Psychosomatics 42:5-13, February 2001
© 2001 The Academy of Psychosomatic Medicine
Operationalizing the Biopsychosocial Model
The INTERMED
Frits J. Huyse, M.D., Ph.D.,
John S. Lyons, Ph.D.,
Fritz Stiefel, M.D., Ph.D.,
Joris Slaets, M.D., Ph.D.,
Peter de Jonge, Ph.D., and
Corine Latour, CNS, RN
Received March 20, 2000; revised May 5, 2000; accepted July 31, 2000. From Department of C-L Psychiatry, Hospital of the Vrije Universiteit Amsterdam, the Netherlands; Institute for Health Services Research&Policy Studies, Northwestern University, Chicago, Illinois; Division Autonome de Medicine Psycho-Sociale, Centr Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Internal Medicine, University Hospital of Groningen, Groningen, the Netherlands. Address correspondence and reprint requests to Dr. Huyse, Psychiatric Consultation Service Vrije Universiteit Amsterdam, De Boelelaan 1117, 1007MB Amsterdam The Netherlands; e-mail: fj.huyse{at}azvu.nl
Key Words: INTERMED • Biopsychosocial
We have witnessed, in the past several decades, a rapid increase in the development of effective medical treatments to address specific diseases. Although these innovations have had a positive impact on the health and well-being of patients, they have reinforced the health care system's movement toward subspecialization and compartmentalization of medical care. Further, factors such as chronicity, multiple comorbid disease states, and behavioral noncompliance to treatment recommendations continue to influence health care utilization, health outcomes, and quality-of-life and make it difficult to provide high quality, effective medical care. It becomes essential to coordinate these factors and avoid the evolving compartmentalized health care system we have today in order to take better care of patients with complex medical problems.
In order to better assess, organize, and treat the biological, psychological, and social needs of such patients, a four-dimensional grid, the INTERMED, was developed by Huyse et al.1–4 The INTERMED embodies an interdisciplinary format, allows for communication and comprehensive assessment that is sufficiently brief so it is clinically feasible and is readily translatable into specific interventions. We use a clinical example described by Engel to exemplify the INTERMED's utilization.6
The INTERMED
Building on Engel's biopsychosocial approach to the practice of medicine,5,6 Huyse et al. developed a four-dimensional grid for assessment and treatment of complex psychiatric consultation cases in day-to-day practice. This grid includes a "checklist" with operationalized interventions.8 The four rows of the grid describe the biological, psychological, and social aspects as well as the health care system in a time perspective, including a column for prognoses that lead to the formation of interventions. Lyons et al.9,10 developed a measurement approach to the assessment of the severity of psychiatric illness that uses a four-level measurement strategy that directly translates into clinical actions. The INTERMED represents a combination of these approaches.2,3
In the INTERMED, the risk factors are defined within the context of a grid that includes four rows reflecting the Biological, Psychological, Social, and Health Care Systems; and the time perspective in three columns: History, Current State, and Prognosis. Each risk factor is assessed on four levels, each with indicator colors similar to those of a traffic light (Table 1).
The INTERMED uses a decision-support approach and has several advantages as a strategy for addressing complex patients. First, the approach is based on a face-valid conceptual framework for identifying health risk factors by the operationalized biopsychosocial model of disease.6 Second, the approach is immediately interpretable through visualization. Third, it reinforces training approaches, such as those suggested by Leigh et al.7 However, the greatest potential for this decision-support approach is in the rapid communication of the patient's risk factors to the service delivery system.
Although most health care professionals will endorse the importance of communication, the practical reality of a busy practice presents numerous barriers to effective communication. Therefore, for effective communication, the INTERMED should be integrated in the electronic medical chart. The use of colors is an optimal strategy for efficient communication of risks in a busy hospital environment. The INTERMED can either be presented on screen or as hard copies to be included in the medical and nurse charts.
Case Report
With the INTERMED, we have begun to address the historical absence of operationalization of the biopsychosocial model of disease focusing on the assessment and management of integrated health risks. To illustrate our approach, we describe a case used by Engel5 in his argument for the biopsychosocial model of disease.
