction, (6) social learning/behavior modification, (7) counseling, and (8) relaxation training. An overall mean effect size (ES) of +0.51 +/- 0.11 was found moderate but significant (P less than 0.05) improvements for all intervention subjects. Physical outcome and knowledge gain were most affected, followed by psychological status and compliance. Diet instruction and social learning interventions showed the strongest (ES = +0.68 +/- 0.58 and ES = +0.57 +/- 0.42, respectively) and relaxation training the weakest (ES = +0.30 +/- 0.74) effects. Associations between study and sample characteristics and mean ES values were explored with type of setting and methodological weaknesses such as single group design and non-random assignment achieving statistical significance. Neither intervention type, number of visits, sex, age, nor type of diabetes were significantly correlated with mean ES values. Implications of these findings for clinical treatment and future research are discussed.

Psychiatric Disorder in the General Hospital

Article

Sep 1986

There have been many reports of psychiatric disorder in medical populations, but few have used standard methods on representative patient groups. Even so, there is consistent evidence for considerable psychiatric morbidity in in-patient, out-patient and casualty department populations, much of which is unrecognised by hospital doctors. We require a better classification of psychiatric disorder in the general hospital, improved research measures, and more evidence about the nature and course of the many different types of problem so that we can provide precise advice for their management of routine clinical practice.

A New Look at Evidence About Reduced Costs of Medical Utilization Following Mental Health Treatment

Article

Nov 1984

Meta-analysis of 58 controlled studies and analysis of the claims files for the Blue Cross and Blue Shield Federal Employees Plan for 1974-1978 provide mutually supporting evidence of the cost-offset effects of outpatient mental health treatment. These two complementary resources provide a powerful tool for investigating the nature of associations between mental health services and subsequent reductions in the use of other medical services. The authors found that the reductions in use of medical services are associated with inpatient rather than with outpatient utilization and tend to be larger for persons over 55 years of age.

A Meta-Analytic Analysis of Effects of Psychoeducational Interventions on Length of Post-Surgical Hospital Stay

Article

Sep 1983

Forty-nine studies of the relationships between brief psychoeducational interventions and the length of postsurgical hospitalization are reviewed using meta-analysis. Results show that interventions reduce hospital stay about 1 1/4 days and that reduction does not depend on whether the studies were published or not, whether the discharging physician was aware of the patient's experimental condition, or whether studies were lacking in internal validity. The interventions' effects on length of hospital stay are distinctly smaller in more recent studies, with analysis suggesting current treatments incorporate fewer components than earlier studies. Lesser effects are also found when the treatment is compared with a placebo-treatment group rather than a usual-care control group. This may be because placebo procedures often include educational and socially supportive components that constitute part of the psychoeducational interventions under review. The present study, providing a more stable foundation than previously available, supports the belief that brief psychoeducational interventions may be cost effective with surgical patients of many kinds because the length of hospital stay is reduced.

Depression following myocardial infarction. Impact on 6-month survival

Article

Nov 1993

To determine if the diagnosis of major depression in patients hospitalized following myocardial infarction (MI) would have an independent impact on cardiac mortality over the first 6 months after discharge. Prospective evaluation of the impact of depression assessed using a modified version of the National Institute of Mental Health Diagnostic Interview Schedule for major depressive episode. Cox proportional hazards regression was used to evaluate the independent impact of depression after control for significant clinical predictors in the data set. A large, university-affiliated hospital specializing in cardiac care, located in Montreal, Quebec. All consenting patients (N = 222) who met established criteria for MI between August 1991 and July 1992 and who survived to be discharged from the hospital. Patients were interviewed between 5 and 15 days following the MI and were followed up for 6 months. There were no age limits (range, 24 to 88 years; mean, 60 years). The sample was 78% male. Survival status at 6 months. By 6 months, 12 patients had died. All deaths were due to cardiac causes. Depression was a significant predictor of mortality (hazard ratio, 5.74; 95% confidence interval, 4.61 to 6.87; P = .0006). The impact of depression remained after control for left ventricular dysfunction (Killip class) and previous MI, the multivariate significant predictors of mortality in the data set (adjusted hazard ratio, 4.29; 95% confidence interval, 3.14 to 5.44; P = .013). Major depression in patients hospitalized following an MI is an independent risk factor for mortality at 6 months. Its impact is at least equivalent to that of left ventricular dysfunction (Killip class) and history of previous MI. Additional study is needed to determine whether treatment of depression can influence post-MI survival and to assess possible underlying mechanisms.

