Psychosomatics 48:46-53, January-February 2007
doi: 10.1176/appi.psy.48.1.46
© 2007 Academy of Psychosomatic Medicine
Spanish Perspective on Enlarging a Small Specialty: The National Research Network for Liaison Psychiatry and Psychosomatics
A. Lobo, M.D.,
P. Saz, M.D.,
A. Sarasola, M.D.,
A. Bulbena, M.D.,
J. DePablo, M.D.,
E. García-Camba,
J.M. Farré, M.D.,
J. García-Campayo, M.D.,
M Girón, M.D.,
M. Lozano, M.D.,
C. Mingote, M.D.,
L. Salvador-Carulla, M.D.,
M.F. Barcones, B.Sc., and
the REPEP Network
Received January 27, 2006; accepted February 8, 2006. From The Spanish Research Network in Liaison Psychiatry and Psychosomatics (REPEP), National Institute of Health, Carlos III, and El Fondo de Investigación Sanitaria (FIS), Spain. Send correspondence and reprint requests to Prof. A. Lobo, Servicio de Psiquiatría, Hospital Clinico Universitario, Planta 3, Avda. San Juan Bosco,15 50009 Zaragoza, Spain. e-mail: alobo{at}unizar.es
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ABSTRACT
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The Spanish Research Network in Liaison Psychiatry and Psychosomatics (REPEP) comprises 11 centers (nodes), and was one of the successful applicants in a very competitive call for a networking program for the National Institute of Health "Carlos III" project. This article describes its general objectives and strategic plans. Both qualitative and quantitative results support our statement that this "perspective" should help to enlarge what is presently a small specialty. Synergies in the network have been potentiated; an ambitious national study on depressive comorbidity in complex medical patients has been executed; and new research and training programs have been initiated.
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INTRODUCTION
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In Spain, the development of Liaison Psychiatry, which might be called Psychosomatic Psychiatry in the future,1 has been rapid over the last decades and compares favorably with most European countries.2 Clinical liaison psychiatry programs have official accreditation in some national or regional medical care plans, and training in the discipline is mandatory in the official programs of the National Commission for the Specialty of Psychiatry. However, there is an acknowledged need for progress in the field, and a recent survey by Campos et al.3 has shown that only half of the general hospitals in the National Health System have a Liaison–Psychosomatic Psychiatry Unit (LPPU).
Research activities in LPPUs have also improved considerably2 and have certainly been a priority in the strategies of the main association for liaison psychiatrists in this country, the Sociedad Española de Medicina Psicosomática (SEMP).4 It was in this context that the first national workgroup appeared, but a crucial turning-point was the birth of the European Consultation–Liaison Workgroup (ECLW) for General Hospital Psychiatry and Psychosomatics.5 The stimulus provided by the ECLW has been seminal in European countries, and Spanish psychiatrists participated from the first stages. Under this umbrella, a new workgroup was supported and partially funded in 1997 by the Fondo de Investigación Sanitaria (FIS), an agency of the National Institute of Health Carlos III (ISCIII). The Spanish researchers have participated in important multicenter, national, and European studies of the ECLW workgroup, including the development of the ARSI/ COMPRI/ INTERMED system for the early detection of complex medical patients6 and the development and implementation of a quality-assurance system (QA), originating in consultation–liaison psychiatry.7
The Spanish Research Network in Liaison Psychiatry and Psychosomatics (REPEP)
The background, structure, and experience of the FIS Workgroup proved to be decisive in the context of the historic and very competitive national call for "Research Networks in Medicine" put forward by the ISCIII in 2002.8 This was an opportunity to apply for unprecedented medical research funding in Spain.
The main LPPUs in the country were invited to participate in the new venture by what is now called the Spanish Research Network in Liaison Psychiatry and Psychosomatics (REPEP). Figure 1 shows the relative geographic distribution of the applicants: a coordinating center in Zaragoza; three hospitals in Madrid, Spain; three in Barcelona, Spain; and the Universities of Elche and Cadiz, in the southern part of the country. Furthermore, as required in the call, two "emergent" nodes (or centers), with "young" researchers and limited experience in the field, both in the Zaragoza area, were also included in the network.
