Treating Depressed Patients with Comorbid Trauma

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1 LearningObjectives TreatingDepressedPatients withcomorbidtrauma RitaHaverkamp,MSN,PMHCNSBC,CNS ExpertCareManagerandAIMSTrainer Bytheendofthistraining,participantsshouldbe ableto: Discussrecenttrendsintraumacareandhowthiscan influencedepressioncare ListwaysinwhichtraumacanIMPACTeachstageof theimpactworkflow Recognizepatientswithtraumahistory Assessimpactoftraumaoncurrentfunctioningandability toengageindepressiontreatment treatmentfordepressioneveninthepresenceof traumahistory Identifypatientswhoneedtohavemoreintensivetrauma treatment Whyarewetalkingabouttrauma? Common Canpreventengagement Canpreventremissionofsymptoms Bidirectionalproblem focusingonitandnotfocusingonitcanaffect engagementand/orremissionofdepressive symptoms Exposuretotraumaticeventsis relativelycommon(kaysen,2009) 39% 90%of Americansendorse lifetimetraumatic stressexposure 50%ofpeople exposedtoone eventhavemultiple incidentexposures 20%endorse current(pastyear) exposure Trauma: Newfadornewtreatmenthorizon? Traumainformedcare ACE s Evidencedbasedtraumatreatments ACEstudy TheACEstudyfindingssuggestthatcertain experiencesaremajorriskfactorsfortheleading causesofillnessanddeathaswellaspoorqualityof lifeintheunitedstates. 1

2 ACEstudy Becareful Correlationversuscausation Causationversuswhattreatmentismosteffective ofthisaceprocess? Thisstudydoesn ttelluswhatwillmitigatethese effectsiftheyhavealreadyhappened MainindicationoftheACEstudyisintervention earlyinhouseholdsatriskforchildhoodincidents maypreventthisprocess TraumaInformedCare Atraumainformedapproachcanbeimplemented inanytypeofservicesettingororganizationandis distinctfromtraumaspecificinterventionsor treatmentsthataredesignedspecificallyto addresstheconsequencesoftraumaandto facilitatehealing.samhsa Notaddingtoapatient straumaorre traumatizationofpatient Resiliency:thepositivesideoftrauma Thetendencytoadapttoriskoradversity Helpspeoplerecoverfromadverseincidents Higherresiliencymakesapatientlesslikelyto developptsd Restoringtheseintreatmentfordepressionmay restoretheirabilitytocopewithtrauma Resiliency Whateverdoesnotkillus,JPSP,2010 Longitudinalstudydemonstratingushapedrelationship betweenadverselifeeventsandmh/wellbeing ResilienceintraumaexposedinnercityPCpatients, JNatl MedAssn,2011 Resiliencewascommondespitehighlevelsoftrauma exposureandptsd 10itemselfreportresiliencescale 2

3 Becareful Realitythatpatienthastraumadoesnotabsolutely leadtoaneedtodealwithtraumaallofthetime IMPACTWorkflow:Identify& ApproachatKaiserandmanyothersystems outpatientpsychiatry notreadyfordealingwith childhoodsexualabuse/othertraumaifdepressed Identifyand Assesstraumabutnotretraumatize Focusonfunction PCLC Tipsforaskingabouttrauma #1 Topreventretraumatizing/ dissociationandtriggeringof PTSDsymptoms Encourageshort,concise descriptionsofthetrauma askfor23sentencesor 25wordsorlesstogeta generalsenseofthe trauma bedirectiveandfeel freetostopthetellingif youseethepatient gettingupset Normalizetheextreme difficultypatientsoften haveinretellingtheir stories #2 Becausepatients Oftenhaveuniquepostinjuryconcerns Interprettraumauniquely Postinjurydistressmaybedescribed differently Dontstartwithachecklist Encouragethemtotelltheir storyintheirownwords Useopenendedquestions Remember,you don tneedthe detailstomake thediagnosisor treatdepression #3 Ifpatientdissociates Helpthepatientground themselvesbydirecting themtoengageintheir immediateenvironment Oncegrounded,educate ondissociation 3CriticalElementsofment Let ssetasideyourrhythmissuesfora momentandworkonyourblues Goals? Tasks? Bond? Working Alliance All3mustbeagreeduponbypatient&provider 3

4 Assesspatient sdesirefortreatmentof trauma Whatbringsyoutoseeme?Whatareyouexpecting inthisvisittoday? Whatareyouhopingtogetfromyourcare? Ifyoupushtraumatreatmentmanywillprobably takeit butisthisbestforthem? Assessingwhethertoworkontraumaor not Isthisaforegroundissueorabackgroundissue? Areyouexperiencedandfullytrainedinan evidencedbasedapproach? Couldthisberesolvedinashorttimeframe? Isthepatientlikelytogetworsebeforebetterand canoursystemhandlethat?canthepatienthandle that? IMPACTWorkflow:Establisha Establisha Theyneedtoeachhaveadiagnosisofdepression ofptsdvs.pasthistoryoftrauma Usecaseloadconsultationtohelpdifferentiate DoestraumaalwayscausePTSD? PTSD&Depression MostpeopledonotgetPTSDasaresultoftrauma (i.e.,postkatrina,9/11studies,combat) 7090%ofpeoplereporthavinghadatleastonetraumaticexperience (Breslau,2002;Kessleretal.,1995) NCSR( ) USlifetime prevalence: 6.8%ofalladults; 3.6%men,9.7%women AmongVetslifetime prevalence: VietnamWar:30.9% men,26.9%women GulfWar:10.1% OEF/OIF(2008):current prevalence13.8% 3550%ofpatients withchronicpain PatientswithPTSD &MDDinprimary care: Campbelletal.(2007) Moreseveredepression Lowersocialsupport Morelikelytoreport suicidalideation Morefrequenthealth carevisits PTSD 30%50%of PTSDpatients havesignificant depressive symptoms Depression 4

