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20 WAYS TO OVERCOME BARRIERS TO RECOVERY Prof. Courtenay M. Harding Professor of Psychiatry and Director, Center for Rehabilitation and Recovery The Coalition.

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Presentation on theme: "20 WAYS TO OVERCOME BARRIERS TO RECOVERY Prof. Courtenay M. Harding Professor of Psychiatry and Director, Center for Rehabilitation and Recovery The Coalition."— Presentation transcript:

1 20 WAYS TO OVERCOME BARRIERS TO RECOVERY Prof. Courtenay M. Harding Professor of Psychiatry and Director, Center for Rehabilitation and Recovery The Coalition of Behavioral Health Agencies - NYC

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3 Good Morning! OVERALL GENERAL INFORMATION FOR TODAY OVERALL GENERAL INFORMATION FOR TODAY  What’s in the folders?  How to work with this information  Take a break for phone & bathroom  Ask questions as we go along  Evaluations and Certificates at end

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

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6 IF RECOVERY AND SIGNIFICANT IMPROVEMENT ARE POSSIBLE ………. THEN WHY ARE SO MANY PARTICIPANTS NOT GETTING BETTER? THEN WHY ARE SO MANY PARTICIPANTS NOT GETTING BETTER? 2.5 – 5 MILLION PEOPLE LANGUISHING IN US ALONE 2.5 – 5 MILLION PEOPLE LANGUISHING IN US ALONE

7 ACKNOWLEDGMENT & APPRECIATION TO ALL THE CLINICIANS & FAMILIES WHO CARE WHO CARE WHO SPEND TIME PROBLEM SOLVING WHO SPEND TIME PROBLEM SOLVING WHO CHALLENGE THE STATUS QUO WHO CHALLENGE THE STATUS QUO WHO SPEND TIME GOING THE EXTRA MILE WHO SPEND TIME GOING THE EXTRA MILE

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

9 Learning to play a detective !

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11 LOOKING FOR THE “PERSON UNDER THE DISORDER” COMPREHENSIVE RE-EVALUATION NEEDED (based on history, careful interview, lab findings & physical exam) COMPREHENSIVE RE-EVALUATION NEEDED (based on history, careful interview, lab findings & physical exam) BIO-PSYCHO-SOCIAL-SPIRITUAL APPROACH BIO-PSYCHO-SOCIAL-SPIRITUAL APPROACH SYSTEMATIC & MULTIDISCIPLINARY SYSTEMATIC & MULTIDISCIPLINARY

12 YOU NEED TO LOOK AT A PERSON TWICE…… once with your heart and then with your head…….. FIRST TO SEE THE SIMILARITIES AND ONLY THEN CAN YOU APPRECIATE THE DIFFERENCES

13 QUESTION #1 HAVE OTHER POSSIBLE CAUSES OF SYMPTOMS AND BEHAVIORS BEEN ELIMINATED? HAVE OTHER POSSIBLE CAUSES OF SYMPTOMS AND BEHAVIORS BEEN ELIMINATED?

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15 DIAGNOSIS OF EXCLUSION (especially schizophrenia) 26 other disorders (medical, neurological, and psychiatric) that masquerade with schizophrenia-like symptoms ! 26 other disorders (medical, neurological, and psychiatric) that masquerade with schizophrenia-like symptoms !

16 DIAGNOSIS OF EXCLUSION (schizophrenia) Autism (esp. Asperger’s Syndrome) Autism (esp. Asperger’s Syndrome) Temporal Lobe Epilepsy Temporal Lobe Epilepsy Tumor Tumor Stroke Stroke

17 MORE THINGS TO EXCLUDE Brain Trauma Brain Trauma Endocrine & Metabolic Disorders (e.g. acute intermittent porphyria (liver enzyme) Endocrine & Metabolic Disorders (e.g. acute intermittent porphyria (liver enzyme) Homocystinuria (a disorder of amino acid metabolism) Homocystinuria (a disorder of amino acid metabolism)

