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Service Delivery Innovation Profile

Hospital Systematically Screens and Initiates Treatment for Depression and Anxiety in Cardiac Patients, Improving Cardiac Symptoms and Mental Health


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Summary

Massachusetts General Hospital systematically screens all cardiac inpatients for depression and anxiety and develops treatment plans for them as appropriate. After a brief screen by the cardiology unit’s admitting nurse, a depression care manager performs a more indepth assessment to confirm a diagnosis in those with suspected problems. The care manager obtains individualized treatment recommendations from a psychiatrist, notifies the patient’s inhospital provider, and obtains approval for the plan from the patient's primary care physician. As necessary, the care manager counsels and follows up with the patient after discharge and/or arranges for a referral for mental health counseling. The program significantly enhanced access to mental health care and adherence to medical recommendations, leading to improvements in cardiac symptoms, severity of depression, mental health-related quality of life, and overall mental health.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial that evaluated key cardiac and mental health process and outcome measures in patients receiving program services to a control group of similar patients receiving usual care; metrics include access to mental health care, adherence to medical recommendations, number and severity of cardiac symptoms, severity of depression, mental health-related quality of life, and other mental health symptoms.
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Developing Organizations

Massachusetts General Hospital
Boston, MAend do

Date First Implemented

2007
September

Problem Addressed

Hospitalized patients with cardiovascular disease frequently suffer from undiagnosed (and hence untreated) mental health disorders that can have a meaningful, negative impact on their physical health. Routine screening and treatment can help to address this problem, but relatively few cardiac inpatient units conduct such screening or initiate treatment in a systematic manner.
  • Many cardiac inpatients with mental health disorders: Many patients with cardiovascular disease suffer from depression and anxiety.1 For example, up to 15 percent of patients with cardiovascular disease and up to 20 percent of coronary artery bypass graft surgery patients have depression.2
  • Often undiagnosed and untreated: Depression and anxiety remain unrecognized, and therefore untreated, in most cardiac inpatients.1,3 One study found that less than 15 percent of cardiac inpatients with depression are diagnosed and up to 50 percent have undiagnosed anxiety.3
  • Contributing to negative outcomes: Depression, depressive symptoms, and anxiety contribute to increased mortality, recurrence of cardiac events, and poor health-related quality of life in patients hospitalized for a heart attack, unstable angina, or congestive heart failure.1 For example, one study found that the 6-month mortality rate in heart attack patients who suffered from depression was more than 5 times higher than in similar patients without depression (17 percent versus 3 percent).4
  • Unrealized potential of routine screening and treatment: The American Heart Association5 recommends that all coronary heart disease patients receive a routine depression evaluation using tools such as the Patient Health Questionnaire (PHQ)-26 or the PHQ-9.7 Yet relatively few inpatient cardiac units apply these recommendations in a systematic fashion or initiate a comprehensive treatment plan based on the results of the screening.

What They Did

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Description of the Innovative Activity

