The Canadian Mental Health Association says 20% of Canadians will experience a mental health illness at least once in their lifetime. Eight percent of Canadians will have major depression. When necessary, we hope that patients with depression and other psychiatric illnesses receive good care while they’re hospitalized. However, according to a new study, once they’re discharged from hospital, it’s a different story.
Researchers at the Centre for Addiction and Mental Health looked at more than 13,000 Ontario patients who were admitted to hospital for treatment of depression and then discharged from hospital when they no longer needed to be admitted. Within 30 days of discharge, one in four patients hospitalized for depression had either visited an ER or was readmitted to hospital for depression.
The study found that men, older patients, and those who live in rural communities (where there’s a chronic lack of mental health services) were more likely to need readmission to hospital or treatment in the ER.
More important, it turns out that the overwhelming majority of the patients who required further treatment in the ER or hospital readmission were those who did not receive appropriate follow up care from a mental health professional or family doctor.
You might be amazed just how many patients with depression do not get follow up care. Of the 13,000 patients studied by researchers at the Centre for Addiction and Mental Health, nearly 5,000 did not receive appropriate follow up care with a family doctor, psychiatrist or community worker.
For context, the researchers also looked at patients from Ontario who had been hospitalized for a heart attack or heart failure. The study found that 99% – in other words, virtually every patient with heart attack or heart failure – had a follow-up visit to a doctor within 30 days of leaving the hospital. That compares to just 62% of the patients admitted with depression. That tells me there’s a yawning gap in the care received by mental health patients.
It’s a gap I see in the ER. Just about every shift, I see patients recently discharged from hospital for depression who need to be readmitted. As well, I see lots of patients with other mental health diseases who also tend to fall through the cracks. In particular, patients with borderline personality disorder tend to go through phases when they’re in and out of hospital. I would also put people who have both depression and alcohol and drug abuse in that category too. Patients who are both homeless and have mental health issues are also at high risk of needed to be readmitted. So too are patients with schizophrenia and other forms of psychosis.
The mental health patients I see from the vantage point of a big city teaching hospital have a fair number of outpatient community resources that can provide some level of after care. Patients with mental health problems who are discharged from rural hospitals have it much worse.
Hospital readmission is not simply the price of doing business. It’s a benchmark of failure that is expensive for a health care system trying to save its pennies. It’s also quite deleterious to the health and wellbeing of patients.
The take home message is that hospitals, family doctors and others who provide community health services need to communicate better with one another so that community services can step in the moment a patient is discharged. Electronic health records would help with that.
More than that, a generation ago, when ‘deinstitutionalization’ of psychiatric services was in vogue, mental health treatment was supposed to move from hospitals to the community. Beds were closed. Community mental health services were supposed to be built up, but in many cases, they weren’t. Some have suggested that deinstitutionalization has been a failure. And now, we’re paying the price.
I say it’s time for governments to pony up with increased services and better coordination of available resources – especially in rural and other underserviced areas. Meanwhile, mental health patients need to be watched carefully in the hours and days following discharge because that’s when they’re at high risk of relapse and suicide attempts.
And, while we’re at it, how about putting a bit of accountability into psychiatric hospitals that discharge patients without adequate follow up? It would be easy to track and penalize hospitals with high readmission rates. In the ER, I have to see and take care of patients within a prescribed period of time or we get penalized. The people who work in psychiatric hospitals should be accountable too.