Change Management Presented by: Karen L. Swartz, M.D. November 1, 2014
Disclosures I have no relevant financial relationships with commercial interests to disclose
Objectives To discuss the many types of potential change in everyone s life To recognize the potential consequences of change including poor health outcomes To recognize when the reaction to change is problematic and needs specific treatment
Holmes and Rahe Social Readjustment Rating Scale Life Event Rating Death of a Spouse 100 Divorce 73 Detention in jail 63 Death of a close family member 63 Marriage 50 Retirement from work 45 Gaining a new family member 39 Outstanding personal achievement 28
Common types of Change Family Role changes Losses Health New diagnoses Changes in level of function Work Job changes Retirement
Autonomic Nervous System Sympathetic Physical Response Parasympathetic Inhibits flow Saliva Stimulates flow Accelerates Heart rate Decreases Dilates Bronchi in lungs Constricts Inhibits Convert glycogen to glucose GI: peristalsis and secretion Liver Stimulates Release of bile FIGHT or FLIGHT REST and DIGEST
Allostasis Definition: process of stability through change Allows adaptation to a changing environment to optimize function and ensure survival Sterling & Eyer, Handbook of Life Stress, Cognition and Health, 1988; McEwen, Ann N Y Acad Sci, 1998; McEwen & Stellar, Arch Intern Med, 1993
Mediators of Allostasis Karatsoreos & McEwen, Trends Cogn Sci, 2011
Resilience The ability to rebound from adversity when one s ability to function has been impaired to some degree The ability to adapt to stressors in the environment by bending but not breaking Karatsoreos & McEwen, Trends Cogn Sci, 2011; Karatsoreos & McEwen, F1000Prime Reports, 2013
Eysenck s Personality Styles Extravert Present focused Immediate gratification Reward seeking Quick emotional responses that shift quickly Easily bored Embraces change Introvert Future focused Able to defer gratification Punishment avoidant Slow emotional responses that resolve slowly Not easily bored Finds change challenging
Allostatic load and overload Cumulative wear and tear on the body after prolonged or poorly regulated allostatic responses
Work-Family Conflicts and Poor Health Behaviors Surveys of 40-60 year old employees British Whitehall II Study, n = 3,397 Finnish Helsinki Health Study, n = 4,958 Japanese Civil Servants Study, n = 2,901 Measurement of conflicts with 8 items Outcomes: smoking, heavy drinking, physical inactivity, and unhealthy food habits Lallukka et al., Int J Behav Med, 2010
Measurement of Work-to-Family Conflicts Job responsibilities interfere with family life 1. Job reduces the amount of time you spend with family 2. Problems at work make you irritable at home 3. Your work involves a lot of travel away from home 4. Your job takes so much energy do not feel up to doing things that need attention at home Family responsibilities interfere with job performance 1. Family matters reduce time you have for your job 2. Family worries or problems distract you from your work 3. Family activities stop you from getting sleep 4. Family obligations reduce time to relax Lallukka et al., Int J Behav Med, 2010
Unhealthy behaviors associated with strong work-family conflicts Current smoking (M > W) Unhealthy food habits (W > M) Heavy drinking (W > M in British and Finnish cohorts) No association with physical inactivity Lallukka et al., Int J Behav Med, 2010
Midlife adversity predicts post-retirement depression 3,939 Whitehall II Study participants Midlife adversities Low occupational position, poor standard of living, high job strain, few close relationships Strong associations between midlife adversity and post-retirement depressive symptoms (CES-D) Virtanen et al., Am J Geriatr Psychiatry, 2014
Stress and well-being among parents of children with rare diseases 138 families in Sweden 136 mothers (20% single mothers) 108 fathers Comparison to mothers and fathers with healthy children Mothers of ill children with more parental stress and high physical and emotional strain than fathers or comparison mothers Highest baseline levels of parental stress with single mothers and more than 1 disabled child Dellve et al., Journal of Advanced Nursing, 2006
Intervention to empower parents to manage child s disability Intensive programs focused on specific rare diseases Fathers with high levels of stress related to incompetence, reduced with education Intervention reduced stress in full-time working mothers, not in mothers primarily at home Mothers reported increased support from spouses following intervention Dellve et al., Journal of Advanced Nursing, 2006
Strategies to manage change Manage expectations Recognize the need to makes changes in response to new challenges Identification of supports and resources to deal with change Use of relaxation techniques
Norman Rockwell s Freedom from Want
Relaxation Techniques Progressive muscle relaxation Yoga Meditation Visualization Mindfulness training Exercise
Alterations in Brain and Immune Function following Meditation Training Randomized Clinical Trial comparing: Meditation training program (n = 25) Wait-list control group (n = 16) 8-week training program in mindfulness meditation (weekly classes of 2-3 hours) plus a retreat and daily home practice Davidson, Kabat-Zinn, et al., Psychosomatic Medicine, 2003
Changes in self-reported anxiety following meditation training Davidson, Kabat-Zinn, et al., Psychosomatic Medicine, 2003