Prevalence of Psychiatric Disorders in Medical Inpatients

Article

Feb 1996

Peter H. Silverstone

The aim of the present study was to determine the prevalence of psychiatric disorders in acutely ill medical inpatients. A total of 313 consecutively admitted patients were interviewed using a semistructured psychiatric interview. Diagnoses were made according to DSM-IV diagnostic criteria during two time periods, the 7 days following admission and the month prior to admission. The results showed that 85 patients (27.2%) received a DSM-IV diagnosis, with several patients having comorbid diagnoses. Major depressive disorder was present in 16 patients (5.1%), most of whom also had major depressive disorder in the month prior to admission. This prevalence rate is above that of the general population (1.2% to 2.8%), but less than that reported in most previous studies (20% to 40%). Forty-three patients (13.7%) had an adjustment disorder, 18 patients (5.8%) had an anxiety disorder, and 17 patients (5.4%) had either alcohol dependence or abuse. Nurses were more proficient than medical staff at identifying patients who had received a DSM-IV diagnosis, recognizing 61% of cases compared with 41% for medical staff.

Improvement of quality of life by treatment with cetirizine in patients with perennial allergic rhinitis as determined by a French version of the SF-36 Questionnaire

Article

Sep 1996
J ALLERGY CLIN IMMUN

Perennial allergic rhinitis impairs social life, but it is not known whether quality of life may be improved when patients are treated with an H1-blocker. A randomized, double-blind, placebo-controlled study was carried out with cetirizine to assess the effect of this drug on quality of life. Two hundred seventy-four patients with perennial allergic rhinitis were tested. Quality of life was measured by using the Medical Outcome Study Short-Form Health Survey (SF-36) questionnaire. After a 2-week run-in period, cetirizine, 10 mg once daily, (136 patients) or placebo (138 patients) was given for the next 6 weeks. The SF-36 questionnaire was administered after the run-in period (at the start of treatment) and after 1 and 6 weeks of treatment. Symptom-medication scores were measured daily during the study. After the run-in period (baseline), there were no significant differences between the cetirizine and placebo groups in terms of symptoms or quality-of-life scores. After 6 weeks of treatment, percentage of days without rhinitis or with only mild rhinitis symptoms was significantly greater in the cetirizine group in comparison with the placebo group (p < 0.0001, Mann-Whitney U test). All of the nine quality-of-life dimensions were significantly improved (from p = 0.01 to p < 0.0001, Mann-Whitney U test) after 1 and 6 weeks of cetirizine treatment compared with placebo. There was no improvement in the placebo group. This study is the first to demonstrate that an H1-blocker, cetirizine, can improve quality of life for patients with perennial allergic rhinitis.

Detection and treatment of psychiatric illness in a general medical ward: a modified cost-benefit analysis

Article

Dec 1998
J PSYCHOSOM RES

The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10

Article

Feb 1998

The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV and ICD-10 psychiatric disorders. With an administration time of approximately 15 minutes, it was designed to meet the need for a short but accurate structured psychiatric interview for multicenter clinical trials and epidemiology studies and to be used as a first step in outcome tracking in nonresearch clinical settings. The authors describe the development of the M.I.N.I. and its family of interviews: the M.I.N.I.-Screen, the M.I.N.I.-Plus, and the M.I.N.I.-Kid. They report on validation of the M.I.N.I. in relation to the Structured Clinical Interview for DSM-III-R, Patient Version, the Composite International Diagnostic Interview, and expert professional opinion, and they comment on potential applications for this interview.

