20 WAYS TO OVERCOME BARRIERS TO RECOVERY

Prof. Courtenay M. HardingProf. Courtenay M. Harding

Professor of Psychiatry and Director, Professor of Psychiatry and Director,

Center for Rehabilitation and RecoveryCenter for Rehabilitation and Recovery

The Coalition of Behavioral Health Agencies - The Coalition of Behavioral Health Agencies - NYCNYC

Good Morning! OVERALL GENERAL INFORMATION OVERALL GENERAL INFORMATION

FOR TODAYFOR TODAY What’s in the folders?What’s in the folders? How to work with this informationHow to work with this information Take a break for phone & bathroomTake a break for phone & bathroom Ask questions as we go alongAsk questions as we go along Evaluations and Certificates at endEvaluations and Certificates at end

THE PRESENTATION PLAN

Review 20 obstacles with Review 20 obstacles with strategies to get some strategies to get some answers or how to better answers or how to better understand the understand the complications. Lots of complications. Lots of resources!resources!

IF RECOVERY AND SIGNIFICANT IMPROVEMENT ARE

POSSIBLE……….

THEN WHY ARE SO MANY THEN WHY ARE SO MANY PARTICIPANTS NOT PARTICIPANTS NOT GETTING BETTER?GETTING BETTER?

2.5 – 5 MILLION PEOPLE 2.5 – 5 MILLION PEOPLE LANGUISHING IN US ALONELANGUISHING IN US ALONE

ACKNOWLEDGMENT & APPRECIATION

TO ALL THE CLINICIANS & FAMILIESTO ALL THE CLINICIANS & FAMILIES WHO CAREWHO CARE WHO SPEND TIME PROBLEM WHO SPEND TIME PROBLEM

SOLVINGSOLVING WHO CHALLENGE THE STATUS WHO CHALLENGE THE STATUS

QUOQUO WHO SPEND TIME GOING THE WHO SPEND TIME GOING THE

EXTRA MILEEXTRA MILE

HOWEVER………..

If your participant seems to be If your participant seems to be “stuck” on the path to recovery let’s “stuck” on the path to recovery let’s look at some possible reasons and look at some possible reasons and ways to change the Individual ways to change the Individual Recovery Plan (IRP)……Recovery Plan (IRP)……

Learning to play a detective !

LOOKING FOR THE “PERSON UNDER THE DISORDER”

COMPREHENSIVE RE-EVALUATION COMPREHENSIVE RE-EVALUATION NEEDED NEEDED (based on history, careful (based on history, careful interview, lab findings & physical exam)interview, lab findings & physical exam)

BIO-PSYCHO-SOCIAL-SPIRITUAL BIO-PSYCHO-SOCIAL-SPIRITUAL APPROACHAPPROACH

SYSTEMATIC & MULTIDISCIPLINARYSYSTEMATIC & MULTIDISCIPLINARY

YOU NEED TO LOOK AT A PERSON TWICE…… once with your heart and then with your head……..

FIRST TO SEE THE FIRST TO SEE THE SIMILARITIESSIMILARITIES

AND ONLY THEN CAN YOU AND ONLY THEN CAN YOU APPRECIATE THE APPRECIATE THE DIFFERENCESDIFFERENCES

QUESTION #1

HAVE OTHER POSSIBLE HAVE OTHER POSSIBLE CAUSES OF SYMPTOMS CAUSES OF SYMPTOMS AND BEHAVIORS BEEN AND BEHAVIORS BEEN ELIMINATED?ELIMINATED?

DIAGNOSIS OF EXCLUSION(especially schizophrenia)

26 other disorders (medical, 26 other disorders (medical, neurological, and psychiatric) neurological, and psychiatric) that masquerade with that masquerade with schizophrenia-like schizophrenia-like symptoms !symptoms !

DIAGNOSIS OF EXCLUSION

(schizophrenia) Autism (esp. Asperger’s Autism (esp. Asperger’s

Syndrome)Syndrome) Temporal Lobe EpilepsyTemporal Lobe Epilepsy TumorTumor StrokeStroke

MORE THINGS TO EXCLUDE

Brain TraumaBrain Trauma Endocrine & Metabolic Disorders Endocrine & Metabolic Disorders

(e.g. acute intermittent porphyria (e.g. acute intermittent porphyria (liver enzyme)(liver enzyme)

Homocystinuria (a disorder of amino Homocystinuria (a disorder of amino acid metabolism)acid metabolism)

MORE THINGS TO EXCLUDE

Vitamin Deficiency (e.g. B 12)Vitamin Deficiency (e.g. B 12) Central Nervous System Infectious Central Nervous System Infectious

Processes (e.g. AIDS, neurosyphilis, Processes (e.g. AIDS, neurosyphilis, or herpes encephalitis)or herpes encephalitis)

Autoimmune Disorders (systemic Autoimmune Disorders (systemic lupus erthymatosa)lupus erthymatosa)

Heavy Metal Toxicity (e.g. Wilson’s Heavy Metal Toxicity (e.g. Wilson’s Disease – too much copper)Disease – too much copper)

EVEN MORE TO EXCLUDE:

Some Drug Induced States (e.g. Some Drug Induced States (e.g. amphetamines, barbiturate withdrawal, amphetamines, barbiturate withdrawal, cocaine, digitalis, disulfram)cocaine, digitalis, disulfram)

Mood disorders, schizoaffective disorder, Mood disorders, schizoaffective disorder, Personality disorders, Personality disorders, Brief Reactive Psychosis, Brief Reactive Psychosis, OCD OCD

Differential Diagnoses for Mood D/O (based on history, careful interview, lab findings

& physical exam)

Multiple SclerosisMultiple Sclerosis StrokeStroke Hyper & Hyper &

HypothyroidismHypothyroidism BereavementBereavement DementiaDementia Cancer (esp. of Cancer (esp. of

Pancreas)Pancreas) Spinal Cord InjurySpinal Cord Injury Peptic UlcerPeptic Ulcer MononucleosisMononucleosis

Huntington’s DiseaseHuntington’s Disease AIDSAIDS End-stage Renal End-stage Renal

