Among the various comorbidities that commonly affect patients with chronic respiratory diseases, psychiatric disorders are highly prevalent. Adults with asthma, for example, have twice the risk for depression and are 83% more likely to have symptoms of anxiety compared with healthy controls.1 In addition, depression has been observed in approximately 27% and 40% of patients with asthma and chronic obstructive pulmonary disease (COPD), respectively, and a recently published population-based study (N=71,874) identified psychiatric comorbidity (eg, anxiety, depression, and panic disorder) in 45% of patients with COPD.1
Comorbid mental health disorders have been linked with a range of adverse outcomes in these patient groups, including reduced survival, more frequent exacerbations and hospital readmissions, and reduced performance on the 6-minute walk test specifically in patients with COPD.1 Despite the high prevalence and poor outcomes associated with psychiatric illness in individuals with respiratory diseases, mental health concerns are undertreated in this population due to several potential factors in addition to general gaps in access to psychiatric care providers.1,2 Providers and patients may not recognize signs of mental health disorders because they often overlap with those of respiratory diseases, including fatigue and sleep impairments, and primary care providers (PCPs) may not conduct routine screenings for these disorders because of time limitations or other reasons.1
The psychiatric collaborative care model (CCM) is one approach that has shown promise in the treatment of patients with comorbid medical and psychiatric diseases, as described in a review published recently in Chest.1 A psychiatric collaborative care team includes a PCP who coordinates the overall care; a care manager (eg, social worker, psychologist, nurse, or other allied health professional), typically located in the PCP’s office, who monitors symptoms and provides support, psychoeducation, and brief behavioral and psychological counseling to patients; and an offsite psychiatrist who recommends psychotropic medications if needed. As explained in the review, “The psychiatrist also reviews the patient’s condition, makes recommendations to the primary care team (eg, communicating with the care manager or PCP), and can see the patient individually for difficult situations and bill separately for that individual service.”1
Study results have demonstrated benefits of the CCM approach, including:
- Improvements in depressive symptoms, functional activities, and quality of life (QoL) in older primary care patients with depression, compared with usual care3
- Improvements in mental health-related QoL, depressive symptoms, treatment rates, and general functioning in cardiac inpatients4
- Reductions in depression and anxiety in veterans with COPD or heart failure (which were maintained at the 12-month follow-up), as well as improved health-related QoL in patients with COPD, compared with usual care5
- Short- and long-term improvements in symptoms of anxiety and depression vs usual care in patients with chronic diseases6
Collaborative models have also demonstrated cost-effectiveness, including one study that found $6.50 in savings for every dollar spent on a CCM.1,7 The adoption of these models is currently more practical since Current Procedural Terminology codes (99492, 99493, and 99494) have been designated for the reimbursement of CCM services; these codes replace the previous codes G0502, G0503 and G0504)
Pulmonology Advisor interviewed one of the coauthors of the review, Abebaw M Yohannes, PhD, FCCP, a professor in the department of physical therapy in the School of Behavioral and Applied Sciences at Azusa Pacific University, to gain further insights regarding CCMs.
Pulmonology Advisor: What is known thus far about psychiatric comorbidity in respiratory disease?
Dr Yohannes: Depression and anxiety are common in patients with chronic respiratory diseases and are associated with increased disability, impaired QoL, acute exacerbations, and increased emergency healthcare utilization and hospital admission. Furthermore, these disorders are often underrecognized and untreated. Barriers to treatment include patients’ perceived difficulties such as lack of knowledge and reluctance to disclose symptoms of anxiety and depression.
In addition, physicians’ perceived barriers may include short consultation times, lack of confidence to pursue in-depth psychological assessment, and lack of adequate resources for mental health treatment. Pulmonary rehabilitation and cognitive behavioral therapy have shown promising results in ameliorating mild to moderate anxiety and depressive symptoms in patients with chronic respiratory diseases in short-term follow-up. However, the long-term benefits are inconclusive.
Pulmonology Advisor: How should these issues be addressed in practice, and what are the benefits of a collaborative care model?
Dr Yohannes: Clinicians and healthcare professionals should actively engage in identifying anxiety and depressive symptoms using screening tools like the Patient Health Questionnaire-9 or Hospital Anxiety and Depression Scale. Patients identified as having significant depressive and anxiety symptoms should be monitored and treated with appropriate treatment using a CCM.
The benefits of CCM include patient support to receive targeted treatments, patient education about the importance of treatment, patient support to adhere to their exercise regimens, and demystifying the fear of taking of antidepressants. It also provides the opportunity for the CCM team to collaborate with patients, monitor their treatment, and evaluate progress.
Pulmonology Advisor: How does this model play out in practice? What are the typical steps with an individual patient?
Dr Yohannes: First, explore whether the patient has anxiety and/or depressive symptoms during routine clinical care. Next, employ a screening questionnaire to quantify the severity of these symptoms. Third, refer patients to the CCM team to receive further assessment and/or treatment. Finally, treat the patient with appropriate interventions such as psychological therapy, exercise, and antidepressants.
Pulmonology Advisor: For doctors who do not currently have a CCM but want to set one up, how should they go about this?
Dr Yohannes: It is important for the physician to establish a strong multidisciplinary care team to participate in the CCM. This involves recruiting a care manager for the CCM model to be effective. The CCM team should communicate regularly and monitor the patient’s progress in a timely fashion. In setting up the care plan and goals, the team should ensure that the patient is at the heart of the discussion. The team should also make sure that the reimbursement plan is set up correctly.
Pulmonology Advisor: What are other relevant takeaways for clinicians, as well as future research needs regarding this topic?
Dr Yohannes: CCM has shown benefits in improving QoL and reducing anxiety, depressive symptoms, and healthcare utilization in patients with chronic respiratory diseases. The long-term efficacy of antidepressants, pulmonary rehabilitation, and cognitive behavioral therapy in the treatment of anxiety and depression in this population warrant further investigation. Addition research is needed to determine the long-term benefits of the CCM.
1. Yohannes AM, Newman M, Kunik ME. Psychiatric collaborative care for patients with respiratory disease [published online February 27, 2019]. Chest. doi:10.1016/j.chest.2019.02.017
2. DeJean D, Giacomini M, Vanstone M, Brundisini F. Patient experiences of depression and anxiety with chronic disease: a systematic review and qualitative meta-synthesis. Ont Health Technol Assess Ser. 2013;13(16):1-33.
3. Unützer J, Katon W, Callahan CM, et al; IMPACT Investigators. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836-2845.
4. Huffman AC, Mastromauero CA, Beach SR, et al. Collaborative care for depression and anxiety disorders in patients with recent cardiac events. The management of sadness and anxiety in cardiology (MOSIAC) randomized clinical trial. JAMA Intern Med. 2014;174(6):927-935.
5. Cully JA, Stanley MA, Petersen NJ, et al. Delivery of brief cognitive behavioral therapy for medically ill patients in primary care: a pragmatic randomized clinical trial. J Gen Intern Med. 2017;32(9):1014-1024.
6. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression anxiety problems. Cochrane Database Syst Rev. 2012;10:CD006525.
7. Unützer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14(2):95-100.