Early Interventions and Use of Primary Care in Mental Health

Early Interventions and Use of Primary Care in Mental Health

Appraised by:

Kathryn Phillipsen LPN, Heather Bosse LPN, Caitlin Suhr LPN, RajinMayi LPN

NDSU School of Nursing LPN-BSN

Clinical Question:

For patients with mental illness, does early interventions help decrease frequent ER visits and decrease the risk for self-harm and suicide?

Articles:

Dueweke,A.R., Rojas,S.M., Anastasia,E.A., & Bridges,A.J. (2017). Can brief behavioral health interventions reduce suicidal and self-harm ideation in primary care patients? Families, Systems, & Health, 35(3), 376-381. doi:10.1037/fsh0000287

Milner,A., Spittal,M.J., Kapur,N., Witt,K., Pirkis,J., & Carter,G. (2016). Mechanisms of brief contact interventions in clinical populations: a systematic review. BMC Psychiatry, 16(1). doi:10.1186/s12888-016-0896-4

Soril,L.J., Leggett,L.E., Lorenzetti,D.L., Noseworthy,T.W., & Clement,F.M. (2015). Reducing frequent visits to the emergency department: A systematic review of interventions. PLOS ONE, 10(4), e0123660. doi:10.1371/journal.pone.0123660

Vigod, S. N., Kurdyak, P. A., Dennis, C., Leszcz, T., Taylor, V. H., Blumberger, D. M., & Seitz, D. P. (2013). Transitional interventions to reduce early psychiatric readmissions in adults: Systematic review. The British Journal of Psychiatry,202(3), 187-194. doi:10.1192/bjp.bp.112.115030

Synthesis of Evidence:

Four studies were reviewed,three systematic reviewscomprised of randomized control studies, non-randomized control trials, and cohort studies, and 1 retrospective study addressing interventions for those with a mental illness who seek out emergency care.

Dueweke, Rojas, Anastasia, & Bridges (2017) conducted a retrospective study of 31 patients ages 14-75 who attended follow up care and provided data from a questionnaire with questions from the Patient Health Questionaire-9, or PHQ-9 for short. PHQ 9 is a tool that helps to identify risk factors for anxiety disorders and depression as well as suicidal ideation and self harm through a series of questions.The results indicated that primary care offers individual support in a timely manner. In addition, it allows for follow through care and treatment long term, thereby reducing the risk by 50-64% for those with moderate levels of suicidal tendencies and self-harm.Thisstudy relies on the patient returning for future appointmentsand may not be the best plan of care for those with extreme ideation. However, it is a way to provide care in a familiar and consistent setting and avoid a crisis situation. Future referrals can be made for more intensive care and treatment thus reducing self-harm or suicide attempts. Primary care for those with self-harm tendencies and suicidalideation is an appropriate and effective first step for treatment.

Milner, Spittal, Kapur, Pirkis, & Carter (2016) conducted a systematic review of 20 studies over the course of 6-20 months with locations worldwide. These studies comprised of randomized control trials and cluster randomized control trials which discuss different mechanisms that supportBrief Contact Interventions (BCIs). BCIs are a way for providers to keep a long-term relationship without the need of other therapies. Mechanisms identified were placed into 3 categories; social support, suicide prevention literacy, and learning alternative behaviors. Results from the reviewindicate that alternative coping mechanisms and social support as it relates to self-harm have proved to have positive results in supporting BCIs in practice.

Soril, Leggett, Lorenzetti, Noseworthy, & Clement (2015) conducted a systematic review of 17 studies including a few randomized control trials and the majority being non-randomized comparative cohort studies focusing on frequent emergency department visits from the general population. Three interventions were recognized in providing reduced emergency department visits from recurring users including case management, individualized care plans, and information sharing. The findings of this review suggest that case management provided moderate cost saving means, but showed variable reductions in frequent use of the ED. The overall variability of the studies included in this review make it difficult to identify the most clinically and cost-efficient method to reducing frequent ED visits.

Vigod et al. (2013) conducted a systematic review on fifteen studies which included randomized control trials, non-randomized control trials, and cohort studies on interventions in dropping readmission in adults with psychiatric issues. The study identified 15 interventions that were placed into 3 categories;pre-discharge, post-discharge, and in between the two also known as Bridging. Of those interventions, the results identified psychoeducation on the management of the disease and the skills to live with it decreased readmission by themselves. Mixed interventions including education on medications, follow-up phone call after discharge and appointments, support from friends/family and visits to home, a transition manager, and communication were effective as well. The results of the study further identified statistically significant reduction in emergency department readmission by 13.6-37%. The findings conclude that interventions are beneficial in those seeking emergency care with a mental illness.

Conclusion:

Evidence suggests that when mental health visits to primary care or inpatient care are followed up by health care interdisciplinary team members. When education is provided, and coping mechanisms and social supports are in place, there is an impact to the number of ED visits and readmission for those doing self-harm activities and with suicidal ideation.

Implications for Nursing Practice

Practice recommendation includes follow up contact post appointment and discharge, encouragement, and reassessment for coping mechanisms, social support, and education. Practice should also include annual staff teaching on mental health issues and screening for at risk behaviors with the effective use of PHQ 9