DiseaseDisease Head InjuryHead Injury Parkinson’s DiseaseParkinson’s Disease LupusLupus Hyper & Hypo Hyper & Hypo

parathyroidismparathyroidism HepatitisHepatitis

SUGGESTED INSTRUMENT

Basis-24Basis-24 ““a leading behavioral health assessment”a leading behavioral health assessment” ComprehensiveComprehensive Cuts across diagnostic categoriesCuts across diagnostic categories Provides weighted averageProvides weighted average Overall score plus 6 subscalesOverall score plus 6 subscales (sub abuse, symptoms and functioning, (sub abuse, symptoms and functioning,

relationships, self harm, emotional liability, relationships, self harm, emotional liability, psychosis, and depression)psychosis, and depression)

SUGGESTED INSTRUMENT

SCID –THE STRUCTURED SCID –THE STRUCTURED CLINICAL INTERVIEW FOR CLINICAL INTERVIEW FOR DSM-IV TRDSM-IV TR

CLINICAL VERSIONCLINICAL VERSION

HOW TO DO BETTER………

Take the time get Take the time get triangulated informationtriangulated information

Get the lab tests doneGet the lab tests done Reassess over timeReassess over time Pay attention to comorbid Pay attention to comorbid

d/od/o

Treat or refer other diagnoses

Establish links and a little black book with other medical colleagues across the local community

Work with your colleagues in other fields to understand what happened and how to understand your participant who may still appear to them to have a psychiatric disorder

Health Homes are coming as networks of partnerships treating person in a holistic way

Partners include hospital, primary care docs, mental health and addiction services + + +

OR IF PSYCHIATRIC DIAGOSIS IS RE-ESTABLISHED

All diagnosis are cross-sectional All diagnosis are cross-sectional working hypothesesworking hypotheses

Not lifetime labelsNot lifetime labels Not able to predict long-term outcomeNot able to predict long-term outcome Write enough evidence to “convict” Write enough evidence to “convict”

person of the diagnosis into the case person of the diagnosis into the case recordrecord

REMEMBER TO LOOK FOR & RECORD STRENGTHS

Strengths of your participant ( e.g. Strengths of your participant ( e.g. insight? Manage meds? Manage S/S ? insight? Manage meds? Manage S/S ? Uses strategies to recognize oncoming Uses strategies to recognize oncoming prodrprodrôôme? Uses coping to reduce me? Uses coping to reduce anxiety? Computer skills? Has driver’s anxiety? Computer skills? Has driver’s license? ETClicense? ETC

Working with the strengths rather than Working with the strengths rather than deficits, problems and disabilities – that is deficits, problems and disabilities – that is what helps people get betterwhat helps people get better

EBP:WELLNESS MANAGEMENT AND RECOVERY PROGRAM-1

CLINICIAN BENEFITS:CLINICIAN BENEFITS: A comprehensive step by step A comprehensive step by step

approachapproach Ready-to-use materialsReady-to-use materials Skills is using motivational , Skills is using motivational ,

cognitive behavioral and cognitive behavioral and educational strategieseducational strategies

Satisfaction to see Satisfaction to see outcomes outcomes

EBP: WELLNESS MANAGEMENT AND RECOVERY PROGRAM-2

CLINICIANS RECEIVE: CLINICIANS RECEIVE: guide with practical tipsguide with practical tips handouts, checklists, planning sheetshandouts, checklists, planning sheets intro videointro video info brochuresinfo brochures fidelity scalefidelity scale outcome measuresoutcome measures

EBP: WELLNESS MANAGEMENT AND RECOVERY PROGRAM-3

• Recovery strategiesRecovery strategies• Practical facts Practical facts

about miabout mi• Stress-Vulnerability Stress-Vulnerability

& treatment & treatment strategiesstrategies

• Building social Building social supportssupports

• reducingreducing• relapsesrelapses• using medsusing meds• effectivelyeffectively• coping withcoping with• stressstress• coping withcoping with• problems & symptomsproblems & symptoms• getting yourgetting your• needs met in the mh needs met in the mh

systemsystem

EBP: ILLNESS (WELLNESS) MANAGEMENT AND RECOVERY PROGRAM-4

RESOURCES:RESOURCES: Wellness Self-Management & Plus by Columbia

University – Paul Margolies and Tony Salerno http://www,mentalhealth.samhsa.gov/cmhs/comm

unitysupport/toolkit http://www.mentalhealthpractices.org/imr_mlpl. html Liberman RL et al, describing UCLA Models,

Innovations & Research, Vol2(2), 1993 P.A. Garrety et al , Schiz Bull, 2000

QUESTION #2

Is there an Is there an additional additional neurological neurological impairment?impairment?

THE DEFICIT SYNDRÔME

+/- S/S of Schizophrenia Come and Go +/- S/S of Schizophrenia Come and Go (esp. + symptoms)(esp. + symptoms)

Attempts to find primary, enduring stable Attempts to find primary, enduring stable negative symptomsnegative symptoms

Subtype or Additional D/OSubtype or Additional D/O Neurological Impairments ( sensory Neurological Impairments ( sensory

integration, stereognosis, graphesthesia, integration, stereognosis, graphesthesia, right-left confusion, the face-hand test, & right-left confusion, the face-hand test, & audiovisual integration)audiovisual integration)

THE DEFICIT SYNDRÔME - 2

Poor premorbid social functioningPoor premorbid social functioning Reduced glucose uptake in the frontal Reduced glucose uptake in the frontal

cortex, parietal & thalamic areas on PET cortex, parietal & thalamic areas on PET scansscans

Increased anhedonia and fewer psychotic Increased anhedonia and fewer psychotic eventsevents

Earlier onset, seems to be unremitting, Earlier onset, seems to be unremitting, suffer spontaneous movement d/o, severe suffer spontaneous movement d/o, severe cognitive impairmentscognitive impairments

THE DEFICIT SYNDRÔME - 3

Deficit PARTICIPANTs in comparison to Deficit PARTICIPANTs in comparison to NonDeficitNonDeficit

PARTICIPANTs show: PARTICIPANTs show: Equal positive symptoms (hallucinations, Equal positive symptoms (hallucinations,

delusions, and formal thought d/o)delusions, and formal thought d/o) Less severe dysphoric symptoms (e.g. Less severe dysphoric symptoms (e.g.

