A Collaborative Partnership. A Collaborative Partnership

Transcription

1 A Collaborative Partnership A Collaborative Partnership David R. Blackburn, PhD Senior Staff, Department of Psychiatry Assistant Professor, Texas A&M Health Science Center 19 February 2009

2 Overview The Problem: Patients we see regularly The Bipolar Patient How the Psychologist can help the Physician Evidence-Based Practices A Collaborative Model The Ultimate Solution

3 The Complicated Patient The Complicated Patient Female patient Dx: heart problems; Hx cardiac surgery; anxiety d/o with focus on cardiac Sx She researches for cause(s) She phones PCP often; demands tests Multiple hospitalizations Pt and PCP both frustrated Pt reports sense of health & wellness

4 Interactions with Complicated Patients Typical patients always have a chief complaint Those patients who have many chief complaints are seen as challenging The PCP has to determine what takes priority; refer to numerous specialists and run numerous tests Medical professionals often wonder if they are missing something For some, the mental health issues may be exacerbating the medical issues Ruddy, Borenson, & Gunn, 2008

5 The Chronically Ill Patient The Chronically Ill Patient Female; professional; Dx: fibromyalgia Can t function in career as lawyer Views life: not in control of Sx; retreats from work/relationships; avoids stressful situations Describes Sx when at doctor Refuses new Tx or to engage in talk about underlying depression

6 Interactions with Chronically Ill Patients Conditions such as hypertension, arthritis, diabetes, pulmonary disease, and obesity are increasingly prevalent These folks have a high prevalence of psychiatric comorbidities Many chronically ill patients experience depression and anxiety related to being sick all the time Those who have a preillness disposition of external locus of control view themselves as victims of uncontrollable circumstances Psychotherapy can help mitigate the effects of ambivalence and denial of self-care Ruddy, Borenson, & Gunn, 2008

7 Conflictual Interactions Conflictual Interactions Middle-aged male; Dx: chronic pain Requires narcotic medication Depression is present making pain worse Demanding wife Insists on more medication Staff sees interaction as manipulative Physician feels caught in the middle

8 Conflictual Interactions Conflictual Interactions Conflict among family members is not the only challenge here Conflicts also occur when symptoms do not improve, causing fear of misdiagnosis or inappropriate treatment When staff and medical professionals become defensive, conflict can escalate Physician/staff conflict often parallel the professional/patient conflict Relationship oriented psychologists have a number of skills to help medical professionals best manage conflictual situations Ruddy, Borenson, & Gunn, 2008

9 What Difficult Patients Need What Difficult Patients Need Wouldn t it be great if I could bring all of these patients together so they could talk to each other and have their own therapy group of sorts? That s when the idea hit me. Talking. Discussion and counseling, not blood tests and X-rays. Exchange of emotions, not more medications. Reassurance, encouragement, and understanding. A shoulder to cry on, a friend to talk to, a person who cares. It actually works. For some of my difficult patients, 30 minutes of listening and nodding with reassurance is far more therapeutic than any medication could ever be. Vanessa Rice, MD

10 Bipolar Disorder

11 What is Bipolar Disorder? Manic-Depression A brain disorder affecting moods and energy that affects over 5 million in the U.S.A. (anywhere from 1-4% --NIMH) Emotions, thoughts and moods are distorted resulting in mood swings that are overly high to extremely sad and hopeless Defined as having one or more manic or mixed episodes and depression episodes lasting most of the day, every day for 2 weeks or more A long-term illness that typically develops in adolescence or early adulthood but symptoms often seen in childhood Often misdiagnosed as ADHD, OCD, ODD, CD &/or depression and sometimes schizophrenia Often leads to suicidal thoughts Individuals can be treated and lead full productive lives

12 Signs and Symptoms Signs and Symptoms MANIC Feelings of grandiosity or very high self-esteem, euphoric Extreme talkativeness, racing thoughts Decreased need for sleep Highly distractible Engaged excessively with pleasurable activities, often recklessly DEPRESSION Ongoing sad, anxious or empty mood Lack of energy and ability to concentrate Sleeping too much or too little Lacks interest in others and activities, irritable, feeling hopeless and worthless Thoughts of death or suicide SIGNS IN YOUNGER CHILDREN Poor sleep and night terrors High activity level Easily startled Bedwetting Oppositional behavior

13 Scott s Comments Scott s Comments 8 years ago my wife pushed my buttons No way to stop the sensation Irate, agitated, raising my voice Something was wrong No control over my helplessness Albrecht & Herrick, 2007

14 Range of Mood and Emotion Range of Mood and Emotion severe mania mild to moderate mania (hypomania) normal-balanced mood mild to moderate depression severe depression

15 Treatment Just like long-term illnesses such as diabetes and heart disease, bipolar disorder is an illness that requires medication to improve quality of life Not all medications work for every person Severity of moods and side effects must be weighed Medical management by a psychiatrist is best A combination of medication and talk therapy is most effective, specifically cognitive behavior and family therapy Long-term management of symptoms reduces risk of suicide ** suicide rate 10-15%, NIMH

