Key Components of Care Management. Integrated Care Workflow What s the job?

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1 University of Washington Key Components of Care Management Building on 25 years of Research and Practice in Integrated Mental Health Care Integrated Care Workflow What s the job? Patient identification and diagnosis Engagement in integrated care Evidence Based Treatment: Medication / Psychotherapy Systematic Follow-up/Treatment Adjustment Communication, Care coordination and Referrals Questions? How does this differ from your usual role? What are some new skills you will have to develop as a Behavioral Health clinician coming to this role? What parts will be challenges for you? Systematic Psychiatric Case Review Focusing on Patients not Improving Program oversight and Quality Improvement IMPACT Treatment Protocol Stepped Care 1. Assessment and Education 2. Behavioral Activation / Pleasant Events Scheduling AND 3. a) Antidepressant Medication Usually an SSRI or other newer antidepressant OR b) Problem-Solving Treatment in Primary Care (PST-PC) 6-8 individual sessions followed by monthly group maintenance sessions 4. Maintenance and Relapse Prevention Plan for patients in remission Systematic follow-up & outcomes tracking Patient Health Questionnaire (PHQ-9) The cheap suit Treatment adjustment as needed Based on clinical outcomes According to evidence-based algorithm In consultation with team psychiatrist Relapse Prevention PM 1

2 Care Manager / BHC: Core Skills Care Manager: Core Skills Actively engages the patient t in therapeutic ti alliance Conducts initial assessment and follow-up visits using standard assessments and symptom scales (e.g., PHQ-9, GAD-7, PCL-C) on a session-to-session basis Provides patient education and reviews goals and expectations of treatment Elicits treatment preferences Encourages treatment adherence Supports medication management by Primary Care Provider Provides brief, structured counseling / psychotherapy py (behavioral activation, PST) or referral for psychotherapy Coordinates care Consults with team psychiatrist Collaborates closely with patient s primary care provider (PCP) Facilitates referrals to specialty care community resources Care Managers Support the Patient s PCP Few PCPs have the time & support necessary to: Fully educate and support patients in treatment Closely monitor treatment & make adjustments in treatment when needed Care Managers: Support treatments initiated by PCP Provide education and brief, structured counseling Refer to other resources (e.g., substance abuse counseling, psychotherapy, social work) Facilitate consultation by a mental health specialist (e.g., psychiatrist) as needed Communication with PCPs Clarify preferred method of communication In person Phone Fax (careful with confidential information) Communicate changes in patient s clinical and functional status Prioritize which changes need to be brought to the attention of the PCP Maintain enough contact so that they remember who you are, but no so much that they see you as a pest Key Elements to Include When Talking to PCP Baseline Clinical measures e.g., g, PHQ-9 Score Current Symptoms Symptoms that aren t improving Length of time on current treatments Problematic side effects Talking with Caregivers About Depression Patient education materials (booklets, videos) can aid caregivers in recognizing g depression symptoms Caregivers may have a better view of the patient s mood and behavior changes over time PM 2

3 Initial Visit Assessment Education Discuss treatment options / plans Coordinate care with PCP Start initial treatment plan Arrange follow-up contact In person or by phone In one week or earlier Document initial visit Discussing Mental Health Diagnosis with Patient Don t argue about whether or not patient has mental illness focus on symptoms and symptom resolution Give hope! You don t have to feel this way This can be treated Educate patient about treatment in primary care To reduce resistance from stigma Depression as a medical condition We have effective treatments for this Patient Education Depression The Cycle of Depression Depression affects the body, behavior, and thinking Physical symptoms may be the most apparent Depression can almost always be treated with antidepressant medications or psychotherapy STRESSORS Medical Illness Family Problems Work Problems Recovery from depression is the rule, not the exception but relapse is common if treatment discontinued THOUGHTS & FEELINGS Negative thoughts Low self esteem Sadness Hopelessness DEPRESSION PHYSICAL PROBLEMS Poor sleep Pain Low Energy Poor concentration Minor tranquilizers, drugs, and alcohol can make depression worse, not better The cycle of depression model BEHAVIOR Social Withdrawal Decreased activities Decreased productivity Address Attitudes & Beliefs About Depression Patients often know little about depression or anxiety disorders Many may feel like they should handle it themselves About 60% of people aged 65 and older believe it is normal for people to get depressed as they age People often think that life problems are a reason to be depressed and it is normal Anxiety Cycle Physical symptoms Thoughts of : dying, going crazy, (e.g., sweaty, losing control; danger and catastrophe; shaking) being negatively judged by others Avoidance and escape behaviors PM 3