18 MORE THINGS TO EXCLUDE Vitamin Deficiency (e.g. B 12) Vitamin Deficiency (e.g. B 12) Central Nervous System Infectious Processes (e.g. AIDS, neurosyphilis, or herpes encephalitis) Central Nervous System Infectious Processes (e.g. AIDS, neurosyphilis, or herpes encephalitis) Autoimmune Disorders (systemic lupus erthymatosa) Autoimmune Disorders (systemic lupus erthymatosa) Heavy Metal Toxicity (e.g. Wilson’s Disease – too much copper) Heavy Metal Toxicity (e.g. Wilson’s Disease – too much copper)

19 EVEN MORE TO EXCLUDE: Some Drug Induced States (e.g. amphetamines, barbiturate withdrawal, cocaine, digitalis, disulfram) Some Drug Induced States (e.g. amphetamines, barbiturate withdrawal, cocaine, digitalis, disulfram) Mood disorders, schizoaffective disorder, Mood disorders, schizoaffective disorder, Personality disorders, Personality disorders, Brief Reactive Psychosis, Brief Reactive Psychosis, OCD OCD

20 Differential Diagnoses for Mood D/O (based on history, careful interview, lab findings & physical exam) Multiple Sclerosis Multiple Sclerosis Stroke Stroke Hyper & Hypothyroidism Hyper & Hypothyroidism Bereavement Bereavement Dementia Dementia Cancer (esp. of Pancreas) Cancer (esp. of Pancreas) Spinal Cord Injury Spinal Cord Injury Peptic Ulcer Peptic Ulcer Mononucleosis Mononucleosis Huntington’s Disease AIDS End-stage Renal Disease Head Injury Parkinson’s Disease Lupus Hyper & Hypo parathyroidism Hepatitis

21 SUGGESTED INSTRUMENT Basis-24 Basis-24  “a leading behavioral health assessment”  Comprehensive  Cuts across diagnostic categories  Provides weighted average  Overall score plus 6 subscales  (sub abuse, symptoms and functioning, relationships, self harm, emotional liability, psychosis, and depression)

22 SUGGESTED INSTRUMENT SCID –THE STRUCTURED CLINICAL INTERVIEW FOR DSM-IV TR SCID –THE STRUCTURED CLINICAL INTERVIEW FOR DSM-IV TR CLINICAL VERSION CLINICAL VERSION

23 HOW TO DO BETTER……… Take the time get triangulated information Take the time get triangulated information Get the lab tests done Get the lab tests done Reassess over time Reassess over time Pay attention to comorbid d/o Pay attention to comorbid d/o

24 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 + + +

25 OR IF PSYCHIATRIC DIAGOSIS IS RE-ESTABLISHED All diagnosis are cross-sectional working hypotheses All diagnosis are cross-sectional working hypotheses Not lifetime labels Not lifetime labels Not able to predict long-term outcome Not able to predict long-term outcome Write enough evidence to “convict” person of the diagnosis into the case record Write enough evidence to “convict” person of the diagnosis into the case record

26 REMEMBER TO LOOK FOR & RECORD STRENGTHS Strengths of your participant ( e.g. insight? Manage meds? Manage S/S ? Uses strategies to recognize oncoming prodrôme? Uses coping to reduce anxiety? Computer skills? Has driver’s license? ETC Strengths of your participant ( e.g. insight? Manage meds? Manage S/S ? Uses strategies to recognize oncoming prodrôme? Uses coping to reduce anxiety? Computer skills? Has driver’s license? ETC Working with the strengths rather than deficits, problems and disabilities – that is what helps people get better Working with the strengths rather than deficits, problems and disabilities – that is what helps people get better

27 EBP:WELLNESS MANAGEMENT AND RECOVERY PROGRAM-1 CLINICIAN BENEFITS: CLINICIAN BENEFITS:  A comprehensive step by step approach  Ready-to-use materials  Skills is using motivational, cognitive behavioral and educational strategies   Satisfaction to see  outcomes

28 EBP: WELLNESS MANAGEMENT AND RECOVERY PROGRAM-2 CLINICIANS RECEIVE: CLINICIANS RECEIVE:  guide with practical tips  handouts, checklists, planning sheets  intro video  info brochures  fidelity scale  outcome measures

