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I recently received a $3 million grant from the National Institutes of Health (NIH) to lead a new, developing center for services research at UMDNJ-Robert Wood Johnson Medical School (RWJMS). Based in the Department of Psychiatry, this research consortium includes other investigators from RWJMS, UMDNJ’s University Behavioral Healthcare (UBHC) and Rutgers University, who will examine new research strategies to assess and manage patients with mental health problems in primary care.
A new center grant for RWJMS, “Medically Unexplained Physical Symptoms (MUPS) in Primary Care Research Center,” $2,911,462 total costs, was competitively funded this July as a Developing Center for Intervention and Services Research (DCISR) by the National Institute of Mental Health (NIMH). I will lead the center and serve as principal
investigator. Michael Gara, MD, professor of psychiatry, is co-principal investigator. Other RWJMS investigators include Denise Rodgers, MD, associate dean for community health and associate professor of medicine, Eric Jahn, MD, assistant professor of medicine, and Lesley Allen, PhD, Paulette Hines, PhD, Edward Kim, MD, Paul Lehrer, PhD, Shula Minsky, William Vega, PhD, Betty Vreeland, MSN, Robert Woolfolk, PhD, and Doug Ziedonis, MD, MPH, from the Department of Psychiatry at RWJMS.
A key mission of this developing center is to forge research collaborations to devise strategies and design projects to improve the understanding and management of primary care patients, particularly those from low-income minority groups. It will also evaluate a set of cost-effective, practical therapeutic interventions within primary care settings to manage medically unexplained physical symptoms (MUPS) and associated depression and anxiety syndromes.
The main site for the clinical studies will be the Chandler Clinic, an RWJMS facility and federally qualified center that offers comprehensive services to an underserved, ethnically diverse, low-income urban population in New Brunswick. At Chandler, 70% of patients speak languages other than English as their primary language; and Latino patients constitute one half of the patient
population, with a predominance of recent immigrants from 11 Latin American countries.
Worldwide, people with common mental disorders such as anxiety/depression tend to first seek help from primary care providers, not from behavioral healthcare specialists. These patients tend to emphasize their MUPS in the way they present to their doctors. Some may acknowledge psychological issues, but the majority do not and prefer seeking treatment specifically for their MUPS in primary care as opposed to treatment for their depression/anxiety in mental health clinics. While stigma and limited resources contribute to this trend, there appears to be a preference on the part of many consumers to seek primary care services. Unfortunately, despite the availability of efficacious interventions for depression/anxiety suitable for use in primary care, these interventions have not been widely disseminated in these settings.
In a previous NIH-funded study of patients presenting with MUPS to
primary care providers (Chandler Clinic and other sites), we learned that their clinical management could be practically enhanced if they were approached at the primary care site, often in a non-traditional manner, by addressing their physical symptoms first, and not the “depression” or “anxiety” per se. That study (1-RO1 MH 60265-01, “Treatment of Somatization in Primary Care,” Javier I. Escobar, MD, principal investigator; Michael Gara, PhD, co-PI; $1,600,000 total costs) began in late 2000 and recruited 180 primary care patients presenting with symptoms such as persistent fatigue, pain or gastrointestinal, cardiovascular or musculoskeletal symptoms that remained medically unexplained. A majority of patients had mild to moderate anxiety/depressive disorders. Ten sessions of an intervention incorporating cognitive-behavioral principles together with a relaxation component were compared to “treatment as usual.” The results were statistically significant and quite impressive in that more than 65% of the patients who received the intervention attained good outcomes (clinical ratings of “very much improved” or “much improved”) whereas about one third of the patients in the “treatment as usual” group demonstrated this kind of outcome.
We also learned in that first study that patients with MUPS and co-morbid anxiety/depression syndromes fare better if we “take them as they come,” addressing their MUPS symptoms first and their psychiatric symptoms next. When we tried the reverse sequence, we ran considerable risk of losing the patient altogether, in the sense of unacceptable increased rates of patient drop-out and non-compliance. We also learned that the “one size fits all” approach is not an appropriate strategy for most MUPS patients and that a more flexible, progressive (one step at a time) approach must be considered. Therefore, one of the goals of our new center grant is to develop and refine an innovative approach that comprises a number of interventions (pharmacological and
non-pharmacological).
Research emanating from our developing center will devise and test new ways to assess and treat these MUPS patients in a culturally relevant manner, determining which approaches/methods work well with each population and which do not, and developing products such as treatment manuals and multi-media to facilitate diffusion of effective interventions in primary care settings nationwide.
Setting up such a center has required tightening the rather loose and informal infrastructure that linked psychiatric and medical specialties with primary care in our University-RWJMS system. A critical new link that had to be added to this infrastructure is between primary care and behavioral healthcare, represented by UMDNJ’s University Behavioral HealthCare (UBHC). The hope is that eventually such a link can be self-sustaining as well as transferable to other settings outside UMDNJ. The success of such a transfer is more likely if ingenuity is harnessed to forge new and replicable communication structures (including computerized ones), financial structures (including revenue sharing), culturally competent behavioral healthcare services rendered at primary care sites, training, research mentoring and so on.
The center will also provide the needed research infrastructure to take advantage of these newly forged links between medicine, psychiatry and UBHC. This research infrastructure would include data management, with the ability to merge the center’s databases with UBHC’s highly sophisticated administrative database, statistical support, and a methods core to develop new, streamlined and biometrically sound ways to assess MUPS and cultural competence in primary care.
In related work, I have for the past five years led a NIH-funded mentoring program (1-R13 MH 66308-01, “Critical Research Issues in Latino Mental Health,” Javier I. Escobar, MD, Principal Investigator, $354,800 direct costs) aimed at training new investigators to conduct research on Latino mental health issues. This program has been adopted nationally as a model for developing similar programs.
Javier I. Escobar, MD, MS, is chair of psychiatry at RWJMS. He received his medical degree from the University of Antioquia Medical School. After postgraduate training at the Complutense University in Madrid, he came to the U.S. He completed a psychiatry residency and research fellowship on psychiatric genetics and received a Master’s degree in psychiatry/medical genetics at the University of Minnesota. He served as Senior Advisor to the Director of NIMH, and as a member of NIMH’s National Advisory Mental Health Council, FDA Advisory Committee and several NIH and VA IRGs and national task forces. An advisor to the World Health Organization, he is past president of the American Society of Hispanic Psychiatry.§
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