4 Most Care Managers are Social Workers or Counselors Video Clip: Initial Visit it The treatment t t that t works is the best one Person-centered care means selecting treatments based on client preference, not clinician preference Try to be unbiased when offering treatment options Be eclectic: One size fits few Medication therapy is not right for everyone Psychotherapy is not right for everyone; Different therapies Supporting whole person treatment is important This may include medication therapy You can support medication therapy within scope of practice Ask questions and collect information Support patient being informed and active about all aspects of treatment plan Discussing Treatment Options Review these as options that the patient can choose from Discuss with patient pros and cons of each option Treatment Expectancies? Outcome expectancy Is treatment going g to work? Self-efficacy efficacy expectancy Can I help myself get better? Typical Course of Care Management: Duration Role Play Discussing Cycle of Depression and Treatment Options 6-10 Months (average) Best if determined by clinical outcomes, not preset 50%-70% of patients will need at least one change in treatment to improve Each change of Tx moves an additional ~20% of patients into response or remission If pre-determined, minimum 6 months with option to extend to 12 months if additional prescription change is wanted PM 4

5 Comparison of Contacts in Usual Care vs. Integrated Care Usual Care 3.5 contacts with PCP per year ~20% treatment response / improvement Integrated Care 3.5 contacts with PCP 10 contacts with Care Manager (average) 2 consultations from psychiatrist to CM / PCP (average) 30-60% treatment t t response / improvement Typical Course of Care Management: Contact Frequency Active Treatment: Initial 3-6 months until patient improved / stable Minimum 2 contacts per month Typical during first 3-6 months of treatment Mix of phone and in-person works Monitoring: 1 contact per month After 50% decrease in PHQ / GAD (or similar) achieved Monitor for ~3 months to ensure patient stable Inactive: After completing Relapse Prevention Plan Continue to see PCP at 6 months, etc. If stopping meds Check in prior to stopping and at 2 months or if symptoms return Follow-Up Contacts Weekly or every other week during acute treatment phase In person or by telephone to evaluate depression severity (PHQ-9) / treatment response Initial focus on Adherence to medications Discuss side effects Follow-up on activation and PST plans Later focus on Complete resolution of symptoms and restoration of functioning Long term treatment adherence Using the Telephone Under utilized tool Check up on adherence to medications Check in about side effects to medications Check in on behavioral activation Check in on symptoms after in remission Client-centered approach Convenient Pro-active Relapse Prevention & Maintenance Treatment After patient is in remission from acute episode Make a relapse prevention plan Follow the patient with monthly contacts Usually by telephone calls Individual OR in a maintenance group Bring patient back in for further evaluation if symptoms recur Purpose of Relapse Prevention Helps patients identify: Their own symptoms of depression Look at first few PHQ-9s if cannot remember Intervene earlier if symptoms return What worked to get better Keep doing these things A plan if symptoms return PM 5

6 Video Clip: Relapse Prevention Plan Role Play Relapse Prevention Plans Evidence-based Non-medication Treatments t Psychotherapy for Depression Psychotherapy for Depression / Anxiety in Primary Care No one therapy fits all clients Choose an evidence-based treatment Choose a therapy that fits the client, the setting and the program CBT, IPT, Psychodynamic y Psychotherapy for Anxiety & PTSD Behavioral Activation / Activity Scheduling Problem Solving Treatment PM 6

