Teaching Psychiatric Formulation to Residents and Faculty.
Academic Article
Overview
abstract
BACKGROUND: Evidence-based pharmacologic and behavioral interventions are often underused or inaccessible to persons with multiple sclerosis (MS) who have chronic pain and/or depression. Collaborative care is an evidence-based, patient-centered, integrated, system-level approach to improving the quality and outcomes of care for behavioral health and other chronic conditions. We describe the development and randomized controlled trial testing of a novel intervention, MS Care, which uses a collaborative care model to improve the care of depression and chronic pain in an MS specialty care setting. OBJECTIVES: The specific aims were as follows: (1) to test the effectiveness of MS Care, a patient-centered collaborative care approach to treating depression and pain in individuals with MS, relative to usual care, in reducing pain and depression posttreatment (primary end point), and at the 6-month follow-up; and (2) to examine the impact of MS Care on secondary outcomes including quality of depression and pain care, disability, patient satisfaction, and quality of life posttreatment and at the 6-month follow-up. METHODS: We conducted a 2-group randomized (1:1) effectiveness trial comparing MS Care with usual care in an outpatient MS specialty care center. Eligible participants (N = 195) with chronic pain of at least moderate intensity (> 3/10) and/or major depressive disorder were randomly assigned to MS Care or usual care. MS Care used a care manager to deliver and coordinate guideline-based medical and behavioral treatments in collaboration with the patient, specialty clinic providers, and pain/depression treatment experts. To facilitate treatment engagement, the care manager offered participants the choice to receive care-management sessions in person, by telephone, or via a combination. Those randomly assigned to usual care received treatment as usual through the clinic. Research staff unaware of intervention allocation obtained all outcome measurements via telephone interview pretreatment (baseline), posttreatment (4 months postrandomization: primary end point), and at the 6-month follow-up (10 months postrandomization). The primary outcome was control of pain and depression (ie, pain and depression were below clinically meaningful cutoffs posttreatment). Secondary outcomes included pain interference with normal activities, depressive symptom severity, quality of life, disability, fatigue, patient satisfaction, health care utilization, and quality of care posttreatment and at the 6-month follow-up. For the primary analysis, we compared the proportion of individuals who had control of depression and pain symptoms between the 2 groups at the end of the treatment period. Attrition and missing data were very low; imputation was not needed. Secondary outcomes were analyzed posttreatment and at the 6-month follow-up using t tests, chi-square tests, and Fisher tests. RESULTS: Participants in both groups were generally middle-aged, female, and diagnosed with MS for > 10 years. The majority of participants met inclusion criteria for moderate or severe pain (72%) or pain and depression (23%); only a few individuals met inclusion criteria for depression alone (5%). There was no statistical difference (using an α level of 0.05 for all statistical tests) between the MS Care and usual care groups in the proportion of individuals whose pain and depression were both under control immediately posttreatment, the primary end point being 18.8% (95% CI, 10.5-27.1) in MS Care vs 12.2% (95% CI, 5.1-19.3) in usual care (p = 0.24). At the 6-month posttreatment follow-up, the MS Care group was statistically different from the usual care group, with more individuals having depression and pain under control (17.9% in MS Care vs 7.4% in usual care; p = 0.04). Secondary outcomes were as follows: immediately posttreatment, the MS Care group showed statistically significant lower pain intensity, pain interference, depression severity, disability, and fatigue than usual care (p = 0.001 vs p = 0.04, respectively). Treatment satisfaction was also higher for the MS Care group (p < 0.001). At the 6-month follow-up, the MS Care group maintained statistically lower pain interference, disability, and fatigue (p = 0.004 vs p = 0.03, respectively). In analyses examining pain and depression outcomes separately, the MS Care group had significantly more pain responders than the usual care group posttreatment (p = 0.01) and at the 6-month follow-up (p = 0.03). For the depression outcome, the MS Care group had significantly more depression responders than the usual care group posttreatment (p = 0.04); this difference was not maintained at follow-up, however (p = 0.36). CONCLUSIONS: Although MS Care was not superior to usual care in controlling pain and depression posttreatment, MS Care was effective in other outcomes of importance to people with MS and resulted in high rates of satisfaction. STUDY LIMITATIONS: These included underrepresentation of patients with depression in the sample, being a single-center study, the restriction of the MS Care intervention to 16 weeks (relative to flexible duration in clinical practice), use of 2 care managers (vs multiple), and insufficient power to measure subgroup effects.