29 EBP: WELLNESS MANAGEMENT AND RECOVERY PROGRAM-3 Recovery strategies Recovery strategies Practical facts about mi Practical facts about mi Stress- Vulnerability & treatment strategies Stress- Vulnerability & treatment strategies Building social supports Building social supports reducing relapses using meds effectively coping with stress coping with problems & symptoms getting your needs met in the mh system

30 EBP: ILLNESS (WELLNESS) MANAGEMENT AND RECOVERY PROGRAM-4 RESOURCES: RESOURCES:   Wellness Self-Management & Plus by Columbia University – Paul Margolies and Tony Salerno Wellness Self-Management & Plus by Columbia University – Paul Margolies and Tony Salerno   mmunitysupport/toolkit mmunitysupport/toolkit   html   Liberman RL et al, describing UCLA Models, Innovations & Research, Vol2(2), 1993   P.A. Garrety et al, Schiz Bull, 2000

31 QUESTION #2 Is there an additional neurological impairment? Is there an additional neurological impairment?

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33 THE DEFICIT SYNDRÔME +/- S/S of Schizophrenia Come and Go (esp. + symptoms) +/- S/S of Schizophrenia Come and Go (esp. + symptoms) Attempts to find primary, enduring stable negative symptoms Attempts to find primary, enduring stable negative symptoms Subtype or Additional D/O Subtype or Additional D/O Neurological Impairments ( sensory integration, stereognosis, graphesthesia, right-left confusion, the face-hand test, & audiovisual integration) Neurological Impairments ( sensory integration, stereognosis, graphesthesia, right-left confusion, the face-hand test, & audiovisual integration)

34 THE DEFICIT SYNDRÔME - 2 Poor premorbid social functioning Poor premorbid social functioning Reduced glucose uptake in the frontal cortex, parietal & thalamic areas on PET scans Reduced glucose uptake in the frontal cortex, parietal & thalamic areas on PET scans Increased anhedonia and fewer psychotic events Increased anhedonia and fewer psychotic events Earlier onset, seems to be unremitting, suffer spontaneous movement d/o, severe cognitive impairments Earlier onset, seems to be unremitting, suffer spontaneous movement d/o, severe cognitive impairments

35 THE DEFICIT SYNDRÔME - 3 Deficit PARTICIPANTs in comparison to NonDeficit Deficit PARTICIPANTs in comparison to NonDeficit PARTICIPANTs show: PARTICIPANTs show:  Equal positive symptoms (hallucinations, delusions, and formal thought d/o)  Less severe dysphoric symptoms (e.g. depressive mood, anxiety, guilt, & hostility)  Less severity of suspiciousness  Similar duration of illness  Brain architecture seems to be more intact in some areas

36 THE DEFICIT SYNDRÔME - 4 Need longitudinal information Need longitudinal information Use SDS or PDS Criteria Use SDS or PDS Criteria Exclude: drug effect & demoralization Exclude: drug effect & demoralization Need 2 of of the following for more than a year: Need 2 of of the following for more than a year:  restricted affect,  diminished emotional range,  poverty of speech,  curbing of interests,  diminished sense of purpose and social drive

37 THE DEFICIT SYNDRÔME - 5 USE SCREENING TOOL: THE Neurological Evaluation Scale (NES) USE SCREENING TOOL: THE Neurological Evaluation Scale (NES) TRY: TRY:  Atypical Neuroleptics  Cognitive Remediation  Other Aggressive Rehab

38 Some Resources: Brian Kirkpatrick et al, 1989, (SDS - The Schedule for the Deficit Syndrome), 1993, 2001 Brian Kirkpatrick et al, 1989, (SDS - The Schedule for the Deficit Syndrome), 1993, 2001 PDS : Proxy for Deficit Syndrome Kirkpatrick 1996 (core deficit + no dysphoria) PDS : Proxy for Deficit Syndrome Kirkpatrick 1996 (core deficit + no dysphoria) Robert W. Buchanan et al, 1990, 1993,1994, 1996 Robert W. Buchanan et al, 1990, 1993,1994, 1996

39 QUESTION # 3 DOES THIS PERSON HAVE OTHER MEDICAL PROBLEMS ABOUT WHICH TO WORRY? DOES THIS PERSON HAVE OTHER MEDICAL PROBLEMS ABOUT WHICH TO WORRY?