7 Anxious Thinking: Common Errors Cognitive Behavioral Therapies to Address Avoidance Behavior View negative events as more likely than they really are ( overestimating the risk ) View negative events as bigger or worse than they really are ( catastrophizing ) Avoidance is common coping mechanism Goal of CBT therapy: learn something new Can tolerate fear and anxiety Improved self efficacy Feared outcomes do not or rarely happen and/or they can be managed I can get back on the freeway and drive to work Cognitive-Behavioral Treatments for PTSD (Kaysen, 2009) Seeking Safety Prolonged Exposure (Foa) Active component is exposure Exposure to feared stimuli naturally disconfirms negative cognitions Includes imaginal and in vivo exposure Cognitive Processing Therapy (Resick) Active component is cognitive restructuring in context of emotional processing CPT effective w/ fewer (or no) exposure sessions Changes in beliefs lead to changes in emotions and symptoms Treatment for substance abuse and trauma CBT specific to these issues-- Behavioral Activation for PTSD Rationale Avoidance leads to withdrawal and limits learning to cope with anxiety When to use it? When there is avoidance related to anxiety/ptsd symptoms When there is avoidance related to depressive symptoms When there is functional impairment leading to depression Behavioral Activation for PTSD Goals Increase activity levels Prevent avoidance behaviors Increase positive and rewarding activities Identify avoidance behaviors and activities that are valued and rewarding Evaluate obstacles for doing these activities Set specific activity goals and track in sessions PM 7

8 Other Skills to Manage Anxiety Symptoms Discussion Deep muscle relaxation Breathing relaxation Preparing for a stressor Attention to health habits: caffeine, alcohol, sleep, deconditioning, substance abuse How does this differ from your usual role? What are some new skills you will have to develop as a Behavioral Health clinician coming to this role? What parts will be challenges for you? Questions Break Case 1 Medication Therapy for Depression /A Anxiety Guiding Principles YP, a 38-year-old Mexican-American woman, presents to her PCP for check-up regarding previous diagnoses of hypertension and elevated cholesterol. YP missed two previously scheduled appointments and presented today after receiving a letter from her PCP s office regarding her missed visits. In the course of the appointment, t she admits thatt there have been days that t she had not taken her medications. Further inquiry reveals that she has been generally unmotivated, has been isolating at home, and not engaging with others or activities as she used to. She reports that she sleeps a lot but always feels tired, that doing anything seems to take a lot of effort, and nothing is fun anymore. YP also admits to feelings of sadness, and hopelessness. She becomes mildly tearful at discussing this because she admits that in recent weeks, she has been having thoughts of not wanting to live, and this scares her. PM 8

9 Case 1 She reports that she has been struggling with these symptoms for at least the past six months after the break up ofher eight-year romantic relationship, and thatt in the past 3 weeks she has been feeling worse. This has been getting in the way of her functioning at work as a cashier. She reports that in the last week she missed 2 days of work because she just didn t feel like going and now is very worried about the possibility of losing her job. She also reports that she has been not getting g along with her sister, who she is usually very close to. With additional inquiry, YP mentioned no prior psychiatric or pharmacological treatment for these symptoms. Using Antidepressants Key principles Use antidepressants, not minor tranquilizers / benzodiazepine for depression and most anxiety disorders Use adequate doses for an adequate amount of time Start slow and work with side effects but titrate to an effective dose as needed Change medication if not effective Usually after 8 10 weeks Choosing Antidepressants Case 2 Prior treatment history in patient/family members Patient preferences Expertise of prescribing provider Side effect profile Safety in overdose 10 days of a TCA can be a lethal overdose Availability and costs Drug-drug interactions Mr. C is a 65 yo African American male with type 2 diabetes, with associated retinopathy, and peripheral neuropathy, who presents with his wife for a scheduled follow-up visit. Six weeks ago, he had been diagnosed with major depression (PHQ9=15) and was prescribed CYMBALTA 30 mg once daily. According to Mr. C, the medication made him feel funny and so he stopped taking it. His wife, who seems frustrated, states that he had been taking the medication for about 2 weeks and that she noticed that his attitude was getting better, but he just stopped taking the medication because he didn t want to be dependent on it. She also reports that he still has not been following his prescribed diabetes diet, continuing to eat sweets and drink sodas. General Office Strategies for Optimizing Adherence Antidepressant Adherence Provide rationale for use Careful attention to side-effects Counter demoralization (BHC/PP) Address fear of dependence and loss of control Enlist family/spousal support (BHC/PP) Address concerns in relation to patient s or significant other s prior experience with medication (BHC/PP) Increase contact with brief phone check-ins (BHC/PP) Specific instructions (take regardless of symptom change, don t stop on own) Use symptom scale (e.g., PHQ-9) 100% 80% 60% 40% 20% 0% Weeks Lin EH., Med Care, 1995;33:67 Key messages: Take medication daily Wait 2-4 weeks for effect Side effects can occur, but often resolve in 1-2 weeks Keep taking medication even if better Check with MD before stopping Not addicting PM 9

