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Integrating Mental and Physical Health Assessment in a Neuro-Otology Clinic

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Integrating Mental and Physical Health Assessment in a Neuro-Otology Clinic Clinical Medicine 2020 Vol 20, No 1: 61–6 ORIGINAL RESEARCH 1 62 2 63 3 64 4 65 5 66 6 67 7 Integrating mental and physical health assessment in a 68 8 69 9 neuro-otology clinic: feasibility, acceptability, associations 70 10 71 11 and prevalence of common mental health disorders 72 12 73 13 74 14 75 Authors: David Herdman,A Helen Sharma,B Anna SimpsonC and Louisa MurdinD 15 76 16 77 17 78 18 79 People with persistent physical symptoms are at risk of impact of chronic vertigo and dizziness together, patient outcomes 19 4 80 20 psychological symptoms, although recognition in medical (disease activity, functioning, quality of life) usually improve. 81 21 settings is low. This is a retrospective observational study of Anxiety and depression exist on a continuum of severity and 82 22 954 patients in a hospital outpatient neuro-otology clinic the point at which psychological distress becomes mental 83 23 in order to assess the feasibility and acceptability of an disorder is not clear-cut. Yet clinicians and patients sometimes 84 ABSTRACT 24 electronic informatics system for collection of patient-reported need to make black and white decisions, such as when to seek 85 25 outcomes, with real-time feedback to guide clinical care and help from mental health services. Recognition of psychological 86 26 describe the prevalence of anxiety and depressive symptoms. disorders by non-mental health professionals is low compared 87 27 The proportion of patients successfully completing the with structured clinical interview even in highly specialised 88 screen was high (70%). The decline rate was low (5%). The neuro-otology clinics, meaning that many patients do not receive 28 5,6 89 29 most common reason to decline was lack of confidence with psychological interventions that are known to be effective. 90 30 technology. The prevalence of probable depression was 21% Even when problems are identified, healthcare teams are often ill- 91 and for probable anxiety was 29%. Suicidal ideation was equipped to provide effective care due to limited access to expert 31 7 92 32 present in 5%. Anxiety and depression were highly correlated psychological support. A structured screening procedure could 93 33 to dizziness specific outcome measures (p<0.01). be a valid alternative since it is not realistic to have psychiatrists 94 34 Electronic screening is feasible and acceptable to patients or psychologists perform detailed standardised interviews in a 95 35 and staff in this setting, helping to identify service needs, routine setting. 96 36 inform care and monitor outcomes. Screening and assessment tools can help some patients, who 97 37 may not otherwise relate their symptoms to mental ill health 98 38 KEYWORDS: Anxiety, depression, dizziness, vertigo, where appropriate, or who may feel unable to raise concerns 99 39 neuro-otology about their thoughts and mood with their healthcare professional. 100 40 These tools can also help healthcare professionals who would 101 41 otherwise be reticent to probe patients’ psychological problems 102 42 and improve their ability to identify patients who may benefit 103 43 Introduction from psychological support. Since completion of an assessment 104 tool is often an important part of triage to talking therapies, early 44 Mental health comorbidities are present in around 30–50% of 105 assessment could lead to more effective signposting and onward 45 patients presenting to outpatient clinics with vertigo and dizziness 106 referral which would enable the patient to access the right care 46 symptoms.1,2 The most common comorbidities are depression 107 earlier in their pathway. 47 and anxiety.2 The relationship between mental illness and chronic 108 This paper is the first to describe the implementation of 48 vertigo and dizziness syndromes is complex and bidirectional, 109 Integrating Mental & Physical healthcare: Research Training 49 although there is clear evidence that depression and anxiety 110 and Services (IMPARTS) service development platform in a 50 contribute to poorer health outcomes.3 The research literature 111 multidisciplinary neuro-otology clinic.8 IMPARTS is an integrated 51 also indicates that when services address the mental and physical 112 52 care package that supports clinical services in detecting and 113 53 managing depression and anxiety among patients attending 114 hospital for physical health conditions. Using paper questionnaires 54 A 115 55 Authors: physiotherapist, Guy’s & St Thomas’ NHS Foundation is time consuming to complete and analyse, and the results alone 116 Trust, London, UK and research fellow, King’s College London, do not clearly guide management. IMPARTS has developed an 56 B 117 57 London, UK; head of practice, Chartered Society of Physiotherapy, electronic informatics system that facilitates routine collection of 118 London, UK; Cproject coordinator, King’s College London, London, patient-reported outcomes, with real-time feedback, uploaded to 58 D 119 59 UK; audiovestibular physician, Guy’s & St Thomas’ NHS the electronic patient record (EPR) to guide clinical care according 120 60 Foundation Trust, London, UK and honorary associate professor, to a structured protocol. The system creates a database that 121 61 UCL Ear Institute, London, UK can be used for audit and research and has been implemented 122 © Royal College of Physicians 2020. All rights reserved. 