"INTERMED": a method to assess health service needs. II. Results on its validity and clinical use

Article

Jan 1999
GEN HOSP PSYCHIAT

The validity and clinical use of a recently developed instrument to assess health care needs of patients with a physical illness, called INTERMED, is investigated. The INTERMED combines data reflecting patients' biological, psychological, and social characteristics with information on health care utilization characteristics. An example of a patient population in which such an integral assessment can contribute to the appropriateness of care, are patients with low back pain of degenerative or unknown origin. It supports the validity and the clinical usefulness of the INTERMED when clinically relevant subgroups in this heterogeneous population can be identified and described based on their INTERMED scores. The INTERMED was utilized in a group of patients (N = 108) having low back pain who vary on the chronicity of complaints, functional status, and associated disability. All patients underwent a medical examination and responded to a battery of validated questionnaires assessing biological, psychological, and social aspects of their life. In addition, the patients were assessed by the INTERMED. It was studied whether it proved to be possible to form clinically meaningful groups of patients based on their INTERMED scores; for this, a hierarchical cluster analysis was performed. In order to clinically describe them, the groups of patients were compared with the data from the questionnaires. The cluster analysis on the INTERMED scores revealed three distinguishable groups of patients. Comparison with the questionnaires assessing biological, psychological, and social aspects of disease showed that one group can be characterized as complex patients with chronic complaints and reduced capacity to work who apply for a disability compensation. The other groups differed explicitly with regard to chronicity, but also on other variables. By means of the INTERMED, clinically relevant groups of patients can be identified, which supports its use in clinical practice and its use as a method to describe case mix for scientific or health care policy purposes. In addition, the INTERMED is easy to implement in daily clinical practice and can be of help to ease the operationalization of the biopychosocial model of disease. More information on its validity in different patient populations is necessary.

'INTERMED': A method to assess health service needs. I. Development and reliability

Article

Feb 1999
GEN HOSP PSYCHIAT

The purpose of this paper is to describe the development and to test the reliability of a new method called INTERMED, for health service needs assessment. The INTERMED integrates the biopsychosocial aspects of disease and the relationship between patient and health care system in a comprehensive scheme and reflects an operationalized conceptual approach to case mix or case complexity. The method is developed to enhance interdisciplinary communication between (para-) medical specialists and to provide a method to describe case complexity for clinical, scientific, and educational purposes. First, a feasibility study (N = 21 patients) was conducted which included double scoring and discussion of the results. This led to a version of the instrument on which two interrater reliability studies were performed. In study 1, the INTERMED was double scored for 14 patients admitted to an internal ward by a psychiatrist and an internist on the basis of a joint interview conducted by both. In study 2, on the basis of medical charts, two clinicians separately double scored the INTERMED in 16 patients referred to the outpatient psychiatric consultation service. Averaged over both studies, in 94.2% of all ratings there was no important difference between the raters (more than 1 point difference). As a research interview, it takes about 20 minutes; as part of the whole process of history taking it takes about 15 minutes. In both studies, improvements were suggested by the results. Analyses of study 1 revealed that on most items there was considerable agreement; some items were improved. Also, the reference point for the prognoses was changed so that it reflected both short- and long-term prognoses. Analyses of study 2 showed that in this setting, less agreement between the raters was obtained due to the fact that the raters were less experienced and the scoring procedure was more susceptible to differences. Some improvements--mainly of the anchor points--were specified which may further enhance interrater reliability. The INTERMED proves to be a reliable method for classifying patients' care needs, especially when used by experienced raters scoring by patient interview. It can be a useful tool in assessing patients' care needs, as well as the level of needed adjustment between general and mental health service delivery. The INTERMED is easily applicable in the clinical setting at low time-costs.

