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American Association for Physician Leadership
American Association for Physician Leadership

Managing Emotional Support Animal Requests in the Primary Care Clinic

by Jillian Baker, OMSIII | Parker Adams, OMSIII | John Paulson, DO, PhD, FAAFP

June 8, 2020


Summary:

Emotional support animal (ESA) requests are becoming more prevalent during patient encounters for primary care physicians. This process is fraught with challenges, including navigating malingering, patient well-being, and rental property agreements.



Review Methods

In preparing this review article, the authors searched a variety of databases, including the EBSCO Psychology and Behavioral Sciences Collection, PubMed, and Google Scholar with keywords including emotional support animals, animal therapy, emotional support animal prescription, and assistance animals. Of these, animal therapy was the broadest, yielding 908 articles. Upon review, however, these articles were about use of animals for treatment of specific diseases and conditions rather than the process of prescribing them. A search for emotional support animals yielded 280 papers, but again, none of them covered the topic from the perspective of prescribing. The search term emotional support animal prescriptions, which was the most specific of the key words we used, recovered 41 papers from Google Scholar; however, even these 41 papers discussed the prescription from the perspective of the patient and when an ESA is required or the process of getting one, not from the perspective of the physician and how to write such a prescription. In conclusion, there is currently very limited research or discussion on the prescription process.

Background

From dogs and cats to turkeys,1 peacocks, and miniature horses (Anderson, et al. v. City of Blue Ash, United States District Court August 14, 2015, USA Uscourts.gov 14-3754), the number of requests for emotional support animals (ESAs) is rapidly increasing.2

All individuals with emotional support animals require a letter from a healthcare provider designating a medical condition that is relieved in some way by their animal.

In 2017 alone, United Airlines reported permitting the travel of 76,000 ESAs.2 Unlike service animals, which are trained to execute specific tasks, ESAs are used to alleviate mental health disabilities.3 All individuals with ESAs require a letter from a healthcare provider designating a medical condition that is relieved in some way by their animal.4 Current estimates indicate that ESA prescriptions have been written by 31% of medical providers.3 Despite these large numbers, the clinical assessment for an ESA often is unstructured and associated with significant administrative burdens. Systematic integration of an ESA into a structured treatment plan will likely reduce malingering, provide additional screening opportunities, and allow physicians to confidently approach this issue in practice.

When a patient approaches a physician requesting ESA approval, the physician essentially has three options:

  • Refer to a specialist for a more comprehensive evaluation;

  • Authorize the request; or

  • Decline the request.

Due to limited availability, specialist referrals may not be feasible in daily practice. Thus, it often falls on the primary care provider to make ESA determinations. Figure 1 provides an algorithm to use as a medical decision-making aid.

Psychological Diagnoses Outside of Anxiety or Depression

Although it is not uncommon for patients to have comorbid mental health disorders, the scope of this paper is limited to uncomplicated anxiety and depression due to their prevalence within the primary care setting. After verifying that the patient does not have any established mental health diagnoses outside of anxiety or depression (or both), it is appropriate to proceed to the next step in the algorithm.

Evaluate for Anxiety and/or Depression

Anxiety and depression in this context include all subcategorical diagnoses—for example, posttraumatic stress disorder and agoraphobia (Norman B. Personal communication, November 21, 2018.) If the patient has an existing, documented diagnosis of anxiety, depression, or other subcategorical diagnosis, it is appropriate to proceed to the subsequent step in the algorithm (Figure 1). Otherwise, it is necessary to screen for one of these diagnoses. The request for an ESA, typically perceived negatively, can be used as a positive tool to evaluate patients for mental health disorders. For anxiety and depression, the Patient Health Questionnaire 9 (PHQ-9) for depression and Beck Anxiety Inventory (BAI) for anxiety can be used to establish a diagnosis.5 The PHQ-9 has strong diagnostic potential, with a score range of 8 to 11.5 The BAI can reveal moderate anxiety (score of 10 to 18), moderate to severe anxiety (score of 19 to 29), and severe anxiety (score of 30 and above).6 If the patient’s screening tests are negative, the physician may deny the request for an ESA or take other circumstances into consideration. However, if a diagnosis of depression or anxiety can be elicited from either of these tests, continue to the next step in the algorithm.