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41 OVERVIEW OF SITUATION % with medical co-morbidity % with medical co-morbidity Not recognized nor treated Not recognized nor treated Participants get “turfed” back to psychiatry or not referred at all Participants get “turfed” back to psychiatry or not referred at all Need primary care, eye & hearing exams, OB etc Need primary care, eye & hearing exams, OB etc Need physical by nurse practitioner, a health history questionnaire and basic lab tests Need physical by nurse practitioner, a health history questionnaire and basic lab tests

42 LABORATORY TESTS TO ORDER BIOCHEM 23 BIOCHEM 23 TOX SCREEN TOX SCREEN COMPLETE BLOOD COUNT COMPLETE BLOOD COUNT URINALYSIS URINALYSIS THYROID FUNCTION TESTS (T4 & TSH) THYROID FUNCTION TESTS (T4 & TSH) B-12 FOLATE VDRL (for syphilis) HIV _______________ CT or MRI (if indicated)

43 Some Suggested Strategies Collaboration and linkages Collaboration and linkages Have a case manager or other person who knows person well go armed with information and written questions and take notes Have a case manager or other person who knows person well go armed with information and written questions and take notes Rescheduling missed appt.s Rescheduling missed appt.s Get outside prescriptions into record Get outside prescriptions into record

44 Medical Algorithm for Detecting Physical Disease in Psychiatric Patients Harold C. Sox, Jr. et al: Hospital and Community Psychiatry, vol.40 (12) Harold C. Sox, Jr. et al: Hospital and Community Psychiatry, vol.40 (12)

45 Some Suggested Strategies Offer preventive programs: e.g. Weight Watchers, Jazzercise, other exercise programs, nutrition, cooking and grocery shopping skills, meditation, other relaxation techniques, walking, blood pressure and diabetes monitoring. Offer preventive programs: e.g. Weight Watchers, Jazzercise, other exercise programs, nutrition, cooking and grocery shopping skills, meditation, other relaxation techniques, walking, blood pressure and diabetes monitoring. Health and Wellness Education Classes Health and Wellness Education Classes

46 PAYING ATTENTION GETS ……… Finding strengths in self care management Finding strengths in self care management Healthier people Healthier people Reduced mortality rates Reduced mortality rates Avoids confounding diagnosis Avoids confounding diagnosis And contraindicated medications And contraindicated medications

47 QUESTION #4 WHO IS THIS PERSON UNDER A COAT OF ILLNESS? WHO IS THIS PERSON UNDER A COAT OF ILLNESS?

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49 ASSESSMENT OF ADULT DEVELOPMENT PSYCHIATRIC PROBLEMS DISRUPT A LIFE PSYCHIATRIC PROBLEMS DISRUPT A LIFE NEED TO GRIEVE FOR LOSS OF TIME AND OPPORTUNITIES NEED TO GRIEVE FOR LOSS OF TIME AND OPPORTUNITIES THE “REHABILITATION CRISIS” (McCRORY, 1982) THE “REHABILITATION CRISIS” (McCRORY, 1982) ASSESSMENT OF PREMORBID LEVELS OF FUNCTIONING (PEER RELATIONS, SCHOOL PERFORMANCE AND DATING etc) ASSESSMENT OF PREMORBID LEVELS OF FUNCTIONING (PEER RELATIONS, SCHOOL PERFORMANCE AND DATING etc)

