Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University, Düsseldorf, Germany.
Department of Clinical Psychology and Psychotherapy, Ulm University, Ulm, Germany.
JAMA Netw Open. 2021 Oct 1;4(10):e2127622. doi: 10.1001/jamanetworkopen.2021.27622.
Despite the high prevalence of anxiety and depression in youths with chronic medical conditions (CMCs), physicians encounter substantial barriers in motivating these patients to access mental health care services.
To determine the efficacy of motivational interviewing (MI) training for pediatricians in increasing youths' use of mental health care.
DESIGN, SETTING, AND PARTICIPANTS: The COACH-MI (Chronic Conditions in Adolescents: Implementation and Evaluation of Patient-Centered Collaborative Healthcare-Motivational Interviewing) study was a single-center cluster randomized clinical trial at the University Children's Hospital specialized outpatient clinics in Düsseldorf, Germany. Treating pediatricians were cluster randomized to a 2-day MI workshop or treatment as usual (TAU). Patient recruitment and MI conversations occurred between April 2018 and May 2020 with 6-month follow-up and 1-year rescreening. Participants were youths aged 12 to 20 years with CMCs and comorbid symptoms of anxiety and depression; they were advised by their MI-trained or untrained physicians to access psychological counseling services. Statistical analysis was performed from October 2020 to April 2021.
MI physicians were trained through a 2-day, certified MI training course; they recommended use of mental health care services during routine clinical appointments.
The primary outcome of uptake of mental health care services within the 6-month follow-up was analyzed using a logistic mixed model, adjusted for the data's cluster structure. Uptake of mental health services was defined as making at least 1 appointment by the 6-month follow-up.
Among 164 youths with CMCs and conspicuous anxiety or depression screening, 97 (59%) were female, 94 (57%) had MI, and 70 (43%) had TAU; the mean (SD) age was 15.2 (1.9) years. Compared with patients receiving TAU, the difference in mental health care use at 6 months among patients whose physicians had undergone MI training was not statistically significant (odds ratio [OR], 1.96; 95% CI, 0.98-3.92; P = .06). The effect was moderated by the subjective burden of disease (F2,158 = 3.42; P = .04). Counseling with an MI-trained physician also led to lower anxiety symptom scores at 1-year rescreening (F1,130 = 4.11; P = .045). MI training was associated with longer conversations between patients and physicians (30.3 [16.7] minutes vs 16.8 [12.5] minutes; P < .001), and conversation length significantly influenced uptake rates across conditions (OR, 1.03; 95% CI, 1.01-1.06; P = .005).
In this study, use of MI in specialized pediatric consultations did not increase the use of mental health care services among youths with CMCs but did lead to longer patient-physician conversations and lower anxiety scores at 1 year. Additional research is required to determine whether varying scope and duration of MI training for physicians could encourage youths with CMCs to seek counseling and thus improve integrated care models.
German Trials Registry: DRKS00014043.
尽管患有慢性疾病（CMC）的青少年中焦虑和抑郁的患病率很高，但医生在促使这些患者获得心理健康护理服务方面仍面临着实质性的障碍。
确定对儿科医生进行动机性访谈（MI）培训是否能增加青少年对心理健康护理的使用。
设计、地点和参与者：COACH-MI（青少年慢性疾病：以患者为中心的协作式医疗保健实施和评估-动机性访谈）研究是德国杜塞尔多夫大学儿童医院专门的门诊诊所的一项单中心集群随机临床试验。治疗儿科医生被随机分为为期 2 天的 MI 研讨会或常规治疗（TAU）。患者招募和 MI 对话于 2018 年 4 月至 2020 年 5 月进行，随访 6 个月，1 年重新筛查。参与者为年龄在 12 至 20 岁之间患有 CMC 和焦虑和抑郁共病症状的青少年；他们的 MI 训练或未训练的医生建议他们咨询心理咨询服务。统计分析于 2020 年 10 月至 2021 年 4 月进行。
MI 医生通过为期 2 天的、经过认证的 MI 培训课程接受培训；他们建议在常规临床预约期间使用心理健康护理服务。
主要结果是在 6 个月的随访中使用心理健康护理服务的情况，使用逻辑混合模型进行分析，并根据数据的聚类结构进行调整。心理健康服务的使用被定义为在 6 个月的随访中至少预约一次。
在 164 名患有 CMC 和明显焦虑或抑郁筛查的青少年中，97 名（59%）为女性，94 名（57%）接受 MI，70 名（43%）接受 TAU；平均（SD）年龄为 15.2（1.9）岁。与接受 TAU 的患者相比，接受 MI 培训的医生的患者在 6 个月时心理健康护理使用的差异没有统计学意义（优势比 [OR]，1.96；95%CI，0.98-3.92；P=0.06）。该效果受到疾病主观负担（F2,158=3.42；P=0.04）的调节。接受 MI 训练的医生进行的咨询也会导致 1 年重新筛查时焦虑症状评分降低（F1,130=4.11；P=0.045）。MI 培训与患者与医生之间更长的对话时间相关（30.3[16.7]分钟与 16.8[12.5]分钟；P<0.001），对话时间的长短对各种条件下的使用率有显著影响（OR，1.03；95%CI，1.01-1.06；P=0.005）。
在这项研究中，在专门的儿科咨询中使用 MI 并没有增加患有 CMC 的青少年对心理健康护理服务的使用，但确实导致了更长的医患对话时间，并在 1 年内降低了焦虑评分。需要进一步研究以确定对医生进行不同范围和持续时间的 MI 培训是否可以鼓励患有 CMC 的青少年寻求咨询，从而改善综合护理模式。
德国试验注册处：DRKS00014043。
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