Psychiatric Characterization of Patients Enrolled in IBD Subspecialty Home

Abstract

BACKGROUND: Understanding the psychiatric needs of IBD patients is important for making the integration of behavioral services into medical care cost-effective. One such integrated model of care, the medical home, has increasingly focused on the Four Quadrant model which describes mental and physical health complexity and risk so that integrated treatment can be personalized and scaled accordingly. This study describes the way that psychiatric risk is determined in an IBD subspecialty medical home (SMH) and characterizes the life-time psychiatric diagnoses, current severity of psychopathology, and the baseline physical and mental complexity of IBD patients enrolled for at least one year. METHODS: Starting in June, 2015, patients were enrolled in an IBD SMH if 1) between ages 18-55; 2) confirmed IBD as primary physical condition; and 3) had UPMC Health Plan insurance. All patients are screened for anxiety (GAD7) and depression (PHQ9) and are offered an intake with a licensed clinical social worker (LCSW) if: 1) self-reported screen scores are above a threshold of >=10; 2) history of psychiatric disorders; 3) on psychotropic medication; or 4) the medical team deems the patient emotionally distressed. The LCSW completes a brief psychiatric diagnostic interview at point of GI care and for a subset with high GAD7 or PHQ9 screen scores, the DSM-V Cross-Cutting Symptom Measure to screen for other mental health domains across psychiatric disorders. The SMH team completes the IBD Complexity Grid to quantify current and past complexity in the biological (IBD), psychological, social, and health systems domains using both patient-reported and objective criteria. Patients who met the 75th percentile cut-off for their IBD Complexity Grid biological and psychological domains were scored as high severity in the quantification of patients into physical and mental quadrants. A psychiatrist is also available within the SMH for more severe or complex psychiatric patients. The patient's team care-plan is determined by a weekly SMH team conference. RESULTS: Of 346 patients enrolled in the medical home, mean age was 34.8 (9.7), 42% male, 81% Caucasian, and 61 with Crohn's disease. 256 patients met with the LCSW and 202 had at least one lifetime psychiatric disorder. The mean PHQ9 and GAD7 screen scores were 7.1 (6.2) and 5.8 (5.7); with 46% and 38% having elevated screen scores respectively. In terms of life-time psychiatric diagnoses, anxiety and depressive disorders followed by somatic symptom disorder, PTSD and ADHD were most common. For the subset with elevated GAD7 or PHQ9, 68% had clinically significant sleep disturbance, 44% irritability, 24% with maladaptive personality traits, 12% with drug or alcohol abuse, 12% with obsessive compulsive and 8% with manic symptoms. In terms of the baseline quadrant characterization, 136 (53%) were low-low and 31(12%) were high-high physical and mental complexity, 46 (18%) were high physical and 44 (17%) were high mental complexity only. CONCLUSION(S): These findings confirm high rates of psychiatric comorbidity in IBD patients within a SMH at a large tertiary medical center. Characterization of mental health needs within an IBD clinic is feasible. Such quantification allows for data-driven behavioral health resource allocation.