Psychosomatics 49:132-136, March-April 2008
doi: 10.1176/appi.psy.49.2.132
© 2008 Academy of Psychosomatic Medicine
Gastroenterologists’ Perceptions of Need and Availability of Psychiatric Services for Patients With Hepatitis C
Ondria Gleason, M.D.,
John Fucci, M.D., and
William Yates, M.D.
Received June 16, 2006; revised September 15, 2006; accepted September 20, 2006. From the Dept. of Psychiatry, Univ. of Oklahoma College of Medicine, Tulsa, OK. Send correspondence and reprint requests to Dr. Ondria Gleason, Dept. of Psychiatry, Univ. of Oklahoma College of Medicine, 4502 E. 41st St., Tulsa, OK 74135-2512. e-mail: ondria-gleason{at}ouhsc.edu
© 2008 The Academy of Psychosomatic Medicine
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ABSTRACT
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The authors examined gastroenterologists’ perceptions of psychiatric comorbidity in hepatitis C, access to, and use of psychiatric services. An eight-item survey was mailed to gastroenterologists, with a total of 75 participating. Fifty-eight (77.3%) agreed with the statement "My patients with hepatitis C have significant rates of psychiatric and substance-abuse comorbidity." Less than half (41%) agreed or strongly agreed that "My patients with hepatitis C have adequate access to psychiatric consultation." However, only eight (11%) referred to a mental health provider. Gastroenterologists are aware of the need for psychiatric services for their hepatitis C patients, but few refer for it, and access may be limited.
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INTRODUCTION
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Hepatitis C is a common condition that affects nearly 4 million Americans.1 Patients with hepatitis C tend to have higher rates of psychiatric illness as compared with the general population.2–4 Ho et al.3 found that 58% of patients with hepatitis C had documented psychiatric conditions before beginning treatment with interferon. In another study, El-Serag et al.4 found that 86% of hepatitis C-infected veterans had at least one past or present psychiatric, drug, or alcohol-use disorder.
The problem of psychiatric and medical comorbidity is compounded by evidence that interferon- , the primary treatment for hepatitis C, is associated with psychiatric side effects.2,5,6 These effects may include depression, mania, increased drug cravings, and suicidal ideation. Physicians may be reluctant to provide medical treatment for hepatitis C to patients with current or past psychiatric problems because of fears of exacerbating these conditions.7,8 Morrill et al.8 found that psychiatric comorbidity was identified as a major barrier to treatment in 15% of cases. Current recommendations are that patients with hepatitis C being considered for interferon- therapy receive psychiatric evaluation and monitoring before and during the course of treatment.5 However, the accessibility of such psychiatric services for this group is unknown.
Gastroenterologists in our area have expressed frustration in accessing psychiatric services for their hepatitis C patients. We are unaware of any published data examining gastroenterologists’ perceptions of need and availability of psychiatric services for patients with hepatitis C. As part of a long-range plan to improve medical care for patients with hepatitis C, we assessed perceived availability, accessibility, and use of psychiatric services in a tri-state region, served by our university clinics. The primary objectives of this study were to evaluate gastroenterologists’ perceptions of psychiatric comorbidity in their hepatitis C patients; type of psychiatric screening performed, if any; perceived ability to access psychiatric services; and perceived usefulness of psychiatric consultation and treatment in this population.
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METHOD
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This study was reviewed and approved by the Institutional Review Board of the University of Oklahoma College of Medicine. The Oklahoma Board of Medical Licensure and Supervision, the Arkansas State Medical Board, and the Kansas State Board of Healing Arts were contacted for listings of physicians specializing in gastroenterology. Gastroenterologists were the focus of this study because our psychiatric consult service has primarily received referrals from this specialty group. The medical boards from these three states identified a total of 212 licensed gastroenterologists. Contact information was obtained from the licensing boards for all gastroenterologists, and surveys were mailed to them. To ensure confidentiality and encourage completion of the survey, no identifying information was requested of the physicians participating in the survey.
Gastroenterologists were-mailed an 8-item survey. The survey asked whether the physician treated patients with hepatitis C; if so, the physician was encouraged to complete and return the survey via postage-paid mail. Survey participants included active, licensed gastroenterologists, male or female, of any age, in Oklahoma, Arkansas, and Kansas. Surveys were mailed in November and December of 2004. Surveys returned by February 28, 2005 were included in the data analysis. Results were analyzed with the statistical software program MedCalc, Version 8.1.0.
Physicians treating patients with hepatitis C were asked whether or not they routinely perform psychiatric screening of these patients. Respondents answering affirmatively were asked to categorize the type of screening. Items were not mutually exclusive. Gastroenterologists also rated their perceptions of psychiatric comorbidity and accessibility and effectiveness of psychiatric consultation on a 5-item scale of agreement ranging from "strongly agree" to "strongly disagree." Rates of agreement with each item were calculated (number of responses to each item divided by total number of respondents).