depressive mood, anxiety, guilt, & hostility)depressive mood, anxiety, guilt, & hostility) Less severity of suspiciousnessLess severity of suspiciousness Similar duration of illnessSimilar duration of illness Brain architecture seems to be more intact in Brain architecture seems to be more intact in

some areassome areas

THE DEFICIT SYNDRÔME - 4

Need longitudinal informationNeed longitudinal information Use SDS or PDS CriteriaUse SDS or PDS Criteria Exclude: drug effect & demoralizationExclude: drug effect & demoralization Need 2 of of the following for more than a Need 2 of of the following for more than a

year: year: restricted affect, restricted affect, diminished emotional range, diminished emotional range, poverty of speech,poverty of speech, curbing of interests, curbing of interests, diminished sense of purpose and social drivediminished sense of purpose and social drive

THE DEFICIT SYNDRÔME - 5

USE SCREENING TOOL: THE USE SCREENING TOOL: THE Neurological Evaluation Scale Neurological Evaluation Scale (NES)(NES)

TRY: TRY: Atypical NeurolepticsAtypical NeurolepticsCognitive RemediationCognitive RemediationOther Aggressive RehabOther Aggressive Rehab

Some Resources:

Brian Kirkpatrick et al, 1989, (SDS -Brian Kirkpatrick et al, 1989, (SDS -The Schedule for the Deficit The Schedule for the Deficit Syndrome), 1993, 2001Syndrome), 1993, 2001

PDS : Proxy for Deficit Syndrome PDS : Proxy for Deficit Syndrome Kirkpatrick 1996 (core deficit + no Kirkpatrick 1996 (core deficit + no dysphoria)dysphoria)

Robert W. Buchanan et al, 1990, Robert W. Buchanan et al, 1990, 1993,1994, 19961993,1994, 1996

QUESTION # 3

DOES THIS PERSON DOES THIS PERSON HAVE OTHER HAVE OTHER MEDICAL PROBLEMS MEDICAL PROBLEMS ABOUT WHICH TO ABOUT WHICH TO WORRY?WORRY?

OVERVIEW OF SITUATION

40-60 % with medical co-morbidity 40-60 % with medical co-morbidity Not recognized nor treatedNot recognized nor treated Participants get “turfed” back to Participants get “turfed” back to

psychiatry or not referred at allpsychiatry or not referred at all Need primary care, eye & hearing exams, Need primary care, eye & hearing exams,

OB etcOB etc Need physical by nurse practitioner, a Need physical by nurse practitioner, a

health history questionnaire and basic lab health history questionnaire and basic lab tests tests

LABORATORY TESTS TO ORDER

BIOCHEM 23BIOCHEM 23 TOX SCREENTOX SCREEN COMPLETE COMPLETE

BLOOD COUNTBLOOD COUNT URINALYSISURINALYSIS THYROID THYROID

FUNCTION FUNCTION TESTS (T4 & TESTS (T4 & TSH)TSH)

B-12B-12 FOLATEFOLATE VDRL (for VDRL (for

syphilis)syphilis) HIVHIV

______________________________ CT orCT or MRI (if MRI (if

indicated)indicated)

Some Suggested Strategies

Collaboration and linkagesCollaboration and linkages Have a case manager or other Have a case manager or other

person who knows person well go person who knows person well go armed with information and written armed with information and written questions and take notesquestions and take notes

Rescheduling missed appt.sRescheduling missed appt.s Get outside prescriptions into recordGet outside prescriptions into record

Medical Algorithm for Detecting Physical Disease in Psychiatric Patients

Harold C. Sox, Jr. et al: Harold C. Sox, Jr. et al: Hospital and Community Hospital and Community PsychiatryPsychiatry, vol.40 (12) , vol.40 (12) 1270-12761270-1276

Some Suggested Strategies

Offer preventive programs: e.g. Weight Offer preventive programs: e.g. Weight Watchers, Jazzercise, other exercise Watchers, Jazzercise, other exercise programs, nutrition, cooking and programs, nutrition, cooking and grocery shopping skills, meditation, grocery shopping skills, meditation, other relaxation techniques, walking, other relaxation techniques, walking, blood pressure and diabetes monitoring.blood pressure and diabetes monitoring.

Health and Wellness Education ClassesHealth and Wellness Education Classes

PAYING ATTENTION GETS ………

Finding strengths in self care Finding strengths in self care managementmanagement

Healthier peopleHealthier people Reduced mortality ratesReduced mortality rates Avoids confounding Avoids confounding

diagnosisdiagnosis And contraindicated And contraindicated

medicationsmedications

QUESTION #4

WHO IS THIS WHO IS THIS PERSON PERSON

UNDER A COAT UNDER A COAT OF ILLNESS?OF ILLNESS?

ASSESSMENT OF ADULT DEVELOPMENT

PSYCHIATRIC PROBLEMS DISRUPT A PSYCHIATRIC PROBLEMS DISRUPT A LIFELIFE

NEED TO GRIEVE FOR LOSS OF TIME NEED TO GRIEVE FOR LOSS OF TIME AND OPPORTUNITIESAND OPPORTUNITIES

THE “REHABILITATION CRISIS” THE “REHABILITATION CRISIS” (McCRORY, 1982)(McCRORY, 1982)

ASSESSMENT OF PREMORBID LEVELS ASSESSMENT OF PREMORBID LEVELS OF FUNCTIONING (PEER RELATIONS, OF FUNCTIONING (PEER RELATIONS, SCHOOL PERFORMANCE AND DATING SCHOOL PERFORMANCE AND DATING etc)etc)

What to do when people deny they have an illness?

Can get better without any insight or admission that they have a diagnosis

Usually aware that something is holding them back from getting a life they want

If want to recapture their dreams and accept some kind of help from others or

Focus on what the person thinks is distressing or getting in the way of dream

Listening and engaging– L. Davidson, 2012

Question #5

WHAT OTHER WHAT OTHER THINGS HELP OR THINGS HELP OR HINDER HINDER PROGRESS?PROGRESS?

