Depression is a leading cause of psychiatric hospitalization in the Veterans Health Administration (VHA), and following discharge depressed patients are at high risk for poor outcomes, including readmission and suicide. Hospitalized depressed patients have complex, chronic conditions and specialized services are needed to facilitate recovery through ongoing monitoring and support beyond the first 7 days after discharge. Research is necessary to provide new information to develop and implement programs to improve health and quality of life following psychiatric hospitalization for depression.
The objectives of this study were to 1) assess the feasibility and acceptability of a peer specialist or family member and technology-assisted care management program for patients following hospitalization for depression, 2) develop preliminary estimates of the program's impact on the quality of patient care and outcomes, 2a) assess changes in depression symptoms, quality of life, mental health recovery, self-efficacy, physical and mental health associated disability, hopelessness, and suicidal ideation from baseline to 6 months, 2b) assess measures of depression care quality, such as adequacy of psychotherapy and hospital readmission among program participants and 3) assess barriers and facilitators to adoption, implementation, and maintenance of the program.
We enrolled patients receiving inpatient psychiatric treatment at the Ann Arbor VA with a primary diagnosis of a depressive disorder, including major depressive disorder, dysthymia, and depression not otherwise specified. Patients must have planned to complete their outpatient mental health treatment at the Ann Arbor VA but could not be receiving post-hospital treatment in the substance abuse clinic or the substance use disorder intensive outpatient program. Patients were also excluded if they had a diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder or dementia. All study participants received weekly phone calls for a 6 month period from the CarePartner program, which utilized interactive voice response (IVR) telephone technology to conduct standardized symptom assessments, monitor treatment adherence, and supported patient self-management. Patients were expected to speak with their "CarePartner" or Peer Specialist weekly. Patients completed study assessments at baseline, 3 month and 6 months. Study participation was complete following the 6 month follow-up meeting.
Of the 355 hospitalized patients who underwent a screening chart review, only 65 were eligible for the study. Of these, 48 (74%) enrolled in the study, demonstrating high initial acceptability. 29 participants chose to work with a Peer Specialist and 19 participants chose to work with a self-identified family member or friend as their "CarePartner". There were no statistically significant differences in demographic characteristics between those who chose a Peer Specialist vs. a family member or friend, however those who chose a Peer Specialist how lower levels of social support according to the multidimensional scale of perceived social support (MSPSS; 52.0 vs. 63.1; p = 0.03).
Of the 48 enrolled participants, 5 formally requested to be removed from the study due to problems with the automated phone system (n=2) or the peer specialist (n=3). Participants completed a mean of 6.0 automated phone contacts during the first 3 months and 3.9 between months 3 and 6. Those who worked with a Peer Specialist had a mean of 6.5 peer contact in the first 3 months and 4.4 between months 3 and 6. A total of 64% completed the 3 month outcomes assessment and 70% completed the outcomes assessment at 6 months.
Participants experienced a significant decrease in depressive symptoms according to the Patient Health Questionnaire (PHQ9) from a mean baseline of 17.3 to a mean of 13.0 at 3 months and 12.0 at 6 months (p <.01). Similar improvements were seen in anxiety symptoms according to the Generalized Anxiety Disorder (GAD7) scale from a mean baseline of 14.6 to a mean of 11.0 at 3 months and 9.3 at 6 months (p < .01). There were not statistically significant changes in participants' clinical outcomes according to the Beck depression inventory, Beck hopelessness scale, Beck suicide scale, interpersonal support evaluation list, MSPSS, patient activation measure, and work and social adjustment scale. Participants received a mean of 6.7 and 11.8 mental health visits in the 3 months and 6 months, respectively, after discharge. Of these visits, 4.2 and 7.4 were psychotherapy visits, respectively. 18.8% of participants were readmitted to the inpatient psychiatric unit between baseline and 3 months and between 3 months and 6 months.
Qualitative interviews with inpatient and outpatient mental health providers indicated general support for programs that provide additional services to patients following hospital discharge. Adoption and maintenance of a post-hospital support program would depend on its demonstrated effectiveness, though inpatient providers did not feel they had the resources to manage such a program. Inpatient providers were particularly interested in effectiveness in reducing readmissions. Outpatient providers thought additional services such as peer support or automated monitoring should not be limited to just those patients who have been psychiatrically hospitalized but might be helpful in preventing hospitalization among particularly at-risk patients.
Our data confirm that peer support, enhanced support from friends and family, and automated monitoring systems are acceptable to patients who have been psychiatrically hospitalized for depression. Findings with respect to clinical improvement during program participation are mixed. Participants exhibited improvements in symptoms according to the PHQ9 and GAD7 but not reductions in depression symptoms according to the BDI or improvements in hopelessness, suicidal ideation, social support, social functioning, or activation. Readmission rates were also similar to historical controls. Future work should seek to enhance the effectiveness of peer support with respect to domains relevant to recovery such as hope, social support, activation, and social functioning.
- Pfeiffer PN, Valenstein M, Ganoczy D, Henry J, Dobscha SK, Piette JD. Pilot study of enhanced social support with automated telephone monitoring after psychiatric hospitalization for depression. Social psychiatry and psychiatric epidemiology. 2017 Feb 1; 52(2):183-191.