50 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

51 Question #5 WHAT OTHER THINGS HELP OR HINDER PROGRESS? WHAT OTHER THINGS HELP OR HINDER PROGRESS?

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53 Assessment of THINGS THAT GET IN THE WAY OF RECOVERY PROCESS NEED TO ASSESS SOCIALIZATION INTO PARTICIPANT ROLE NEED TO ASSESS SOCIALIZATION INTO PARTICIPANT ROLE LIMITED ECONOMIC OPPORTUNITIES LIMITED ECONOMIC OPPORTUNITIES MEDICATION SIDE EFFECTS, LACK OF REHABILITATION, EXTREME VIRULENCE OF ILLNESS, LACK OF STAFF EXPECTATIONS, & LOSS OF HOPE MEDICATION SIDE EFFECTS, LACK OF REHABILITATION, EXTREME VIRULENCE OF ILLNESS, LACK OF STAFF EXPECTATIONS, & LOSS OF HOPE

54 ASSESSMENT OF CHARACTERLOGICAL TRAITS Can get in the way or aid progress Can get in the way or aid progress How did the person respond to crises before mental illness? How did the person respond to crises before mental illness? Is the schizophrenia gone but not the personality ? Is the schizophrenia gone but not the personality ? Look for problem-solving, a sense of humor, a philosophical approach, optimism, persistence and strengths in functioning Look for problem-solving, a sense of humor, a philosophical approach, optimism, persistence and strengths in functioning

55 QUESTION #6 ARE THERE SPECIFIC NEUROCOGNITIVE DEFICITS BEING COPED WITH BY THIS PERSON? ARE THERE SPECIFIC NEUROCOGNITIVE DEFICITS BEING COPED WITH BY THIS PERSON?

56 SCHIZOPHRENIA & NEUROCOGNITIVE DEFICITS Attention Attention Vigilance Vigilance Executive functioning (reasoning, judgment, problem-solving, anticipation, planning, decision-making) Executive functioning (reasoning, judgment, problem-solving, anticipation, planning, decision-making) Learning Learning Memory Memory Ability to read affect on faces Ability to read affect on faces Find cognitive strengths Find cognitive strengths

57 MUTLIMODAL APPROACH Tests of laterality- prefrontal, frontal, parietal, temporal functioning Tests of laterality- prefrontal, frontal, parietal, temporal functioning Semantic, episodic & working memory Semantic, episodic & working memory Expressive & receptive language Expressive & receptive language Constructional skills Constructional skills

58 MUTLIMODAL APPROACH - 2 NEW COGNITIVE RETRAINING EFFORTS NEW COGNITIVE RETRAINING EFFORTS VIDEO CUE TRAINING VIDEO CUE TRAINING GOAL IS TO: MATCH REHAB TYPE AND INTENSITY TO NEEDS GOAL IS TO: MATCH REHAB TYPE AND INTENSITY TO NEEDS

59 SOME RESOURCES: G.E. Hogarty - Cognitive Enhancement Therapy – Guilford Press G.E. Hogarty - Cognitive Enhancement Therapy – Guilford Press G.E. Hogarty & S. Flescher (1999) G.E. Hogarty & S. Flescher (1999) H.D. Brenner et al Hografe & Huber Toronto, 1994 H.D. Brenner et al Hografe & Huber Toronto, 1994 W. Spaulding et al BJP, 1989 W. Spaulding et al BJP, 1989 Michael F. Green AJP, 1996 Michael F. Green AJP, 1996 MATRICS new 60 minute battery MATRICS new 60 minute battery Harding - A Classical but short battery Harding - A Classical but short battery

60 QUESTION #7 ARE THE MEDICATIONS REALLY WORTH THE TRADE-OFF? ARE THE MEDICATIONS REALLY WORTH THE TRADE-OFF?

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62 ASSESSMENT OF NEED FOR, RESPONSE TO, AND SIDE EFFECTS FROM MEDICATION TAKE A THOROUGH HISTORY TAKE A THOROUGH HISTORY GET OLD RECORDS GET OLD RECORDS TALK TO OTHERS WHO KNOW PERSON TALK TO OTHERS WHO KNOW PERSON COLLABORATE, COLLABORATE, COLLABORATE, COLLABORATE COLLABORATE, COLLABORATE, COLLABORATE, COLLABORATE

