Telephone-based program augments primary care mental health management

By Larry Hand

NEW YORK (Reuters Health) - A telephone-based program that provides mental health (MH) care management plus symptom monitoring to geographically scattered older adults is more effective than providing symptom monitoring alone, according to a new trial.

"Our results suggest that a program of telephone MH care management is feasible and scalable, and should be considered as an adjunct to first-line treatment received in primary care," said Dr. Shahrzad Mavandadi, of the Perelman School of Medicine at the University of Pennsylvania and the Department of Veterans Affairs, Philadelphia.

"Our study also suggests that evidence-based MH care management can be successfully delivered, by telephone, across a large geographical region to low-income, community-dwelling older adults who may be particularly vulnerable to behavioral health conditions and poor access to and response to treatment," she told Reuters Health by email.

"The results of this study also specifically point to the added value of offering measurement-based care management services - which involve education, counseling, and decision support to patients and their providers - over simply monitoring symptoms," she said.

Dr. Mavandadi and colleagues randomly assigned older adults to one of two treatment arms of varying intensity of monitoring, care, and access to resources by telephone. The trial was part of the Supporting Seniors Receiving Treatment and Intervention (SUSTAIN) program.

The trial involved more than 1,000 low-income, community-dwelling participants enrolled in SUSTAIN from August 2010 to May 2014. Eligible participants had to be at least 65 years old, have at least one new prescription from a nonpsychiatric clinician for an antidepressant or anxiolytic, and have clinically significant symptoms for depression or anxiety at baseline.

Half the participants received symptom monitoring alone during up to four brief assessments over 12 weeks after baseline assessment and the other half received monitoring plus care management delivered by behavioral health professionals.

Of the 509 randomized to each arm, 377 of the monitoring-alone arm and 401 of the monitoring-plus-care-management arm completed at least two follow-up assessments, the team reports in an article online November 11 in JAMA Psychiatry.

Participants who received care management experienced greater improvements in the overall mental functioning (p=0.04), reduction of depressive symptoms (p<0.001), and reduction of anxiety symptoms (p<0.001) at six-month follow-up.

"As with any program or intervention, further replication is needed," Dr. Mavandadi told Reuters Health. "Future studies also should include a control group. But what is particularly important is that future studies more carefully examine the elements of MH care management that are most beneficial to patients in order to improve clinical effectiveness and the actual impact of these types of programs on patient symptoms and function."

"With the aging of the population, it is increasingly important to develop strategies for identifying and treating behavioral health conditions among community-dwelling older adults," she continued. "One of the interesting findings from our study is the relatively small number of older adults with severe symptoms and the very large number with mild symptoms, all of whom had been prescribed a psychotropic medicine. This speaks to the need for services that differ from specialty care."

"By the same token, attention should be paid to interventions for older adults who may be more vulnerable to developing severe behavioral health conditions and have less access to specialty mental health care," she concluded.

Dr. Donovan Maust, of the University of Michigan and the Veterans Affairs Ann Arbor Healthcare System, who has done research in this area, told Reuters Health by email, "Given the limited availability of psychiatrists overall and geriatric psychiatrists in particular, care management programs using technology are critical to reach patients that are geographically scattered as well as their primary care providers. There is an overwhelming amount of evidence that care management in general as well as telephone-based are better than usual care."

"This work raises several questions for me, as this is a unique window into a population much older (average age of nearly 80 years) than is often seen in clinical research," he continued.

"First, while it is heartening that symptoms improved for all these patients, what is most remarkable to me is how low the level of symptoms was for having been newly started on psychotropic medication - at baseline, just 35% had clinically significant depressive symptoms and just 13% had clinically significant anxiety symptoms," Dr. Maust said. "Care management was clearly effective for patients who have been started on these medications - which is good - but I think future research might now focus at the point of prescribing and whether the prescription is necessary at all for all of these older adults, in light of the potential harms."

The Pennsylvania Department of Aging supported this research. The authors reported no disclosures.

SOURCE: http://bit.ly/1kEGMz4

JAMA Psychiatry 2015.

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