Mean changes in antibody response to influenza vaccine Davidson, Kabat-Zinn, et al., Psychosomatic Medicine, 2003
Anxiety Response Cycle Anxiety Increases Trigger Anxious Interpretation Avoidance Safety Behavior Perpetuates Anxiety, Fears Never Disconfirmed Anxiety Decreases Temporarily
Response to anxiety Two options with anxiety Avoid Tolerate the distress The disability associated with anxiety disorders often comes from avoidance
Grief Bereavement a loss through death Grief the feelings and associated behaviors accompanying the awareness of irrevocable loss (including, but not limited to a loss through death)
Five Stages of Grief: Elisabeth Kübler-Ross 1. Denial and Isolation 2. Anger 3. Bargaining 4. Depression 5. Acceptance Elisabeth Kübler-Ross, On Death and Dying, 1969
Typical symptoms of grief Waves of emotions of varying intensity Crying and sadness Shock Anger Decreased appetite Difficulty sleeping Poor concentration
Predictors of long-term response to grief Degree to which person acknowledges the reality and consequences of the event Flexibility and effectiveness of the person s coping skills Availability of support and the individual s willingness to use it Bassuck & Birk, Emergency Psychiatry, 1984
Grief & Unhealthy Behaviors Stressful life events including grief as a potential antecedent for initiating potentially destructive behaviors Stressful life events triggering a relapse or intensifying the behavior Anniversary dates as a time of increased risk of relapse
Grief & Mood Disorders Comorbid disorders increase the risk of a complicated grief reaction or worsening symptoms Grief may trigger an episode of illness Grief induced depression often missed Grief induced mania dramatic example, less likely to be interpreted as a normal reaction
Grief vs. Depression Grief Intense, 1-2 months Suicidal ideas rare Hallucinations transient, linked to deceased Intense waves of emotion Self-attitude usually intact Major Depression Sustained symptoms Suicidal ideas often present Hallucinations mood congruent, not linked to deceased Continuous symptoms Self-attitude decreased
Symptoms of Major Depression Depressed or irritable mood or feeling nothing Decreased interest or pleasure in activities (anhedonia) Change in appetite or weight Sleeping more or less than usual Feeling restless or slowed down Fatigue or loss of energy Decreased concentration Feelings of guilt or worthlessness Recurrent thoughts of death or suicide
Major Depression Five or more of the depressive symptoms present during the same two week period The symptoms cause clinically significant distress or impairment in functioning The symptoms are not due to the effects of alcohol or other substances or a medical condition (but comorbidity common) Depressive episodes only, no manic or hypomanic episodes
Epidemiology of Major Depression Lifetime prevalence rates Women 10% 25% Men 5% 12% Rates equal for pre-pubertal boys and girls Rates in women twice those of men following menarche
Depression and Neurologic Disorders Prevalence of Depression Parkinson s Disease 40 50 % Multiple Sclerosis 35 % Migraine Headaches 40 % Alzheimer s disease 30 50 % Amyotrophic Lateral Sclerosis no increase Mayeux R, Handbook of Parkinson s Disease, 1992; Sadovnick et al., Neurology, 1996; Breslau et al., Neurology, 2000; Rabkin, et al., Psychosomatic Medicine 2000; 62:271-9
Treatment of Mood Disorders Medications antidepressants & mood stabilizers Individual psychotherapy Education and support Family involvement and/or family therapy Control of behaviors (alcohol abuse, substance abuse, eating disorders, and cutting) Other treatments Electro-convulsive therapy (ECT) Bright Light Therapy
Practical Supplemental Treatments Adequate, regular sleep Exercise or physical activity Healthy eating habits No alcohol, drugs, destructive behaviors Distracting activities (movies, easy books, or seeing friends) Regular schedule get up, take a shower, and leave the house Smoking cessation may worsen symptoms
Antidepressant Medications Selective Serotonin Reuptake Inhibitors Celexa, Lexapro, Paxil, Prozac, Zoloft Tricyclics Nortriptyline, Desipramine, Imipramine Selective Serotonin-Norepinephrine Inhibitors Cymbalta, Effexor MAO Inhibitors Nardil, Parnate Others Remeron, Trazodone, Wellbutrin
Antidepressant Celexa Lexapro Starting dose 10 20 mg 5 10 mg Therapeutic dose range 20 40 mg 10 20 mg Luvox 50 mg 100 300 mg Paxil 10 20 mg 20 50 mg Prozac 10 20 mg 20 80 mg Zoloft 25 50 mg 50 200 mg Effexor XR 37.5 75 mg 75 375 mg Nortriptyline 10 25 mg 50 150 mg Rosenbaum et al., Handbook of Psychiatric Drug Therapy, Fifth Edition, 2005
Types of change Change that happens around you Job and family Change that happens within you Health and attitudes Change that you cause in yourself Attitudes, behaviors and treatment
Factors influencing the impact of change Expected vs. Unexpected Short-term vs. Chronic Choice vs. Imposed
Take home points Change is a normal part of life Having a positive response to change takes an active effort Depression, anxiety and other conditions may be triggered by change A comprehensive approach to change management should consider an evaluation for other conditions
29 th Annual Mood Disorders Research & Education Symposium Tuesday, April 21, 2015 The Best-Practices in the Treatment of Mood Disorders For additional information: www.hopkinscme.edu