63 CAUSES OF MISINTERPRETATION MUST LISTEN TO THE WAY MEDS MAKE PEOPLE FEEL FROM THE INSIDE OUT MUST LISTEN TO THE WAY MEDS MAKE PEOPLE FEEL FROM THE INSIDE OUT SOMETIMES CLIENTS CAN’T DESCRIBE SUBTLE FEELINGS SOMETIMES CLIENTS CAN’T DESCRIBE SUBTLE FEELINGS E.g. Side Effect of Akathisia- being compelled to be in motion- pacing, rocking, etc thought to be agitation, elopement, need for seclusion, acting out, and left untreated. E.g. Side Effect of Akathisia- being compelled to be in motion- pacing, rocking, etc thought to be agitation, elopement, need for seclusion, acting out, and left untreated. USE AIMS + EPS EXAM q.6 MOS USE AIMS + EPS EXAM q.6 MOS

64 MORE ON SIDE EFFECTS OTHER SIDE EFFECTS e.g. DYSKINESIAS, DYSTONIAS, PARKINSONISM OTHER SIDE EFFECTS e.g. DYSKINESIAS, DYSTONIAS, PARKINSONISM EVEN NEW ATYPICALS CAN HAVE SIDE EFFECTS – DOSE DEPENDENT EVEN NEW ATYPICALS CAN HAVE SIDE EFFECTS – DOSE DEPENDENT NEED TO SYSTEMATICALLY CHECKED q.6 MOS WITH INSTRUMENTS NEED TO SYSTEMATICALLY CHECKED q.6 MOS WITH INSTRUMENTS TRAIN PARTICIPANTS TO SELF- MONITOR TRAIN PARTICIPANTS TO SELF- MONITOR ATTEND TO SEX DIFFERENCES ATTEND TO SEX DIFFERENCES

65 DEFINITION OF THE WORD “COMPLIANCE” GIVING IN TO A REQUEST, DEMAND, WISH; ACQUIESENCE; A TENDENCY TO GIVE IN TO OTHERS

66 vs “ADHERENCE” TO STICK FAST TO STICK FAST TO BECOME ATTACHED TO BECOME ATTACHED TO GIVE ALLEGIANCE TO TO GIVE ALLEGIANCE TO TO GIVE DEVOTION OR SUPPORT TO GIVE DEVOTION OR SUPPORT

67 MORE ADVICE nothing in the literature that says everyone needs meds for a lifetime only maybe a small group nothing in the literature that says everyone needs meds for a lifetime only maybe a small group taper, taper very very slowly if on for a long time taper, taper very very slowly if on for a long time

68 EBP- MedMAP – MEDICATION MANAGEMENT APPROACHES IN PSCYHIATRY Provides a systematic & structured plan for med management Provides a systematic & structured plan for med management Documentation is clearer and more concise Documentation is clearer and more concise Objective measures of outcome Objective measures of outcome Shared decision-making Shared decision-making

69 EBP- MedMAP – MEDICATION MANAGEMENT APPROACHES IN PSCYHIATRY - 2 “New developments in antipsychotic therapy” - an interesting discussion report of a group of psychopharmacologists J. Clin Psych Nov 2003 “New developments in antipsychotic therapy” - an interesting discussion report of a group of psychopharmacologists J. Clin Psych Nov 2003 CATIE = Clinical Antipsychotic Trials of Intervention Effectiveness CATIE = Clinical Antipsychotic Trials of Intervention Effectiveness CATIE: Results underscore need for access to full range of medications” in and also NEJM Sept 22, 2005 J. Lieberman et al CATIE: Results underscore need for access to full range of medications” in and also NEJM Sept 22, 2005 J. Lieberman et al

70 Morbidity & Mortality

71 MORBIDITY AND MORTALITY The Metabolic Syndrome The Metabolic Syndrome Abdominal obesity (excessive fat tissue in and around the abdomen) Abdominal obesity (excessive fat tissue in and around the abdomen) Atherogenic dyslipidemia (blood fat disorders — high triglycerides, low HDL cholesterol and high LDL cholesterol — that foster plaque buildups in artery walls) Atherogenic dyslipidemia (blood fat disorders — high triglycerides, low HDL cholesterol and high LDL cholesterol — that foster plaque buildups in artery walls) Elevated blood pressure Elevated blood pressure