10 Case 3 Maintenance Therapy on Basis of Episodes Ms. Tis a 45 yo female with hypertension, chronic low back pain, hypothyroidism, who also has previous diagnoses of Major Depressive Disorder, and PTSD both related to an accident that occurred 18 months ago. At the time, Ms. T was working as a tow truck driver and she witnessed a terrible MVA caused by a drunk driver and witnessed the mangling and death of a passenger. After 6 months of severe depression and PTSD symptoms, she was seen by a psychiatrist and was prescribed SERTRALINE, PRAZOSIN, and AMBIEN, and was seen by a therapist for a course of CPT. She responded well to treatment, and though she no longer works as a tow truck driver, she is able to drive. She presents to your office today with concerns about recent increased depressed mood, increased irritability, poor sleep that s been goingg on for the past 4 weeks. She had stopped her medicine 2 months ago and was fine at first. f Recurre ence (% %) Risk of ~ 90% ~ 70% 40 ~ 50% First Episode Second Third+ Episode Episode 1 Judd LL et al., Am J Psychiatry, Mueller TI et al., Am J Psychiatry, DSM-IV-TR. Washington, DC: American Psychiatric Association, 2000 Depression is a Chronic Disease 5 15 years after recovery, *85% of patients have experienced a recurrence 1,2 robability y of Recu urrence 1 Cumu ulative Pr Mueller TI et al., Am J Psychiatry, Keller MB et al., JAMA, Years After Recovery When and How to Stop Antidepressants? Treat all adults for 9-18 months after initial response Treat those at high risk for relapse for 2 years or longer. Some may need lifetime treatment Maintenance treatment should be at full dose Make a relapse prevention plan Taper antidepressants slowly to avoid discontinuation syndrome discontinuation syndrome Anxiety Anxiety Cycle Stress responses are normal reactions Anxiety is often experienced in your body Anxiety can be a normal reaction that has become too intense or is triggered at times when it is not really needed Physical symptoms Thoughts of : dying, going crazy, (e.g., sweaty, losing control; danger and catastrophe; shaking) being negatively judged by others Avoidance and escape behaviors PM 10

11 PTSD Does Trauma Always Cause PTSD? >1 month Significant distress or impairment PCL-C Exposure to Trauma Hyperarousal (2) Criterion D Sleep difficulties Hypervigilance Irritability & anger Startle Focus & concentration Reexperiencing (1) Criterion B Flashbacks Distressing Recollections Dreams Physiologic Reactivity Psychological Distress at reminders Avoidance (3) Criterion C Thoughts/feelings/Conversations gs/co e sat o s Activities/Places/People Amnesia/Detachment Loss of Interest Restricted Affect Foreshortened Future Most people do not get PTSD as a result of trauma (i.e., post Katrina, 9/11 studies, combat) 70-90% of people report having had at least one traumatic experience (Breslau, 2002;Kessler et al., 1995) NCS-R ( ) US lifetime prevalence: Among Vets lifetime prevalence: Vietnam War: 30.9% 6.8% of all adults; men, 26.9% women 3.6% men, 9.7% Gulf War: 10.1% women OEF/OIF (2008): current prevalence 13.8% 35-50% of patients with chronic pain PTSD & Depression Depression symptoms & PTSD common occurrence 30%-50% of PTSD patients have significant depression symptoms Campbell et al., 2007 analysis of 677 depressed d primary care patients 36% with co-morbid PTSD Patients with PTSD & Major Depressive Disorder More severe depression Lower social support More likely to report suicidal ideation More frequent health care visits PTSD & Substance Use Disorders* % with lifetime history of PTSD suffer with SUD 75% of combat veterans with PTSD struggle with alcohol abuse or dependence 15-41% of people with lifetime history of SUD have current PTSD *Schäfer & Najavits, 2008 Case 4 Mr. P is a 32 yo male recently diagnosed with panic disorder and started on FLUOXETINE about 4 weeks ago. He comes today for follow-up appointment and states that his panic symptoms are much improved, but that he feels emotionally flat. I m not anxious, but I don t feel much of anything either. He also states that his main concern is that since starting the medication, he has had difficulty with ejaculation and at times maintaining an erection, which is also very concerning to his wife. PM 11