Massachusetts General Hospital systematically screens all cardiac inpatients for depression and anxiety and develops a treatment plan for them as appropriate. After a brief screen by the cardiology unit’s admitting nurse, a depression care manager performs a more indepth assessment to confirm a diagnosis in those with suspected problems. The care manager obtains individualized treatment recommendations from a psychiatrist, notifies the patient’s inhospital physician, and obtains approval from the patient's primary care physician. As necessary, the care manager counsels and follows up with the patient after discharge and/or arranges for a referral for mental health counseling. Key program elements include the following:
  • Three-step evaluation: All patients admitted to a cardiac care unit with an acute cardiac condition (such as heart attack, unstable angina, heart failure, or arrhythmia) are evaluated for mental health disorders, as follows:
    • Simple screening by admitting nurse: As part of the admission interview, admitting nurses ask all new inpatients a question related to their general mental health—"have you recently been feeling depressed, irritable, hostile, anxious, or fearful?" The answer becomes part of the patient’s chart.
    • General screening by care manager: A social worker serving as a depression care manager reviews all new patient charts each day and visits any patient who responded positively to the question during the admission interview. The care manager asks five additional questions related to whether over the past 2 weeks the patient has: (1) felt down, depressed, or hopeless; (2) had little interest or pleasure in doing things; (3) been bothered by feeling nervous, anxious, or on edge; (4) been bothered by not being able to stop or control worrying; or (5) had a panic attack. If the patient answers affirmatively to any of the questions, the care manager asks the patient if he/she would be willing to undergo a more indepth evaluation.
    • Indepth diagnostic evaluation: The diagnostic evaluation uses the PHQ-9,7 a nine-item questionnaire that screens for clinical depression, along with two modules from the Primary Care Evaluation of Mental Disorders (also known as PRIME-MD),8 a mental illness diagnostic interview designed for the primary care setting. Patients who screen positive for depression, generalized anxiety disorder, and/or panic disorder receive further evaluation using diagnostic tools for bipolar disorder, psychotic symptoms, and substance use disorder. The care manager offers to facilitate a psychiatric consultation for more complex patients and asks less complex patients if they would like to participate in the program and hence have treatment initiated for their mental health issues.
  • Patient education: The care manager provides the patient with written and verbal education about depression and other mental health issues and their impact on cardiovascular disease and outcomes. She also describes medication and nonpharmacologic (therapy) treatment options, and helps the patient plan simple, pleasurable activities (such as lunch with a friend) after discharge.
  • Psychiatrist-generated treatment plan: The care manager telephones the psychiatrist to discuss the patient's case. Using the care manager's input and information from the patient's electronic medical record, the psychiatrist develops individualized treatment recommendations, taking into account prior treatment history, co-occurring medical conditions, current medications, and patient preferences. The psychiatrist may also seek additional input from the inpatient treating physicians, if necessary.
  • Coordination with other providers: The care manager sends a letter to the patient’s inpatient medical care providers (typically an attending physician or nurse practitioner) with the psychiatrist's recommendations (e.g., medications at discharge, referrals for nonpharmacologic therapy). The care manager also telephones the patient’s primary care physician to report the recommendations, get approval for any medications to be prescribed at discharge, and request that the physician continue prescribing the medication if it benefits the patient.
  • Provision of or referral for nonpharmacologic therapy: As appropriate, the care manager either provides telephone-based therapy and/or arranges a referral for nonpharmacologic therapy, as outlined below:
    • Telephone-based therapy: With the patient's permission, the care manager calls every 2 weeks after discharge. Together, the care manager and patient complete a workbook based on the principles of cognitive behavioral therapy that includes exercises to reduce automatic negative thinking and help identify pleasurable activities to pursue.
    • Referral for nonpharmacologic therapy: When recommended or if requested by the patient, the care manager arranges a referral for mental health counseling as an alternative to telephone-based therapy.
  • Followup contact: A research assistant contacts the patient by telephone four times (every 6 weeks for 6 months after discharge) to reassess the patient’s mental health status using the PHQ-9, the Hospital Anxiety and Depression Scale, and severity scales for generalized anxiety disorder and panic disorder. Patients who have ongoing depression or anxiety receive an additional telephone call from the care manager, who evaluates the need for further intervention.
  • Weekly case review: Each week, the care manager, psychiatrist, and research assistant meet to discuss all new patients and patients who received a followup call that week. The team discusses potential interventions and develops an action plan, such as contacting the primary care physician to increase a medication dosage or making referrals for therapy.

Context of the Innovation

Massachusetts General Hospital, a 900-bed teaching hospital in Boston, MA, handles more than 45,000 admissions annually. The hospital includes two cardiac units and one cardiac intensive care unit (ICU) that care for approximately 8,000 patients each year. The impetus for this program came from a psychiatrist working at the hospital who often got called in to perform consultations. He found that many patients with heart disease had depression and other mental health issues, but noted that no formal process existed to identify and ensure adequate mental health treatment for these patients.

Did It Work?