Case complexity and clinical outcome in diabetes mellitus. A prospective study using the INTERMED

Article

Oct 2000
DIABETES METAB

The aim of this study was to assess a population of patients with diabetes mellitus by means of the INTERMED, a classification system for case complexity integrating biological, psychosocial and health care related aspects of disease. The main hypothesis was that the INTERMED would identify distinct clusters of patients with different degrees of case complexity and different clinical outcomes. Patients (n=61) referred to a tertiary reference care centre were evaluated with the INTERMED and followed 9 months for HbA1c values and 6 months for health care utilisation. Cluster analysis revealed two clusters: cluster 1 (62%) consisting of complex patients with high INTERMED scores and cluster 2 (38%) consisting of less complex patients with lower INTERMED. Cluster 1 patients showed significantly higher HbA1c values and a tendency for increased health care utilisation. Total INTERMED scores were significantly related to HbA1c and explained 21% of its variance. In conclusion, different clusters of patients with different degrees of case complexity were identified by the INTERMED, allowing the detection of highly complex patients at risk for poor diabetes control. The INTERMED therefore provides an objective basis for clinical and scientific progress in diabetes mellitus. Ongoing intervention studies will have to confirm these preliminary data and to evaluate if management strategies based on the INTERMED profiles will improve outcomes.

Timing of psychiatric consultations: the impact of social vulnerability and level of psychiatric dysfunction

Article

Nov 2000
PSYCHOSOMATICS

Assessment of Psychological Distress in the Setting of Medical Disease

Article

Jun 2001

The biopsychosocial model of disease has recently been depicted as the basis for a renewed emphasis on the multiaxial diagnostic system of the DSM-IV. The authors challenge this stance, underscoring the clinical inadequacies of the DSM-IV in the setting of medical disease, particularly the chapters concerned with somatoform disorders and psychological factors affecting medical conditions. Diagnostic criteria which are based on the clinical insights derived from psychosomatic research in the past decades may offer new opportunities to psychosomatic medicine and consultation-liaison psychiatry. The development of the Diagnostic Criteria for Psychosomatic Research (DCPR), encompassing alexithymia, type A behavior, irritable mood, demoralization, disease phobia, thanatophobia, health anxiety, illness denial, functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion symptoms and anniversary reaction, is described. Preliminary results obtained with the combination of DSM and DCPR criteria appear to be promising.

Referral pattern of neurological patients to psychiatric Consultation-Liaison Services in 33 European hospitals

Article

May 2001
GEN HOSP PSYCHIAT

The referral pattern of neurological patients to 33 European psychiatric consultation-liaison (C-L) services in the general hospital was examined. Analyses were conducted on the ECLW CS data set, which consists of 14,717 psychiatric C-L referrals made in 56 European hospitals during 1991. Psychiatric referrals of patients admitted to neurological wards were compared to referrals from other wards. Information was obtained from 33 neurological wards, consisting of 34,506 neurological admissions. Of these admissions, 839 were referred to C-L psychiatry. The median consult rate among the hospitals was 1.8%. Compared to other hospital wards, patients referred from neurology were more frequently diagnosed as suffering from somatoform (P<.01) and dissociative disorders (P<.01), and less from substance abuse (P<.01) and delirium (P<.01). Referral to C-L psychiatry from neurological wards is characterized by an underestimation of psychiatric co-morbidity and a late detection, comparable to other medical specialties. An appeal is made for a standardized referral procedure including admission screening method, detecting patients at risk for nonstandard care during their hospital admission.

Interrater reliability of the INTERMED in a heterogeneous somatic population

Article

Feb 2002
J PSYCHOSOM RES

The INTERMED has been developed to score biopsychosocial case complexity and care needs. In this study, the interrater reliability of the INTERMED was assessed by calculating the agreement of two independent raters, based on the same information. Forty-three in- and outpatients with varying somatic complaints were double scored by a psychologist and a psychiatric C-L nurse. Correlations between total scores of the two raters were ranging from 0.91-0.96. On item level, in 83% there were no differences between the raters, in 16% there was a 1-point difference and in 1% a 2-point difference. Based on a cut-off score of 20/21, a constant k of 0.85 was found. We concluded that the two experienced raters had a high agreement, and that after sufficient training the INTERMED can be reliably scored. Its utility in improving health care delivery for patients with complex biopsychosocial care needs still has to be demonstrated.

