Clinical Service Delivery and Benefits in General Medical Care of Psychosomatic Illness

April 2006, Vol. XXIII, No. 5

The renaming of consultation-liaisonpsychiatry as psychosomaticmedicine, a new formal subspecialtyof psychiatry, may require someadjustment in our understanding ofthese terms. Both consultation-liaisonpsychiatry and psychosomatic medicinehave focused on treatment and researchof illnesses with mind-body interactions.Despite considerable overlap,consultation-liaison psychiatry hastraditionally been associated with treatmentand clinical research of comorbidmental disorders of the medicallyill, while psychosomatic medicine hasbeen associated with research into thephysiologic mechanisms underlyingmind-body interactions and classicalpsychosomatic diseases such as hypertension,asthma, and ulcerative colitis.This article addresses the future directionfor the integration of consultationliaisonpsychiatry and psychosomaticmedicine in general medical care anddescribes how this integration holds thepromise for improved health care.

From the 1930s through the 1960s,psychoanalytic and stress theoriesattempted to explain how the mindmight create somatic symptoms. In1977, Weiner¹ concluded that theprocesses by which a mental oremotional experience could be transformedinto physical disease and altercell function and structure had not beenexplained by the then current theoriesand remained the major challenge ofthe field. He recommended the developmentof prospective, longitudinal,interdisciplinary studies, with collaborationbetween mental health professionalsand general medical physicians.

In 1994, Wells,² a health servicesresearcher, recommended the developmentof interdisciplinary teams todeliver better mental health care to theprimary care sector and identifiedconsultation-liaison psychiatrists as thespecialists best suited to work with theirgeneral medical colleagues. Similarconclusions were reached about themental health needs of patients hospitalizedwith a physical illness. At thattime, mental health care for primarycare patients was much less advancedthan programs of consultation-liaison psychiatry in general hospitals thatprovided a model of integrated care.

Since the 1970s, interdisciplinaryclinical and research collaborationamong psychiatry, psychology, andother specialties in medicine has grown.As the field of consultation-liaisonpsychiatry has expanded, so have developmentsin newer methods of understandingmind-body interrelationships.The data from health services researchand recent discoveries in neuroimaging,neuroimmunology, cell biology,and genetics have enriched our understandingof psychosomatic disordersand the variety of bidirectional interactionsthat occur between mental andphysical disorders.

OUTCOME STUDIES

Outcome studies of general medicalpatients with psychiatric disorders canbe divided into 3 main categories:general health care costs; improvementof psychiatric disorders; and improvementin prognosis for comorbid physicaldisorder, which is most intimatelyrelated to the Holy Grail of psychosomaticresearch--the influence of themind or brain on physical disease. Butsince each type of outcome researchcontributes to the progress of the others,the convergence of all 3 is needed toinform clinical practice. This convergencemay also influence the developmentof integrated models of mentalhealth care of patients in the generalmedical sector.

Outcome studies in the late 1980sand early 1990s established the significantimpact of psychiatric disorderson health care costs and provided apowerful stimulus for further research.Wells and colleagues³ equated theimpact of mental disorders with that ofphysical illness by demonstrating thatthe impairment of functioning and wellbeingdue to depression were of thesame order of magnitude as impairmentsof physical illness, with theirimplied contribution to societal costs.

FINANCIAL CONSIDERATIONS

Clinical and health care research documentedthe effect of comorbid psychiatricdisorders on extended length ofstay for hospitalized medical patients. The studies showed that comorbid psychiatricdisorders increased the readmissionrate, resulted in excessive useof health care services, and increasedgeneral health care costs.⁴ Conversely,comorbid physical illness in psychiatricinpatients with depression were shownto add an estimated $2 billion a year inmental health care costs in the United States.⁵ A review of research studies ofmental disorders in primary care showedthat major depression, dysthymic disorder,panic disorder, social phobia andother anxiety disorders, and somatizationdisorders also increased utilizationof general medical health care resourcesand increased health care costs.⁶

Since disability and the associatedcosts paralleled the severity of thepsychiatric disorders,⁷ it was reasonableto assume that the successful treatmentof psychiatric disorders wouldsecondarily decrease general health carecosts. Based on an ultimately unsuccessfulpremise in a climate of reducingreliance on physician specialists tocut costs, the primary care physicianwas charged with this task. Unfortunately,underrecognition, inadequatemedication dosing, and abbreviatedfollow-up of patients with psychiatricdisorders were the norm, resulting inpoor clinical and economic outcomes.⁶Even with the use of screening instrumentsfor psychiatric disorders, the clinicalresults remained poor.