The general objectives of the network are summarized in Table 1. It is apparent that the attempt is to coordinate research in hospitals throughout the country in such a way that complementarity and synergies in different centers should be promoted. Large, multicenter studies could be targeted, so as to take advantage of specialized knowledge and expertise in different nodes. Multidisciplinary studies would be favored and, in fact, are likely, in view of the fact that different disciplines are involved in each node (psychiatry, medicine, epidemiology, primary care, psychology, social sciences, statistics, etc.). Ideally, powerful scientific plans might be developed and implemented; transfer of research results to the National Health System (NHS) might be facilitated, having an impact in preventive and clinical medicine; and, certainly, the potential for training of new researchers would be strengthened. Since our discipline should be progressively more grounded in empirical research,9 we believe that this perspective might help to enlarge what is presently a small specialty.
Table 2 summarizes the strategy used to reach these objectives. It included the building of the appropriate structure, and links with universities and NHS institutions. Specific research plans were to be developed, including an immediate, nuclear project to be designed and implemented in all participating "nodes." A publications policy was developed, which included the strengthening of the official journal of the SEMP. The new consensus research project was considered to be crucial in this strategy, and would be a "common denominator" in starting the coordinated venture. It would require the selection of a subject considered to be a public-health problem and a priority in the area of Liaison–Psychosomatic Psychiatry (LPP); the standardization of both instruments and researchers; a joint effort to design, implement, and report the results of the study; and, certainly, a good coordination effort, taking advantage of the experience of different teams and researchers. The study should have a good potential for the transfer of results and the potential to have an impact on the field; finally, it should be the starting-point for subsequent, coordinated studies.
Plans to train researchers were also considered to be important in the network strategy; these included an annual doctoral or similar-level course to be organized in each node, a research methodology course for young researchers that was required for completion of the education stage; and the strategy to implement, as much as possible, educational programs at excellent research centers, and exchange programs for researchers (Table 3). Strategies for eventual transfer and dissemination of research results were also planned; these included the development of a website. The design and implementation of a QA system was determined, with support coming from the Spanish experience with the original, European, QA system.7 Finally, an evaluation method was specified, which included both qualitative and quantitative assessments.
The application was quite successful: a total of 223 networks from different medical fields applied, and 69 were selected.10 Small psychiatric subgroups included in multidisciplinary networks mainly run by geneticists, neurologists, or even basic scientists also participated in this national call, but REPEP is a multidisciplinary network run by psychiatrists. January 2003 was the time-point for starting the development of the strategic plans, and the national system is now evaluating the results of this initiative. It is also an appropriate time for reporting the results of the LPP Network (Table 4).
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RESULTS
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We will review the results of 3 years of operation of the Network, following the qualitative and quantitative schema planned in the original application.
Qualitative
1. The structure of the Network was consolidated; in all, 11 centers have participated, and the nodes have a reasonable geographic dispersion over the country; 99 researchers supported the initial application; more were later incorporated; and a total of 139 eventually participated. There is a program-management group, and organizational norms have been developed and implemented, including a publications policy. Important interdisciplinary links have been established, a total of 29 medical teams having been involved in the process; and links with other university and hospital groups have been formed.
2. The quality of the process has been judged to be adequate according to the programmed QA system.11 It has included the implementation of different strategic plans, both in the research and the educational areas; the standardization of eight different questionnaires and interviews; the organization of 19 local workgroups, with 90 researchers involved and 323 local meetings completed; and the organization of three general meetings of the Network every year, with a mean of 30 members attending.
3. A crucial point has been the successful implementation of the new research, a multicenter project on comorbid depression in medical patients. This project fulfilled the study requirements. Depression is one of the main diagnostic groups referred to liaison psychiatrists in our country.12 It is often underdetected and undertreated,13 and, because of its negative implications, it may be a public health problem.
The design of the study is shown in Figure 2. Medical patients would be screened during hospital admission by trained lay interviewers in Phase 1, and research clinicians would confirm in Phase 2 the patients as cases of depression or as control subjects. A 6-month follow-up in primary care was included in the design, the intention being the verification of hypotheses related to the poor outcome of depression in this setting. The recruitment of up to 400 depressed patients and a similar number of control subjects was considered to be necessary to have enough statistical power in the verification process, and, for this purpose, up to 4,000 patients were initially to be invited to participate in the study.
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FIGURE 2. Design of the Study
SPPI: Standardized Polyvalent Psychiatric Interview; ICD-10: International Classification of Diseases, 10th Edition; PC: primary care; HADS: Hospital Anxiety and Depression Scale.
