Journal Article Annotations
2021, 4th Quarter

Integrated Care

Annotations by Jai Gandhi, MD
December, 2021

Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care: A Pragmatic Randomized Comparative Effectiveness Trial.

PUBLICATION #1 — Integrated Care

Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care: A Pragmatic Randomized Comparative Effectiveness Trial.

John C Fortney, Amy M Bauer, Joseph M Cerimele, Jeffrey M Pyne, Paul Pfeiffer, Patrick J Heagerty, Matt Hawrilenko, Melissa J Zielinski, Debra Kaysen, Deborah J Bowen, Danna L Moore, Lori Ferro, Karla Metzger, Stephanie Shushan, Erin Hafer, John Paul Nolan, Gregory W Dalack, Jürgen Unützer

Abstract: JAMA Psychiatry. 2021 Nov 1;78(11):1189-1199. doi: 10.1001/jamapsychiatry.2021.2318.

Importance:
Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings.

Objective:
To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics.

Design, setting, and participants:
This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months.

Interventions:
Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing.

Main outcomes and measures:
Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects.

Results:
Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (β = 1.0; 95% CI, -0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (β = 2.0; 95% CI, -1.7 to 5.7; P = .29).

Conclusions and relevance:
In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable.

Annotation

The finding:
Patients with bipolar disorder and/or posttraumatic stress disorder can achieve clinically significant improvements in the primary care setting through the use of either telepsychiatry collaborative care (TCC), where psychiatric providers deliver consultation, or telepsychiatry/telepsychology enhanced referral (TER), where psychiatric providers assume responsibility for the treatment. The primary outcome (Veterans RAND 12-item Health Survey Mental Component Summary score) and every secondary outcome (including multiple disorder specific symptom checklists) demonstrated statistically significant improvements across both methods of care delivery. Only the PTSD Checklist-5 demonstrated a statistically significant difference across groups, with statistically significant greater reductions in score for those enrolled in TER. Another notable difference found between arms was that the number telepsychiatry encounters were 3-fold greater in TER compared to TCC (mean [SD] of 4.3 [3.1] vs 1.4 [0.9]).

Strength and weaknesses:
This trial has multiple strengths: a large sample size, patients recruited from multiple different federally qualified health centers across multiple states, diversity in sexual orientation, gender identity, and race, and an incredibly inclusive approach to enrollment in the trial. The inclusive approach to enrollment suggests the trial represents a heterogeneous and generalizable patient population; the population notably included 3.8% of patients diagnosed with schizophrenia. While not a weakness, an important piece of information would have been a fiscal analysis of each arm. Ideally, the trial would have included a “usual care” arm to definitively establish the utility of these interventions compared to usual primary care.

Relevance:
These findings further emphasize the utility and scalability of collaborative care interventions, especially in the context of the overwhelming need for increased accessibility of mental health care. The enormous difference in demand on psychiatrist time between the two interventions (a mean of 1.4 encounters for TCC compared to a mean of 4.3 encounters for TER) without clinical superiority of either arm for most outcomes means that the best method to improve access and outcomes for patients within most systems or primary care clinics will be to establish TCC interventions. The important exception based on this trial would be the improved outcomes for PTSD seen with TER, an especially important consideration for populations with higher rates of PTSD.