Assessment of THINGS THAT GET IN THE WAY OF RECOVERY

PROCESS

NEED TO ASSESS SOCIALIZATION INTO NEED TO ASSESS SOCIALIZATION INTO PARTICIPANT ROLEPARTICIPANT ROLE

LIMITED ECONOMIC OPPORTUNITIESLIMITED ECONOMIC OPPORTUNITIES MEDICATION SIDE EFFECTS, LACK OF MEDICATION SIDE EFFECTS, LACK OF

REHABILITATION, EXTREME VIRULENCE REHABILITATION, EXTREME VIRULENCE OF ILLNESS, LACK OF STAFF OF ILLNESS, LACK OF STAFF EXPECTATIONS, & LOSS OF HOPEEXPECTATIONS, & LOSS OF HOPE

ASSESSMENT OFCHARACTERLOGICAL

TRAITS Can get in the way or aid progressCan get in the way or aid progress How did the person respond to crises How did the person respond to crises

before mental illness?before mental illness? Is the schizophrenia gone but not the Is the schizophrenia gone but not the

personality ?personality ? Look for problem-solving, a sense of Look for problem-solving, a sense of

humor, a philosophical approach, humor, a philosophical approach, optimism, persistence and strengths in optimism, persistence and strengths in functioningfunctioning

QUESTION #6

ARE THERE SPECIFIC ARE THERE SPECIFIC NEUROCOGNITIVE NEUROCOGNITIVE DEFICITS BEING COPED DEFICITS BEING COPED WITH BY THIS WITH BY THIS PERSON?PERSON?

SCHIZOPHRENIA & NEUROCOGNITIVE DEFICITS

AttentionAttention VigilanceVigilance Executive functioning (reasoning, Executive functioning (reasoning,

judgment, problem-solving, anticipation, judgment, problem-solving, anticipation, planning, decision-making)planning, decision-making)

LearningLearning MemoryMemory Ability to read affect on facesAbility to read affect on faces Find cognitive strengthsFind cognitive strengths

MUTLIMODAL APPROACH

Tests of laterality- prefrontal, Tests of laterality- prefrontal, frontal, parietal, temporal frontal, parietal, temporal functioningfunctioning

Semantic, episodic & working Semantic, episodic & working memorymemory

Expressive & receptive languageExpressive & receptive language Constructional skillsConstructional skills

MUTLIMODAL APPROACH -2

NEW COGNITIVE RETRAINING NEW COGNITIVE RETRAINING EFFORTSEFFORTS

VIDEO CUE TRAININGVIDEO CUE TRAINING GOAL IS TO: MATCH REHAB GOAL IS TO: MATCH REHAB

TYPE AND INTENSITY TO TYPE AND INTENSITY TO NEEDSNEEDS

SOME RESOURCES:

G.E. Hogarty - Cognitive Enhancement G.E. Hogarty - Cognitive Enhancement Therapy – 2002- Guilford PressTherapy – 2002- Guilford Press

G.E. Hogarty & S. Flescher (1999)G.E. Hogarty & S. Flescher (1999) H.D. Brenner et al Hografe & Huber H.D. Brenner et al Hografe & Huber

Toronto, 1994Toronto, 1994 W. Spaulding et al W. Spaulding et al BJP,BJP, 1989 1989 Michael F. Green Michael F. Green AJPAJP, 1996 , 1996 MATRICS new 60 minute battery MATRICS new 60 minute battery Harding - A Classical but short batteryHarding - A Classical but short battery

QUESTION #7

ARE THE ARE THE MEDICATIONS MEDICATIONS REALLY WORTH THE REALLY WORTH THE TRADE-OFF?TRADE-OFF?

ASSESSMENT OF NEED FOR, RESPONSE TO, AND SIDE

EFFECTS FROM MEDICATION

TAKE A THOROUGH HISTORYTAKE A THOROUGH HISTORY GET OLD RECORDSGET OLD RECORDS TALK TO OTHERS WHO KNOW TALK TO OTHERS WHO KNOW

PERSONPERSON COLLABORATE, COLLABORATE, COLLABORATE, COLLABORATE,

COLLABORATE, COLLABORATECOLLABORATE, COLLABORATE

CAUSES OF MISINTERPRETATION

MUST LISTEN TO THE WAY MEDS MAKE MUST LISTEN TO THE WAY MEDS MAKE PEOPLE FEEL FROM THE INSIDE OUTPEOPLE FEEL FROM THE INSIDE OUT

SOMETIMES CLIENTS CAN’T DESCRIBE SOMETIMES CLIENTS CAN’T DESCRIBE SUBTLE FEELINGSSUBTLE FEELINGS

E.g. Side Effect of Akathisia- being compelled E.g. Side Effect of Akathisia- being compelled to be in motion- pacing, rocking, etc thought to to be in motion- pacing, rocking, etc thought to be agitation, elopement, need for seclusion, be agitation, elopement, need for seclusion, acting out, and left untreated.acting out, and left untreated.

USE AIMS + EPS EXAM q.6 MOSUSE AIMS + EPS EXAM q.6 MOS

MORE ON SIDE EFFECTS

20-30 OTHER SIDE EFFECTS e.g. 20-30 OTHER SIDE EFFECTS e.g. DYSKINESIAS, DYSTONIAS, DYSKINESIAS, DYSTONIAS, PARKINSONISMPARKINSONISM

EVEN NEW ATYPICALS CAN HAVE SIDE EVEN NEW ATYPICALS CAN HAVE SIDE EFFECTS – DOSE DEPENDENTEFFECTS – DOSE DEPENDENT

NEED TO SYSTEMATICALLY CHECKED NEED TO SYSTEMATICALLY CHECKED q.6 MOS WITH INSTRUMENTSq.6 MOS WITH INSTRUMENTS

TRAIN PARTICIPANTS TO SELF-TRAIN PARTICIPANTS TO SELF-MONITORMONITOR

ATTEND TO SEX DIFFERENCESATTEND TO SEX DIFFERENCES

DEFINITION OF THE WORD “COMPLIANCE”

GIVING IN TO A REQUEST, GIVING IN TO A REQUEST, DEMAND, WISH; DEMAND, WISH;

ACQUIESENCE; A ACQUIESENCE; A TENDENCY TO GIVE IN TO TENDENCY TO GIVE IN TO

OTHERSOTHERS

vs “ADHERENCE”

TO STICK FAST TO STICK FAST TO BECOME ATTACHEDTO BECOME ATTACHED TO GIVE ALLEGIANCE TO TO GIVE ALLEGIANCE TO TO GIVE DEVOTION OR TO GIVE DEVOTION OR