Mr. G. is a 55-year-old married real estate salesman who presented at the emergency room(ER) with symptoms of a myocardial infarction. Mr. G. had experienced his first myocardial infarction 6 months earlier. After his diagnosis was confirmed, the subsequent procedure of an arterial puncture, which failed after several probes and led to the departure of the doctor to get assistance, resulted in increasing Mr. G.'s doubts in the doctor's competence. Mr. G.'s subsequent rage coincided with a period of ventricular fibrillation. At this point, Engel ended his description.
In his analyses, Engel focused on the psychological factors important for the understanding of the occurrence of the cardiac event, including the denial or misinterpretation of the cardiac event and the doctor not being aware of the role of psychological stresses in the ventricular fibrillation. In addition, Engel emphasized the need to include Mr. G.'s wife in the treatment.
In our treatment of the same case, we can observe the clinical staff using the INTERMED as part of Mr. G.'s admission procedure. Mr. G. is sedated, cardioverted, and admitted. A trained nurse will do the INTERMED interview the next day after Mr. G. has had some rest. A cardiologist evaluates Mr. G. on the ward and informs the nurse of the full diagnosis and the related physical status. Mr. G., whose circulation has been stabilized, will be bedridden and will have a cardiac work-up, including a catheterization. For the next few days, Mr. G. will not be capable of any activity. The diagnosis was clear—a second myocardial event in a person known to have hypertension. According to the protocol, this myocardial event requires standard cardiology follow-up and a postdischarge rehabilitation program. Most likely, Mr. G. will be slightly limited in his physical activities (New York Heart Association score: 1–2). Because Mr. G. has not seen his wife during the past month, his sister acts as his family representative. She is called and will come to the hospital within the next days.
After a stable night, in which Mr. G. was asleep on provided medication, the nurse begins the INTERMED interview. The INTERMED interview is structured by a series of questions leading to specific risk factors. In case of a lack of response, additional questions are suggested in the manual, including the CAGE, the Hopkins Symptom Checklist (SCL-8) and core questions from the Mini-Mental State Exam (MMSE).11–13 The nurse begins the interview.
"Now, first of all, I would like to better understand how you feel physically?" Mr. G. reports that he is not experiencing any pain or any other physical complaints. He knows that he did not feel well the day before. He remembers having visited the ER and that the doctor informed him that he had suffered a myocardial event. He still cannot believe it. He thought his bad feeling was related to a poor night's sleep. The nurse informs him that, although he is currently stable, he has to stay in bed for awhile.
"I will tell you what I know about the reason for your admission and your current state and you should correct me when I am wrong." Here the nurse provides the information given by the cardiologist. Then she informs Mr. G. that she would like to be better informed on the circumstances of this current illness episode.
"Now I would like to know how you felt emotionally during the last week?" Mr. G. responds that he has been tense. He has not been sleeping well and felt "blue" during the past weeks. To try to get to sleep and to cheer himself up, he has been drinking whiskey. The nurse asks him whether his drinking is related to problems with his wife; Mr. G. confirms this. The nurse says she will come back to this issue later in the interview.
"I would like to have some more information concerning physical illnesses and treatments in the past 5 years." Mr. G. tells the nurse that he was admitted for a myocardial infarction about 6 months previously. For about 15 years he has been suffering from uncomplicated hypertension, for which he takes captopril. Mr. G. indicates that there have not been any other reasons to see a doctor.
"Who have been the doctors who have been taking care of you in the last 5 years?" A primary care physician has been treating Mr. G.'s hypertension. After his cardiac admission, Mr. G. has seen a cardiologist twice.
"Have you ever seen a psychiatrist in your life or have there been periods that you have been anxious, depressed, or confused?" Mr. G. responds that he was depressed once a long time ago. His first wife divorced him after he had recently been fired from his job. He was admitted for a week to a psychiatric ward. He ended his psychiatric follow-up when he moved to another state. Mr. G. stated that he might be depressed now. His new job is tense and he is without the support of his wife. Living in a hotel room for the past few weeks has been tough.
"Who are the doctors, nurses, social workers, or psychologists who you are currently seeing and who take care for you?" Mr. G. responds that he has not sought much medical care. He goes on to say that he has been tense and busy and should have seen a cardiologist, but he had failed to find one. Mr. G. indicates that he probably should have seen a psychologist too.
