Sunday, March 21, 2010

Treating Depression after Surgery

In a program known as “Bypassing the Blues”, nurse care managers are routinely screening patients after cardiac bypass surgery for symptoms of depression in seven Pittsburgh area hospitals. The program centers on giving on-going telephone support over an eight month period.

The problem is that many patients report depressive symptoms after coronary artery bypass graft surgery (CABG) and these symptoms can have a negative effect on the quality of life, lead to an increased risk of chest pain, and possibly result in more hospitalizations and even death.

Hospitals and physicians seldom conduct systematic screening to identify depressed patients after CABG surgery or provide ongoing treatment and support to help manage depression. In addition, available support often does not always align with patient preferences.

While nurse-led collaborative care programs have been effective with depressed patients in primary care settings and in patients with other chronic conditions, they have generally not been used in post-CABG patients suffering from depression.

By using the collaborative care model, these nurses educate patients about depression, help them practice self-management skills, and encourage adherence to recommended treatment options. The nurses met weekly to review the cases with a psychiatrist, psychologist, internist, and routinely communicate with the primary care physician to ensure that coordinated and consistent care is given. If needed, the nurse is able to secure verbal authority from the physician to prescribe medications with a follow-up fax to obtain written authorization. In some states, nurses already have this authority but this is not the case in all states.

Electronic support is provided with each nurse using a tablet personal computer where information is obtained from every patient. The data is formatted with entry questionnaires linked to an electronic data management system or patient registry. This registry helps to provide information on weekly case reviews and can track a patient’s progress over time.

Discharged CABG patients are followed up with in-hospital and other screening to identify eligible patients for the program. This is accomplished by having:

• A series of screening tests performed just prior to discharge for all CABG patients
• The nurse calls those passing the screening two weeks after discharge to administer a second screening
• Patients scoring at or above 10 on the survey that show a moderate level of depressive symptoms qualify for additional telephone-based support but not if they are already actively seeing a mental health specialist.
• Biweekly calls made lasting 15 to 45 minutes to support self management treatment
• Less frequent maintenance calls after recovery is achieved but the calls are continued until the patient has been in the program for eight months
• The final call made at the end of the eight month period. The patients still exhibiting symptoms are encouraged to initiate pharmacotherapy or make a change to existing pharmacotherapy, or see a mental health specialist. Those patients no longer exhibiting symptoms are reminded to continue adherence to the treatment approach

The program ongoing at the Pittsburgh hospitals has been shown to improve mental and physical health in both men and women. It also has been found that men experience a greater degree of benefit, and men are less likely to be readmitted into the hospital if part of this program.

For more information, email Bruce L. Rollman, MD