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Eight hospitals participated in the field study, and a total of 365 depressed and 811 control subjects had been recruited at the time of writing the last report.14 These preliminary results tend to confirm the working hypotheses: the prevalence of depression across centers is approximately 20% at the time of hospital discharge; compared with controls, the depressed subjects have a poorer outcome at the time of follow-up, and approximately three-fourths of them either continue to be depressed or have died (mean age of the sample is 72 years); and the use of medical services is also higher among the depressed survivors.
This common study has strengthened the links and the coordination of the Network. It should be the starting-point for subsequent, coordinated studies, the first one being an intervention study to face the challenge posed by the poor outcome of depression in patients discharged from medical wards, as reported in this study.
4. Synergies in the Network have been strengthened. The main areas of expertise and contribution of each node are shown in Table 5.
5. New collaborative projects have been designed. Following the specific strategies, new national applications have been presented in the last FIS call, to study in medical samples, in a coordinated way, the following conditions: delirium and acute deterioration of cognitive functioning (ADCog); differences in outcome of depression between geriatric and non-geriatric patients; the impact of depression in patients followed up in primary care; and health-economy implications of comorbid depression.
6. Furthermore, we have achieved advances in coordination. The following studies have been designed in a coordinated way by two or more nodes and are now in process: epidemiology of dementia in the general population and implications for primary-care physicians; issues of health-economy in depression in primary care; noncognitive psychopathology in patients with Alzheimer’s disease and other dementias in elderly patients; a collaborative study, with Iowa University, to verify, in elderly populations, hypotheses about depression in cerebrovascular accidents; standardization of new delirium scales; the European protocol of delirium; and basic research (including genetics) in mind–body relationships. Furthermore, new doctoral courses have been organized in eight different nodes, and the improvement of Cuadernos de Medicina Psicosomatica y Psiquiatria de Enlace, the official journal of the SEMP has been proposed by members of the Network.
7. Advances in dissemination of research can now be documented, and quantitative results of articles and book chapters directly related to LPP are reported in the last section. The REPEP web is now in operation (www.repep.com), Dissemination of LPP issues is also facilitated by the editors of Cuadernos, and a crucial event has been the appointment of the coordinator of REPEP as the new Editor of the European Journal of Psychiatry, a general-psychiatry journal that we expect should soon be a privileged window for advances in the discipline (www.scielo.isciii.es).
8. Training programs have been developed that follow the strategic plans. Consensus objectives, as well as the strategies to achieve them, have been reached. The network is committed to speaking a homogeneous "language," which includes the standardization of both instruments (scales, questionnaires, interviews, etc.) and researchers. Furthermore, doctoral courses have been given in 10 nodes. The content and the level of knowledge to be learned by students are targeted to reach European standards, and, in some courses, quality criteria have been included, such as the elaboration by students of research projects that could be submitted for a peer-review process. Finally, "mobility programs" have been implemented: research students, but also senior researchers have traveled to different nodes in the network and to advanced centers in Europe and America to learn special techniques.
9. The transfer of results and data to different agencies in the National Health System has been strengthened during the study period. Members of the network sit on or lead hospital committees, and, certainly, the voice of LPP is well heard. Some members of the Network are also consultants in regional government agencies and are on the advisory committee of the Minister of Health. There are also members of REPEP in the National Commission of the Specialty of Psychiatry, and they have been dominant in the development of directives for eventually applying for the status of Subspecialty in Psychiatry.
The transfer of research results has also reached the pharmaceutical industry. Members of the Network actively participate in new research, such as the study on somatic symptoms of depression in primary care, and in clinical trials relevant to the discipline. They have also contributed their expertise in developing and implementing plans to standardize research instruments targeted to medical patients, and have participated in teaching activities addressed to non-psychiatrists, in particular in an industry-supported teaching program for medical specialists of six different disciplines (such as oncology, neurology, etc.) across the country.15
10. We have concluded that the synergy between Spanish and international groups has also been strengthened: there are new analyses of data from BIOMED; European Union-funded previous projects are now in process; the mobility plan for young Spanish researchers has added stages in advanced centers such as the Universities of Gröningen in the Netherlands, and both Iowa and New Jersey in the United States; a trans-national, European study on transplant patients by means of INTERMED is now in process with the contribution of Spanish researchers; and, certainly, the contribution of Spanish members to the EACLPP continues to be quite active. An example of this is the invitation to present the Network research paradigm at the last annual EACLPP meeting.16
The contribution of Spanish authors, co-editing and writing a chapter for the new (American) Textbook of Psychosomatic Medicine should certainly be emphasized here.17 First-line American researchers have systematically been invited to present papers at the national LPP Spanish meetings, and the American Academy of Psychosomatic Medicine will be formally invited to contribute in a unique event to be held in Zaragoza in 2008: The 11th Meeting of the EACLPP and 27th European Conference of Psychosomatic Research, coinciding with the International Exhibition EXPO Zaragoza.