72 MORBIDITY AND MORTALITY-2 More of The Metabolic Syndrome More of The Metabolic Syndrome Insulin resistance or glucose intolerance (the body can’t properly use insulin or blood sugar) Insulin resistance or glucose intolerance (the body can’t properly use insulin or blood sugar) Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor–1 in the blood) Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor–1 in the blood) Proinflammatory state (e.g., elevated C-Reactive Protein in the blood) Proinflammatory state (e.g., elevated C-Reactive Protein in the blood)

73 MORBIDITY AND MORTALITY-3 Increased risks of: Increased risks of:  Coronary heart disease  Stroke  Peripheral vascular disease  Type 2 Diabetes  Physical inactivity  Hormonal Imbalance  Expression of familial genetic profile

74 MORBIDITY AND MORTALITY-4  Graded relationship between number of neuroleptics taken and mortality  (even after adjusting for known risk factors of premature death such as: smoking, lack of exercise, BMI, B/P, serum total and HDL cholesterol).

75 MORTALITY-5  Graded relationship between number of neuroleptics taken and mortality and dosage levels with…  Fatal arrhythmias  Sudden cardiac deaths  Venus thrombosis  Pulmonary embolism  Asthma deaths

76 MORBIDITY AND MORTALITY-6  On 1 st Generation drugs mortality risk = 2.84 and was just slightly reduced to 2.25 after adjusting for other factors such as: somatic diseases, BMI, exercise, B/P, BMI, alcohol intake and education.  Relative risk for each new drug added 2.50 additional risk. –Joukamaa et al, 2006  Similar Findings for Atypicals and for Antidepressants (both SSRIs and Tricyclics)

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78 New Considerations for optimization of medications Some people seem to need no medications; Some people seem to need no medications; Some people seem to need medications for a short while; Some people seem to need medications for a short while; A few people seem to need medication for a longer period. A few people seem to need medication for a longer period.

79 Support for optimization of medications…………. Literature says that 1 st episode participants may need little or no medications Literature says that 1 st episode participants may need little or no medications Nothing in the literature that says everyone needs meds for a lifetime only maybe a small group Nothing in the literature that says everyone needs meds for a lifetime only maybe a small group Taper, taper very very slowly if on for a long time Taper, taper very very slowly if on for a long time

80 More Resources: Personal Therapy – GE Hogarty et al 1997 helps adherence Personal Therapy – GE Hogarty et al 1997 helps adherence W. Fenton Psych Times 2006 Combined therapy W. Fenton Psych Times 2006 Combined therapy MedMAP – g MedMAP – g g g APA – 2004 Practice Guidelines APA – 2004 Practice Guidelines Texas Medication Algorithm – No! Texas Medication Algorithm – No!

81 QUESTION # 8 WHY IS THIS PERSON TAKING STREET DRUGS IN PLACE OF OR IN ADDITION TO PRESCRIPTIONS ? WHY IS THIS PERSON TAKING STREET DRUGS IN PLACE OF OR IN ADDITION TO PRESCRIPTIONS ?

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83 INFO ON USING STREET DRUGS At least 47% + co-occurring disorders At least 47% + co-occurring disorders Most costly to treat Most costly to treat IS PERSON TREATING DEPRESSIONS OR MEDICATION SIDE EFFECTS (e.g. Akinesia) or to ameliorate lack of motivation and pleasure or to combat loneliness or to get a social group ? IS PERSON TREATING DEPRESSIONS OR MEDICATION SIDE EFFECTS (e.g. Akinesia) or to ameliorate lack of motivation and pleasure or to combat loneliness or to get a social group ?