SUPPORTSUPPORT

MORE ADVICE

nothing in the literature that says nothing in the literature that says everyone needs meds for a lifetime only everyone needs meds for a lifetime only maybe a small groupmaybe a small group

taper, taper very very slowly if on for a taper, taper very very slowly if on for a long timelong time

EBP- MedMAP – MEDICATION MANAGEMENT APPROACHES IN

PSCYHIATRY Provides a systematic & Provides a systematic &

structured plan for med structured plan for med managementmanagement

Documentation is clearer and Documentation is clearer and more concise more concise

Objective measures of outcomeObjective measures of outcome Shared decision-makingShared decision-making

EBP- MedMAP – MEDICATION MANAGEMENT APPROACHES IN

PSCYHIATRY - 2 ““New developments in antipsychotic New developments in antipsychotic

therapy” - an interesting discussion therapy” - an interesting discussion report of a group of report of a group of psychopharmacologists psychopharmacologists J. Clin PsychJ. Clin Psych Nov 2003Nov 2003

CATIE = Clinical Antipsychotic Trials of CATIE = Clinical Antipsychotic Trials of Intervention EffectivenessIntervention Effectiveness

CATIE: Results underscore need for CATIE: Results underscore need for access to full range of medications” in access to full range of medications” in www.szdigest.com and also and also NEJMNEJM Sept 22, Sept 22, 2005 J. Lieberman et al2005 J. Lieberman et al

Morbidity & Mortality

MORBIDITY AND MORTALITY

The Metabolic SyndromeThe Metabolic Syndrome Abdominal obesity (excessive fat tissue in and Abdominal obesity (excessive fat tissue in and

around the abdomen) around the abdomen) Atherogenic dyslipidemia (blood fat disorders Atherogenic dyslipidemia (blood fat disorders

— high triglycerides, low HDL cholesterol and — high triglycerides, low HDL cholesterol and high LDL cholesterol — that foster plaque high LDL cholesterol — that foster plaque buildups in artery walls) buildups in artery walls)

Elevated blood pressure Elevated blood pressure

MORBIDITY AND MORTALITY-2

More of More of The Metabolic SyndromeThe Metabolic Syndrome Insulin resistance or glucose intolerance (the Insulin resistance or glucose intolerance (the

body can’t properly use insulin or blood sugar) body can’t properly use insulin or blood sugar) Prothrombotic state (e.g., high fibrinogen or Prothrombotic state (e.g., high fibrinogen or

plasminogen activator inhibitor–1 in the blood) plasminogen activator inhibitor–1 in the blood) Proinflammatory state (e.g., elevated C-Reactive Proinflammatory state (e.g., elevated C-Reactive

Protein in the blood) Protein in the blood)

MORBIDITY AND MORTALITY-3

Increased risks of:Increased risks of: Coronary heart diseaseCoronary heart disease StrokeStroke Peripheral vascular diseasePeripheral vascular disease Type 2 DiabetesType 2 Diabetes Physical inactivityPhysical inactivity Hormonal ImbalanceHormonal Imbalance Expression of familial genetic profileExpression of familial genetic profile

MORBIDITY AND MORTALITY-4

Graded relationship between number Graded relationship between number of neuroleptics taken and mortality of neuroleptics taken and mortality

(even after adjusting for known risk (even after adjusting for known risk factors of premature death such as: factors of premature death such as: smoking, lack of exercise, BMI, B/P, smoking, lack of exercise, BMI, B/P, serum total and HDL cholesterol).serum total and HDL cholesterol).

MORTALITY-5

Graded relationship between number Graded relationship between number of neuroleptics taken and mortality of neuroleptics taken and mortality and dosage levels with…and dosage levels with…

Fatal arrhythmiasFatal arrhythmias Sudden cardiac deathsSudden cardiac deaths Venus thrombosisVenus thrombosis Pulmonary embolismPulmonary embolism Asthma deathsAsthma deaths

MORBIDITY AND MORTALITY-6

On 1On 1stst Generation drugs mortality risk = Generation drugs mortality risk = 2.84 and was just slightly reduced to 2.25 2.84 and was just slightly reduced to 2.25 after adjusting for other factors such as: after adjusting for other factors such as: somatic diseases, BMI, exercise, B/P, BMI, somatic diseases, BMI, exercise, B/P, BMI, alcohol intake and education.alcohol intake and education.

Relative risk for each new drug added 2.50 Relative risk for each new drug added 2.50 additional risk. additional risk.

– Joukamaa et al, 2006Joukamaa et al, 2006 Similar Findings for Atypicals and for Similar Findings for Atypicals and for

Antidepressants (both SSRIs and Tricyclics)Antidepressants (both SSRIs and Tricyclics)

New Considerations for optimization of medications Some people seem to need no Some people seem to need no

medications;medications; Some people seem to need Some people seem to need

medications for a short while;medications for a short while; A few people seem to need A few people seem to need

medication for a longer period.medication for a longer period.

Support for optimization of medications………….

Literature says that 1Literature says that 1stst episode episode participants may need little or no participants may need little or no medications medications

Nothing in the literature that says Nothing in the literature that says everyone needs meds for a lifetime only everyone needs meds for a lifetime only maybe a small groupmaybe a small group

Taper, taper very very slowly if on for a Taper, taper very very slowly if on for a long timelong time

More Resources:

Personal TherapyPersonal Therapy – GE Hogarty et al – GE Hogarty et al 1997 helps adherence1997 helps adherence

W. Fenton W. Fenton Psych TimesPsych Times 2006 2006 Combined therapyCombined therapy

MedMAP – MedMAP – http://www.mentalhealth.SAMHSA.org

APA – 2004 Practice GuidelinesAPA – 2004 Practice Guidelines Texas Medication Algorithm – No!Texas Medication Algorithm – No!

QUESTION # 8WHY IS THIS PERSON WHY IS THIS PERSON

TAKING STREET TAKING STREET DRUGS IN PLACE OF DRUGS IN PLACE OF OR IN ADDITION TO OR IN ADDITION TO PRESCRIPTIONS ?PRESCRIPTIONS ?

INFO ON USING STREET DRUGS

At least 47% + co-occurring disordersAt least 47% + co-occurring disorders Most costly to treatMost costly to treat IS PERSON TREATING DEPRESSIONS OR IS PERSON TREATING DEPRESSIONS OR

MEDICATION SIDE EFFECTS (e.g. MEDICATION SIDE EFFECTS (e.g. Akinesia) or to ameliorate lack of Akinesia) or to ameliorate lack of motivation and pleasure or to combat motivation and pleasure or to combat loneliness or to get a social group ? loneliness or to get a social group ?