Quantitative
The quantitative assessment of results of the Network follows the strategic plans presented in the original application to the IS CIII and completes the assessment process.
Table 6 shows the main results. With regard to publications, a total of 326 articles by members of the Network have been recorded, but only 168 were published in "impact-factor" international journals listed in the SCI. Some researchers in the Network, multidisciplinary teams, publish in other medical journals, but 113 articles were related to LPP. The mean impact of the compiled articles was 2.18. Table 6 also summarizes the number of book chapters written by network members (few are complete books) and the number of papers presented in international meetings. Funded research projects completed or in process are also computed, since this is considered to be an important parameter reflecting the productivity of the Network.
The training program can also be assessed, to a certain extent, by quantitative parameters, and the most relevant ones are summarized in Table 6. Rather intense activity is apparent in relation to doctoral theses read and doctoral courses. Furthermore, 76 young researchers have been trained in standardized interviews, and 29 have participated in "mobility" programs. Finally, 12 research awards have been awarded to Network members over the last 3 years.
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DISCUSSION
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The data reviewed adequately summarize the results of 3 years of activity in the Network. The general objectives in this venture were directly targeted to improve the structure, process, and results of research in the field of LPP in the most active units in Spain by coordinating their efforts. However, we also believe this "perspective" might help to enlarge what is presently a small specialty. It has been argued that "on the level of scientific work, consultation–liaison psychiatry has often been on the periphery."2 However, the degree to which LPP "can continue to demonstrate clinical and cost-effectiveness will determine the future vitality and viability of the discipline."18
With regard to the general objectives, the assessment of the Network and each one of the nodes, according to the official standards of the IS CIII, was positive. However, we have also concluded that strengths and weaknesses are apparent. Among the former, the qualitative assessment shows a firmly ingrained research workgroup, with an adequate working atmosphere and personal relationships. The interdisciplinary nature of the Network, the fact that we are involved in a subject of public-health interest, and the level of psychiatric comorbidity in medical, often complex, patients, clearly counts on the positive side of the results. Similarly, the seniority (both at the hospital and academic levels) of most coordinators in the nodes and the fact that these are generally supported by quite experienced LPPUs in the NHS have certainly helped to develop the group. Both "emergent nodes" that were monitored have been very productive and should be considered to be senior nodes in the future. Although the Network already has considerable geographic coverage, new candidate nodes have now been attracted and could eventually enlarge the structure to cover all areas in the country.
We believe that the new, multicenter, national study on depressive comorbidity in medical patients was the kind of study on a subject of public-health interest that was required to initiate the Network venture. Because of the size and representativeness of the sample, and the geographical dispersion of the hospitals, the results might be generalizable to the whole country; and because of the original aspects in the design, it might have an input in the international literature. Should the main hypotheses about the negative implications of frequently undetected/ untreated depression be confirmed, the transfer of results to the NHS in Spain would be facilitated. Furthermore, this study should lay the groundwork for an adequately designed, challenging intervention study. We are confident that LPP-guided interventions will able to improve the outcome of depression in medical patients followed up in primary care. A research network facilitates the implementation of large studies targeted to documenting the effectiveness and efficacy of interventions in our field.
Several other aspects are also considered to be strengths in the Network: the links with national and European groups, specifically with EACLPP, and the expectation of improving the existing links with American groups; the training achieved for a considerable number of young researchers, including their standardization in useful research methods and instruments; the ability of the network to implement a QA system specific to the field; the addition of a national journal, and, in particular, an international journal in English; and, certainly, the demonstrated ability to report papers in international journals and meetings.
