Proactive Psychiatry

IN THIS ISSUE:  HOME Study | Proactive Psychiatry | Workshop | A&E Abstracts and Extracts

Absence of Evidence from Randomized Controlled Trials Remains a Critical Gap in the Literature

Proactive C-L Psychiatry SIG chair, Mark Oldham, MD, assesses the current evidence base for Proactive Psychiatry


Mark Oldham, MD
Mark Oldham, MD

C-L Psychiatry in the general hospital provides invaluable clinical care and services to patients, colleagues, and health care institutions. Attesting to this fact is a wealth of personal experience and even intuition. Additionally, from an ethical perspective, parity for mental health care requires that it be available alongside other specialties in acute medical settings. However, decision makers, even those who accept all this to be true, often need more than conviction. They need this value to be articulated, translated into good data, and ideally converted into the language of financials.

What exactly is the value of C-L Psychiatry? And, just as importantly, how do we demonstrate it? After all, fee-for-service models don’t always cover the C-L psychiatrist’s salary, and that money has to come from somewhere.

Here it is, 2023, and our field is still plagued by the perennial challenge of financial viability, a challenge our field has stared down from its earliest days. Daunting as this is, it is nevertheless the crucial backdrop against which to understand modern efforts to innovate the practice of C-L Psychiatry in the general hospital.

Proactive C-L is an adaptable model of C-L Psychiatry that aspires to achieve the Triple Aim, which includes enhancing care quality, improving population health, and reducing costs—or, at the very least, demonstrating cost neutrality.

It does so by systematically screening a target inpatient population for mental health concerns and by delivering care as part of an interdisciplinary team: in other words, equal parts proactivity and integrated care delivery. 1, 2, 3.

The past little over a decade has witnessed a series of quality improvement projects seeking to refine and adapt the model of Proactive C-L, and to define its value in relation to traditional or ‘reactive’ C-L services. The Proactive C-L Psychiatry SIG webpage features an updated bibliography and a growing list of implementation resources for C-L psychiatrists and their institutions to use in advocacy of this model.

Proactive C-L addresses unmet mental health needs in the hospital, supports colleagues in medicine and nursing, and improves overall care delivery. Studies have found that this care model is associated with greater mental health care utilization, higher clinician ratings of satisfaction with mental health services and of self-reported safety, and reduced hospital length of stay. 1. Although the data are promising, the absence of evidence from randomized controlled trials (RCTs) remains a critical gap in the literature. 2.

Compare the current state of Proactive C-L Psychiatry with that of collaborative care. In 2002, results from the seminal IMPACT Trial, now the second largest RCT in C-L Psychiatry, were published in JAMA. Unützer and colleagues enrolled 1,801 older adults with a depressive disorder and found that collaborative care led to an overall reduction in depressive symptoms and functional impairment as well as greater quality of life relative to usual care. And this is just one of more than 90 RCTs exploring the value of collaborative care.

The value of collaborative care in the community is well established, but what about Proactive C-L? Although Proactive C-L shares much the same mission as collaborative care, only in acute medical settings, one cannot simply extrapolate these data from collaborative care across levels of care. For instance, Proactive C-L is tailored to meet the unique needs of specific inpatient medical populations—populations that are both smaller than those in outpatient settings but that incur substantially higher per-patient costs of care. The care team composition and daily workflow of Proactive C-L also differ from those of collaborative care models.

But now…enter the HOME Study, the first RCT comparing Proactive C-L to usual care for length of stay among older adults—and now the largest RCT ever conducted in C-L Psychiatry.

See: Results of the Biggest-Ever Randomized Trial of Inpatient C-L Psychiatry to be Presented at CLP 2023 Plenary, this issue


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