Figure 1. Emotional support animal (ESA) medical decision-making algorithm. BAI, Beck Anxiety Index; PHQ-9, Patient Health Questionnaire 9.

Initial Three-Month Treatment Plan

After ascertaining that the patient has a diagnosis of anxiety or depression and obtaining baseline PHQ-9 and BAI scores, initiate a treatment plan. According to UpToDate, current evidence-based treatment involves a serotonergic antidepressant or cognitive behavioral therapy (or both) for anxiety and combination pharmacotherapy and psychotherapy for depression.7,8 Implementing these therapies is the first step in management of the patient’s disease. An ESA is not included in the initial treatment for two reasons:

  • First, it is currently not an evidence-based therapy for anxiety or depression.

  • Second, it is vital to establish rapport with the patient and understand the nuances of his or her specific disease before promoting the care of an animal.

Conclude the visit by scheduling a follow-up appointment with the patient in three months to evaluate the success of the initial treatment plan.

Refractory to Initial Treatment Plan

When the patient returns for the three-month follow-up visit, administer another PHQ-9 or BAI to quantitatively evaluate the success of the treatment. If the patient reports significant lifestyle benefit and the scores have improved accordingly, it is appropriate to continue with the current treatment regimen. However, if there is no improvement in scores or the improvement is not clinically substantial, it is reasonable to consider supplementing the current treatment program with an ESA.

Integration of an Emotional Support Animal

Contraindications

The purpose of an ESA is to assist in alleviation of the negative effects associated with the patient’s psychological disease. It is necessary, therefore, to ensure that prescribing an ESA will not burden the patient further. A number of warning signs should deter physicians from prescribing an ESA:

  • Financial instability: If a patient is economically unstable, the additive cost of an ESA is likely to be another origin of stress for the patient.

  • Inability to participate in self-care activities: If the patient is unable to engage in daily
    activities of living, such as making meals and self-hygiene, it may be difficult to have to provide care to their ESA as well.

  • Fall risk: For elderly patients requesting an ESA, it is necessary to decide whether the fall risk incurred by the presence of the animal outweighs its potential mental health benefits.

If the physician has any doubt regarding the patient’s ability to integrate an ESA into his or her lifestyle in a healthy manner, the physician should not prescribe an ESA. If all contraindications are removed, the possibility of prescribing an ESA may be revisited.

Disadvantages

Once it has been established that the patient meets the medical requirements for an ESA, it is vital to have a candid discussion with the patient regarding the implications of an ESA prescription. Specifically, it is essential for the patient to recognize that an ESA prescription is equivalent to a disability determination, which has the potential to affect future employment or education endeavors.5 Furthermore, if the patient has a landlord with a strict animal policy, their ESA may induce strain on their relationship with their landlord. Even though an ESA prescription will prevail over any animal restrictions, the patient needs to be aware that having an ESA will likely create a degree of friction with their landlord, which can cause additional stress in their life.

Physician Writes an Emotional Support Animal Letter

Once any contraindications to an ESA have been removed, the physician writes a letter (Figure 2).

Figure 2. Example of emotional support animal physician letter.

Follow-Up Plan

Just as we do when starting a patient on a new psychiatric medication, it is important to establish follow-up after a patient receives a new ESA. Consider a three-month follow-up appointment after the patient receives his or her ESA to reassess with the BAI or PHQ-9. Compare the new BAI/PHQ-9 scores with those from the patient’s initial assessment. If the scores are the same or lower, consider routine follow-up at intervals of 3 to 12 months, with continued BAI or PHQ-9 assessments. However, if the scores have increased, it is imperative to question the efficacy of the ESA and consider the need for alternative therapy or referral for a higher level of mental health evaluation and treatment.