Personality disorders in a nonclinical sample of adolescents

Article

Nov 2002
ENCEPHALE

To examine the comorbidity of borderline personality disorder and other personality disorders in a nonclinical sample of high-school students. 311 high-school students who completed the French version of the CES-D (Center for Epidemiological Studies-Depression Scale), were asked to participate to interviews evaluating personality functioning: 60 subjects (19%) accepted to participate in the study. The mean CES-D score of these 60 subjects (16 boys, 44 girls, mean age=17.7 1.7) was significantly higher than the mean score of the whole sample (23.9 10.4 versus 16.7 9.8). Thus the interviewed sample was not representative of the population of high-school students. Subjects were assessed using the major depressive episode module of the MINI (Mini International Neuropsychiatric Interview) and the SIDP IV (Structured Interview for DSM IV Personality). Inter-rater reliability was determined by comparing the independent ratings of interviewers and an experienced clinician on a random sample of 20 interviews. For DSM IV borderline personality disorder diagnosis, the Cohen's kappa coefficient was 0.85. For personality disorder criteria, kappa ranged from 0.6 to 1.0 (average kappa=0.79). Sixteen of these subjects (26,7%, 4 males, 12 females) received a diagnosis of borderline personality disorder according to DSM IV criteria. The mean CES-D score of borderline subjects (30.6 10.2) was significantly higher than the mean score of nonborderline subjects (21.6 10.5). Of the 16 borderline subjects, 11 (75%) received a diagnosis of major depressive disorder versus 14 (31%) of the non borderline subjects. None of the other personality disorders approached the frequency of borderline personality disorder. The next most frequent diagnoses were depressive and dependent personality disorders which occurred in respectively in 16.6% and 10% of the 60 subjects. All the personality-disorders occurred at higher rates in the group with borderline personality disorder with the exception of obsessive-compulsive personality disorder which was diagnosed only in nonborderline subjects. Of the 16 borderline subjects, 11 (68.7%) met the criteria for another personality disorder which were depressive personality disorder (N=5), paranoid personality disorder (N=4), dependent personality disorder (N=3), antisocial personality disorder (N=2), histrionic personality disorder (N=2), avoidant personality disorder (N=2), negativistic personality disorder (N=2), schizotypal personality disorder (N=1), narcissistic personality disorder (N=1), self-defeating personality disorder (N=1). The optional diagnoses (self-defeating, depressive and negati-vistic personality disorders) accounted for 8 of 23 (34.7%) cases of personality disorders diagnosed among borderline subjects. Among these 11 adolescents, 5 received 2 diagnoses of personality disorders (borderline and paranoid personality disorders, N=1; borderline and dependent personality disorders, N=1; borderline and depressive personality disorders, N=3), 3 received 3 diagnoses (borderline, antisocial and histrionic personality disorders, N=1; borderline, avoidant and negativistic personality disorders, N=1; borderline, depressive and negativistic personality disorders, N=1), 3 received 5 diagnoses (borderline, paranoid, histrionic, narcissistic and dependent personality disorders, N=1; borderline, paranoid, dependent, avoidant and depressive personality disorders, N=1; borderline, paranoid, schizotypal, antisocial and self-defeating personality disorders, N=1). Among the 44 adolescents (12 boys, 32 girls) without borderline personality disorder, 10 (22.7%) (3 boys, 7 girls) met the criteria for another personality disorder which were depressive personality disorder (N=5) or cluster C disorders -obsessive-compulsive personality disorder (N=4), dependent personality disorder (N=2), avoidant personality disorder (N=1) - with the exception of one diagnosis of histrionic personality disorder. Two subjects received 2 diagnoses (obsessive-compulsive and depressive personality disorder). The internal consistency of personality disorders criteria was assessed with Cronbach's alpha coefficient. Borderline personality disorder criteria had high internal consistency (0.82). The factor structure of borderline personality disorder criteria was studied with an exploratory factorial analysis which extracted three factors. The eigenvalues were 3.70, 1.06, and 1.01. Confirmatory factorial analyses were conducted. The correlated two-factor model and the three-factor model fit the data well but the correlation between factors was, however, judged too high, ranging from 0.70 to 0.78. The one-factor model proved to have a good fit (Goodness of Fit Index=0.89, Comparative Fit Index=0.90, Root Mean Square Residual=0.07). As a previous study showed the frequency of two schizotypal personality disorder criteria (odd beliefs/magical thinking experiences and unusual perceptual experiences), an exploratory factorial analysis was performed on the combined set of criteria of borderline and schizotypal personality disorders. It yielded 2 factors: the first factor consisted of all the borderline personality disorder criteria, odd beliefs/magical thinking, and unusual perceptual experiences and could be called the borderline factor; the second factor consisted of the paranoid and the social avoidance criteria and could be called the interpersonal hypersensitivity factor. A confirmatory factor analysis showed that this two-factor model provided a good fit to the data (GFI=0.82, CFI=0,91, RMSR=0.10). The correlation between factors was weak (0.25). These results suggest that odd beliefs/magical thinking and unusual perceptual experiences are a component of borderline symptomatology in adolescents. The high frequency of major depressive disorder and personality disorders in the interviewed sample may be due to the possibility that adolescents with psychological problems have used the interview as a way to obtain attention and support from a psychologist. The interviewed sample, which was characterized by a high intensity of depressive symptomatology and by a high frequency of borderline personality disorder, could thus be seen as intermediate between a clinical and a community sample. Our results may be more generalizable to an outpatients population of adolescents. This study found conflicting results about the construct validity of borderline personality disorder in adolescent. The high internal consistency and the one-factor structure of the borderline personality disorder criteria argue for their validity in adolescents. However, the high rates of comorbidity of borderline personality disorder with depression and other personality disorders, extended to clusters A, B and C and to optional diagnoses, suggest the lack of construct validity of either borderline personality or cluster B disorders in adolescents. Borderline symptomatology in adolescents appears more in adequacy with a dimensional model than with a typological classification. More studies are needed to assess and improve the construct validity of borderline personality disorder in adolescents.