12 Short term: Common Side Effects GI upset / nausea Jitteriness / restlessness / insomnia Sedation / fatigue Long term: Sexual dysfunction (up to 33%) Weight gain (5 to 10%) Orgasmic Dysfunction 25 33% of SSRI-treated patients Change to Bupropion Mirtazapine Augment Bupropion SR 100mg PO BID Buspirone 15mg PO BID to 30mg PO BID Weight Gain 5 to 10% of SSRI treated patients Rx Bupropion, Fluoxetine Managing Side Effects Consult with pharmacist / team psychiatrist Are side effects physical or psychological? Short term strategies Wait and support (e.g., GI side effects of SSRIs) Adjust medication timing (e.g., take sedating meds at bedtime) Consider temporary dose reduction Treat side effects (if drug effective) Change to a different antidepressant Change to or add PST-PC What if Patients Don t Improve? Over 30 50% of patients will have a complete response to initial treatment 50 70% will require at least one change in treatment on the way to getting better What if Patients Don t Improve? Is the patient adhering to treatment? Is the dose high enough? See max dose guidelines Is the diagnosis correct?? Bipolar depression? Medical conditions (hypothyroidism, sleep apnea, pain)? Meds: steroids, interferon, hormones? Withdrawal: stimulants, anxiolytics Are there untreated comorbid conditions / life stressors? PM 12

13 Good Reasons to Stop a Medication Questions Intolerable side effects Dangerous interactions with necessary medications The medication was not indicated to start with (e.g., bipolar depression) Medication has been at maximum therapeutic dose without improvement for 4-8 weeks Medication Therapy for Depression /A Anxiety / PTSD Medication Review FDA-Approved Antidepressants Serotonin Reuptake Inhibitors (SSRIs) fluoxetine (Prozac), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), sertraline (Zoloft), fluvoxamine (Luvox) Newer Antidepressants (atypical) bupropion SR (Wellbutrin), mirtazapine (Remeron), venlafaxine XR (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta) Tricyclics (TCAs) secondary amines: nortriptyline, desipramine tertiary amines: imipramine, doxepin, amitriptyline Not recommended for older adults Serotonin Reuptake Inhibitors (SSRIs) Common side effects in all SSRIs (>10 %): GI distress (nausea, diarrhea),insomnia, restlessness, agitation, fine tremor, effects in distress (nausea diarrhea) insomnia restlessness agitation fine tremor headache, dizziness, sexual dysfunction. *mg Drug name Unit doses Therapeutic Usual Starting ti Comments avail.* Fluoxetine 10, daily Long half-life Sertraline 50, daily Citalopram 20, daily Few drug interactions Escitalopram 5, 10, daily Few drug interactions Paroxetine 10, 20, 30, daily Dry mouth, constipation PM 13

