Don't ignore the mind/body connection
Don’t ignore the mind/body connection
Here’s why the holistic approach works
You can call patients the "walking wounded" or "survivors," but if you fail to recognize the impact that psychosocial issues have on health and recovery, you may fail to achieve good clinical outcomes, say behavioral health experts and health promotion professionals interviewed by Case Management Advisor.
The medical literature is full of examples that support the argument that many patients referred to medical case management are at risk for behavioral health problems. One recent article in the Journal of the American Medical Association (JAMA) found that women who miscarried were 21¼2 times more likely to suffer from major depression than women who had not been pregnant in the preceding year.1
A recent study in the Archives of Family Medicine found that patients who experience symptoms of anxiety and depression are at significantly increased risk of developing high blood pressure. In fact, whites who reported experiencing anxiety or depression ran twice the risk of needing later treatment for hypertension and blacks about triple the risk over individuals who had never experienced anxiety or depression.2
Case managers can probe gently into the emotional health of their patients even during telephone assessments. The American Psychological Association in Washington, DC, has identified the following signs and symptoms of depression that case managers can use:
• feelings of helplessness and pessimism;
• sleep disturbances and irregular sleep patterns;
• appetite disturbance;
• social withdrawal, refusal to go out;
• feelings of self-blame or worthlessness;
• inability to concentrate;
• substance abuse.
"Patients don’t go into the doctor’s office saying that they feel sad.’ They do complain to their doctors and case managers that they have no energy, that they feel stressed, that they’re eating too much, or eating too little," says Donna DePaul-Kelly, acting executive director of the National Depressive and Manic-Depressive Association (NDMDA). "Case managers and primary care physicians have to pick up on those types of indicators and realize it’s time to screen that patient for depression."
NDMDA sponsored a consensus report on the undertreatment and underdiagnosis of depression, which appeared in a recent issue of JAMA.3 The consensus panel of behavioral health professionals found that of the total population of Americans with depression, one-third never seeks help, another third seeks help but never gets properly diagnosed, and a final third seeks help, receives the proper diagnosis, but does not receive proper treatment.
"From a case management standpoint, that’s significant because we know that depression is one of the most easily treated medical problems," DePaul-Kelly says. "We also know that if depression coexists with other illnesses such as cancer or AIDS, patients will never feel well enough to face necessary treatments if they remain depressed. In addition, if depression is caught and treated early, case managers run a much higher chance of avoiding the need for hospitalization or acute care."
Physicians agree. "Depressed patients are high utilizers of all medical services," says Robert M.A. Hirschfeld, MD, who chaired the NDMDA consensus panel. Hirschfeld is a professor and chair of the department of psychiatry and behavioral sciences at the University of Texas medical branch in Galveston. "If patients are treated properly for their depression, their high utilization drops perceptively, and the literature supports that argument. If patients come to the attention of case managers as high utilizers, I suggest case managers screen those patients for mental health issues."
There are several good paper-and-pencil assessment tools readily available to case managers that can be self-scored or administered by health care professionals, Hirschfeld says. "The best programs come out of the pharmaceutical companies, and all have developed programs that will screen for mental illness, especially depression." (See insert, "Resources: How to Recognize Depression and Other Mental Disorders," for more information on behavioral health screening tools.)
Individuals suffering from anxiety and stress not only show up in the primary care and acute care settings but on the disability roles as well, say workplace health promotion experts. "There have been several large studies that show, for example, that the best predictor of whether someone will file a claim for back pain is their relationship to their supervisor, not the extent of their injury," notes Walter S. Elias, PhD, chief executive officer of Kosmeo, a health promotion and disease management consulting company in Minneapolis. "The case manager is in an excellent position to cross the boundaries between the corporation and the managed care plans, put the pieces together, and bring all the resources necessary to bear on each individual case."
"Corporations have for too long put everything into separate silos, or bins, when it comes to workplace health and disability management. We had employee assistance programs, and wellness programs, and workers’ compensation/disability management programs. But you can’t look at helping people lose weight without addressing depression. You can’t deal with different aspects of health in isolation," Elias says. "And corporations can’t afford to run all these separate programs anymore. They are turning to their managed care organizations to develop and implement programs in the workplace, and case managers can play a role in developing and delivering these programs."
Anxiety and depression due to issues such as workplace or personal stress often cause psychosomatic or exaggerated illness, adds Howard Eisenberg, MSc, MD, president of Syntrek, a health care consulting firm in Stowe, VT, and clinical associate professor of medicine at the University of Vermont in Burlington. Eisenberg specializes in helping organizations, including health care clients such as Johns Hopkins in Baltimore, enhance performance through stress reduction, team building programs, and creative thinking skills.
"We find as counselors that the more people are struggling, the more illness they have. Illness is a reflection of our lives and the balance we have in it. For most of us, when our bodies get sick, it is an outward manifestation of our minds," says Karen M. Carrier, MEd, president of Human Solutions, a health assessment and promotion company in Houston.
"Traditional health appraisals used by health care professionals and by workplace health promotion programs focus on biomedical measures such as cardiovascular risk factors. But an individual’s general sense of well-being is much more relevant to individual risk for disease than biomedical measures such as blood pressure or cholesterol levels," she says.
"You see this in workers’ compensation, as well. You may have an employee with a leg injury that never seems to heal. The injury forces them to take time off work. But it could be that the employee just needs to be away from the workplace and doesn’t know how to speak out. Their unhappiness is not the reason they got the leg injury, but it might well be why the leg never heals properly," Carrier says.
Carrier developed an appraisal tool called the Life’s Odyssey Health Appraisal and Resource Guide, which covers seven areas of holistic health and well-being. Those include:
• life and health attitudes;
• optimism about life, or locus of control;
• emotional well-being;
• physical well-being;
• rest, pleasure, and play;
• purpose and meaning;
• self-care, or ability to access the health care system.
"Traditional health appraisals don’t address psychosocial issues. When I score people using this tool, people whose scores go way outside the norm are the same people suffering from high anxiety, back pain, migraines, chest pains. We see the correlation very quickly," notes Carrier. "Thoughts, attitudes, and beliefs have a powerful effect on the immune system. The literature shows that social isolation is a far better predictor for whether a patient will survive cancer or have a second heart attack than many biomedical measures of health."
Case managers who accept the mind/body connection and include psychosocial assessment and counseling in their care plans will achieve much better outcomes, Carrier and Elias say.
References
1. Neugebauer R, Kleine J, Shrout P, et al. Major depressive disorder in the six months after miscarriage. JAMA 1997; 277(5):383-388.
2. Jonas BS, et al. Are symptoms of anxiety and depression risk factors for hypertension? Longitudinal evidence from National Health and Nutrition Examination Survey I epidemiological follow-up study. Arch Fam Med 1997; 6:43-49.
3. Hirschfeld R, Keller MB, et al. National Depressive and Manic Depressive Association Consensus Statement on the Undertreatment of Depression. JAMA 1997; 277(4):330-340.
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