Implementing Psychiatric Interventions on a Medical Ward: Effects on Patients’ Quality of Life and Length of Hospital Stay

Article

Nov 2003
PSYCHOSOM MED

The authors investigated the effects of implementing psychiatric interventions on a general medical ward by means of a stepped detection and treatment strategy conducted by a consultation-liaison (CL) nurse in terms of reducing length of hospital stay (LOS) and improving quality of life (QOL) at discharge. One hundred ninety-three patients participated in a controlled trial, in which patients were screened with COMPRI and INTERMED. A nurse under supervision of a CL psychiatrist conducted interventions, consisting of simple psychiatric interventions by herself, referral to auxiliary services, or initiation of postdischarge care. Intervention patients were compared with historic controls on LOS and QOL (SF36) at discharge. In multivariate analysis of variance, a significant effect of the intervention on QOL (p = 0.037) was found, which diminished after controlling for confounders (p = 0.28). No significant effect on LOS was found for the whole sample (p = 0.72), but in patients age 65 years or older, a reduction in LOS (p = 0.05) was found. This effect remained after controlling for confounders (p = 0.06). These data suggest that screening for risk of increased health care might improve outcomes in general medical inpatients. Because of the design of the study, however, these findings should be considered preliminary and confirmed in a larger, multicenter, randomized controlled trial.

Psychometric Theory Is an Obstacle to the Progress of Clinical Research

Article

May 2004

Psychometric theory is the basis for the development of assessment instruments in psychiatric research. However, the psychometric model appears to be largely inadequate in the clinical setting because of its lack of sensitivity to change and its quest for homogeneous components. Clinimetrics offers a viable alternative to psychometrics, both from a conceptual and a methodological viewpoint. Current diagnostic entities (DSM) are based on clinimetric principles, but their use is still influenced by psychometric models. Suggestions for switching gears in assessment research are offered.