INFO ON USING STREET DRUGS -2

MAKES INITIAL DIAGNOSIS DIFFICULTMAKES INITIAL DIAGNOSIS DIFFICULT USE OF STRUCTURED INTERVIEWS USE OF STRUCTURED INTERVIEWS

HELPFUL (SCID OR ASI)HELPFUL (SCID OR ASI) INFO ON STREET DRUG OF CHOICE MAY INFO ON STREET DRUG OF CHOICE MAY

BE HELPFUL TO ADD INTO DIAGNOSTIC BE HELPFUL TO ADD INTO DIAGNOSTIC PROCESSPROCESS

STANDARD CONFRONTATIONAL MODELS STANDARD CONFRONTATIONAL MODELS MIGHT NOT WORK FOR PEOPLE WITH MIGHT NOT WORK FOR PEOPLE WITH SCHIZOPHRENIASCHIZOPHRENIA

BLENDED FUNDING STREAMS AND BLENDED FUNDING STREAMS AND INTEGRATED CARE MORE HELPFULINTEGRATED CARE MORE HELPFUL

Co-Occurring or Dual Dx D/Ocan lead to:

SymptomSymptom RelapsesRelapses hospitalization hospitalization financial and financial and

family problemsfamily problems homelessness homelessness suicidesuicide

Violence, Violence, Sexual and physical Sexual and physical

victimization, victimization, Incarceration, Incarceration, HIV, HIV, Hepatitis B and C Hepatitis B and C and early death.and early death.

EBP: Integrated Dual Disorders Treantment (IDDT)

Services provided Services provided concurrentlyconcurrently

Individualized assessment Individualized assessment and treatment planning in and treatment planning in heavy collaborationheavy collaboration

Use SCID-SA ScreenerUse SCID-SA Screener

EBP: Integrated Dual Disorders Treatment

DUAL DISORDERS TREATMENT DUAL DISORDERS TREATMENT IMPLEMENTATION RESOURCE KITIMPLEMENTATION RESOURCE KIT InformationInformation Training MaterialsTraining Materials Annotated BibbsAnnotated Bibbs RefsRefs http:://http:://

www.mentalhealthpractices.orgwww.mentalhealthpractices.org

EBP: Integrated Dual Disorders Treatment

BlendingBlending Stage-wise TreatmentStage-wise Treatment Motivational TreatmentMotivational Treatment Substance Abuse CounselingSubstance Abuse Counseling Involving all stakeholdersInvolving all stakeholders 4 basic skills for clinicians4 basic skills for clinicians

Knowledge of substances & how they affect MIKnowledge of substances & how they affect MI Assessment skillsAssessment skills Motivational interviewing skillsMotivational interviewing skills SA Counseling skillsSA Counseling skills

QUESTION #9

WHAT ARE THE WHAT ARE THE RELEVANT SEX RELEVANT SEX DIFFERENCES?DIFFERENCES?

SEX DIFFERENCES ACROSS THE LIFE SPAN

NEURAL DEVELOPMENTAL GROWTHNEURAL DEVELOPMENTAL GROWTH BIRTH COMPLICATIONSBIRTH COMPLICATIONS PEDIATRIC INJURIESPEDIATRIC INJURIES PUBERTY AND HORMONESPUBERTY AND HORMONES METABOLIC DIFFERENCESMETABOLIC DIFFERENCES MENOPAUSEMENOPAUSE PRESCRIBING PRACTICES ARE PRESCRIBING PRACTICES ARE

DIFFERENTDIFFERENT

QUESTION # 10

WHERE IS THIS WHERE IS THIS PERSON IN THE PERSON IN THE COURSE OF COURSE OF ILLNESS?ILLNESS?

COURSE INFORMATION

Schizophrenia is virulent Schizophrenia is virulent early and tapers off laterearly and tapers off later

Like other general medical Like other general medical disordersdisorders

Mother nature is trying to Mother nature is trying to helphelp

BURNT OUT vs. The phoenixBURNT OUT vs. The phoenix

MORE ON COURSE ALSO COURSE OF LIFE, ITSELFALSO COURSE OF LIFE, ITSELF USE A LIFELINE OR LIFE HISTORYUSE A LIFELINE OR LIFE HISTORY MUTUAL PARTICIPATION MODELMUTUAL PARTICIPATION MODEL LONGITUDINAL PATTERNS AND LONGITUDINAL PATTERNS AND

TRENDSTRENDS DIFFERENT USES OF SOCIAL DIFFERENT USES OF SOCIAL

RELATIONSHIPSRELATIONSHIPS BUILD THERAPEUTIC BUILD THERAPEUTIC

RELATIONSHIPSRELATIONSHIPS

QUESTION # 11

WHAT MYTHS AND WHAT MYTHS AND MISINFORMATION MISINFORMATION ARE STRESSING ARE STRESSING THE PERSON?THE PERSON?

ASSESSMENT OF UNDERSTANDING THE ILLNESS

AND MEDICATIONS

““Knowledge is power”Knowledge is power” Collaboration and educationCollaboration and education Helps change the stressful valence – can Helps change the stressful valence – can

reduce relapse ratesreduce relapse rates Teaches how to manage symptomsTeaches how to manage symptoms Promotes competency and empowersPromotes competency and empowers Increases self-esteem Increases self-esteem

QUESTION # 12

WHO DEPENDS ON WHO DEPENDS ON THE CLIENT FOR THE CLIENT FOR HELP?HELP?

