If you don’t ask, you won’t know. Bridging the gap between mental health and acute care.

Abstract

The close relationship between physical and mental health is well established. Mental health is the primary driver of disability worldwide. A recent NCEPOD audit explored the quality of mental health care provided to patients admitted with a physical illness and found that 80% of patients lacked an adequate mental heath history. They recommended that national guidelines should be developed outlining the expectations of general hospital staff in the management of mental health conditions. Currently no strategy exists for identifying mental health problems in patients in acute care. This study describes the pilot of introducing screening for psychiatric symptoms to all acute medical patients at the Ipswich Hospital.

Full text

Addenbrooke’s Hospital Rosie Hospital
If you don’t ask, you won’t know.
Bridging the gap between mental health and acute care.
Guruparan T1, Arun K1, Ansari S1, Naruka V1, Weichert I2
1 University of Cambridge Clinical School, 2 Department of Acute Medicine, The Ipswich Hospital
Methods
Patients admitted to the Emergency Assessment Unit at The
Ipswich Hospital were screened for mental health conditions using
a short screening questionnaire which was incorporated into
clerking proformas in the systems enquiry or “direct questions”
(see figure 1).
Figure 1: Poster with instructions for medical staff
Doctors were asked to give a PHQ-SADS (Patient Health
Questionnaire - Somatic, Anxiety, and Depressive Symptom
Scales) 3,4 to patients who answered “yes” to all three screening
questions. The completed form was then placed in the patients’
notes. Based on the results, interventions such as an inpatient
psychiatric review or alerting the GP in the discharge letter could
be implemented by a senior clinician. Doctors were regularly
reminded about the screening pilot and the above poster
explaining the project was placed in the doctors’ offices.
Data was collected during an initial one month pilot starting
November 15th, 2016.
Outcomes
Questionnaire results:
The results of the project are summarized in table 1 as well as
figures 2 and 3. Of the patients that were self reporting mental
health issues, 64% did not have any past psychiatric history
documented and 60% were not taking psychiatric medication. The
median scores for somatisation and anxiety fall within the
moderate category, the median score for PHQ-9 screening for
depressive symptoms falls within the severe category.
Background & Aims
The close relationship between physical and mental health is well
established. Mental health is the primary driver of disability
worldwide.1 A recent NCEPOD audit explored the quality of
mental health care provided to patients admitted with a physical
illness and found that 80% of patients lacked an adequate mental
heath history.2 They recommended that national guidelines
should be developed outlining the expectations of general hospital
staff in the management of mental health conditions. Currently no
strategy exists for identifying mental health problems in patients in
acute care. This study describes the pilot of introducing screening
for psychiatric symptoms to all acute medical patients at the
Ipswich Hospital.
References
1. Lozano, R. et al. (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010. a systematic analysis for the global burden of disease study 2010.
The Lancet. 380(9859), 2095–2128.
2. National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Treat as One. Bridging the gap between mental and physical healthcare in general hospitals. 2017.
http://www.ncepod.org.uk/2017report1/downloads/TreatAsOne_FullReport.pdf [accessed 2017. April5th]
3. Patient Health Questionnaire (PHQ) Screeners. Instructions for Patient Health Questionnaire ( PHQ ) and GAD-7 Measures [Internet]. www.phqscreeners.com. [accessed 2016 Nov 2].
4. Kroenke K, Spitzer RL, Williams JBW, Löwe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: A systematic review. Gen Hosp Psychiatry.
2010;32(4):345–59.
The Ipswich Hospital
Table 1: Summary of results
Figure 2: System involved in the Figure 3: Severity of the symptoms identified
main admission diagnoses
Barriers to implementation:
We identified a number of barriers to implementation of our
screening tool for identifying patient mental health issues in acute
medicine. Doctors felt uncomfortable discussing mental health
problems with patients who were attending hospital with other
acute medical problems. Time constraints meant that they could
not afford to discuss in length about mental health problems with
patients and the topic was perceived to be quite time consuming
by the doctors. Doctors also felt unsure about how to proceed with
the results of the PHQ-SADS questionnaire, given that the
management was left to the discretion of the treating clinician.
Patient perspective:
In contrast to these issues raised by the doctors, we found that
patients were very open to discuss their mental health.
Furthermore, in general, our screening tool took 5-10 minutes to
complete.
Conclusion
Screening for psychiatric issues has a high response rate
amongst acute patients and can help identify otherwise missed
symptoms. Barriers amongst staff need addressing to further
integrate this with medical history taking. As a result of this
successful pilot, the Ipswich Hospital is now introducing mental
health screening for all patients in the acute medical unit.