They'll be back

Depression may pose as a big a risk for hospital readmission as other, better known factors.

As the television commercial says, “Depression hurts.” Now a new study has quantified exactly how much being depressed hurts patients recently discharged from the hospital.

Researchers screened more than 700 general medical patients for depression before discharge from Boston Medical Center. Almost a third of them tested positive and those who did were significantly more likely to return to the hospital within the next 30 days. The hospital utilization rate was 56 per 100 people among patients with depressive symptoms compared to 30 per 100 in the non-depressed, according to the results published in the Journal of Hospital Medicine in September.

Photo by Thinkstock
Photo by Thinkstock.

The findings indicate that depression poses as big a risk as better-known factors associated with readmission. “Depression is as important a risk factor as having a prior hospital admission, which is one of the most important and significant risk factors for early hospital utilization,” said Suzanne Mitchell, MD, lead author of the study and a family physician at Boston University/ Boston Medical Center.

The study also confirmed prior research that found depression to be a significant risk for certain subgroups—cardiac patients, the elderly—and the anecdotal impressions of physicians practicing in the hospital. “My experience is that patients who have symptomatic depression have more problems with self-care and after-care, particularly patients with chronic illnesses that require maintenance… it made sense to me that patients with depression were at increased risk for readmission,” said Dr. Mitchell.

The association between depression and readmission is likely a result of physiologic effects, as well as worse self-care, according to Jeff Huffman, MD, a psychiatrist at Massachusetts General Hospital in Boston who has researched depression in cardiac patients.

“[Depression] has effects on inflammatory markers. It may be associated with activation of platelets, making platelets more sticky. It may be associated with endothelial dysfunction. There's a whole host of other physiologic things that go wrong in patients with depression,” he said.

Importance of screening

Most hospitalized patients are not screened for this common risk factor. “One of the problems with depression is its low level of being identified and diagnosed accurately,” Dr. Mitchell said. “[Depression] often gets overlooked in the inpatient setting unless it's really obviously interfering with the patient's care.”

In light of the evidence that depression is interfering with recovery, hospitalists may want to take a closer look at the mental health of their patients. Screening can be as simple as asking one or two questions.

“‘Have you felt depressed most of the time in the past two weeks?’ or ‘Have you felt that you've lost interest in activities that you usually enjoy in the past two weeks?’ are great screening questions for depression. If somebody says yes to those, it's worth asking them about the symptoms of major depression,” said Dr. Huffman.

Of course, if a patient has been in the hospital for the past two weeks, it wouldn't be surprising if he or she has been enjoying life less. It's important to distinguish between these transient issues and major depression. “It's not the patient who has a heart attack and three days after says, ‘Yes, I've been feeling depressed ever since my heart attack.’ It's the patient who says, ‘Yes, I had a heart attack and, oh by the way, I've been feeling terribly depressed for the last six months,’” explained Dr. Huffman.

Sometimes the distinction is made during post-discharge follow-up, explained Bruce L. Rollman, ACP Member, an associate professor of medicine and psychiatry at the University of Pittsburgh who has experimented with depression treatment after hospitalization. “We screened in the hospital and then we called people up two weeks later and administered the PHQ-9 [Patient Health Questionnaire],” he said. About half of the patients in the study tested positive at discharge and the percentage had dropped to 31% at the two-week follow-up.

Treatment options

If you've definitively identified a depressed patient, there's no need to wait two weeks to do something about it. A diagnosis of major depression should lead to treatment. “If you identify a problem and you don't have any treatment to offer, then what have you done for your patient?” Dr. Mitchell said. “Try to implement some kind of intervention that can begin in the inpatient setting and can be transitioned to the primary care setting.”

The intervention could be pharmaceutical. “Treatment is very straightforward. We typically use generic SSRIs, which are safe and effective in these patients. We use standard doses for standard durations,” said Dr. Huffman.

Implementation of a treatment plan may be less straightforward, he acknowledged.

“Actually coordinating the screening of somebody for depression, making the diagnosis of depression, starting treatment, and [determining] who's going to follow that patient for treatment is actually a fairly complicated series of things that has to happen, especially for hospitalized patients.”

One complication could be the patient. “Patients who embrace treatment do remarkably well and they do well remarkably fast, but getting patients to embrace treatment is a potential barrier,” said Dr. Mitchell.

“Patients may not recognize that this is a life-threatening issue,” agreed Wei Jiang, MD, an associate professor of medicine at Duke University in Durham, N.C. who has researched the medical impacts of depression. Limited access to mental health care can also make it financially and logistically difficult for patients to comply with depression treatment, she noted.

Some efforts are being made to resolve these obstacles and make it easier for recently discharged patients to get depression treatment. Dr. Rollman recently conducted a trial called Bypassing the Blues, in which patients who were depressed after coronary artery bypass grafting (CABG) received depression care management over the phone. Patients who got eight months of telephone support from nurses had better mood symptoms and mental-health-related quality of life, according to the results published in the Nov. 18, 2009 Journal of the American Medical Association.

“Now that we've demonstrated the effectiveness of our intervention, we want to see if it's also cost-effective or cost-saving,” said Dr. Rollman.

Post-discharge depression could become more of a cost issue for hospitals, if and when payment penalties for preventable readmissions are implemented. “Identifying risk factors for readmission is on everybody's mind,” said Dr. Mitchell.

Given the attention, depression screening and treatment may eventually join more well-known factors as a marker of hospital quality, Dr. Rollman said.

“Depression screening should be routine, just like Medicare asks whether people are being asked about tobacco use in the hospital, or getting a pneumonia vaccine,” said Dr. Rollman. “It's really an untapped opportunity to further reduce morbidity and it's not that expensive to treat, as opposed to giving everybody a left-ventricular assist device.”