61 David Herdman, Helen Sharma, Anna Simpson and Louisa Murdin 1 in medical specialties such as rheumatology, dermatology and All patients completed the Dizziness Handicap Inventory, 62 2 chronic pain.9 which is a validated self-report of dizziness related interference.10 63 3 Screening for anxiety and depression in patients with vertigo and Patients were then asked whether they experienced dizziness in 64 4 dizziness can be challenging since they are often concerned about visual contexts (eg supermarkets or watching moving objects). If 65 5 their symptoms being labelled or judged as purely psychological or they answered ‘yes’, the Situational Characteristics Questionnaire 66 6 even imaginary. Many patients with vertigo and dizziness disorders was presented to measure symptoms of visually induced 67 7 also report symptoms related to visual motion and so find using dizziness.11 The next branching question asked about the presence 68 8 computer screens difficult. There was therefore also a concern that of headaches and those patients who experienced headaches 69 9 this method of screening may be problematic for this particular completed the Headache Impact Test-6 and scores ≥50 were 70 10 patient group. We therefore aim to describe the feasibility and flagged up on the EPR as ‘high-impact headache’ with instructions 71 11 acceptability of universal digital mental health screening in for the clinician to ‘check for headache plan and consider 72 12 a neuro-otology clinic; validated physical outcome measures analgesic overuse’.12 The level of disability due to dizziness was 73 13 including the level of dizziness related handicap, disability, visual assessed using the disability rating scale in which the patient was 74 14 vertigo, headache, anxiety and depression including suicidal asked to select their level of disability based on six statements 75 15 ideation identified; and the cross-sectional relationships between ranging from ‘negligible symptoms’ to ‘unable to work for more 76 16 the physical and mental outcome measures. than 1 year or established permanent disability’.13 77 17 Depression was assessed using the Patient Health 78 18 Methods Questionnaire-9 (PHQ-9) and anxiety was assessed using the 79 19 Generalised Anxiety Disorders-7 Questionnaire (GAD-7).14,15 80 20 Study design These questionnaires have been widely validated in physically ill 81 21 This is a retrospective data analysis of the results from the first populations and are the current tools used by Improving Access 82 22 year of implementing an informatics screening tool in the tertiary to Psychological Therapy (IAPT) services in the UK to determine 83 23 multidisciplinary balance clinic at Guy’s Hospital, London, from suitability for talking therapies. For depression status there were 84 24 January 2017 to January 2018. three options. 85 25 86 > Probable major depression. Either item 1 or 2 of the PHQ-9 was 26 87 ‘more than half the days’ or above and five or more of the nine 27 Ethical considerations 88 PHQ-9 items were at least ‘more than half the days’ except for 28 IMPARTS has generic ethical approval for a pseudonymised 89 item nine (suicidal ideation) which only counted towards the 29 research database (REC reference: 18/SC/0039), with additional 90 diagnosis if checked at least ‘several days’. 30 governance of approval from the IMPARTS patient-led research 91 > Some depressive symptoms. If either 1 or 2 of the PHQ-9 were 31 oversight committee. Institutional approval was granted from 92 ‘more than half the days’ or above. 32 Guy’s and St Thomas’ NHS Foundation Trust. 93 > Depression screen negative. 33 94 34 Consent An alert also appeared on the patient record to indicate suicidal 95 35 ideation if the patient responded ‘more than half the days’ or 96 36 No patient information or patient identifiable images are included ‘nearly every day’ to item nine (‘have you been bothered by 97 37 in this article. thoughts that you would be better off dead or of hurting yourself 98 38 in some way’). Criteria for probable generalised anxiety disorder 99 39 Procedure was met if patients scored ≥10 on the GAD-7. Scores of 5–9 100 40 indicated some symptoms of anxiety. 101 41 Consecutive patients who attended the tertiary multidisciplinary 102 42 balance clinic were invited to complete questionnaires on a Care pathways 103 43 touch-screen e-tablet by the receptionists while waiting for their 104 44 appointment. After logging on, using their hospital identification All clinical staff undertook three 1-hour training sessions in core 105 45 number, patients completed a series of outcome measures mental health skills so that they would feel confident discussing 106 46 concerning their mental and physical health.
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