5 SIF Webinar: Treating Depressed Patients with Comorbid Trauma PTSD Checklist Four Item Screen PTSD Symptoms Criterion B ReͲexperiencing Flashbacks Distressing recollections Dreams Physiological reactivity Psychological distress at reminders P ost T raumatic S tress D isorder 05/13/2015 (1) Criterion C Thoughts, feelings, & conversations Activities/Places/People Amnesia Detachment Loss of interest Restricted affect Foreshortened future PTSD Hyperarousal Avoidance (3) (2) Criterion D Sleep difficulties HyperͲvigilance Irritability & anger Startle Concentration Kaysen, 2009 PTSD Screening IMPACT Workflow: The total score is the sum of all 17 items A score of ш 45 suggests the presence of a significant level of symptom severity Goal: 50% drop in score or < 30 Walker EA, Katon W, Russo J, Ciechanowski P, Newman E, Wagner AW. Health care costs associated with posttraumatic stress disorder symptoms in women. Arch Gen Psychiatry Apr;60(4): WHO stress guidelines, 2013 First step is most often focus on depression BA and PST can be used to help the avoidance symptoms Antidepressants can also help PTSD symptoms Special considerations if patients have PTSD TraumaͲfocused tx s should be provided to adults with ASD or PTSD if provider is trained; otherwise, stress management If moderateͳsevere depression is concurrent, provider should follow WHO depression guidelines as well Consider prazosin to target nightmare Avoid benzodiazipenes 5

6 VA/DoD ClinicalPracticeGuidelinefor PTSD,2010 CautionsforCBTinPTSD ComorbidtreatmentcanusuallybeprovidedinPC setting(lotsofcaveatsre:providercomfort/skills; specialtyprovideravailability,etc.),butmore severecomorbiditiesshouldbereferredtospecialty oratleastconsultationsought IatrogenicDangers: Exposurewithnocopingorhabituation Repressedmemories Exploringthepastinpsychotherapy RequiredforengagingTrauma FocusedCBT(goldstandardtx): abletocometosessions support resourcesavailable adequatementalstatus copingskills BAandPSTforPTSD Goals Increaseactivitylevels Preventavoidancebehaviors Increasepositiveandrewardingactivities Whattodo? Identifycurrentavoidancebehaviorsandactivitiesthatarevaluedand rewarding Depressiveavoidance:dobehaviorsresultfromfeelingdepressedandis anxietyreduced Dobehaviorsfunctiontoreduceanxiety/fear Dobehaviorsleadtofunctionalimpairmentanddepression Evaluateobstaclesfordoingtheseactivities Setgoalsfornumberandfrequencyandtrackinsession OtherSkillstoManageAnxiety Symptoms Deepmusclerelaxation Breathingrelaxation Preparingforastressor Activeproblemsolving Attentiontohealthhabits caffeine,alcohol,sleep,deconditioning,substanceabuse IMPACTWorkflow:FollowupCareand Treatto FollowupandAdjust Importanttoconsiderifpatient sdepressionisnot responding Whentoconsiderreferraltospecializedcare 6

7 FollowupConsiderations Watchpatient sphq9carefully Watchtheirresponsetotreatment feelingsatend ofsession Maintainbriefnatureofinterventions Consultregularly moreoftenthan8weeks Changetreatmentifpatientishavingdifficulties Contraindicationsforprolongedexposure EuroJPsychotraumalogy,2012 Patientswithdepressionmuchmoreseverethan theirptsdorpatientswithcurrentsuicidalintent andbehavior,asdiscussedabove,areroutinely excludedfromptsdtrials,asclinicallyappropriate carewouldrequirestabilizingtheseissuespriorto addressingtheirptsd. ConsultationandConsiderationsfor ReferralforSpecialtyCare IMPACTWorkflow:Relapse PatienthasahighPTSD PCLCscoreabove45 Patientisn timprovingwitheitherorbothpcland PHQoveraperiodoftime Youaren ttrainedinanevidencedbasedapproach forthistraumaandpatientneedsmorespecificcare Patientisrespondingbutwillneedlongertermcare Relapse Considerbothdepressionandtraumatriggers Highlightthecognitiveandrelaxationtechniques thathavebeenhelpful makingspecific connectionswhenyoucan SelectingaCase FollowupCaseCall Wednesday,June10 th, 10:0011:30am CasePresentationForm 7