Sick at heart? Psychiatric intervention may help cardiac patients

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Some patients hospitalized for various cardiac illnesses who had or developed mental health conditions fared better under a low-intensity care program in a clinical trial. The results were published online April 14 in JAMA Internal Medicine.

“[T]here has been minimal use of CC [collaborative care] interventions among patients hospitalized for heart conditions, despite the fact that such patients appear to be at the highest risk of adverse cardiac events in the context of psychiatric symptoms,” wrote lead author Jeff C. Huffman, MD, of Harvard Medical School in Boston, and colleagues. Nor do studies of collaborative care models typically attempt to treat a swath of mental health conditions simultaneously despite their comorbidities.

“[S]uch a model may be particularly useful in patients with heart disease given the independent (and possibly additive) association of depression and anxiety disorders with adverse cardiac events,” they reasoned.

The researchers designed the MOSAIC (Management of Sadness and Anxiety in Cardiology) clinical trial to assess the feasibility and effectiveness of an intervention that enrolled patients admitted to a medical center for acute coronary syndrome, heart failure or arrhythmia between 2010 and 2012. To be eligible for the study, patients had to be diagnosed with clinical depression, generalized anxiety disorder or panic disorder in a screening.

Patients were randomized to 24 weeks of collaborative care or enhanced usual care. The collaborative care model was intentionally low resource: It was telephone based and the intervention was delivered by a part-time social worker/care manager who collaborated with a team of psychiatrists. The care manager consulted with patients and physicians to determine treatment recommendations, educated patients before discharge and conducted telephone follow-ups.

The primary outcome was health-related quality of life at six months, as measured on the Medical Outcomes Short Form-12 Mental Component Score (SF-12 MCS).  

Most of the 223 patients in the study were diagnosed with depression or anxiety, with 92 enrolled in the intervention group and 91 in the control group. The care manager contacted patients in the intervention groups for a median of three times during the six-month period.

At six months, the intervention group had a mean SF-12 MCS score of 11.21 vs. 5.53 in the usual care group. The intervention patients were more likely to have adequate treatment for their mental health condition at discharge and have fewer depressive symptoms and better overall functioning at six months.

Readmission rates were similar for both groups, although time to first readmission was longer in the intervention group. Anxiety scores, rates of disorder response and rates of self-reported adherence also were similar.

The study reflected a real-world patient population with multiple and sometimes complex conditions, Huffman et al wrote. “We found that a single CM [case manager] was able to coordinate care of three psychiatric conditions in patients with a wide range of cardiac diagnoses living within and outside the metropolitan area of a hospital.”

Use of only one social worker was also a study limitation, they conceded, because the results may be due to the case worker’s proficiency. Also, 90 percent of the patients were white and so the study population was not representative of patients as a whole.