5. PROPUESTA DIDÁCTICA 26
5.7. CONCLUSIONES POR SESIONES 54
5.7.5 Sesión 5: And Tango makes Three 65
Answering Machines and Too Little Reliable Follow-up
“The Wessex [England] In-Patient Suicide Study” identified patients at high risk for non-atten- dance using retrospective case-control methods. 15 Their sample consisted of almost 300 suicides within 12 months of inpatient discharge; 32 percent died within the first month of discharge and 83 percent within six months. Each index suicide was suitably matched to case controls. The absence or departure of key outpatient clinicians, becoming unemployed, new onset relationship difficulties (e.g., forced to live alone), involuntary hospitalization, unplanned discharge, and racial minority status were the most important death-related discontinuity factors. Every experienced clinician knows that patients with these attributes are hard to engage. The authors conclude their report with: “Discontinuity of care from a significant professional is associated with increased risk of suicide.” Indeed, suicide and reductions in care are correlated. 42, 59, 79, 339 Organizational poli- cies and procedures may facilitate patient engagement with follow-up plans. If, for example, the patient will have a new outpatient clinician, a patient-new-clinician phone call prior to inpatient discharge may provide the necessary motivation to get to the first appointment. If discharge is to a large clinic, a representative from that clinic could meet with the patient prior to inpatient dis- charge. Efforts to improve follow-up and continuity of care and forestall readmission should target higher-risk patients prone to disengagement. 341
The absence of these possible solutions and the associated hurdles pursuing follow-up care are demonstrated by a recent study of pretend patients with serious depression. Many of these “pa-
Continuity of Care for Suicide Prevention and Research
tients” were lost to follow-up after leaving the ED. For this study, Karin Rhodes and her research colleagues employed a strategy used often to identify discrimination in housing and employment. Graduate students were trained to be fake patients just diagnosed in the ED with serious depres- sion. Since major depression and suicide risk are frequent partners, it would be important to have near-term follow-up. The students’ mission was to obtain an appointment with a mental health professional within 14 days of leaving the ED. These mock patients called a sample of 322 clinics in nine major American cities in nine different states. Regardless of insurance status, approximate- ly 1 in 10 callers got community-based appointments within the 14 day limit. Answering machines were common; 45 percent of callers had to leave a message. Calling for help a second time got an answering machine 80 percent of the time. These disappointing findings are contrasted with far greater success in getting appointments for serious general medical conditions like pneumonia or hypertension. For example, only 8 percent of general medical “patients” calling for the first time had to leave a message. 205
Persistent, motivated, highly educated, non-depressed, mock-patients had considerable trouble getting a follow-up mental health appointment regardless of insurance. The more typical patient may have misgivings about having a psychiatric diagnosis in the first place and may minimize the importance of follow-up and medication adherence. Failure to follow through with an ED referral is surely more complex than lack of motivation or ability. 342, 343 The point is that this panoply of access-to-care obstacles places the psychiatric patient at a real disadvantage compared to a general medical patient. 173, 206, 207 As a result, non-price barriers to obtaining follow-up care may prove insurmountable for the seriously depressed patient. 207, 343, 344 Efforts to enhance patient engage- ment with the recommended discharge plan are wasted if the plan fails because the outpatient clinic doesn’t answer the phone! (Rhodes and colleagues draw attention to these problems and difficulties by titling their article: “Referral Without Access: For Psychiatric Services, Wait for the Beep”). When attempts to obtain help fail, the depressed patient’s feelings of rejection and inadequacy are reinforced. In turn, depression may worsen and suicide risk increase. 19, 206, 345 The consequences for ED clinicians of unreliable follow-up care for the mentally ill were not studied by the Rhodes-led research team. It seems fair to say that the very best attitudes toward the men- tally ill and a set of exemplary complementary skills goes for naught if the ED physician cannot access easily follow-up care for psychiatric patients. 127, 136, 137, 342
Other studies of adult populations find disengagement predicted by persistent and severe mental illness, longer lengths of stay (likely more severely ill and therefore harder to place), high overall use of health care, and Medicaid participation. 204, 207, 210, 346, 347 The initiation of medication in the ED or during inpatient hospitalization fails to predict follow-up. 348 A mismatch between patients’ expectations and perceived needs and the realities of the outpatient care result in “no shows” to the first outpatient appointment. 32, 343
These profiles differ somewhat for children and adolescents. Overwhelmed and under-skilled fami- lies and under-involved parents may be indifferent to follow-up recommendations. In these situa- tions, recommendations for parent guidance and family therapy tend to be ignored. 181, 236-238, 327, 349
The necessary inclusion in the ED of the family of adolescents is illustrated by a study done in the ED of Columbia Presbyterian Medical Center in New York. Using a quasi-experimental design and a study population of 140 female adolescent suicide attempters presenting to an ED, the Rotheram-Borus research team provided a three-part intervention for enhancing adherence to the follow-up plan: One crisis session; a video depicting the emergency room experience of two ado- lescents who have attempted suicide; and related discussions were furnished to both mothers and daughters by specially trained staff. Follow-up out-patient family sessions were recommended. The suicide attempters’ attendance at therapy sessions following the ED visit was significantly as- sociated with only one outcome—family adaptability (e.g., receptiveness to new skills taught). 236
Section-at-a-Glance:
Adult and child-adolescent patients with severe and persistent mental illness and few skills, minimal resources and socioeconomic distress are hard to engage in outpatient treat- ment. All too often these patient attributes resist change, but organizational attributes can be altered more easily. An array of access-to-care obstacles places the psychiatric patient at a real disadvantage compared to a general medical patient. As a result, non-price barri- ers to obtaining follow-up care may prove insurmountable for many seriously mentally ill patients. Professional staff and organizational discontinuities and unplanned discharges, for example, need not undermine hard-won clinical gains and impede the route to follow- up. Efforts to improve follow-up and continuity of care and to and forestall readmission should target higher-risk patients prone to disengagement and non-adherence.