16 Medications for Bipolar Disorder Medications for Bipolar Disorder Divalproex sodium is helpful for mania, depression associated with bipolar disorder, and headaches Lithium carbonate needs to be used more often Carbamazepine is helpful as mood stabilizer, not for migraine prophylaxis Many patients need two to four different medications (e.g. lamotrigine, lithium, and antidepressant) Robbins & Goldfein, 2008

17 Bipolar and Migraine Headaches Bipolar and Migraine Headaches In a recent survey of 1000 consecutive migraineurs, results are as follows: Bipolar I: 2.1% Bipolar II: 2.4% Cyclothymic Disorder: 1.3% Bipolar Disorder NOS: 2.8% Total Bipolar Spectrum: 8.6% Other studies have confirmed at least 7% of headache patients fit into bipolar spectrum Robbins & Goldfein, 2008

18 Leslie s Comments Leslie s Comments Tried many different medications What if the medication doesn t work Feeling like a guinea pig Being on a combination of medications makes it manageable Albrecht & Herrick, 2007

19 Bipolar Disorder Made Easy Bipolar Disorder Made Easy

20 Bipolar I Disorder, Single Manic Episode, Unspecified Bipolar I Disorder, Single Manic Episode, Mild Bipolar I Disorder, Single Manic Episode, Moderate Bipolar I Disorder, Single Manic Episode, Severe, Without Psychotic Features Bipolar I Disorder, Single Manic Episode, Severe, With Psychotic Features Bipolar I Disorder, Single Manic Episode, In Partial Remission Bipolar I Disorder, Single Manic Episode, In Full Remission Bipolar I Disorder, Most Recent Episode Hypomanic

21 Bipolar I Disorder, Most Recent Episode Manic, Unspecified Bipolar I Disorder, Most Recent Episode Manic, Mild Bipolar I Disorder, Most Recent Episode Manic, Moderate Bipolar I Disorder, Most Recent Episode Manic, Severe Without Psychotic Features Bipolar I Disorder, Most Recent Episode Manic, Severe With Psychotic Features Bipolar I Disorder, Most Recent Episode Manic, In Partial Remission Bipolar I Disorder, Most Recent Episode Manic, In Full Remission Bipolar I Disorder, Most Recent Episode Depressed, Unspecified

22 Bipolar I Disorder, Most Recent Episode Depressed, Mild Bipolar I Disorder, Most Recent Episode Depressed, Moderate Bipolar I Disorder, Most Recent Episode Depressed, Severe Without Psychotic Features Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features Bipolar I Disorder, Most Recent Episode Depressed, In Partial Remission Bipolar I Disorder, Most Recent Episode Depressed, In Full Remission Bipolar I Disorder, Most Recent Episode Mixed, Unspecified Bipolar I Disorder, Most Recent Episode Mixed, Mild

23 Bipolar I Disorder, Most Recent Episode Mixed, Moderate Bipolar I Disorder, Most Recent Episode Mixed, Severe Without Psychotic Features Bipolar I Disorder, Most Recent Episode Mixed, Severe With Psychotic Features Bipolar I Disorder, Most Recent Episode Mixed, In Partial Remission Bipolar I Disorder, Most Recent Episode Mixed, In Full Remission Bipolar I Disorder, Most Recent Episode Unspecified Bipolar Disorder NOS

24 Bipolar II Disorder Must describe with the following, as applicable: o Hypomanic or Depressed o Mild, Moderate, Severe With or Without Psychotic Features o Chronic; With Catatonic, Melancholic, or Atypical Features o Postpartum Onset o In Partial or Full Remission o With or Without Interepisode Recovery o With Seasonal Pattern o With Rapid Cycling Cyclothymic Disorder

25 How the Psychologist Can Help Primary Care Physicians

26 Leading Causes of U.S. Preventable Deaths Tobacco Obesity Alcohol Infectious Diseases Toxins Firearms Sexual Behavior Illnesses Vehicles Drug Abuse Rohack, (thousands)

27 3 Major Mistakes Doctors Make 3 Major Mistakes Doctors Make Anchoring Availability Attribution Groopman, 2008

28 Three Questions Patients Need to Ask 1. What else could it be? 2. Could two things be going on to explain my symptoms? 3. Is there anything in my history, physical examination, laboratory findings, or other tests that seems not to fit with your working diagnosis? Groopman, 2008

29 Primary Care Includes Mental Health Care 50% of all Mental Health care is done in primary care 67% of psychiatric meds AND 80% of all antidepressants are prescribed by PCPs not psychiatrists Only 10-25% of patients follow through with your Mental Health referrals Patients receiving care from both PCP and a psychologist have better outcomes than those receiving care from PCP alone Zoberi, 2008

30 Specific Ways Psychologists Can Help Pain management, compliance Non-pharmacologic depression treatment ADHD diagnosis Smoking cessation Alcohol abuse Crisis management Obesity: managing overeating, exercise plan, diet issues Zoberi, 2008

