Manavizadeh, Jeanne, BSN, RN, PCCN

Petruccelli, Donna, MSN, CRNP, NP-C

Stern, Gail, MSN

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksPatient Care Services / NursingPsychiatric Nursing Care for Patients With CardiacDiseaseGail Stern MSNLehigh Valley Health Network, Gail.Stern@lvhn.orgDonna Petruccelli MSN, CRNP, NP-CLehigh Valley Health NetworkJeanne Manavizadeh BSN, RN, PCCNLehigh Valley Health Network, Jeanne.Manavizadeh@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/patient-care-services-nursingPart of the Cardiology Commons, Cardiovascular Diseases Commons, Mental DisordersCommons, Nursing Commons, and the Psychiatry CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtStern, G., Petruccelli, D., & Manavizadeh, J. (2013). Psychiatric nursing care for patients with cardiac disease. Poster presentation.Lehigh Valley Health Network, Allentown, PAPsychiatric Nursing Care for Patients With Cardiac Disease© 2013 Lehigh Valley Health NetworkNursing Care of CardiacPatients With DepressionPatient Health Questionnaire (PHQ-2)Serious Mental Illlness and Heart Disease“Patients with severe mental illnesses, such as schizophrenia, bipolar disorder and depression together affect 5%-10% of the U.S. population, lose 25 or more years of life expectancy, with the majority of the excess premature deaths due to CVD, not suicide.” (Newcomer and Hennekens)Heart Disease and Mental Illness •  1 in 5 people will have an episode of major depression in their lifetime. That number climbs to about 1 in 2 for people with heart disease. •  The risk of heart disease is double for people with a history of depression. •  Major depression puts heart attack victims at greater risk and appears to add to the patient’s disability from heart disease. (World Federation of Mental Health) •  Hospitalized patients over 70 years-of-age who suffer from a combination of HF and depression experience readmission rates of 67% versus 44% among the same age group with HF but without depression. (Rozzini)  •  Patients with HF are twice as likely to die if they have depression compared with those who did not have depression. (Silver) •  A multicenter study demonstrated that even at three months following a hospitalization, 63% of HF patients reported symptoms of depression. •  Patients with stable CHD plus generalized anxiety disorder (GAD) have a higher risk of experiencing cardiovascular events such as stroke, myocardial infarction, and death than patients with CHD only. •  GAD was associated with a 74% increased risk for adverse cardiovascular outcomes. (E. Martins, World Federation for Mental Health)Primary vs. Secondary Diagnosis •  It is unclear if it is an independent primary diagnosis or if the depressive symptoms are secondary to the patients’ chronic, complex illness. •  Both diagnoses share common pathophysiologic pathways and benefit from disease specific specialty care early in their diagnosis.Depression and NYHA Functional Class •  A meta-analysis in 2006, performed by Rutledge, et. al., demonstrated a direct relationship between HF functional class and severity of depression. •  Patients with NYHA functional class I (mild) HF suffered an 11% occurrence of depression; 20% in class II, 38% in class III, and 42% in class IV.References:1.	 	Rozzini	R,	Sabatini	T,	Frisoni	GB,	et	al.	Depression	and	Major	Outcomes	in	Older	Patients	with	Heart	Failure	[letter].	Arch	Intern	Med	2002;	162:362–364.2.	 	Silver	M.	Depression	and	Heart	Failure:	An	overview	of	what	we	know	and	don’t	know.	Cleveland	Clinic	Journal	of	Medicine	2010;	vol.	77	(3):S7-S11.3.	 	Sherwood	A,	Blumenthal	J,	Hinderliter	A,	et	al.	Worsening	depressive	symptoms	are	associated	with	adverse	clinical	outcomes	in	patients	with	heart	failure.	JACC	2011;	57:418-423.4.	 	Rutledge	T,	Reis	V,	Linke	S,	et.al.	Depression	in	Heart	Failure:	A	Meta-Analytic	Review	of	Prevalence,	Interventions,	Effects,	and	Associations	with	Clinical	Outcomes.	JACC	2006;	48:1527-1537.5.	 	Lichtman	J,	Bigger	T,	Blumenthal	J,	et	al.	Depression	and	Coronary	Heart	Disease.	Circulation	2008;	118:1768-1775.6.	 	Gottlieb	SS,	Khatta	M,	Friedmann	E,	et	al.	The	influence	of	age,	gender,	and	race	on	the	prevalence	of	depression	in	heart	failure	patients.	JACC	2004;	43:1542–1549.7.	 	Freudenberger	R,	Cahn	S,	Skotzko	C,	et	al.	Influence	of	age,	gender,	and	race	on	depression	in	heart	failure	patients.	JACC	2004;	44:2254-a-2255.8.	 	Li	C,	Friedman	B,	Conwell	Y,	et	al.	Validity	of	the	Patient	Health	Questionnaire	2	(PHQ-2)	in	identifying	major	depression	in	older	people.	