While some patients with uncomplicateddepression may benefit froma prescription for an antidepressant,two thirds of the patients in primarycare have depression that is complicatedby more than one psychiatric diagnosis,which worsens the prognosisand requires more sophisticated management.⁸ In patients who do notrespond to the first antidepressantprescribed, who experience side effects,or in whom interactions with comorbidmedical condition(s) complicate thechoice of antidepressant, it is notsurprising that primary care physiciansare not always able to provide effectivepsychiatric treatment.

BENEFITS OF INTERVENTION

Integrated models have demonstratedthat mental health interventions weresuccessful in treating psychiatric disordersin patients hospitalized with medicaldisorders and that their length ofstay was shorter.^9-11 In addition, depressionin primary care outpatients wassuccessfully treated6,¹² when the psychiatricor psychological interventionwas integrated into a multidisciplinarygeneral medical team setting.

With the demonstration of successfultreatment of depression in primarycare, it became possible to ask whetherreduction of depression severity wasparalleled by reductions in physicalillness. Of particular interest was thegrowing body of evidence that confirmedthat depression severity worsenedthe severity of and prognosis forvascular disease and diabetes mellitus.These associations provided a settingin which to study the interveningpsychosomatic mechanisms behindmind/brain and physical disease.

Cerebrovascularand coronary disease

Clinical research, stimulated by healthservices research, has established theadverse dose-dependent impact thatdepression has on coronary vasculardisease^13,14 and vascular disease ingeneral. Levels of depression have beenshown to correlate with increased levelsof vascular illness. Depression was alsofound to increase the incidence ofstrokes in hypertensive patients¹⁵ and to increase mortality in stroke patients.¹⁶

Two intervention treatment studiesusing antidepressants demonstrated areduction of subsequent vascular eventsin stroke patients.^17,18 It was suggestedthat antidepressants were effective inreducing depression in stroke patientsand also improved the poorer medicalprognosis conferred by depression. Itwas also suggested that antidepressantsmight have an independent anticlottingmechanism that reduces vasculardisease in both depressed and nondepressedpatients.

In addition to stroke and cerebrovasculardisease, depression has beenidentified as a risk factor for the developmentof coronary heart disease inpreviously healthy patients19 and forrecurrent cardiac events in postmyocardialinfarction patients.²⁰ While it hasbeen shown that antidepressants cansafely and successfully treat depressionin heart attack patients,²¹ 2 recent studiessuggest that antidepressant treatmentmay also reduce recurrent cardiovascularincidents in depressed cardiacpatients.^22,23 It has been hypothesized that this effect in stroke and heart attack patients may stem from the reductionof levels of platelet factor IV and β-thromboglobulin, which were found tobe elevated in depressed patients.^24,25What makes this association so intriguingis the postulated psychosomaticinteraction between depression andcoronary and cerebrovascular diseaseand the potential reversal of these effectsby antidepressant medications.

Diabetes mellitus

The most sophisticated integration ofhealth services research, clinical treatmentand research, and the explorationof bidirectional mind-body interactionshas been in the area of diabetes mellitus.The experience gained in treatingdepression in patients with diabetesmay serve as a model for treating depressionin other primary care patients withchronic illnesses, as well as exploringthe behavioral and physiologic psychosomaticinteractions between depressionand chronic diseases.

Depression has been found to be arisk factor for the subsequent developmentof type 2 diabetes mellitus in adose-dependent fashion²⁶ and is twiceas common in patients with diabetes asin nondiabetic controls. Patients with acomorbidity of diabetes and depressionalso had more cardiovascular riskfactors, were more likely to be overweight,smoke, lead a sedentary lifestyle,²⁷ and have a greater incidence ofdiabetic complications.²⁸

Many of the factors in diabetes anddepression are bidirectional. While weknow that a higher illness load causedby diabetes can lead to depression, itappears that depression also predicts theonset and course of diabetes. Depressioncan result in a sedentary lifestyle, buta sedentary lifestyle can also causedepression.²⁹ Depression and diabetescan result in weight gain and the metabolicsyndrome (the reverse is alsotrue), and each has been cited as a riskfactor for cardiovascular disease. Justas cardiovascular disease can also resultin depression, the associations of depressionwith smoking are bidirectional, andboth are risk factors for cardiovasculardisease. Depression is associated withan increased incidence of smoking andhigher failure rates of smoking cessationattempts, while smoking cessationcan increase symptoms of depression.³⁰

