Digging up and dealing with inpatient depression

Accurately diagnosing depression in a medically ill person can be tricky, but hospitalists can take steps to improve inpatient and postdischarge mental health care.

Treating depression remains a pernicious health care challenge, especially in the inpatient setting, where continuity can be an issue.

Photo by Thinkstock
Photo by Thinkstock.

“The current state of depression care for hospital patients is fragmented,” said Sophia Wang, MD, a psychiatrist, assistant professor, and mental health researcher at Indiana University School of Medicine in Indianapolis. “Mental health is not at the forefront when patients are being screened for another medical condition. There is not a solidified plan of care.”

This poses a substantial problem, as depression is common among inpatients. A 2017 report published in the Journal of Hospital Medicine found a 33% median rate of depression among hospitalized patients, compared with about 7% in the general population.

Incentives to reduce readmissions may provide additional motivation for hospitals to remedy that situation. According to a statistical brief released in October 2017 by the Healthcare Cost and Utilization Project (HCUP), mood disorders were the fourth-leading cause of readmissions among uninsured patients in 2014. A 2015 HCUP brief noted that the average hospital cost was higher for readmissions involving mood disorders ($7,200) than for readmissions for any cause ($5,800).

Treatment challenges

Depression treatment typically falls into three main categories: antidepressant medications, neurostimulation, and psychotherapy. Neurostimulation therapies include electroconvulsive therapy, which has been used for many years by psychiatrists, as well as more novel treatments such as transcranial magnetic stimulation.

Although there is strong evidence of the efficacy of these treatments for depression, hospitalists' treatment options are limited by the realities of the modern hospital stay, physicians said.

“Clinicians may not always have access to prior outpatient records,” Dr. Wang said. “Health care providers may not know what decisions other providers may have made about mental health treatment while these patients have been various settings, such as inpatient, outpatient, a rehab facility, or other areas. We have a lot of effective treatments. But maybe [patients] have not been able to tolerate the regimen, had an adverse reaction to the regimen, or could not afford it.”

Patients are unlikely to actually be admitted for depression, experts noted. “The requirements for inpatients from third-party payers are largely limited to patients who are suicidal or can't take care of themselves outside,” said Charles Nemeroff, MD, PhD, chair of the department of psychiatry and behavioral sciences and clinical director of the University of Miami Miller School of Medicine Center on Aging. “So it needs to be pretty severe.” Thus, depression is most likely to be seen by hospitalists as a comorbid condition in conjunction with other conditions, like diabetes, he noted.

If patients have not been diagnosed with depression prior to admission, identification during admission depends on screening practices, which vary widely by hospital, experts said. A popular tool is the Patient Health Questionnaire-9 (PHQ-9), a simple but accurate assessment containing nine questions.

Although electronic health record systems vary, many contain prompts and information on mental health. There is concern, however, that the information can become buried or feel like white noise to overwhelmed clinicians, Dr. Wang said.

Accurately diagnosing depression in a medically ill person can also be tricky, experts cautioned. “We found that a depression screening tool may pick up false-positive screens because of the physical symptom burden associated with hospitalization,” said Suzanne Mitchell, MD, a family physician, researcher, and assistant professor at Boston University School of Medicine and Boston Medical Center.

“One of the most common diagnostic errors is confusing hypoactive delirium for depression,” added Dr. Wang. “A thorough workup for delirium, especially hypoactive delirium, should be done first. This includes doing an objective assessment such as the CAM [Confusion Assessment Method test] in the general hospital setting or the CAM-ICU in the intensive care unit.”

Once depression is suspected based on a screen, the best course is usually for a hospitalist to seek a consult, according to Dr. Wang. “Ideally a psychiatric consultation service should be called if the patient has never been on an antidepressant before, and especially if there has never been any mental health history,” she said.

Even with specialist expertise, it may be difficult to decide how to respond to the appearance of depression in an inpatient. “These days, the admissions are so short, it may not be possible to firmly establish that a patient has a new diagnosis of major depression that warrants drug therapy,” said Dr. Mitchell.

Dr. Wang believes inpatient prescriptions are appropriate in some cases. “Once all medical causes have been exhaustively ruled out, then an antidepressant can be provided for a short duration—one to three weeks, depending on when the patient has an outpatient mental health appointment,” she said.

However, other experts cautioned against hospitalists taking such matters into their own hands. “To my knowledge, there is no evidence supporting initiating new depression drug therapy during an acute medical stay by a hospitalist,” Dr. Mitchell said.