Psychiatric Comorbidity and Work Disability in Patients With Inflammatory Rheumatic Diseases

Article

May 2004
PSYCHOSOM MED

To determine the relative contribution of psychiatric comorbidity to work disability in patients with inflammatory rheumatic diseases (IRD). Parallel analyses were also performed in a matched control group with no diagnosis of IRD to investigate if predictors of work disability in medical patients are independent from the presence of IRD. The patient group with IRD (73.9% female; mean age, 42.7 years) and the control group (73.9% female; mean age, 42.2 years) consisted of 356 outpatients each. Psychiatric comorbidity was diagnosed using the Patient Health Questionnaire (PHQ), functional disability was measured with the 12-item Short-Form Health Survey (SF-12), and severity of illness was assessed by the treating physicians. Stepwise logistic regression analyses were performed to identify independent predictors of work disability controlling for psychiatric comorbidity, functional disability, severity of illness, additional clinical variables, and demographics. Psychiatric comorbidity increased work disability in patients with severe IRD from 25% to 50%, and from 5% to 17% in mild disease. Physical functioning (OR = 0.6; p <.0001), depression severity (OR = 1.6; p =.005), and illness severity (OR = 1.8; p =.006) were identified as independent predictors of work disability in patients with IRD. Similar predictors of work disability were identified in the control group, but depression severity did not meet statistical significance at the 5% level. This study provides evidence that depression is an independent risk factor of work disability in patients with IRD, but this result cannot be generalized to other medical conditions. Improved diagnosis and treatment of depressive disorders in patients with IRD may help avoid work disability.

Length of hospital stay and health services use of medical inpatients with comorbid noncognitive mental disorders: A review of the literature

Article

Feb 2005
GEN HOSP PSYCHIAT

We reviewed 23 studies on the association between noncognitive mental disorders and the use of general health care services by medical patients admitted to a general hospital. Only studies with a prospective design and with a correction for possible confounding factors were included. In most studies, only service use during index admission was observed, but eight studies included a longer observation period during follow-up after hospital discharge. The 15 studies that were restricted to service use during index admission showed mixed results: length of hospital stay was related to common mental disorders in some studies, but other studies did not find such an association. The eight studies that used a longer observation period showed findings that are more consistent. They demonstrated mainly that symptoms or complaints of depression are related to a higher resource use within general medical services.

Potentially Modifiable Factors Associated With Disability Among People With Diabetes

Article

Mar 2005
PSYCHOSOM MED

This article seeks to identify potentially modifiable factors associated with disability among people with diabetes. Among people with diabetes (N = 4357) in a large health maintenance organization, disease severity, psychologic and behavioral risk factors for disability were assessed. Disability was evaluated by the WHO Disability Assessment Scale (WHO-DAS-II), the SF-36 Social Functioning scale, and days of reduced household work. Depression was associated with a tenfold increase in elevated WHO-DAS-II and low SF-36 Social Functioning scores, and a fourfold increase in 20+ days of reduced household work. Minor depression and the presence of three or more diabetic complications were associated with approximately a twofold increase in disability risk. Diabetic symptoms, chronic disease comorbidity, and reduced exercise were also associated with disability. Among people with diabetes, depression, diabetic complications, and exercise are potentially modifiable factors associated with disability. This suggests that integrated, biopsychosocial approaches may be needed to understand and to ameliorate disability among people with diabetes.

Effects of a Multifaceted Psychiatric Intervention Targeted for the Complex Medically Ill: A Randomized Controlled Trial

Abstract

No full-text available

Recommended publications

Energy keep us going

University of Groningen in 83rd place on THE ranking list

Origins Center to open at Fundamentals of Life in the Universe symposium

A grand future with small particles. Nanotechnology affects many aspects of our lives

Improving heart failure outcomes with pharmacist-physician collaboration: How close are we?

[The role of diabetes convention centres in Belgium]

An overview of rheumatoid arthritis

Diabetes care by primary care physicians in Minnesota and Wisconsin