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Caring for the psyche while treating the body

January 05, 2015
by Kathy Katella

A slender young woman admitted to Yale-New Haven Hospital (YNHH) for a bad case of flu is picky about food and finally refuses it altogether. A middle-aged man with pacemaker issues is shaky, perhaps experiencing alcohol withdrawal. An elderly woman who lives alone and is diagnosed with diabetes seems confused and can’t follow instructions on diabetes care.

Each day members of a group called the Behavioral Intervention Team (BIT) huddle with charge nurses on YNHH’s medicine floors to see whether a behavioral issue has become a barrier to receiving what may be lifesaving medical treatment. If there is a behavioral concern, the BIT team will send a provider to evaluate the patient and provide therapy or medication, as well as a referral to continue that treatment at discharge.

While the approach sounds simple, Yale’s BIT has been described as a cutting-edge model, and it has attracted the attention of other medical centers across the country. The difference is that while health care traditionally minimizes the importance of psychiatric care or seeks a psychiatric consultation only in a crisis, BIT members act as partners to medical colleagues to address mental health issues early.

“The whole point of it is to be proactive. We come in and provide proactive advice,” said Kimberly Yonkers, MD, a Yale psychiatrist and member of the team. “Sometimes we can shorten the patient’s length of stay. Sometimes we can save lives.”

The goal is to screen all patients

William Sledge, MD, medical director of the Yale-New Haven Psychiatric Hospital, pioneered the Behavioral Intervention Team in 2010. Now the service provides psychiatrists, nurse practitioners, clinical nurse specialists, and clinical social workers to the entire YNHH medical service, with plans for similar coverage in other inpatient services.

“It’s just common sense for psychiatry to become involved with patients earlier, rather than later,” Dr. Sledge said. “What has come to light in the last decade with a growing drumbeat is that co-occurring mental illness is very prominent in our society. It makes medical care more expensive, and it makes a patient’s ability to recuperate from a medical illness difficult.” In fact, scientific literature shows that patients with psychiatric disorders tend to receive general medical care less often, and when they do receive care, it is often of suboptimal quality. “These patients are more likely to return to the hospital, and return repeatedly,” said Dr. Sledge.

While he is still collecting data to analyze the program’s impact, Dr. Sledge said the team is saving health care dollars by reducing patients’ length of stay; a team implemented at Dartmouth has reported similar results. At Yale, there also have been fewer requests for “patient sitters”—constant companions sometimes assigned to patients who have severe psychiatric issues or are suicidal.

Helping with a variety of disorders

Members of the BIT team have treated patients for anxiety, bipolar disorder, delirium, depression, eating disorders, post-traumatic stress syndrome, schizophrenia, and substance abuse, among other psychiatric problems.

“We help in a variety of ways,” said Dr. Sledge. Someone who is mildly depressed might benefit from a single visit from a social worker, while an elderly patient showing serious signs of dementia might be referred to a specialized living facility. “Patients with alcohol-related problems don’t go into withdrawal under our care. We prescribe treatment for them early and quickly. We prescribe medication for people who are depressed. For patients who are loudly distressed, we help them calm down.”

For some people, a visit to the hospital can be a tipping point, said Hochang Lee, M.D., director of the Yale Psychological Medicine Service, who oversees the BIT program at YNHH. For patients with chronic mental illness, “the transition from the community to the hospital can be very daunting. Maybe a patient is already paranoid at baseline. Maybe he hasn’t been taking psychiatric medication properly or he doesn’t understand his mental illness.” Suddenly that patient is in a new environment in which doctors are drawing blood and performing medical procedures. “It’s a scary situation,” Dr. Lee said.

Addressing a widespread problem

The hope is that early intervention will be a successful step toward tackling the problem of mental health in general. About 25 percent of U.S. adults have some sort of mental illness, according to the Centers for Disease Control and Prevention. Several studies have shown that people with severe mental illness live 20 years less than those without because of poorly managed medical problems. “The psychiatric morbidity has a tremendous impact on the medical outcomes in these patients. People who have psychiatric disorders tend to do worse than those who simply have medical diseases,” said Dr. Lee.

It helps that “we can be on top of their care,” Dr. Yonkers said. “We really go the extra mile for people to make sure they get optimal care. We want to be there to make sure their psychiatric needs are met.”

Submitted by Mark Santore on January 05, 2015