14 New Antidepressants: SNRIs New Antidepressants: SNRIs II SNRI side effects: GI distress (NAUSEA, diarrhea), insomnia, restlessness, agitation, fine tremor, headache, dizziness, effects: distress diarrhea) insomnia restlessness agitation fine tremor headache dizziness constipation, decreased appetite, sexual dysfunction. Small risk of elevation of blood pressure at higher doses => check BP. * mg Drug name Unit doses avail.* Therapeutic Usual Starting Venlafaxine 25, 37.5, 50, bid bid 25 daily 75, 100 XR 37.5, XR daily daily 37.5 daily 75, XR 150 (XR) (XR) (XR) Comments Once daily dosing with XR preparation. SNRI side effects: GI distress (NAUSEA, diarrhea), insomnia, restlessness, agitation, fine tremor, headache, dizziness, effects: distress diarrhea) insomnia restlessness agitation fine tremor headache dizziness constipation, decreased appetite, sexual dysfunction. Small risk of elevation of blood pressure at higher doses => check BP. * mg Drug name Unit doses avail.* Therapeutic Usual Starting Duloxetine 20, 30, daily daily 30 daily (no generic) Comments Nausea, dry mouth, constipation, decreased appetite, fatigue, sweating, sexual dysfunction. Enteric coated. DO NOT break tablets! Desvenlafaxine (no generic) Comments 50, daily 50 daily Active metabolite of venlafaxine; similar side effect profile. Mirtazapine Bupropion Drug name Unit doses avail.* Therapeutic Usual Starting Drug name Unit doses avail.* Therapeutic Usual Starting Mirtazapine 15, qhs qhs qhs Bupropion 75,100 SR 100, 150 XL 150, tid bid (SR) daily (XL) tid 75 daily bid (SR) 100 daily (SR) daily (XL) 150 daily (XL) Comments *mg Sedation, weight gain. Minimal sexual side effects. May help with anxiety / nausea. Comments *mg TID dosing with regular preparation. BID dosing with SR. Daily dosing with XL. Insomnia, agitation, tremor. Anorexia; no weight gain. Risk of seizures at high doses. Minimal sexual side effects. Perhaps less mania induction in bipolars. Not good for anxiety. Secondary Amine Tricyclics (TCAs) Common side effects in all TCAs (>10 %): arrhythmias (particularly with pre existing i th i ( ti l l ith iti conduction defects), dry mouth, constipation, blurry vision, orthostatic hypotension, and weight gain. Highly lethal in overdose. *mg Drug name Unit doses avail.* Nortriptyline 10, 25, 50, 75 Desipramine 10, 25, 50, 75, 100, 150 Therap Usual Starting Side effects qhs Weakness/fatigue daily Tachycardia, insomnia, agitation Is Patient at Maximum Therapeutic Dosage?* Fluoxetine 60mg Paroxetine 60mg Escitalopram 20mg Citalopram 40mg Sertraline 200mg Venlafaxine 300mg Desvenlafaxine 100mg Duloxetine 60mg Bupropion SR 450mg Mirtazapine 60mg Nortriptyline 150mg (check serum level) Despramine 300mg (check serum level) *Consider titrating to these doses unless patient does not tolerate them maximum doses due to side effects. PM 14

15 Problems Early in Treatment Nonadherence Medical and psychiatric comorbidity Side effects Unmasking bipolar disorder Activation and suicidal ideation Incomplete response Drug-Drug Interactions Antidepressants are metabolized by the P450 isoenzyme system in the liver. They can change blood levels of other drugs that are metabolized by the same hepatic enzymes displace other protein-bound drugs Rule of thumb: if a patient is on a drug with a narrow therapeutic window (e.g., digoxin, warfarin, theophylline, antiarrhythmics, lithium, TCAs, anticonvulsants), check a serum level of that drug when a steady state of the antidepressant is reached or if there are side effects Consult pharmacist Antidepressant Summary PTSD There are over 30 FDA-approved antidepressants Each is effective in ~ 40 50% of patients It may take several trials until an effective medication is identified Patients need support during this time (work with BHC) If medications are not effective after 8 10 weeks at a therapeutic dose Is patient taking medication as prescribed? Consider substance abuse, bipolar disorder, anxiety disorders, cognitive impairment. Ask every patient about suicidal ideation Consult with team psychiatrist and change treatment (medications, other somatic treatments, psychotherapy) >1 month Significant distress or impairment PCL-C Exposure to Trauma Hyperarousal (2) Criterion D Sleep difficulties Hypervigilance Irritability & anger Startle Focus & concentration Reexperiencing (1) Criterion B Flashbacks Distressing Recollections Dreams Physiologic Reactivity Psychological Distress at reminders Avoidance (3) Criterion C Thoughts/feelings/Conversations gs/co e sat o s Activities/Places/People Amnesia/Detachment Loss of Interest Restricted Affect Foreshortened Future PTSD Pharmacotherapy Medications selected should target PTSD symptoms AND associated co-morbid symptoms Intrusive, avoidant, & arousal symptoms Depression, pain, somatic symptoms Careful clinical evaluation Consider potential side effects of medications PTSD Pharmacotherapy Selective Serotonin Reuptake Inhibitors (SSRI s) First line treatment Paroxetine (Paxil) & Sertraline (Zoloft) FDA approved All SSRI s have demonstrated efficacy in treating core symptoms of PTSD Effective for acute (10-12 week) and extended (24 week) treatment Maintenance Non-responders become responders PM 15