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RESULTS
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A total of 82 respondents participated in the survey, a 39% response rate; 75 of the 82 respondents (91%) affirmed treatment of patients with hepatitis C and completed the entire survey. The responses of these 75 respondents are presented. Only seven respondents (9%) indicated use of a structured rating scale as part of their psychiatric screening (Table 1). Three respondents listed The Center for Epidemiologic Studies–Depression Scale (CES–D)9 in the comment section of the questionnaire, and this was the only scale specifically cited as being used.
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TABLE 1. Gastroenterologists’ Responses to Survey of Perceived Psychiatric Comorbidity in Patients With Hepatitis C, Availability of Psychiatric Consultation, and Psychiatric Screening and Referral Patterns, N (%)
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The majority of respondents did not feel that their patients with hepatitis C have adequate access to psychiatric consultation. Only 31 (41%) of respondents strongly agreed or agreed with this statement in the survey. Responses regarding access from gastroenterologists reporting higher rates of psychiatric comorbidity in their hepatitis C patients did not differ from responses by those reporting lower rates of comorbidity:  2[1]=0.07; p=7.91. Despite the fact that only eight respondents (11%) indicated that they refer their patients to a mental health provider, 65 (87%) strongly agreed or agreed with the statement "Effective psychiatric consultation and treatment can improve the medical and psychiatric outcome for patients with hepatitis C and comorbid psychiatric disorders."
To determine whether or not there was a difference in perceived access or use of mental health services by gastroenterologists in rural, small city, or metropolitan areas, we compared the answers from each group. Using the statistical software program MedCalc Version 8.1.0, we found no statistically significant differences in the perceived access to psychiatric services or use of psychiatric services between gastroenterologists identifying themselves in a small city or metropolitan area (2[8]=5.66; p=0.69). Only one respondent identified himself/herself as being in a rural location, and that survey was not included in this comparison.
The Comments section of the survey provided insight into when psychiatric services are utilized. One gastroenterologist commented that "Psychiatry is consulted when the depression screen is positive for the questions: Can he be treated with interferon/ribavirin? Does the patient have absolute or relative contraindications? Does he need psychiatric management or treatment prior to interferon and/or during interferon therapy? Frequently, the questionnaire is returned without the questions being answered and then has to be resubmitted... " Comments related to lack of access to mental health services included the following: "A high percentage of patients have Medicaid [and] most psychiatrists in Oklahoma will not take Medicaid;" "We do not have any psychiatrist who will see these people;" "Psychiatric consultation in my area is not readily available;" "Ready access for psych referrals is not always available, and communication from psychiatrists seems more limited." Other comments included the following: "I will not treat patients with active ‘psych’ problems without a letter from [the] psych[iatrist] saying they’ll hold my hand with the patient." "A special clinic for hepatitis C patients for the region would be used and, I think, supported by gastroenterologists;" "Psych referral and help can often make or break treatment competence for hepatitis C."
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DISCUSSION
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These results indicate awareness among gastroenterologists in Oklahoma, Arkansas, and Kansas of the psychiatric evaluation and treatment needs of the hepatitis C population and a perceived need for improved access to such services. The majority of psychiatric screening of patients with hepatitis C is being done during the history and physical examination. These data point to a low use of psychiatric screening and questionnaires despite such recommendations in the literature. Routine screening for psychiatric symptoms may increase psychiatric referral rates, given that previously published studies have shown that low rates of psychiatric problems are found in those studies relying on self-report. Conversely, studies utilizing systematic psychiatric measures find high rates of psychopathology.2,10 These data suggest that the low rate of screening done by surveyed physicians in this study may lead to under-diagnosis of psychiatric illness and, therefore, few referrals.
The surprisingly low rates of psychiatric referral for this population may be a more significant problem than the perceived lack of access. Lack of referral may reflect a more complex combination of factors impeding care; these may include lack of access, underfunding of psychiatric services by payors, patient preference, stigmatization, or efforts to avoid stigmatization of patients. There is a growing literature regarding stigmatization related to hepatitis C.11,12 The risk factors for contracting hepatitis C, such as illicit intravenous drug use history, may lead to the stereotyping of patients infected with the virus, and such stereotyping can be a barrier to treatment.13 Although only one gastroenterologist self-identified as practicing in a rural area, patients in rural settings may have even more difficulty accessing hepatitis C and mental health resources than patients residing in more populated areas.
There are potential weaknesses of this study that may limit the generalizability of the results. We do not know whether or not gastroenterologists in other parts of the country would have different perceptions because no such reports are available. In an effort to ensure anonymity and encourage study participation, identifying information was not collected from the gastroenterologists responding to the questionnaire. One drawback to this approach was that we did not collect the data necessary to send out reminders to non-responders. The resultant response rate of 39% may not be representative of all gastroenterologists in this area. There is the possibility of response bias in studies conducted using surveys. Respondents feeling strongly about the subject may have been more likely to reply than those with less interest. It is also unknown whether or not there are differences in the years since completion of specialty training, years in practice, board-certification, practice patterns, perceptions, and patient bases of those gastroenterologists who responded to the survey, as compared with those who did not.
