Abstracts: Psychosomatic Medicine and Integrated Care

Dtsch Arztebl Int 2012; 109:803-813

Background: 4%−10% of the general population and 20% of primary care patients have what are called “non-specific, functional, and somatoform bodily complaints.” These often take a chronic course, markedly impair the sufferers' quality of life, and give rise to high costs. They can be made worse by inappropriate behavior on the physician's part. Methods: The new S3 guideline was formulated by representatives of 29 medical and psychological specialty societies and one patient representative. They analyzed more than 4000 publications retrieved by a systematic literature search and held two online Delphi rounds and three consensus conferences. Results: Because of the breadth of the topic, the available evidence varied in quality depending on the particular subject addressed and was often only of moderate quality. A strong consensus was reached on most subjects. In the new guideline, it is recommended that physicians should establish a therapeutic alliance with the patient, adopt a symptom/coping-oriented attitude, and avoid stigmatizing comments. A biopsychosocial diagnostic evaluation, combined with sensitive discussion of signs of psychosocial stress, enables the early recognition of problems of this type, as well as of comorbid conditions, while lowering the risk of iatrogenic somatization. For mild, uncomplicated courses, the establishment of a biopsychosocial explanatory model and physical/social activation are recommended. More severe, complicated courses call for collaborative, coordinated management, including regular appointments (as opposed to ad-hoc appointments whenever the patient feels worse), graded activation, and psychotherapy; the latter may involve cognitive behavioral therapy or a psychodynamic-interpersonal or hypnotherapeutic/imaginative approach. The comprehensive treatment plan may be multimodal, potentially including body-oriented/nonverbal therapies, relaxation training, and time-limited pharmacotherapy. Conclusion: A thorough, simultaneous biopsychosocial diagnostic assessment enables the early recognition of nonspecific, functional, and somatoform bodily complaints. The appropriate treatment depends on the severity of the condition. Effective treatment requires the patient's active cooperation and the collaboration of all treating health professionals under the overall management of the patient's primary-care physician.

J Nucl Med 2013; 54:1011-1013

Amyloid PET imaging is a novel diagnostic test that can detect in living humans one of the two defining pathologic lesions of Alzheimer disease, amyloid-β deposition in the brain. The Amyloid Imaging Task Force of the Alzheimer's Association and Society for Nuclear Medicine and Molecular Imaging previously published appropriate use criteria for amyloid PET as an important tool for increasing the certainty of a diagnosis of Alzheimer disease in specific patient populations. Here, the task force further clarifies and expands 3 topics discussed in the original paper: first, defining dementia experts and their use of proper documentation to demonstrate the medical necessity of an amyloid PET scan; second, identifying a specific subset of individuals with mild cognitive impairment for whom an amyloid PET scan is appropriate; and finally, developing educational programs to increase awareness of the amyloid PET appropriate use criteria and providing instructions on how this test should be used in the clinical decision-making process.

The integration of physical and mental health care is an important aspect of the Medicaid health home model. Collaborative care programs are one approach to integration in which primary care providers, care managers, and psychiatric consultants work together to provide care and monitor patients’ progress. These programs have been shown to be both clinically-effective and cost-effective for a variety of mental health conditions, in a variety of settings, using several different payment mechanisms. This brief highlights the collaborative care model as one approach to implementing integrated care under the Medicaid health homes authority.

Psychiatr Serv 2013; 64:828-831

This column describes recent policy and program initiatives implemented by the New York State Office of Mental Health to enhance integration of general medical and behavioral health services throughout the state public mental health system. Recent initiatives were implemented to improve access to health and wellness-oriented services, redesign managed care programs to improve engagement and retention of high-need individuals, and raise the bar on quality while lowering costs. Taken as a whole, these initiatives represent a 21st-century transformation of a state mental health authority into an accountable and more fully integrated public health delivery system.

Am J Psychiatry 2011; 168:1171-1178

Objective: The authors assessed the 2-year outcomes, costs, and financial sustainability of a medical care management intervention for community mental health settings. Method: A total of 407 psychiatric outpatients with serious mental illnesses were randomly assigned to usual care or to a medical care manager who provided care coordination and education. Two-year follow-up chart reviews and interviews assessed quality and outcomes of care, as well as costs from both the health system and managerial perspectives. Results: Sustained improvements were observed in the intervention group in quality of primary care preventive services, quality of cardiometabolic care, and mental health-related quality of life. From a health system perspective, by year 2, the mean per-patient total costs for the intervention group were $932 (95% CI=−1,973 to 102) less than for the usual care group, with a 92.3% probability that the program was associated with lower costs than usual care. From the community mental health center perspective, the program would break even (i.e. revenues would cover setup costs) if 58% or more of clients had Medicaid or another form of insurance. Given that only 40.5% of clients in this study had Medicaid, the program was not sustainable after grant funding ended. Conclusions: The positive long-term outcomes and favorable cost profile provide evidence of the potential value of this model. However, the discrepancy between health system and managerial cost perspectives limited the program's financial sustainability. With anticipated insurance expansions under health reform, there is likely to be a stronger business case for safety net organizations considering implementing evidence-based interventions such as the one examined in this study.

Psychiatr Serv 2013; 64:660-665

Objective: This article describes the characteristics and early implementation experiences of community behavioral health agencies that received Primary and Behavioral Health Care Integration (PBHCI) grants from the Substance Abuse and Mental Health Services Administration to integrate primary care into programs for adults with serious mental illness. Methods: Data were collected from 56 programs, across 26 states, that received PBHCI grants in 2009 (N=13) or 2010 (N=43). The authors systematically extracted quantitative and qualitative information about program characteristics from grantee proposals and semistructured telephone interviews with core program staff. Quarterly reports submitted by grantees were coded to identify barriers to implementing integrated care. Results: Grantees shared core features required by the grant but varied widely in terms of characteristics of the organization, such as size and location, and in the way services were integrated, such as through partnerships with a primary care agency. Barriers to program implementation at start-up included difficulty recruiting and retaining qualified staff and issues related to data collection and use of electronic health records, licensing and approvals, and physical space. By the end of the first year, some problems, such as space issues, were largely resolved, but other issues, including problems with staffing and data collection, remained. New challenges, such as patient recruitment, had emerged. Conclusions: Early implementation experiences of PBHCI grantees may inform other programs that seek to integrate primary care into behavioral health settings as part of new, large-scale government initiatives, such as specialty mental health homes.