On the other hand, we have also observed weaknesses in the network, and some of them might be difficult to correct. Most node coordinators have strong clinical responsibilities, difficult to avoid in the Spanish NHS. Similarly, the lack of seniority in some node coordinators, or the lack of appropriate teaching and research facilities in their units hinders their ability to organize specific programs. However, some weaknesses in the system have been targeted for improvement in the coming years. The limited command of written English by some researchers may be circumvented with the help of translators. In any case, we are not satisfied with the number of reported papers directly related to priority issues in our discipline, and we are committed to improvement in the immediate future. Multi-national, European Union (EU)-funded projects with participation of Spanish researchers were extremely productive in previous years,2,6,7 but we have failed in the most recent applications. We are now targeting for the participation of REPEP in the most competitive EU calls for new research in the coming years, in conjunction with other European colleagues.
Some lessons might be learned from the exciting experience of organizing a research network in LPP. One of them is the growth opportunity, since two crucial events occurred in our particular case that may explain the relative success achieved. The first one was the invitation by the ECLW, a workgroup with high potential, to participate in an ambitious, European research venture. Although preparatory work and previous experience may be necessary, such an opportunity cannot be wasted, no matter how inconvenient it may initially seem. The ECLW experience taught us, among other things, how to organize and run a large, multidisciplinary research group; it facilitated the incorporation of methods applicable in national and trans-national multicenter research groups and studies and the development and implementation of documentation instruments that have increased the armamentarium of Spanish groups. The influence of the ECLW in NHS hospitals has, in many ways, facilitated the new enterprise, and the European research network has always been a supporting as well as a critical observer of our efforts. Around this group, as has been the case in countries such as Italy,2 the Spanish workgroup started a new "generation" of activities, with a highly productive interchange with European colleagues.
The second opportunity, obviously, was the national call of IS CIII, with unprecedented funding, to develop biomedical research networks. Again, previous experience may determine the outcome, and, in our particular case, the preparatory work in the SEMP and FIS working groups was probably crucial to convincing the Spanish agency about the potential of the new Network. The success of the application has allowed us the appointment of a research-manager expert in QA programs and of research students and auxiliary personnel in each node that greatly facilitated the logistics of the new project. The results of the REPEP Network reviewed in this article suggest that the research potential of the whole group has increased considerably over the last 3 years.
The lessons to be learned in the Network venture also relate to the importance of building the potential of the team on the basis of previous experience. The experience acquired in both the Spanish and the European workgroups has directed, to a large extent, the successful results of our new system. We previously learned how to organize a consortium, build a structure, and develop strategic plans guiding the process and learned the importance of using a common scientific language and standardized procedures. We also acquired a good deal of information from previous studies, specifically about epidemiological data in LPP, the characteristics of referrals, and the complexity of patient issues, and about screening and case-finding methods in this setting. The experience gained in the European QA studies7 greatly facilitated the documentation of process and results in the new project.
The final lesson learned in the Network relates to the importance of leadership, organization, and camaraderie, which, at least in part, are also learned from previous experience. We believe that those in our Network were all inextricably united. Interpersonal, working relationships were excellent, and the organizational structure, built on previous workgroups, was reasonably solid. Furthermore, the knowledge of being involved in a project with public-health implications greatly facilitated the commitment and persistence in the effort demanded by an ambitious project such as the one we describe here.
We definitely believe that this kind of organization is in a good position to help in the development of Psychosomatic Medicine and Consultation–Liaison Psychiatry.
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ACKNOWLEDGMENTS
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The following researchers of the REPEP Workgroup have also contributed as authors in this article: Aguirre JA, Gil C, Lobo-Escolar A, Arnal P, Cazcarra RA, Gonzalez I, Guiote I, Ibáñez M, Lobo-Escolar E, Martínez B, Pascual A, Tomás L, Zapata C.
This work was supported by grant PM99-0084 from the Dirección General de Enseñanza Superior e Investigación Científica and by grant RTIC G03-128 from the Fondo de Investigación Sanitaria, Ministerio de Sanidad y Consumo, Madrid, Spain.
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REFERENCES
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- Campos R, Iglesias C, Zabala I, et al: Present State of C-L Psychiatry in Spain: Proceedings of the 3rd Annual Scientific Meeting of the European Association of Consultation-Liaison Psychiatry and Psychosomatics, 2000, June 16-21, 2000, Oslo, Norway
- Lobo A: Presente y futuro de la psiquiatría "de enlace." Cuad Med Psicosom Psiquiatr Enlace 1997; 42-43, 93-104
- Huyse FJ, Herzog T, Lobo A, et al: European consultation-liaison services and their user populations: The European Consultation-Liaison Workgroup Collaborative Study. Psychosomatics 2000; 41:330–338[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