Yet hospitalists may often find themselves handling patients' mental health issues alone. A report released in spring 2017 by the National Council for Behavioral Health revealed a 6.4% shortage in the psychiatrist workforce. In the ED, psychiatrist wait times can reach 23 hours, with study authors noting a “shrinking number of inpatient psychiatric services.”

“Many hospitals don't have attending psychiatrists,” Dr. Nemeroff said. “Some hospitals have consultation-liaison psychiatrists and can serve as a link to connect them with case managers, which are integral to this process. If you compare our system with those outside the U.S., we're really Byzantine in taking care of mental health.”

A reason to seek expert advice is that initiation of antidepressants does carry risks, for example, the black box warning on selective serotonin reuptake inhibitors about suicidal thoughts in young patients, Dr. Wang noted.

Another challenge with antidepressants is the drugs' delayed effect. It can be hard to get a handle on a patient's depression during the typical short hospital stay, Dr. Nemeroff explained. “There is lots of structure for an inpatient's life, and they can appear to be doing well. But antidepressants can take a considerable amount of time to work, about three to five weeks, and we're not keeping them that long.”

If a hospital has suitable expertise on hand, there may be another way to treat patients' depression. “Psychotherapy, if available in the hospital, can be considered for mild depressive symptoms in patients with no previous psychiatric history,” said Dr. Wang.

Dr. Mitchell agreed, and she specifically recommended cognitive behavioral therapy (CBT). “An inpatient approach to CBT could be a reasonable intervention during hospitalization to help patients cope with depressive symptoms until they can be seen by an outpatient provider,” she said.

Improving care by improving handoffs

Having hospitals and hospitalists more consistently coordinate care with their outpatient counterparts, who tend to be better equipped to address depression, appears to be the most promising answer. Improving these handoffs could both support patients' mental health and reduce readmissions, according to experts.

“There is growing recognition of social determinants and unmet mental health issues contributing to medical readmissions,” said Dr. Wang. “The main barriers, however, to successful reduction of hospital readmissions are the lack of evidence-based models of integrated care that traverses both inpatient and outpatient settings and the need to integrate mental health services in both primary care and subspecialty clinics where these patients go for their discharge care.”

The appropriate outpatient clinician to receive the handoff of a patient's mental health care will depend on the severity of the problem, experts said. “In certain cases, patients who have only mild depressive symptoms and receiving their first trial of an antidepressant can be managed by PCPs with adequate training in providing first-line mental health treatment,” said Dr. Wang.

The receiving primary care physician should have experience in treatment of mood and anxiety disorders, Dr. Nemeroff said. Ideally, patients should be handed off to settings with integrated medical and mental health care, so a behavioral health specialist or psychiatric consultation is available if complications arise, Dr. Wang added.

Patients with more serious mental health issues, including any history of suicide attempts or self-injurious behavior, homicidal behavior or physical aggression, or prescriptions for an antipsychotic or a mood stabilizer, should be connected with outpatient psychiatric care from the start.

Case managers and discharge planners can help facilitate this handoff as well as optimizing care for patients with depression during hospitalization, experts said.

To improvement treatment and transitions for medically complex patients with mental health needs, the intensive care survivor research group at Indiana University, which includes Dr. Wang as well as medical director Babar Khan, MBBS, has proposed a new model of care.

This model, which they applied to geriatric ICU patients requiring psychiatric care, utilizes recovery care coordinators. “A recovery care coordinator tracks the patient's journey throughout the health care system, whether it be in the ICU, hospital floor, or the outpatient setting,” Dr. Wang said. “They track with that patient, and then if there are crucial mental health issues identified, they would appropriately reach out to a specialist.”

The recovery care coordinator can collaborate with inpatient physicians to create and implement individual care plans and facilitate smooth transitions. Although Dr. Wang's research has focused on geriatric ICU patients and psychiatry, she said that a recovery care coordinator could also be applied to the general patient population.

After discharge, the recovery care coordinator continues to serve as a point of contact, helping patients navigate the health care system and making connections among clinicians in and out of the hospital, Dr. Wang said.

In general, to ensure outpatient follow-up, hospitals and hospitalists need protocols for exporting the information that a patient may be depressed.

“The better you communicate with the outpatient providers, the better,” said Dr. Mitchell. “Make it your team's priority. When you get a positive screening, what do you do with that? What do you say about it on the discharge summary? The hospitalist can be active in engaging on that.”