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Results

The program significantly enhanced access to mental health care and adherence to medical recommendations, leading to improvements in cardiac symptoms, severity of depression, mental health-related quality of life, and overall mental health.
  • Enhanced access to mental health care: Those participating in the program were much more likely to receive treatment for depression, with 71.9 percent of participants who screened positive receiving treatment, compared to just 9.5 percent of those receiving usual care.1
  • Greater adherence to medical recommendations: Six months after discharge, patients who participated in the program reported significantly greater adherence to their medical recommendations than those receiving usual care.9
  • Improvements in cardiac symptoms: Also 6 months after discharge, participants experienced significantly greater reductions in both the number and intensity of cardiac symptoms than patients receiving usual care. However, there was no significant difference in the rate of cardiac readmissions.9
  • Improvements in mental health: Participants experienced greater improvements in mental health at 6 and 12 weeks postdischarge,9 as described below; however, these improvements diminished after 6 months postdischarge.
    • Depression and anxiety: Patients had significantly greater improvements in PHQ-9 depression scores at 6 and 12 weeks after discharge than those receiving usual care, with scores improving by 59.7 percent at 6 weeks (versus 33.7 percent in the control group) and 51.5 percent at 12 weeks (versus 34.4 percent). Participants also reported greater improvements in anxiety and cognitive symptoms of depression than those in the control group.
    • Mental health-related quality of life: Participants reported greater improvements in mental health-related quality of life (as measured by the Short Form-12) than those receiving usual care. Six weeks after discharge, the scores of participants had improved by 7.32 more points than those of usual-care patients; at 12 weeks, the difference was 5.92 points.
    • Overall mental health: Participants reported greater improvements in overall mental health than those receiving usual care.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial that evaluated key cardiac and mental health process and outcome measures in patients receiving program services to a control group of similar patients receiving usual care; metrics include access to mental health care, adherence to medical recommendations, number and severity of cardiac symptoms, severity of depression, mental health-related quality of life, and other mental health symptoms.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Obtaining approval from unit leaders and staff: The psychiatrist met with medical directors and nurse managers on the cardiac care units to describe the impact of mental health conditions on cardiac outcomes and to describe the program. After receiving their approval and support, he met with unit nurses to explain the program and its merits. He continues to meet with them periodically to obtain feedback and address program-related problems.
  • Selecting diagnostic tools and education materials: The psychiatrist selected diagnostic tools to screen and evaluate patients and educational materials to be distributed to patients.
  • Hiring and training care manager and research assistant: The psychiatrist hired a part-time social worker to serve as care manager and a research assistant to help collect and analyze data to evaluate the program. He trained both by educating them on depression and anxiety disorders in cardiac patients and reviewing patient educational materials and the use of the diagnostic tools. The care manager practiced using the tools on staff and patients, and listened to audiotaped assessments performed by mental health professionals.
  • Designing monitoring system: The psychiatrist selected a time frame during which patients would be reassessed for mental health conditions, and tasked the research assistant with placing followup calls to patients to collect the relevant information and enter it into an existing hospital database.

Resources Used and Skills Needed

  • Staffing: The program includes one half-time social worker serving as the depression care manager, a psychiatrist who spends approximately 3 to 5 hours a week on the initiative, and one part-time research assistant (who handles followup calls not assigned to the care manager). The care manager conducts an initial screen on up to eight inpatients a day. Potential adopters would only need to hire a part-time research assistant if interested in conducting a formal study of the clinical intervention.
  • Costs: Data on program costs are not available. The primary expense consists of the labor costs associated with staff time spent on program-related activities, as outlined above.
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Funding Sources

American Heart Association
The American Heart Association provided two grants totaling $360,000 over a 6-year period to support the program, including the research component.end fs

Tools and Other Resources

Information about the PHQ-9 is available in the following article: Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13. [PubMed]

Information about the PRIME-MD is available in the following article: Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA. 1994 Dec 14;272(22):1749-56. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