Journal	of	the	American	Geriatric	Society	2007;	55(4):596-602.9.	 	Gallagher,	R;	McKinley,	S:	Dracup,	K.	Effects	of	a	telephone	counseling	intervention	on	psychosocial	adjustment	in	women	following	a	cardiac	event.	Heart	and	Lung:	The	journal	of	critical	care	2003,	Volume	32,	Issue	2,	p	79	-87.10.	 	Newcomer,	John	W	and	Hennekens,	Charles	H.		Severe	Mental	Illness	and	Risk	of	Cardiovascular	Disease.		JAMA.2007:298(15):	1794-1798.11.	 	Mental	Health	and	Chronic	Physical	Illnesses:		The	Need	for	Continued	and	Integrated	Care			Word	Federation	for	Mental	Health,	October	10,	2010.12.	 	Yancy,	CW	et	al.2013		ACCF/AHA	Heart	Failure	Guideline.GAIL STERN, MSN, PMHCNS-BC        DONNA PETRUCCELLI, MSN, CRNP, NP-C, CFHN, CNS    JEANNE MANAVIZADEH, RN, BSN, PCCN                           Depression and NYHA Functional ClassScreening for endogenous or prolonged reactive depression in patients with HF is recommended by the 2012 HFSA guidelines following diagnosis. The AHA recommends screening and treatment for depressive symptoms in an  attempt to improve self-care behaviors and physical functioning.Patient Health Questionnaire (PHQ-9)CONTACT INFORMATIONGail	Stern,	MSN,	PMHCNS-BCGail.Stern@lvhn.orgLehigh Valley Health Network is a 985 bed tertiary care hospital in Northeastern Pennsylvania with Heart Failure (HF) patient volumes 4 to 6 times the national average. In an effort to reduce 30 day all cause readmissions in this high risk population, a multidisciplinary team was convened. To prioritize continuum of care issues leading to measurable improvements consistent with the fundamental priorities of People, Service, Quality, Cost and Growth, Psychiatric nurse leadership was invited to provide expertise in the management of our complex HF patients with depression. Subsequently, a plan was developed to educate our cardiac nurses.A LVHN Heart Failure Readmission Reduction Project Team works on improved outcomes and the reduction in inpatient readmissions for our patients with Congested Heart Failure.  In 2012, they invited a Psychiatric Nurse to join this group.  We made a plan to educate our cardiac nurses on depression and screen all patients admitted to our Regional Heart Center who carried the diagnosis of CHF.  We screened for depression utilizing the PHQ2. This depression screen along with Suicide screening results were reported and discussed with the attending physician. In some cases immediate consults to Psychiatry were made to provide for patient safety and initiate treatment. Patients with positive scores, who were not in immediate need, were referred for follow up in outpatient settings.  PHQ2 and PHQ9 screening of patients in LVHN practices can be completed and monitored through our Electronic Medical Record, Centricity Physician Office.  We have begun to standardize the monitoring process in multiple settings.  It is through these nursing collaborations that Cardiac Nurses and Psychiatric Nurses educate and coordinate improved care for our patients.  Integration occurs… two nurses at a time!Depression Screening ResultsPositive Scores vs. Consultations Ordered42% Positive ScreeningsConsults Ordered on 10%of Positive ScreeningsPHQ-9 Patient Depression QuestionnaireFor initial diagnosis:1. Patient completes PHQ-9 Quick Depression Assessment.2. If there are at least 4 s in the shaded section (including Questions #1 and #2), consider a depressivedisorder. Add score to determine severity.Consider Major Depressive Disorder- if there are at least 5 s in the shaded section (one of which corresponds to Question # 1 or #2)Consider Other Depressive Disorder- if there are 2-4 s in the shaded section (one of which corresponds to Question #1 or #2)Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician,and a definitive diagnosis is made on clinical grounds taking into account how well the patient understood thequestionnaire, as well as other relevant information from the patient.Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social,occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, ahistory or a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as thebiological cause of the depressive symptoms.To monitor severity over time for newly diagnosed patients or patients in current treatment fordepression:1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) athome and bring them in at their next appointment for scoring or they may complete the questionnaireduring each scheduled appointment.2. Add ups by column. For every : Several days = 1 More than half the days = 2 Nearly every day = 33. Add together column scores to get a TOTAL score.4. Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score.5. Results may be included in patient files to assist you in setting up a treatment goal, determining degree ofresponse, as well as guiding treatment intervention.Scoring: add up all checked boxes on PHQ-9For every ? Not at all = 0; Several days = 1;More than half the days = 2; Nearly every day = 3Interpretation of Total ScoreTotal Score Depression Severity1-4 Minimal depression5-9 Mild depression10-14 Moderate depression15-19 Moderately severe depression20-27 Severe depressionPHQ9 Copyright © Pfizer Inc. all rights reserved. Reproduced with permission. PRIME-MD ® is atrademark of Pfizer Inc.A2662B 10-04-2005The Patient Health Questionnaire-2 (PHQ-2) - OverviewThe PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past twoweeks. The PHQ-2 includes the first two items of the PHQ-9. The purpose of the PHQ-2 is not to establish final a diagnosis or to monitor depressionseverity, but rather to screen for depression in a “first step” approach. Patients who screen positive should be further evaluated with the PHQ-9 to determinewhether they meet criteria for a depressive disorder.Clinical UtilityReducing depression evaluation to two screening questions enhances routine inquiry about themost prevalent and treatable mental disorder in primary care.ScoringA PHQ-2 score ranges from 0-6. The authors¹ identified a PHQ-2 cutoff score of 3 as the optimalcut point for screening purposes and stated that a cut point of 2 would enhance sensitivity,whereas a cut point of 4 would improve specificity.Psychometric Properties¹Major Depressive Disorder (7% prevalence) Any Depressive Disorder (18% prevalence)PHQ-2ScoreSensitivity Specificity PositivePredictiveValue (PPV *)PHQ-2ScoreSensitivity Specificity PositivePredictiveValue (PPV *)1 97.6 59.2 15.4 1 90.6 65.4 36.92 92.7 73.7 21.1 2 82.1 80.4 48.33 82.9 90.0 38.4 3 62.3 95.4 75.04 73.2 93.3 45.5 4 50.9 97.9 81.25 53.7 96.8 56.5 5 31.1 98.7 84.66 26.8 99.4 78.6 6 12.3 99.8 92.9* Because the PPV varies with the prevalence of depression, the PPV will be higher in settings with a higher prevalenceof depression and lower in settings with a lower prevalence.1. Kroenke K, Spitzer RL, William JB. The Patient Health Questionnaire-2: Validity of a Two-Item DepressionScreener. Medical Care 2003, (41) 1284-1294.The Patient Health Questionnaire-2 (PHQ-2)Patient Name Date of VisitOver the past 2 weeks, how often have youbeen bothered by any of the followingproblems?NotAt AllSeveralDaysMoreThan Halfthe DaysNearlyEveryDay1. Little interest or pleasure in doing things 0 1 2 32. Feeling down, depressed or hopeless 0 1 2 3©1999 Pfizer Inc. All rights reserved. Used with permission.PATIENT HEALTH QUESTIONNAIRE (PHQ-9)NAME: DATE:Over the last 2 weeks, how often have you beenbothered by any of the following problems?(use “? ” to indicate your answer)Not at all SeveraldaysMore than halfthe days Nearlyevery day1. Little interest or pleasure in doing things0 1 2 32. Feeling down, depressed, or hopeless 0 1 2 33. Trouble falling or staying asleep, or sleeping too much 0 1 2 34. Feeling tired or having little energy 0 1 2 35. Poor appetite or overeating 0 1 2 36. Feeling bad about yourself - or that you are a failure or have let yourselfor your family down0 1 2 37.Trouble concentrating on things, such as reading the newspaper orwatching television0 1 2 38. Moving or speaking so slowly that other people could have noticed. Orthe opposite – being so fidgety or restless that you have been movingaround a lot more than usual0 1 2 39.Thoughts that you would be better off dead, or of hurting yourself 0 1 2 3add columns + +(Healthcare professional: For interpretation of TOTAL,please refer to accompanying scoring card).TOTAL10. If you checked off any problems, how difficulthave these problems made it for you to doyour work, take care of things at home, or getalong with other people?Not difficult at allSomewhat difficultVery difficultExtremely difficultCopyright © 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD© is a trademark of PfizerInc.A2663B 10-04-2005

Psychiatric Nursing Care for Patients With Cardiac Disease

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Psychiatric Nursing Care for Patients With Cardiac Disease

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Lehigh Valley Health Network: LVHN Scholarly Works