Despite these limitations, we believe that these results provide some insight into the gastroenterologists’ perceived need and accessibility of psychiatric services for their hepatitis C patients. This information can be used to increase awareness of these issues for mental health providers and policymakers. This is important because gastroenterologists who perceive limited access to psychiatric services may be less likely to refer patients for appropriate psychiatric evaluation and treatment, which may, in turn, negatively affect their hepatitis C patients’ treatment outcome.
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CONCLUSIONS
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Efforts need to be made to increase access to and availability of effective psychiatric services for the hepatitis C patient population. Provision of comprehensive services to patients with hepatitis C is particularly important given the complex interaction between psychiatric illness, hepatitis C, and their treatment. The effect of psychiatric-care "carve-outs" by insurance companies, Medicaid, and other payors should be assessed, and appropriate changes in policy initiated.
To provide effective consultation and treatment to patients with hepatitis C, psychiatrists must possess knowledge of hepatitis C risk factors, treatment, prognostic indicators, and potential psychiatric effects of interferon therapy. Focused efforts are needed to increase such awareness in the psychiatric community, perhaps through continuing medical education activities. Inclusion of such information in residency training programs would also be valuable.
Increasing gastroenterologists’ awareness of psychiatric services and how to access those services may improve collaboration. Written submissions in general-medical newsletters describing available psychiatric and mental health services and how they are accessed would increase awareness. Inclusion of psychiatric services in referral databases, psychiatrist involvement in general hospital committees and medical organizations, provision of effective psychiatric consultation services within general hospitals, and personal contact with local gastroenterologists or internists may also open the lines of consultation and referral.
An ideal solution may be the incorporation of a psychiatric-liaison model within gastroenterology clinics. Particularly for higher-volume gastroenterology clinics, a psychiatry-liaison service could be developed with a psychiatrist present 1 day or one-half day per week, on site, within the gastroenterology clinic. This model would increase access for patients and allow for informal consultation and education between the gastroenterologist and the psychiatrist. Furthermore, it may help reduce stigma in this population. Patients may be more willing to see a psychiatrist who is located within the same office or building as their treating physician. This arrangement would be most workable in those situations where both specialties are part of the same physician group, such as in teaching hospitals or large, multispecialty practices.
More studies are needed to determine what level of psychiatric screening is necessary before psychiatric referral. In this study, rather simple screening questions, such as, "Does the patient have a previous history of depression?" were noted, followed by referral for more formal psychiatric evaluation in those patients screening positive. It would be useful to investigate the predictability of such screening in identifying those individuals who go on to have psychiatric problems with or without interferon therapy. Further research and multidisciplinary collaboration are needed in the area of comorbid hepatitis C and psychiatric illness.
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REFERENCES
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- Williams I: Epidemiology of hepatitis C in the United States. Am J Med 1999; 107(6B):2S-9S
- Zdilar D, Franco-Bronson K, Buchler N, et al: Hepatitis C, interferon alfa, and depression. Hepatology 2000; 31:1207–1211[CrossRef][Medline]
- Ho SB, Nguyen H, Tetrick LL, et al: Influence of psychiatric diagnoses on interferon-a treatment for chronic hepatitis C in a veteran population. Am J Gastroenterol 2001; 96:157–164[Medline]
- El-Serag HB, Kunik M, Richardson P, et al: Psychiatric disorders among veterans with hepatitis C infection. Gastroenterology 2002; 123:476–482[CrossRef][Medline]
- National Institutes of Health: National Institutes of Health Consensus Development Conference Panel Statement: Management of Hepatitis C, June 10-12, 2002. Hepatology 2002; 36(suppl 1):S3-S20
- Valentine AD, Meyers CA, Kling MA, et al: Mood and cognitive side effects of interferon-a therapy. Semin Oncol 1998; 25:39–47[Medline]
- Rowan PJ, Tabasi S, Abdul-Latif M, et al: Psychosocial factors are the most common contraindications for antiviral therapy at initial evaluation in veterans with chronic hepatitis C. J Clin Gastroenterol 2004; 38:530–534[CrossRef][Medline]
- Morrill JA, Shrestha M, Grant RW: Barriers to the treatment of hepatitis C: patient, provider, and system factors. J Gen Intern Med 2005; 20:754–758[CrossRef][Medline]
- Radloff LS: The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977; 1:385–401[CrossRef]
- Goldsmith RJ, Mindrum G, Myaing M: Psychiatric assessment of patients with hepatitis C virus before initiating interferon treatment. Psychiatr Ann 2003; 33:369–376
- Zickmund S, Ho EY, Masuda M, et al: "They treated me like a leper:" stigmatization and the quality of life of patients with hepatitis C. J Gen Intern Med 2003; 18:835–844[CrossRef][Medline]
- Grundy G, Beeching N: Understand social stigma in women with hepatitis C. Nurs Stand 2004; 19:35–39[Medline]
- Corley MC, Goren S: The dark side of nursing: impact of stigmatizing responses on patients. Scholarly Inquiry for Nursing Practice 1998; 12:99–118[Medline]
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ABSTRACT
INTRODUCTION
