Don’t let your patients’ depression get you down by running up rehab costs
Don’t let your patients’ depression get you down by running up rehab costs
Clinical depression can stand in the way of a facility’s treatment goals
What your staff don’t know about their patients’ depression can hurt your bottom line. Studies have shown that depressed patients heal more slowly and, particularly in the case of rehabilitation medicine, are less likely to cooperate with therapy. Moreover, clinical depression exacts a big toll in hospital stays, mortality, and loss of productivity.
Rehabilitation psychologists say that early intervention, team efforts, and a treatment approach that includes both medication and counseling will lead to better patient outcomes and improve patients’ emotional states. "Almost every patient in rehabilitation has some sort of reason to be depressed because of what has happened to them," says Ralph Bruno, PhD, rehabilitation psychologist for the Walton Rehabilitation Hospital in Augusta, GA. "Their lives have been turned upside down because of an accident that led to comprehensive rehab, or they had a medical event that led to rehab, so they wouldn’t be here if something major hadn’t happened to them," Bruno says.
"Whenever you’ve had an acute event that’s caused you to become disabled, you have a loss of meaning in your life, which people have described as like suddenly aging 20 years overnight," says Nicky Ozbek, PhD, supervisor of psych ological services at Siskin Hospital for Physical Rehabilita tion in Chatt a nooga, TN. "So it puts tremendous strain on the person’s coping skills."
Researchers at Siskin were concerned about the psychological barriers some patients may bring to recovery. They surveyed patients admitted to the hospital, assessing them for clinical signs of depression and perceived presence of the disease.
The investigators at the 80-bed, freestanding facility found that about one-third of patients met the clinical definition of depression. However, an even greater number surveyed (42%) thought they were depressed. While the two groups overlapped, the greater number of patients who thought they were depressed shows how patients sometimes think the distress they are experiencing is the same as depression, Ozbek says.
When so many patients have clinical depression, and even more are feeling blue, it can cause serious setbacks to a rehabilitation facility’s treatment goals. And depression can lead to escalating treatment costs and greater loss of productivity.
According to a recent Johns Hopkins Univer sity study, the disease of depression costs society more than AIDS, breast cancer, and emphysema combined. The study compared National Insti tutes of Health (NIH) research and program development funding of 29 diseases, looking at each disease separately — not in terms of comorbidity.
The study evaluated the diseases’ societal impact in the industrialized world, using a metric called disability-adjusted life-years (DALYs). The study assessed total mortality, years of life lost, number of hospital days in 1994, and the number of healthy years lost to illness.
Researchers concluded that depression resulted in 8.5 million DALYs, which is consid erably more than their estimates for AIDS (1.27 million), breast cancer (1.42 million), and emphy s ema (2.28 million). Depression, however, was one of the diseases that received the least amount of NIH funding, receiving only $148.8 million in federal grants in fiscal year 1996. AIDS received $1.4 billion in grants, the study also showed.1
The good news is that now depression can be treated more easily and successfully than was previously possible. The mental health industry today has the advantages of newer drugs and a better understanding of how debilitating depression can be. (See story on how some facilities assess and treat depression, p. 139.)
However, before rehabilitation facilities will succeed with depression treatments, they have to train their staffs to recognize signs of depression, and ideally they should have a psychologist on staff to evaluate depressed patients, Bruno says.
"At our hospital, the staff are pretty much on their toes; everybody’s looking for those barriers," he adds. "At other places, they may miss the signs."
Signs of depression can be confusing
Some signs of depression can be easily confused with other problems. For example, a patient who stubbornly refuses to participate in physical therapy activities might be labeled as obstinate, when in truth the patient is too depressed to make the effort therapy requires.
These examples illustrate some of the other signs that a patient may be clinically depressed:
• A patient continually complains to family members that he is not being treated right by the rehab staff.
• A patient cooperates with therapists but appears listless, and therapists suspect she is not trying as hard as she could.
• A patient expresses anxiety and apprehension about the future and sometimes wonders aloud if it’s worthwhile to go to all of this effort.
• A patient confides in a therapist that he wishes he had not survived the accident and would rather have died than continue living with the physical disability.
"Some of the most profound cases of depression we’ve had are of people who’ve had brain injuries and strokes, because with brain injuries, the person’s instrument of coping is the instrument that’s damaged," Bruno explains. "And depressed feelings and behaviors are associated with insults to the brain, so it becomes a tangled problem."
Rehab staff also should be taught to watch patients at certain critical junctures in treatment, Ozbek notes. For instance, a patient may have been a real trooper during the acute phase of treatment because he was so grateful just to have survived. But the patient also might have assumed that once inpatient treatment ended, he would return to life as it was before the incident. Those thoughts might result in profound disappointment.
"Their early optimism could lead to depression later on if someone doesn’t work with them," Bruno says.
Bruno and Ozbek recommend rehab staff look for signs that patients have those types of unrealistic expectations that are eventually shattered.
"That’s when we often see people making statements like, I should have died,’ or a behavioral statement of not getting out of bed and not participating," Ozbek says.
Reference
1. Gross CP, Anderson GF, Powe NR. The relation between funding by the National Institutes of Health and the burden of disease. N Engl J Med 1999; 340:1,881.
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