SOCIAL SUPPORTS

CONNECTION BETWEEN KIND AND CONNECTION BETWEEN KIND AND AMOUNT OF SOCIAL SUPPORTS AMOUNT OF SOCIAL SUPPORTS AND RECOVERY FROM AND AND RECOVERY FROM AND PREVENTION OF ILLNESS OF ALL PREVENTION OF ILLNESS OF ALL KINDSKINDS

NETWORKS = TYPE, AMOUNT, NETWORKS = TYPE, AMOUNT, DENSITY, SIZE, DEGREE OF DENSITY, SIZE, DEGREE OF INTERDEPENDENCE, CLUSTERING, INTERDEPENDENCE, CLUSTERING, DEGREE OF INTIMACYDEGREE OF INTIMACY

SOCIAL SUPPORTS - 2

Social Skills Training (Promising Rehab Social Skills Training (Promising Rehab Practice)Practice) Reading social cuesReading social cues Acting appropriatelyActing appropriately Practicing acceptable social behaviorsPracticing acceptable social behaviors (e.g. eye contact, small talk etc)(e.g. eye contact, small talk etc) Decrease lonelinessDecrease loneliness Increase possibility of finding friends Increase possibility of finding friends

and significant others.and significant others.

More resources…………

Robert Liberman’s Social & Robert Liberman’s Social & Independent Living Skills Independent Living Skills Modules at UCLAModules at UCLA

See See Innovations & ResearchInnovations & Research Vol2 (2) 1993Vol2 (2) 1993 Harding’s Star Chart (Social Harding’s Star Chart (Social

Network) Harding & Keller, Network) Harding & Keller, 19981998

QUESTION #13

WHAT IS THE WHAT IS THE PERSON’S PERSON’S WORLD VIEW?WORLD VIEW?

CULTURAL SENSITIVITY

ONLY RECENTLY APPRECIATEDONLY RECENTLY APPRECIATED DIVERSITY IS HALLMARK OF WORLDDIVERSITY IS HALLMARK OF WORLD NEED TO UNDERSTAND AT INTAKE NEED TO UNDERSTAND AT INTAKE

ONWARDONWARD WHAT IS IMPORTANCE OF RELIGIOUS WHAT IS IMPORTANCE OF RELIGIOUS

THINKING versus RELIGIOSITY?THINKING versus RELIGIOSITY? SENSE OF TIME?SENSE OF TIME? DISPLAYED AFFECT?DISPLAYED AFFECT?

CULTURAL SENSITIVITY-2

Disorganized sounding speech - Disorganized sounding speech - a linguistic variation?a linguistic variation?

Importance of family, Importance of family, community and church?community and church?

Is the interpreter asking the Is the interpreter asking the same questions you are? (see same questions you are? (see Utah DMH video)Utah DMH video)

CULTURAL SENSITIVITY-2

WWW.WICHE.EDU/MENTALHEALTH SAMHSA’s only approved standards for SAMHSA’s only approved standards for

anythinganything BenchmarksBenchmarks GuidelinesGuidelines Outcome MeasuresOutcome Measures Lit ReviewLit Review For everyone and for the core 4 minority For everyone and for the core 4 minority

groupsgroups

Question # 15

IS THERE ANY IS THERE ANY COHESION IN THE COHESION IN THE SYSTEM OF CARE?SYSTEM OF CARE?

LINKAGES - 1

Coordination and linkage between all Coordination and linkage between all the players are criticalthe players are critical

Need semi-permeable membranes for Need semi-permeable membranes for information sharing, flexibility, information sharing, flexibility, coordination, continuity and coordination, continuity and integrationintegration

Clear and consistent policies from the Clear and consistent policies from the top downtop down

The more we have our act together The more we have our act together the better the participants become the better the participants become

LINKAGES - 2

Clear and consistent policies from Clear and consistent policies from the top downthe top down

Use community resource checklist Use community resource checklist (cmhcs, extension serv, consumer (cmhcs, extension serv, consumer groups, nat support)groups, nat support)

The more we have our act together The more we have our act together the better the participants become the better the participants become

QUESTION # 14 – RISK MANAGEMENT - 2

Research has found the following Research has found the following risk factors for minor and serious risk factors for minor and serious violence:violence:PERSECUTORY IDEATIONPERSECUTORY IDEATIONSUBSTANCE ABUSESUBSTANCE ABUSECHILDHOOD CONDUCT D/OCHILDHOOD CONDUCT D/OVICTIMIZATIONVICTIMIZATION

#14 – WHAT TO DO WITH AN OUT OF CONTROL PERSON?

RISK MANAGEMENT

Relapse Prevention StrategiesRelapse Prevention Strategies Try Paul and Lentz Social Learning Try Paul and Lentz Social Learning

Environments (behavioral)Environments (behavioral) Tony Menditto’s program for forensic Tony Menditto’s program for forensic

participantsparticipants Individualized Token Behavioral Individualized Token Behavioral

Programs which tend to generalize to Programs which tend to generalize to other environmentsother environments

Reduce Restraint and Seclusion with other Reduce Restraint and Seclusion with other psychological strategies firstpsychological strategies first

QUESTION #16 WHERE DO THE WHERE DO THE

CLINICIAN AND CLINICIAN AND CONSUMER BEGIN TO CONSUMER BEGIN TO START BUILDING THE START BUILDING THE

RECOVERYRECOVERY PROCESS?PROCESS?

ASSESSMENT OF STRENGTHS

REHAB IS BUILT ON STRENGTHS NOT REHAB IS BUILT ON STRENGTHS NOT PROBLEMS OR DEFICITSPROBLEMS OR DEFICITS

STRENGTHS OF: PERSON, SYSTEM OF STRENGTHS OF: PERSON, SYSTEM OF CARE, FAMILY, CASE MANAGER, THE CARE, FAMILY, CASE MANAGER, THE DOC ETCDOC ETC

SENSE OF HUMOR, DRIVERS LICENSE, SENSE OF HUMOR, DRIVERS LICENSE, COMPUTER SKILLS, CARE OF OTHERS, COMPUTER SKILLS, CARE OF OTHERS, WATERING PLANTS AND EVEN THE WATERING PLANTS AND EVEN THE MANIPULATION OF SYSTEMSMANIPULATION OF SYSTEMS

New questions

17) AT SOME POINT WE NEED TO 17) AT SOME POINT WE NEED TO FIND OUT ABOUT PREVIOUS FIND OUT ABOUT PREVIOUS TRAUMATIC EXPERIENCESTRAUMATIC EXPERIENCES

Avoidance, hypervigilance, emotional Avoidance, hypervigilance, emotional difficulties, and recall behaviors, anxiety, difficulties, and recall behaviors, anxiety, depression, probs sleeping, and depression, probs sleeping, and sometimes hopelesssometimes hopeless