"Had there been conflicts with doctors during the past 5 years, that gave you a bad feeling? For instance, have there been any events that have eroded your trust in doctors?" At the end of his previous cardiac admission, the patient next to Mr. G. died unexpectedly during the night. Afterward, there were rumors that the hospital did not function well and a lawsuit had been considered. In addition, during his last visit to his cardiologist, Mr. G. mentioned that he and his wife were in conflict concerning his current job. The cardiologist was uninterested in this information and wanted to focus on his cardiac condition. These events changed Mr. G.'s view of doctors—Mr. G. indicated that he cannot rely on doctors. The nurse confirms that she thinks this is important information and that she will come back to it.
"I would like to know how you follow your doctor's recommendations. Are you a person who is, generally speaking, inclined to do what doctors say?" Mr. G. responds that he had taken his medication regularly for years. However, because the last month was so hectic, without his wife, it was impossible for him to keep up with the regimen.
"Now I would like to change the subject and ask you how you currently live?" As Mr. G. previously stated, his wife did not want to follow him to his new job. There were quarrels concerning the interference of his work with the quality of their marriage. When Mr. G. insisted on changing jobs and moving, his wife said she did not want to see him for a while. This happened about 1 month previously. As a result, he has been living in a hotel and looking for an apartment. Mr. G.'s life currently consists of working, meeting a colleague once a week, and eating his meals in restaurants.
"Now I would like to know about what kind of person you are. Generally speaking, are you an easygoing person?" Mr. G. indicates that his wife would say that he is difficult, but he disagrees. He indicates that he does not need many people as long as he can work. Mr. G. feels that it is important to be successful and being successful is not an easy job. For the past weeks, Mr. G. had the feeling that he was not fully in control of his situation. The nurse asked him if everything was an effort or if he felt "blue" or hopeless about the future, and he confirmed this. Mr. G. ignored the nurse's question about whether he had given up or wanted to die. The nurse confirms the importance of this information and that she and the cardiologist will consider appropriate consultation and will develop follow-up soon after the interview.
"Now, coming to the end of the interview, I would like to ask you about your smoking and drinking habits and their relation to the current problems?" Mr. G. acknowledges that he drank up to six whiskey's per day for the past month. He has had earlier periods of heavier drinking and smoking. The nurse now indicates that Mr. G. has provided a lot of relevant information in a short period of time . She confirms that she understands that he has had a difficult time and that he has not been functioning well. The nurse indicates that she and the cardiologist will take this into consideration in their follow-up.
"Finally, I want to know how you feel about this interview? Do you think that this will be helpful information or did you think this was inappropriate?" Mr. G. seems to be somewhat relieved and indicates that the questions were appropriate and helpful.
Scoring this case using the INTERMED demonstrates the application of the decision-support approach in the assessment and management of integrated health risks. In summary, Mr. G. is a 55-year-old man suffering from a chronic condition (hypertension) that was recently complicated by another chronic condition (heart disease). There have not been other episodes of physical illness in the past 5 years. Mr. G. has a clear diagnostic condition and is currently immobilized. He has been denying his cardiac condition recently, and he tries to reduce tension by smoking and drinking. His history provides evidence of an earlier period of mood disorder and impaired coping after separation from his first wife. Currently, there is evidence for both substance-related and depressive disorder. These disorders interfere with his compliance to treatment as reflected in the recent decrease in compliance with his medication as well as behavioral cardiac risks. Over the past 5 years, work has dominated his life to such an extent that he now lives apart from his wife. In the past 5 years, Mr. G. has been admitted once to a hospital and has been treated by a primary care physician and a cardiologist. Presently, he does not see any medical personnel (e.g., doctors or nurses) or other caretakers (e.g., social workers). His trust in doctors was negatively influenced by recent events related to his cardiac condition.
Prognosis
Mr. G.'s physical prognosis has been described. In addition to his cardiac situation, Mr. G. could be at risk for both physical and psychological withdrawal; this should be monitored during hospitalization. A psychiatric consultant should evaluate the interrelation among coping, compliance, substance abuse, and depression as a major depressive disorder that has impact on the cardiac outcome and the Mr. G.'s quality-of-life.14 As a result of our assessment, it should be decided if psychiatric treatment should be started in the hospital or postdischarge by a psychiatrist or by a primary care physician. Regarding Mr. G.'s social situation, his wife should be invited to clarify his social and relational situation. The intensity of the rehabilitation program should be adjusted to both his physical and psychiatric conditions. Consequently, a multidisciplinary case conference should be organized in the following days to integrate the opinions of the several consultants (e.g., rehabilitation, psychiatry, and social work). This information obtained led to the following INTERMED score (Figure 1).