16 PTSD Pharmacotherapy Selective Serotonin and Norepinepherine Reuptake Inhibitor (SNRI) Venlafaxine XR Davidson et al RCT compared Venlafaxine, Sertraline, Placebo Significant improvement in PTSD core symptoms Particular impact on re-experiencing experiencing and avoidance symptoms Start low dose- initial goal 150 mg po qd (SNRI function) Discontinuation syndrome Elevated blood pressure PTSD Pharmacotherapy Benzodiazepines Is NOT first line agents for treating core PTSD symptoms Studies of alprazolam (Xanax), Temazepam (Restoril), Clonazepam (Klonopin) No effect on core symptoms of PTSD Used clinically as adjunctive treatment for sleep, irritability HIGH abuse potential and risk for dependence PTSD Pharmacotherapy SSRI (fluoxetine/prozac, sertraline/zoloft, paroxetine/paxil, citalopram/celexa) SNRI (venlafaxine/effexor, duloxetine/cymbalta) Prazosin & Trazadone / Desyrel targeting arousal symptoms (e.g., sleep) Medical evaluation before prescription PTSD Treatment Summary Psychopharmacological Management Screening and follow-up with PCL Treat core symptoms Target symptoms Insomnia Nightmares Treat co-morbid psychiatric syndromes Major Depressive Disorder Substance Use Disorder Augment with psychotherapy Questions Thank you! PM 16

17 Making Use of a Registry Systematic Outcome Tracking Registry What is it? Why have one? Why Track Outcomes Facilitate treatment planning and adjustment (know when it s time to change) Avoid Patients staying on ineffective treatments for too long Know when to refer for consultation / get help Example: Blood Pressure How Can a Registry Help? Keep track of all clients so no one falls through h the cracks Up to date client contact information Referral for services Tells us who needs additional attention ti Clients who are not following up Clients who are not improving i Reminders for clinicians & managers Customized caseload reports Facilitates communication, mental health specialty consultation and care coordination consultation, and care coordination Caseload Summary: Prioritizing Cases to Review Track Treatment Outcome Over Time PM 17

18 BHC Use of Registry Set aside time each week to review the registry Look for gaps people who need to be contacted high PHQ9 scores people you want to discuss with psychiatrist Consider what other information do I need for the psychiatrist p y Consulting with Behavioral Health Cliniciani i How Recommendations are Created Collaborative Team Approach PCP Consultation ti Video Patient BHC New Roles Core Program Consulting Psychiatrist Other Behavioral Health Clinicians Additional Clinic Resources Substance Treatment, Vocational Rehabilitation, Other Community Resources Outside Resources Working with CM / BHC Collaborative Care Who are the BHCs? Typically MSW, LCSW, RN, or MA / LMFT What makes a good BHC? Effective organization skills Persistence Creativity and flexibility Willingness to learn Strong patient advocate Caseload-focused psychiatric consultation supported by a behavioral health specialist Psychiatrist has Better access More patients regular (weekly) PCPs get input on their covered by one meetings with a BHS patients behavioral psychiatrist health problems: same Reviews all patients who are not improving and makes treatment recommendations Focuses in-person visits iit on the most challenging patients day or within a week versus months Psychiatrist provides input on patients in a half day as opposed to 3-4 patients PM 18