Use SCID-D for assessmentUse SCID-D for assessment

# 17 – WHAT ABOUT TRAUMA?

Predictors of the Emergence of PTSD LACK OF SOCIAL SUPPORTLACK OF SOCIAL SUPPORT LACK OF EDUCATIONLACK OF EDUCATION TOUGH FAMILY BACKGROUNDTOUGH FAMILY BACKGROUND PRIOR PSYCHIATRIC HISTORYPRIOR PSYCHIATRIC HISTORY DISSOCIATIVE REACTIONDISSOCIATIVE REACTION

• (Berwin et al 2000, Ozer et al, 2003)(Berwin et al 2000, Ozer et al, 2003)

Some Trauma Studies

50-60% of US have a traumatic 50-60% of US have a traumatic experience experience

10% - 17 % Chronic PTSD 10% - 17 % Chronic PTSD (Galea et al, 2002)(Galea et al, 2002)

In community 1 in 10 women/girls and 1 In community 1 in 10 women/girls and 1 in 20 men/boys have PTSD in 20 men/boys have PTSD (Kessler et al, 1995)(Kessler et al, 1995)

Most do not. Not pathological! Most do not. Not pathological! (Bonanno et al, (Bonanno et al,

2002)2002)

Psychophysiological Sequelae of Stress and Trauma Psychogenic Stress of all kinds can be Psychogenic Stress of all kinds can be

Genotoxic in Cellular Structures Genotoxic in Cellular Structures Changes in both internal and external Changes in both internal and external

environments can lead to environments can lead to ± ± changes in changes in gene structuresgene structures

The Brain is a Plastic Organ as wellThe Brain is a Plastic Organ as well Healing is possibleHealing is possible

Mnemonic for PTSD

FEARSFEARS

FearsFears Ego construction (numbing & withdrawal)Ego construction (numbing & withdrawal) AngerAnger Repetition (Flashbacks & nightmares)Repetition (Flashbacks & nightmares) Sleep disturbanceSleep disturbance

• Jean GoodwinJean Goodwin

Mnemonic for COMPLEX PTSD

FEARSFEARSFugue & Other Dissociative statesFugue & Other Dissociative states

Ego fragmentationEgo fragmentation

Antisocial BehaviorsAntisocial Behaviors

Re-enactmentRe-enactment

Suicidality & SomatitizationSuicidality & Somatitization

• Jean GoodwinJean Goodwin

# 18 – CAN THIS PERSON READ?

Realizing that admitting you can’t read is Realizing that admitting you can’t read is more embarrassing to a person than more embarrassing to a person than talking about symptoms!talking about symptoms!

Receiving information in the way a person Receiving information in the way a person can understandcan understand

Learning to read might improve self-Learning to read might improve self-esteem and reduce symptomsesteem and reduce symptoms

Helps close the gap in healthcare Helps close the gap in healthcare disparitiesdisparities

Assessment of the level of functional literacy

REALM-R Rapid Estimate of Adult Literacy

in Medicine, Revised

(a 5 minute 11 word list for English (a 5 minute 11 word list for English speakers which provides a quick speakers which provides a quick

measure of literacy)measure of literacy)Bass et al 2003 Bass et al 2003

Ways to enhance understanding in persons with low level literacy-1

Slow down speech fluencySlow down speech fluency Use “living room” language Use “living room” language

instead of medical terminologyinstead of medical terminology Show or draw pictures to Show or draw pictures to

enhance understanding and enhance understanding and subsequent recallsubsequent recall

Ways to enhance understanding in persons with low level literacy-2

Limit amount of information given at each Limit amount of information given at each interaction and repeat instructionsinteraction and repeat instructions

Use a “teach back” or “show me” approach to Use a “teach back” or “show me” approach to confirm understandingconfirm understanding

Be respectful, caring, and sensitive thereby Be respectful, caring, and sensitive thereby empowering people to participate in their own empowering people to participate in their own health care.health care.

– Williams, Davis, Parker & Weiss. Fam Med. 2002, 34:387)

# 19 Does this person believe in something bigger than self?

USE OF SPIRITUALITY

Research shows that about half of every Research shows that about half of every sample relies on some sort of faith sample relies on some sort of faith (Western formal, informal, nature, (Western formal, informal, nature, Eastern, personal) to provide help and Eastern, personal) to provide help and supportssupports

Need to ask and talk about it if person is Need to ask and talk about it if person is interestedinterested

AND 20) “WHAT DOES THE PERSON THINK HE OR SHE IS RECOVERING FROM?”

CHERYL GAGNE’S LIST from peers:

Loss of self, connection, & hopeLoss of roles and opportunitiesdevaluing and disempowering

programs, practices, and environments

Prejudice and discrimination in society

Internalized oppression and shame

!!

WHAT MADE THE DIFFERENCE ACCORDING TO THOSE INTERVIEWED? Decent food, Decent food,

clothing and clothing and housinghousing

People with whom People with whom to beto be

A way to be A way to be productiveproductive

A way to manage A way to manage s/s and medss/s and meds

Individualized Individualized rx rx

Case Case managementmanagement

Psycho-Psycho-educationeducation

Integrated back Integrated back into the into the communitycommunity

WHAT DID THE VERMONTERS SAY MADE

THE DIFFERENCE?Hope!Hope!

““Someone believed in me”Someone believed in me” ““Someone told me i had a chance to Someone told me i had a chance to

get better”get better” ““My own persistence”My own persistence” Hope connects with natural self-Hope connects with natural self-

healing capacitieshealing capacities

“HOPE CAN ARRIVE ONLY WHEN YOU RECOGNIZE THAT THERE ARE REAL OPTIONS AND THAT YOU HAVE GENUINE CHOICES.” Jerome Groopman, MD (2004)

“To hope under the most extreme circumstances is an act of defiance that….permits a person to live his [her] life on his [her] own terms. It is the part of the human spirit to endure and give a miracle a chance to happen.” Jerome Groopman, MD (2004)

BEING SYSTEMATIC CREATIVE, & STRUCTURED IN YOUR APPROACH YOURSELF AND YOUR YOURSELF AND YOUR

RELATIONSHIP ARE THE BEST RELATIONSHIP ARE THE BEST TOOLS IN YOUR KIT BAGTOOLS IN YOUR KIT BAG

SHOW ME THE EVIDENCE AND MANY THANKS FOR COMING!