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Original Investigation |

Collaborative Care for Depression and Anxiety Disorders in Patients With Recent Cardiac Events:  The Management of Sadness and Anxiety in Cardiology (MOSAIC) Randomized Clinical Trial

Jeff C. Huffman, MD1,2; Carol A. Mastromauro, LICSW1,2; Scott R. Beach, MD1,2; Christopher M. Celano, MD1,2; Christina M. DuBois, BA1,2; Brian C. Healy, PhD1,3; Laura Suarez, MD1,2; Bruce L. Rollman, MD4; James L. Januzzi, MD1,5
[+] Author Affiliations
1Harvard Medical School, Boston, Massachusetts
2Department of Psychiatry, Massachusetts General Hospital, Boston
3Biostatistics Center, Massachusetts General Hospital, Boston
4Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
5Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston
JAMA Intern Med. 2014;174(6):927-935. doi:10.1001/jamainternmed.2014.739.
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Importance  Depression and anxiety are associated with adverse cardiovascular outcomes in patients with recent acute cardiac events. There has been minimal study of collaborative care (CC) management models for mental health disorders in high-risk cardiac inpatients, and no prior CC intervention has simultaneously managed depression and anxiety disorders.

Objective  To determine the impact of a low-intensity CC intervention for depression, generalized anxiety disorder, and panic disorder among patients hospitalized for an acute cardiac illness.

Design, Setting, and Participants  Single-blind randomized clinical trial, with study assessors blind to group assignment, from September 2010 through July 2013 of 183 patients admitted to inpatient cardiac units in an urban academic general hospital for acute coronary syndrome, arrhythmia, or heart failure and found to have clinical depression, generalized anxiety disorder, or panic disorder on structured assessment.

Interventions  Participants were randomized to 24 weeks of a low-intensity telephone-based multicomponent CC intervention targeting depression and anxiety disorders (n = 92) or to enhanced usual care (serial notification of primary medical providers; n = 91). The CC intervention used a social work care manager to coordinate assessment and stepped care of psychiatric conditions and to provide support and therapeutic interventions as appropriate.

Main Outcomes and Measures  Improvement in mental health–related quality of life (Short Form-12 Mental Component Score [SF-12 MCS]) at 24 weeks, compared between groups using a random-effects model in an intent-to-treat analysis.

Results  Patients randomized to CC had significantly greater estimated mean improvements in SF-12 MCS at 24 weeks (11.21 points [from 34.21 to 45.42] in the CC group vs 5.53 points [from 36.30 to 41.83] in the control group; estimated mean difference, 5.68 points [95% CI, 2.14-9.22]; P = .002; effect size, 0.61). Patients receiving CC also had significant improvements in depressive symptoms and general functioning, and higher rates of treatment of a mental health disorder; anxiety scores, rates of disorder response, and adherence did not differ between groups.

Conclusions and Relevance  A novel telephone-based, low-intensity model to concurrently manage cardiac patients with depression and/or anxiety disorders was effective for improving mental health–related quality of life in a 24-week trial.

Trial Registration  clinicaltrials.gov Identifier: NCT01201967

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Figure 1.
CONSORT Flow Diagram for Management of Sadness and Anxiety in Cardiology (MOSAIC) Trial

GAD indicates generalized anxiety disorder; MDD, major depressive disorder; PD, panic disorder.

a5-Item screen: Patient Health Questionnaire-2, Generalized Anxiety Disorder-2, and panic disorder item.

bDisorder-specific evaluation: Patient Health Questionnaire-9, Primary Care Evaluation of Mental Disorders modules for PD and GAD.

cEvaluation for psychiatric exclusion criteria: Mini International Neuropsychiatric Interview modules for bipolar disorder and psychosis, substance abuse assessment (CAGE questionnaire), and structured suicidality assessment.

dDeclined cognitive behavioral therapy and pharmacotherapy at enrollment.

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Figure 2.
Trajectory of Improvement in Outcome Measures Over 24 Weeks

A-D, The left-hand graph shows mean scores in each treatment group, and the right-hand graph, between-group difference in change from baseline.

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