31 A PCPs Perspective on Collaborating Well ANYTHING which helps us stay on schedule! Tell us what you can do Be available Make sure we re on the same page with therapy You must use evidence-based medicine Zoberi, 2008

32 Zoberi, 2008 Evidence Pyramid Evidence Pyramid

33 Core Evidence-Based Practice Skills Asking a specific, clinical question Accessing the best available research Appraising critically the research evidence Translating the research into practice with a particular patient Integrating clinician s expertise and patient characteristics, culture, & preferences with the research Evaluating effectiveness of the entire process Norcross, Hogan, & Koocher, 2008 AAA TIE

34 TRIGGERING EVENTS 12 BEHAVIORS OR ACTIONS TAKEN AS A RESULT 9 CLOCK METAPHOR 3 THOUGHTS ABOUT THE EVENTS 6 EMOTIONS EXPERIENCED Meichenbaum, 2007

35 Doctors vs. Internet Doctors vs. Internet Have you ever doubted a medical provider s opinion or diagnosis because it conflicted with information you had read on the Internet? Survey of 1000 people YES NO 35% 42% 58% 65% WOMEN MEN 0% 20% 40% 60% 80%

36 Psychological Instruments Psychological Instruments

37 MMPI-2-Restructured Format MMPI-2-Restructured Format New, 338-item version of MMPI-2 (in contrast to 567 items) Subset of MMPI-2 pool Norms based on MMPI-2 sample MMPI-2 will remain available and fully supported Ben Porath, 2008

38 MMPI-2-RF: RC Scales MMPI-2-RF: RC Scales RCd: Demoralization General unhappiness and dissatisfaction RC1: Somatic Complaints Diffuse physical health complaints RC2: Low Positive Emotions Lack of positive emotional responsiveness RC3: Cynicism Non-self-referential beliefs expressing distrust and a generally low opinion of others RC4: Antisocial Behavior Rule breaking and irresponsible behavior Ben Porath, 2008

39 MMPI-2-RF: RC Scales MMPI-2-RF: RC Scales RC6: Ideas of Persecution Self-referential beliefs that others pose a threat RC7: Dysfunctional Negative Emotions Maladaptive anxiety, anger, irritability RC8: Aberrant Experiences -- Unusual perceptions or thoughts RC9: Hypomanic Activation Over-Activation, aggression, impulsivity, and grandiosity Ben Porath, 2008

40 Existing Screening Instruments Existing Screening Instruments General Health Questionnaire (GHQ; Goldberg, 1974) Symptom-Driven Diagnostic System for Primary Care (SDDS-PC; Broadhead et al., 1995) PRIME-MD (Spitzer et al., 1994) Quick Diagnostic Panel (QDP; Shedler et al., 2000) Limitations Too long Health literacy issues Not comprehensive Impractical for busy setting Inadequate psychometric data Not useful as an outcome measure Pollard, 2008

41 Primary Care Behavioral Health Screen (PCBHS) 2 main questions - symptom checklist (from 26 items) - severity rating of each item checked Designed for use as screener and pre-to-post outcome measure Uses common language ( a whole lot ) Pollard, 2008

42 Collaborative Model Collaborative Model

43 Why Integrated Care? Why Integrated Care? Broken system Most MH care done in PC Patients expecting more Failures in screening; adherence PCPs treat 70+% of all behavioral health problems 67% of psychotropics 92%-98% of adults in HMOs expect behavioral health advice & intervention from PCP Improved Clinical Outcome Improved Patient & Provider Satisfaction Improved Adherence Functional & Symptom Improvements Maintained Improved Access to Treatment Improved Cost Effectiveness Niemiec, 2008

44 Specialty/Tertiary Care Primary Care

45 Behavioral Health Components in Primary Care Adherence Chronic medical conditions Patient education Prevention/health promotion Impact of illness on family system Lifestyle interventions Relapse prevention Pre-clinical conditions Niemiec, 2008

46 Models of Integrated Care Models of Integrated Care LESS MORE Behavioral Health Consultation Model Interdisciplinary Teamwork Co-located Model in-house shrink Staff Advisor Model consultation liaison Separate Offices standard referral sources Niemiec, 2008

47 Behavioral Health Consultation Model minute initial visit; 1-3 total visits Open access open scheduling: interruptible No limits on patient problem or # per day Behavioral Health Consultant (BHC) available any time a PCP is present PCP in charge of treatment plan ¼ - ½ page notes Population management Niemiec, 2008

48 Integrated Care: Flow Timing Physician visit with patient Physician primer to patient Warm hand-off to BHC BHC meets with patient 1) Introduction 2) Assessment functionality 3) Conceptualization & intervention 4) Action plan review Teach Back Curbside consult (feedback to PCP) 5-30 min sec N/A 2 min 5-35 min 1-2 min min min 1-5 min 30 sec 5 min Niemiec, 2008

49 Summary The Problem Patients The Bipolar Patient How the Psychologist can help the Physician Evidence-Based Practices A Collaborative Model The Ultimate Solution

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