19 Consultation Demonstration Commonly Used Screeners Ms Smith 31 yo female PHQ9=18 GAD7=15 GAIN-SS 0/5 CIDI- PCL-C=71 Mood Disorders PHQ-9: Depression MDQ: Bipolar disorder CIDI: Bipolar disorder Anxiety Disorders GAD- 7: Anxiety, GAD PCL-C: PTSD OCD: Young- Brown Social Phobia: Mini social phobia Psychotic Disorders Brief Psychiatric Rating Scale Positive and Negative Syndrome Scale Substance Use Disorders CAGE-AID AUDIT Cognitive Disorders Mini-Cog Montreal Cognitive Assessment Provisional Diagnosis Preparing for Consulting Psychiatrist i t Screeners filled out by patient Assessment by CM and PCP Provisional diagnosis and treatment plan Consulting Psychiatrist Case Review or Direct Evaluation Consulting Psychiatrist Note I Consulting Psychiatrist Note - II Ms Smith 31 yo female PHQ9=18; GAD7=15; GAIN-SS 0/5; CIDI-; PCL-C=71 presents with poor motivation, anhedonia, rumination, increased anxiety, increased worry history of trauma exposure, and presenting with re-experiencing, avoidance, and hyper-arousal symptoms reports poor sleep initiation and middle insomnia due to nightmares currently on CITALOPRAM 40 mg once daily for the past 6 weeks previous history: no hospitalizations, no suicide attempts; previous diagnosis of PTSD related to experience of dog attack; previous medication trial WELLBUTRIN MEDICAL HISTORY: Migraine, Back Pain ALLERGIES: DICLOFENAC BMI BP 126/100 LABS: BUN/Cr/Glucose 11/0.73/78 AST/ALT 16/23 TSH 3.67 ASSESSMENT: Major Depression, Anxiety with prominent PTSD features, previous diagnosis PTSD RECOMMENDATIONS: 1. increase CITALOPRAM to 20 mg once daily 2. start PRAZOSIN 2 mg at bedtime; monitor for orthostasis (anticipate further modification based on response) 3. start t AMBIEN 10 mg at bedtime e for 2 weeks 4. follow-up regarding elevated blood pressure and adjustment of current antihypertensive treatment 5. refer to nutritionist to discuss diet and exercise plan 6. Follow treatment response with PHQ9 and PCL-C 7. Weekly follow-up with CM (BHC) to support treatment adherence PM 19

20 Consulting Psychiatrist Note - III Assessment and Diagnosis in the Primary Care Clinic The above treatment considerations and suggestions are based on consultation with the patient's care coordinator and a review of information available in the Mental Health Integrated Tracking System (MHITS). I have not personally examined the patient. All recommendations should be implemented with consideration of the patient's relevant prior history and current clinical status. Please feel free to call me with any questions about the care of this patient. Wayne Bentham, MHIP Psychiatric Consultant. Telephone: wbentham@uw.edu Provide intervention Gather information Generate a treatment plan Exchange information Diagnosis i can require multiple iterations of assessment and intervention Advantage of population based care is longitudinal observation and objective data Start with diagnosis that is your best understanding A Different Kind of Note Communication: How and When? Traditional Consult Note One consult note Integrated Care Consult Note Note 1: January Pt still has high PHQ Note 2: February Side effects Note 3 - Pt improved! Communication is key to team function! Consider modality: In person Staff (MA or nurse) Phone Fax (careful with confidential info) EMR Frequency Scheduled As needed PCP Core Program Patient t Consulting BHC Psychiatrist Other Behavioral Health Clinicians Substance Treatment, Vocational Rehabilitation, CMHC, Other Community Resources Additional Clinic Resources Outside Resources Most Common Consultation Questions Thank-you! Clarification of diagnosis Consider re-screening patient Patient may need additional assessment Address treatment resistant disorders Make sure patient has adequate dose for adequate duration Provide multiple additional treatment options Recommendations for managing difficult patients Help differentiate crisis from distress Support development of treatment plans/team approach for patients with behavioral dyscontrol Support protocols to meet demands for opioids, benzodiazepines etc Support the providers managing THEIR distress James D. Ralston PM 20