  • Identify appropriate psychiatrist to lead effort: Treating patients with a medical illness and co-occurring depression or anxiety requires a psychiatrist who is interested in depression in the medically ill and who understands drug interactions, the effects of medications on the heart, and other issues.
  • Make screening routine for all cardiac patients: Build screening into the workflow of the nursing staff and make it a systematic part of the process. The admission interview represents a good time to complete this task, since it is performed for all patients.
  • Obtain buy-in from cardiac unit nurses: The initial screening by admitting nurses represents an important step in the process. Consequently, all nurses on the cardiac units should understand the rationale for the program and be willing to participate in it.
  • Choose units carefully: Program developers initially implemented the intervention on two cardiac units and a cardiac ICU, but found that ICU patients were too sick to benefit from the program.
  • Use social workers as depression care managers: Social workers are typically prepared for and comfortable with the idea of discussing mental health issues with patients, dealing with patients and families during times of medical crisis, and helping patients solve problems. Program developers note that nurses also possess similar skills and could be used as care managers, though this would likely increase expenses.
  • Design program to do as much as possible in the hospital: A hospitalization often represents a “teachable moment” during which patients are amenable to hearing messages about their health and treatment. As a result, conducting evaluations and developing and initiating treatment plans during the inpatient stay can improve quality of care.

Sustaining This Innovation

  • Systematically follow up with patients: Develop a system to track patients on a systematic basis, thus allowing program services to be tailored to their needs as they change.
  • Ensure ongoing funding: The program can be relatively easily sustained as long as a source of funds exists to cover the main program cost—salary and benefits for the care manager.

More Information

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Contact the Innovator

Jeff C. Huffman, MD
Massachusetts General Hospital
55 Fruit Street
Blake 11
Boston, MA 02114
Phone: 617-724-2910
E-mail: jhuffman@partners.org

Innovator Disclosures

Dr. Huffman has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Huffman JC, Beach SR, Suarez L, et al. Design and baseline data from the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized controlled trial. Contemp Clin Trials. 2013 Nov;36(2):488-501. [PubMed]

Huffman JC, Mastromauro CA, Sowden G, et al. Impact of a depression care management program for hospitalized cardiac patients. Circulation Cardiovasc Qual Outcomes. 2011;4(1):198-205. [PubMed]

Huffman JC, Mastromauro CA, Sowden G, et al. A collaborative care depression management program for cardiac inpatients: depression characteristics and in-hospital outcomes. Psychosomatics. 2011 Jan-Feb;52(1):26-33. [PubMed]

Sowden G, Mastromauro CA, Januzzi JL, et al. Detection of depression in cardiac inpatients: feasibility and results of systematic screening. Am Heart J. 2010;159(5):780-7. [PubMed]

Footnotes

1 Huffman JC, Mastromauro CA, Sowden G, et al. A collaborative care depression management program for cardiac inpatients: depression characteristics and in-hospital outcomes. Psychosomatics. 2011 Jan-Feb;52(1):26-33. [PubMed]
2 Jiang W, Davidson JRT. Antidepressant therapy in patients with ischemic heart disease. Am Heart J. 2005 Nov;150(5):871-81. [PubMed]
3 Huffman JC, Smith FA, Blais MA, et al. Recognition and treatment of depression and anxiety in patients with acute myocardial infarction. Am J Cardiol. 2006 Aug 1;98(3):319-24. [PubMed]
4 Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction. Impact on 6-month survival. JAMA. 1993 Oct 20;270(15):1819-25. [PubMed]
5 Lichtman JH, Bigger JT Jr, Blumenthal JA, et al. Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation. 2008 Oct 21;118(17):1768-75. [PubMed]
6 Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003 Nov;41(11):1284-92. [PubMed]
7 Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13. [PubMed]
8 Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA. 1994 Dec 14;272(22):1749-56. [PubMed]
9 Huffman JC, Mastromauro CA, Sowden G, et al. Impact of a depression care management program for hospitalized cardiac patients. Circulation Cardiovasc Qual Outcomes. 2011;4(1):198-205. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 15, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: January 14, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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