Discussion and Conclusion

Navigating requests for an ESA can be both time consuming and difficult, yet it is becoming a more frequent request, with potential therapeutic benefits. According to the provided algorithm, an ESA request initiates a process that involves multiple points of contact between the patient and the physician (Figure 1). Thus, taking a patient through the proposed ESA request process provides additional opportunities to discuss and achieve preventative healthcare that may have been missed in a patient population more vulnerable due to existing mental health disease.

It is necessary to consider the many public health concerns associated with ESAs that may affect other people. For instance, the increased prevalence of ESAs on commercial flights corresponds with a greater health risk for passengers with allergies and asthma.9 It is crucial to balance the public health impact with individual treatment.

There is a significant gap in existing research regarding ESAs. Numerous topics require further investigation, including the following:

  • Selecting the appropriate ESA species (e.g., dog, cat);

  • Evaluating the extent of therapeutic relief provided by ESAs;

  • Determining the optimal length of treatment; and

  • Deciding when and how to discontinue the ESA therapy.

These questions are outside of the scope of this article, but it is judicious to consider all aspects when incorporating ESA prescriptions into clinical practice.

The proposed algorithm provides a systematic clinical decision tool that will allow physicians to navigate ESA requests with evidence-based treatment standards while increasing mental and preventative health screening and treatment opportunities (Figure 1). Furthermore, considering that many ESA requests are made by patients intending to circumvent the system (such as taking their pet onto an airplane without incurring additional costs), use of a systematic ESA prescription method will assist in the reduction of both malingering and physician frustration with the overall process.

References

1.   Castrodale J. Passenger takes turkey on Delta flight as emotional support animal, and now we’re so confused. USA Today. January 12, 2016.
www.usatoday.com/story/travel/roadwarriorvoices/2016/01/12/passenger-takes-turkey-on-delta-flight-as-emotional-support-animal-and-now-were-so-confused/83290688/.

2.   Bomkamp S. Emotional support animals—from dogs to peacocks, real or fake—present challenges for businesses. Chicago Tribune. February 9, 2018.
www.chicagotribune.com/business/ct-biz-emotional-support-animals-20180211-story.html.

3.   Boness CL, Younggren JN, Frumkin IB. The certification of emotional support animals: differences between clinical and forensic mental health practitioners. Professional Psychology: Research and Practice. 2017;48:216-223. doi:10.1037/pro0000147.

4.   Wisch RF. (2015). Assistance animals in housing. Michigan State University College of Law. Retrieved from https://www.animallaw.info/article/faqs-emotional-support-animals.

5.   Manea L, Gilbody S, McMillan D. Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis. CMAJ. 2012;184:E191-196.
https://www.cmaj.ca/content/cmaj/184/3/E191.full.pdf.

6.   Leyfer OT, Ruberg JL, Woodruff-Borden J. Examination of the utility of the Beck Anxiety Inventory and its factors as a screener for anxiety disorders. J Anxiety Disord. 2006;20:444-458.

7.   Craske M, Bystritsky A. UpToDate. December 1, 2017. Approach to treating generalized anxiety disorder in adults.
https://www.uptodate.com/contents/approach-to-treating-generalized-anxiety-disorder-in-adults?search=approach%20to%20treating%20generalized%20anxiety%20disorder%20in%20adults&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

8.   Simon G. Unipolar major depression in adults: choosing initial treatment. UpToDate. November 12, 2017. https://www.uptodate.com/contents/unipolar-major-depression-in-adults-choosing-initial-reatment?search=unipolar%20major%20depression%20in%20adults&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

9.   Baumann BC, Macarthur KM, Baumann JC. Emotional support animals on commercial flights: a risk to allergic patients. Lancet Respir Med. 2016;4:544-545.


Jillian Baker, OMSIII

OMSIII, Kansas City University of Medicine and Biosciences, Joplin, Missouri




Parker Adams, OMSIII

OMSIII, Kansas City University of Medicine and Biosciences, Joplin, Missouri




John Paulson, DO, PhD, FAAFP

Department Chair—Primary Care Medicine, Kansas City University of Medicine and Biosciences, Joplin, Missouri



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