This interrelated web of bidirectionaland multidirectional effects poses achallenge in the search for clear causeand-effect relationships of the underlyingmind-body interactions and,ultimately, for coherent treatmentapproaches. Diabetes and depressionhave a synergistic effect on poorer prognosisin both psychiatric and medicaloutcomes. Any effective treatmentapproach, therefore, will need to be multidisciplinary and informed by datafrom clinical and health servicesresearch and investigations into underlyingpsychosomatic mechanisms.

Two related programs have been developedthat exemplify this approach--thePathways study³¹ and the ImprovingMood-Promoting Access to CollaborativeTreatment (IMPACT) study.^32,33The Pathways study uses the samecollaborative approach in diabetes thathas previously been shown to successfullytreat depression in primary carepatients. It is a structured approach thatincludes on-site nonpsychiatrist mentalhealth professionals working togetherwith primary care physicians andpsychiatrists. It provides enhancededucation, problem solving, and assistancefor the primary care physicianprescribing antidepressant medication.

The intervention in patients who haddiabetes successfully treated depression,improved medication adherence, andcontributed to overall improvement butdid not improve hemoglobin (Hb)A1clevels. Based on their experience andresults of other studies, the authorsconcluded that the failure to reduceHbA1c levels could have been causedby several factors, including insufficientstatistical power and low baseline levelsof HbA1c. They concluded that an integratedbiopsychosocial intervention thatfocuses on psychopharmacologic andpsychotherapeutic treatment of depressiontogether with diabetes managementis necessary to successfully treat coexistingdepression and diabetes.

The IMPACT study had similarresults for similar reasons but alsodemonstrated better adherence to exer-cise regimens. The costs of the projectwere offset by reductions in generalhealth care costs at 12 months. Theauthors concluded that the effectivetreatment of depression in patients withdiabetes mellitus bodes well for patientswith different forms of chronic illness,despite the belief that chronic illnessmight impede success in treating depression.These integrated approaches fortreating depression in primary care, inpatients with diabetes or those withosteoarthritis, are now being exportedbeyond the 18 original primary care clinicsthrough structured training for mentalhealth providers across the country.

Four steps in this pioneering modelinclude:

• Research in the clinical epidemiologyof depression in primary care.
• Development of an evidence-basedintervention.
• Evaluation of effectiveness andcost-effectiveness in diverse clinicalsettings.
• Exporting the model by trainingmental health specialists to apply thepractice model in their own widespreadinstitutions.³⁴

As of this writing, there have beenmore than 500 mental health careproviders trained in the principles ofthe IMPACT program who can bringthe methods to their own institutions(J. Unutzer, personal communication,January 2006).

This kind of clinical research modeloffers an exciting framework for advancingpsychosomatic research into thechanges in neuroendocrine, immunoinflammatory,and clotting factors andtheir relationship to depression severityin patients with diabetes and othercomorbid medical illness.³⁵

While the advantages of integrativecare for depression in vascular diseaseand diabetes have been described above,other models of integrative care basedon different health care perspectives thattarget different patient populations havealso proved successful. These includework with general medical units, geriatricunits, and surgical units; inpatientswith delirium; patients with alcoholabuse¹¹; and primary care outpatientswith panic disorder.³⁶ While mostconsultation-liaison psychosomaticprograms across the country struggleto provide quality care in mostly unintegratedclinical settings, the integratedprograms described above stand asmodels for the future of psychiatricintervention in medical care settings.By combining research studies in healthservices, effectiveness of psychiatrictreatment, and the impact of psychiatricimprovement on medical disorders, theyprovide a fertile ground for the investigationof the psychosomatic mechanismsresponsible for mind-bodyinteractions and the gains in treatmentthe results of those studies will provide.

Dr Saravay is president of the Academy ofPsychosomatic Medicine and chief of theconsultation-liaison/psychosomatic medicineservice at the Long Island Jewish MedicalCenter and Clinical Campus of the NorthShore, LIJ Health System; he is also clinicalprofessor of psychiatry at the Albert EinsteinCollege of Medicine in New York City. He hasno conflicts to report concerning the subjectmatter of this article.

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