After an evaluation of the findings with the cardiologist, a treatment plan is implemented. Presently, a low dosage of benzodiazepines will be added to prevent distress. Symptoms of withdrawal and patterns of sleep will be monitored. The nurse will inform Mr. G., initiate the consultations, and organize an interdisciplinary meeting.
Implications
As illustrated by the case of Mr. G., the assessed health risks have direct implications for the physical prognosis and for its long-term treatment. Mood- and substance-related disorders and coping and compliance problems have consequences for the communication with Mr. G. and health care professionals in his current treatment episode. The distress related to his work, the relationship with his wife, and his current living situation interfere with his health status. Coordination of interdisciplinary care and its transmural or long-term continuation have proven to be effective for several complex patient populations.15–19 The impact of the INTERMED as a tool to assess and address health care risks and needs is evident. Not only will the awareness of the hospital staff of their patients' specific health risks increase; the staff is also directed through the meaning of the scores in their clinical and management decisions with individual patients. In addition, the aggregated health-risk scores of multiple patients allow for an empirical assessment of the health risks and treatment needs of specific populations.20–23 Such data will be helpful for the design of health service networks for specific patient populations.
The following cost aspects need to be addressed. First, the INTERMED should be implemented for selected patients. This selection should be based on indicators such as those mentioned in the consultation-liaison (C-L) literature (e.g., patients treated under high emotional distress, such as certain kinds of cancer and cardiovascular surgery, transplantation, or hemodialyses). Another cost aspect is excess utilization, or its prediction. A 5-minute screening instrument to predict high utilization during hospital admission referred to as care complexity: the COMPRI (Complexity Prediction Instrument) was developed by de Jonge et al.25–28 The COMPRI was developed for patients admitted to internal medical wards (11 wards, 2,300 patients in 7 European countries). It can be used by the staff of internal medicine wards to predict at the day of admission if there will be expected care complexity. Care complexity is defined in terms of length of stay, postdischarge placement and functional status, mental disturbance, amount of medication and tests performed, nursing staff intensity, number of consultants involved, and the perceived clinical and organizational complexity.1 The previously mentioned indicators, or such risk prediction, of health care utilization offer a selection mechanism for an optimal implementation of the INTERMED. Second, in relation to the cost of implementation, the professional qualification of the INTERMED interviewer is paramount.
Until now in our studies C-L nurses, medical doctors, psychologists, and medical students have applied the interview method under close supervision by a researcher. Reliability studies have been reported.2 In our opinion the method can be taught to nonspecialized nurses and gradually be included in routine medical care in risk populations, when a combination of the continual use of the manual and randomly selected case-supervision by C-L nurses or other staff members of a C-L team is guaranteed. Decision-based methods for patient oriented care—such as the COMPRI and the INTERMED—and their empirical underpinning offer tools for a more strategic development of C-L psychiatry, especially in Europe.1
In the United States, the INTERMED can easily be used to satisfy the mandate of the Joint Committee on Accreditation of Hospital and Health Organizations for a psychosocial evaluation for all patients in health care organizations, including hospitals and ambulatory surgical centers. The INTERMED could help satisfy this requirement in a standardized manner. The dramatically decreased lengths of stay in hospitals in the United States and in Europe and the shortage of nurses in medical and surgical hospitals might be seen as an argument against using the INTERMED; since it may be seen as too time consuming. However, on the contrary, using the INTERMED for 20 minutes at admission could actually save time since it quickly shows how vulnerable or strong patients are and which care needs should be satisfied for an efficient hospital stay. A procedure such as the INTERMED, which uses a standardized nurse assessment, adds structure and targets a clear outcome, and enhances the effectiveness of nursing.24 Finally, the INTERMED is also useful in outpatient settings as a starting point to assess the needs of complex patients who require long-term case management.
ACKNOWLEDGMENTS
This study was supported by a grant of the Biomed1 program of the European Union titled "A Screening Instrument for the Detection of Psychosocial Risk Factors in Patients Admitted to General Hospital Wards" (BMH1-CT93–1180).
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