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Site Matters: Winning the Hearts and Minds of Patients in a Cardiology Clinic

Received November 13, 2006; revised January 31, 2007; accepted February 9, 2007. From the Depts. of Psychiatry, Mount Sinai Medical Center, New York, NY; Cardiology and Psychiatry, Elmhurst Hospital Center, Queens, NY; the Dept. of Cardiology, and the Duke University Medical Center, Durham, NC. Send correspondence and reprint requests to Rachel A. Annunziato, Ph.D., Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1230, New York, NY 10029. e-mail: rachel.annunziato{at}mssm.edu
© 2008 The Academy of Psychosomatic Medicine

ABSTRACT

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BACKGROUND: In medical care settings, mental health symptoms of depression and distress are associated with poor medical outcomes, yet they are often underrecognized. OBJECTIVE: Authors sought to examine the effect of having immediate mental-health screening in the cardiology clinic. METHOD: The Patient Health Questionnaire and the Impact of Event Scale were used to screen for depression and distress in 316 patients at an urban cardiology clinic. Because of poor follow-up rates, a psychiatrist was placed on the premises of the cardiology clinic to facilitate referrals. RESULTS: Placing a psychiatrist within the cardiology clinic significantly improved the rate of successful referrals. CONCLUSION: Because 45 patients (14%) endorsed suicidal thoughts, authors conclude that mental health screening programs should include an immediate evaluation by a clinician.

INTRODUCTION

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In medical care settings, mental health symptoms of depression¹ and distress² are associated with poor medical outcomes, yet they are often underrecognized.^3,4 Therefore, mental-health screening (especially for depression) in primary healthcare settings has been recommended.⁵ Unfortunately, there is little information about the implementation of such programs in "real-world" settings. For example, it is not known whether patients who are identified through screening require immediate care or whether a standard referral is sufficient. Further complicating matters, it has become clear that mental-health referrals are not likely to be followed through in primary care.^6–8 Indeed, the President’s New Freedom Commission on Mental Health⁹ emphasizes the development of approaches that increase successful referral rates, rather than simply providing referrals. It is important to study procedures that may increase rates of successful referrals in medical-care settings.

Rates of depression among coronary heart disease patients range from 7% to 40%.^10–12 Depression is associated with poorer medical outcomes and quality of life in these patients¹³ and is a consistent predictor of mortality after myocardial infarction (MI).¹⁴ The association between MI and posttraumatic stress disorder (PTSD) has also been shown, with as many as 8%–25% of MI patients developing this disorder in the first year after an MI. Also, PTSD is associated with poor medical outcomes in these patients.^15–18 It is therefore reasonable to attempt screening for both of these mental-health conditions (depression and PTSD) in cardiovascular patients.¹⁹

In 2002, the New York City Health and Hospitals Corporation (HHC) announced an initiative that included mental-health screening directed toward patients with cardiovascular illnesses.²⁰ It was specifically geared toward "establishing patient-friendly services that make it easier to access care and follow up on referrals." The authors of the present report implemented a mental-health screening program in an HHC urban cardiology clinic. At first, patients who screened positive on measures of depression or distress did not follow up on referrals. The authors then placed a psychiatrist in the cardiology clinic, which seemed to substantially increase the rate of successful referrals. The following short report summarizes this experience. The purpose of the present study was to determine retrospectively whether the program’s policy of immediate evaluation of all individuals screening positive has indeed resulted in provision of acute psychiatric care in some cases. The authors also evaluate whether any changes in successful referrals can be attributed to the change in service location (i.e., before and after the psychiatrist was placed on the premises of the cardiology clinic).

METHOD

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Subjects
Data have been evaluated for the first 316 patients screened between June 2005 and April 2006 in this ongoing program. The cardiology clinic of Elmhurst Hospital is located in the western portion of the borough of Queens, in New York City. It is part of the New York City HHC. All patients receive services irrespective of insurance status. In instances where patients present for evaluation and/or treatment but do not have insurance, they are referred to the "HHC Options" program to establish a sliding fee-scale within their financial means. Elmhurst is one of the most ethnically diverse zip-codes in the United States,²¹ with more than 40 nationalities represented in its community. The primary cardiac diagnoses in the clinic are coronary artery disease (CAD) and heart failure. Since this was a clinical program, no specific inclusion/exclusion criteria were applied (all patients who presented to the clinic were screened). Institutional Review Board (IRB) approval was obtained to review screened patients’ medical charts.

