Improved mental health quality in cardiac patients via collaborative care [MOSAIC trial]

Image: PD 

1. Mental health-related quality of life (HRQoL) and overall QoL were better in patients who underwent telephone-based collaborative care intervention post discharge. 

2. Patients in the collaborative care arm were more likely to receive adequate treatment of their mental health disorder, and had improvement in their depression symptoms and general functioning at 24 weeks. 

Evidence Rating Level: 1 (Excellent) 

Study Rundown: Mental health issues including depression, anxiety, and panic disorder following acute cardiac conditions are associated with poor cardiovascular outcomes. Further, depression and anxiety are important determinants of, and negatively impact, HRQoL. The Management of Sadness and Anxiety in Cardiology (MOSAIC) trial employed a collaborative care (CC) intervention model that resulted in better mental health-related quality of life at 24 weeks following discharge. Further, these patients were more likely to have appropriate treatment of their psychiatric conditions at discharge. There were no differences in rates of depression response or anxiety response at 24 months.

The strengths of this study include an elegant design, well fleshed out exclusion/inclusion criteria (to include a substantial portion of patients admitted to cardiac units including patients post cardiac transplantation), and good follow-up rates in both treatment arms. Further, the low-intensity collaborative care intervention administered via a social worker as case manager points to a resource-efficient system to track patients and their mental health care after discharge. Weaknesses of this study include no significant differences in rates of depression and anxiety response, and no effects on medical outcomes like adherence or readmissions.

Click to read the study in JAMA Internal Medicine

Relevant Reading: Essential Articles on Collaborative Care Models for the Treatment of Psychiatric Disorders in Medical Settings: A Publication by the Academy of Psychosomatic Medicine Research and Evidence-Based Practice Committee

In-Depth [randomized controlled trial]:  This study evaluated the effects of a 24-week low intensity telephone-based collaborative care (CC) intervention to identify and manage depression, generalized anxiety disorder (GAD) and panic disorder (PD) amongst patients hospitalized for cardiac illness, including acute coronary syndrome, heart failure, or arrhythmia. 183 patients admitted to cardiac units between 2010-2013 who had depression, GAD, or PD were randomized to either the CC intervention (n=92) or to enhanced usual care involving serial notification of primary medical providers (n=91). A social work case manager coordinated the assessment and relevant care for psychiatric conditions of the patients randomized to the CC arm. A combination of SSRIs, CBT, and/or other drugs was used in the CC group. Short Form-12 Mental Component Score (SF-12 MCS) was used to track mental health-related quality of life using intention-to-treat analysis.

The patients in the CC arm had significantly improved mean SF-12 MCS scores at 24 weeks, 11.21 points (from 34.21 to 45.42) as opposed to 5.53 points (from 36.30 to 41.83) in the usual care control group.  The estimated mean difference was 5.68 points (95%CI, 2.14-9.22, p = .002). The number of patients with adequate treatment by discharge was also higher in the CC group (p<0.001).  Additional mental health and functional outcomes as measured by PHQ-9 and DASI were also better in the CC arm.  The number of cardiac readmissions at 24 weeks did not vary between the 2 groups.

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