Procedure
Patients received two questionnaires, available in English and Spanish, screening for depression and distress. Volunteers were on-hand to help patients read or translate. A positive screening result generated immediate evaluation by the cardiology team (a nurse-practitioner or a physician), who decided, with the patient, whether to suggest a referral for a psychiatric evaluation. Clinicians were also free to refer any patient for a psychiatric evaluation, independent of screening results. A suicide evaluation was done immediately by the cardiology team in instances where the suicide-ideation question on the depression questionnaire was endorsed. The result of this evaluation determined the urgency and nature of follow-up and referral.

Before the inception of this program, patients were not routinely assessed for depression, distress, or suicidality by their cardiology practitioner. A month-long pilot implementation of these procedures was conducted before launching the program. When the program began, the cardiology and psychiatry teams created a system ensuring that all patients referred via a positive screen would be accommodated immediately in Psychiatry. Cardiology practitioners electronically generated a referral to psychiatry and informed the patients. Patients were informed that the psychiatry clinic was located one floor above the cardiology clinic, and, because of the arrangement with cardiology, they would be seen within 1 week. During the initial course of the program, the authors observed that none of the referred patients came to a scheduled visit in the psychiatry clinic. In October of 2005, the authors therefore introduced a new system: the psychiatrist assigned to see referred patients was placed in the cardiology clinic once a week.

Measures
Successful Referrals
Successful referrals were counted as those referred patients who attended a mental-health visit for further evaluation and care.

Patient Health Questionnaire (PHQ²²)
This validated 9-item self-report depression measure is recommended by HHC for use in screening efforts in medical-care settings,²⁰ and has proven utility in identifying cases.²³ The authors used a score of 15, corresponding to the lower boundary for moderately-severe depression,²⁴ as the threshold criterion for further evaluation by a cardiologist. For the final item, assessing suicidality, any response other than 0 generated immediate evaluation by the cardiologist (regardless of other responses).

Impact of Events Scale (IES²⁵)
The IES is a 15-item, validated self-report questionnaire measuring current subjective distress related to a specific event. A high score on the IES was shown to be associated with increased risk for nonadherence to medical recommendations,^18,26 cardiovascular admissions,^18,26 and a higher cardiovascular risk profile^18,26 in patients with cardiovascular illnesses. A positive screen was defined as a cumulative score of 24, corresponding to a moderate level of symptoms.²⁶ A positive screening on either measure generated further action.

Statistical Analysis
Analyses used the SPSS 12.0 Statistical Package. Independent-sample t-tests were used to compare means of continuous variables between the two groups (patients screened before or after change in service location). Chi-squares tests were used to examine differences on dichotomous measures. A p value of 0.05, two-tailed, was chosen as the level of statistical significance.

RESULTS

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Table 1 displays the demographic characteristics of our sample, before (N=132) and after (N=184) the psychiatrist was placed in the cardiology clinic. There were no significant baseline differences between the cohorts. Table 2 presents the mean scores on the psychiatric measures in both phases. There were no significant differences in psychiatric-measure scores between the cohorts. In both phases, 6% of the screened patients did not complete the PHQ, and 16% (Phase I) versus 23% (Phase II) did not complete the IES.

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TABLE 1. Demographic Characteristics of the Sample

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TABLE 2. Screening Measure Results Before and After Change in Location of Psychiatric Services

Referral Outcomes
Table 3 summarizes all referral outcomes. In Phase I, before the change in service location, none of the 12 patients who were referred by the cardiologist for further psychiatric evaluation followed up on this referral. In Phase II (psychiatrist on the premises of the cardiology clinic), 13 of 17 referred patients came to the psychiatric evaluation. The difference in rates of successful referrals (percentage of patients who did come to the psychiatric evaluation after being referred by a cardiologist) between phases I and II was significant (²=16.63; p<0.01).

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TABLE 3. Screening and Referral Outcomes

Suicidality
During the screening, 45 patients (14% of all screened) expressed varying degrees of suicidal ideation. The cardiology team was alerted to the responses of these patients, and a cardiologist or nurse-practitioner immediately conducted a suicide evaluation. This evaluation determined what would be the next step in the management of the patient. These patients could either receive no additional care (e.g., if the practitioner determined that the patient did not really have suicidal thoughts but, rather, misunderstood the item on the questionnaire), were provided with a referral to psychiatric services, or were taken to the emergency room (in acutely suicidal cases). Two patients (4% of all patients who endorsed the suicide-ideation item; <1% of all screened patients) presented as acutely suicidal and were hospitalized in a psychiatric unit immediately after a psychiatric evaluation.

DISCUSSION

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In the present study, the implementation of a mental-health screening program in an urban cardiology clinic resulted in the identification of a substantial minority of patients (9%) who, upon further evaluation, required psychiatric follow-up. Although there have been studies documenting that patients who present with cardiovascular illnesses are indeed predisposed to develop symptoms of depression^10–12 and posttraumatic stress,^15–18 there is a dearth of information about the impact of mental-health screening in this setting.

The fact that two patients needed immediate psychiatric care suggests that adequate resources must be in place to evaluate the screening results and offer immediate clinical assessment as needed. The data therefore suggest that screening for mental-health symptoms in a cardiology clinic may well be a worthy undertaking (because it leads to identification of clinically-verified cases), but that resources must be devoted to addressing patients’ needs as they are discovered. In our example, cardiologists and nurse-practitioners, with adequate training, were able to evaluate screening results and manage patients’ referrals after a brief evaluation that they conducted themselves. This finding is consistent with the U.S. Preventive Services Task Force²⁷ conclusion that screening for depression in medical clinics should be attempted, provided that systemic changes are implemented to ensure treatment and follow-up. The placement of a psychiatrist on the premises of the cardiology clinic was associated with a significant increase in the rate of successful referrals. This difference was not due to changes in patient characteristics (demographics, severity of mental-health symptoms) over time. Because the authors ensured that referred patients received timely appointments with a dedicated physician, and because all patients had full-service coverage, the increase in successful referrals cannot be attributed to increased availability or cost-advantage. The psychiatrist was placed in the clinic for only 4 hours per week (1 day), and, still, the rate of successful referrals increased dramatically. It is conceivable that, had the authors increased the amount of time the psychiatrist spent in the cardiology clinic, the resulting rate of successful referrals would have been even higher. However, it could also be that any further increase in psychiatrists’ time would not have resulted in a substantial increase beyond what the authors observed. Note, too, that the placement of the psychiatrist did not influence how actively suicidal patients were approached. Such patients were taken to the emergency room, rather then receiving a referral.

Our study was not designed to answer the question of what is the optimal time a psychiatrist should spend in the cardiology clinic; but we can conclude that even 4 hours a week was sufficient to improve follow-up in the majority of cases. Our results seem to substantiate the recommendation by the President’s New Freedom Commission on Mental Health⁹ that in order to provide successful care for patients identified through the use of a mental-health screening program, it is preferable that psychiatric evaluation and treatment occur on the premises of the medical clinic. To our knowledge, this is the first study documenting that this simple change, in the absence of any other changes, improves the rate of successful referrals. Of note, because we did not prospectively identify a Study versus a Control group, our ability to draw definitive conclusions is weakened. However, we were able to evaluate the impact of a specific, focused change (changing the psychiatrist’s location in this "real-world," clinical setting, rather than in a more experimental setting, which may have been less relevant clinically). Because we did not change the general setting or the providers in the clinic, we were able, in post-hoc comparisons, to demonstrate that the dramatic increase in successful referrals when a psychiatrist was placed on the premises of the clinic was not likely to be due to changes in demographic variables, symptom levels, or provider characteristics.

How can one explain this substantial increase in successful referrals? It is probable that this change was associated with an increase in the comfort level that both patients and practitioners feel toward mental-health treatment when it is delivered on "medical" territory. The psychiatrist was present in the cardiology clinic only once a week, whereas referrals were made at any point in time during the week, during normal clinic hours. Thus, it is not the case that the reason for the increased referral rate can be attributed to the fact that patients could see the psychiatrist immediately (many had to come to see the psychiatrist on a different day). Nevertheless, should this approach develop and become the standard of care for an extended period of time, certainly the immediate availability of a psychiatrist might lead cardiologists to schedule particularly vulnerable patients for an appointment on the day that the psychiatrist is present. If managed in this way (our experience was too brief to effect these changes), this model may lead, through not only close proximity but also through greater awareness, to more expedited psychiatric care. Our study, however, was not designed to provide explanations for the observed phenomena. The next step in terms of program evaluation might be to explore outcomes of successfully-referred patients and compare them with those who screened positive but were not successfully referred.

CONCLUSION

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This study was performed in one specialty clinic within a single medical center that services an ethnically diverse population. To the extent that they generalize to other centers, our results strongly suggest, first and foremost, that a mental-health screening program can result in the identification of cases, some of which require immediate assistance. The results suggest that it is possible to implement mental-health screening programs with active participation of cardiology clinicians (physicians and nurses) who can partake in the initial assessment of identified cases. Our findings also strongly suggest that positioning mental-health providers on the premises of medical-care clinics (in effect, creating a "patient-centered" clinic) might well improve service delivery.

ACKNOWLEDGMENTS

 
This study was supported by NIMH grant MH-071249 to Dr. Eyal Shemesh.

REFERENCES

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