84 INFO ON USING STREET DRUGS -2 MAKES INITIAL DIAGNOSIS DIFFICULT MAKES INITIAL DIAGNOSIS DIFFICULT USE OF STRUCTURED INTERVIEWS HELPFUL (SCID OR ASI) USE OF STRUCTURED INTERVIEWS HELPFUL (SCID OR ASI) INFO ON STREET DRUG OF CHOICE MAY BE HELPFUL TO ADD INTO DIAGNOSTIC PROCESS INFO ON STREET DRUG OF CHOICE MAY BE HELPFUL TO ADD INTO DIAGNOSTIC PROCESS STANDARD CONFRONTATIONAL MODELS MIGHT NOT WORK FOR PEOPLE WITH SCHIZOPHRENIA STANDARD CONFRONTATIONAL MODELS MIGHT NOT WORK FOR PEOPLE WITH SCHIZOPHRENIA BLENDED FUNDING STREAMS AND INTEGRATED CARE MORE HELPFUL BLENDED FUNDING STREAMS AND INTEGRATED CARE MORE HELPFUL

85 Co-Occurring or Dual Dx D/O can lead to: Symptom Symptom Relapses Relapses hospitalization hospitalization financial and family problems financial and family problems homelessness homelessness suicide suicide Violence, Sexual and physical victimization, Incarceration, HIV, Hepatitis B and C and early death.

86 EBP: Integrated Dual Disorders Treantment (IDDT) Services provided concurrently Services provided concurrently Individualized assessment and treatment planning in heavy collaboration Individualized assessment and treatment planning in heavy collaboration Use SCID-SA Screener Use SCID-SA Screener

87 EBP: Integrated Dual Disorders Treatment DUAL DISORDERS TREATMENT IMPLEMENTATION RESOURCE KIT DUAL DISORDERS TREATMENT IMPLEMENTATION RESOURCE KIT  Information  Training Materials  Annotated Bibbs  Refs  org

88 EBP: Integrated Dual Disorders Treatment Blending Blending Stage-wise Treatment Stage-wise Treatment Motivational Treatment Motivational Treatment Substance Abuse Counseling Substance Abuse Counseling Involving all stakeholders Involving all stakeholders 4 basic skills for clinicians 4 basic skills for clinicians  Knowledge of substances & how they affect MI  Assessment skills  Motivational interviewing skills  SA Counseling skills

89 QUESTION #9 WHAT ARE THE RELEVANT SEX DIFFERENCES? WHAT ARE THE RELEVANT SEX DIFFERENCES?

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91 SEX DIFFERENCES ACROSS THE LIFE SPAN NEURAL DEVELOPMENTAL GROWTH NEURAL DEVELOPMENTAL GROWTH BIRTH COMPLICATIONS BIRTH COMPLICATIONS PEDIATRIC INJURIES PEDIATRIC INJURIES PUBERTY AND HORMONES PUBERTY AND HORMONES METABOLIC DIFFERENCES METABOLIC DIFFERENCES MENOPAUSE MENOPAUSE PRESCRIBING PRACTICES ARE DIFFERENT PRESCRIBING PRACTICES ARE DIFFERENT

92 QUESTION # 10 WHERE IS THIS PERSON IN THE COURSE OF ILLNESS? WHERE IS THIS PERSON IN THE COURSE OF ILLNESS?

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94 COURSE INFORMATION Schizophrenia is virulent early and tapers off later Schizophrenia is virulent early and tapers off later Like other general medical disorders Like other general medical disorders Mother nature is trying to help Mother nature is trying to help BURNT OUT vs. The phoenix BURNT OUT vs. The phoenix

95 MORE ON COURSE ALSO COURSE OF LIFE, ITSELF ALSO COURSE OF LIFE, ITSELF USE A LIFELINE OR LIFE HISTORY USE A LIFELINE OR LIFE HISTORY MUTUAL PARTICIPATION MODEL MUTUAL PARTICIPATION MODEL LONGITUDINAL PATTERNS AND TRENDS LONGITUDINAL PATTERNS AND TRENDS DIFFERENT USES OF SOCIAL RELATIONSHIPS DIFFERENT USES OF SOCIAL RELATIONSHIPS BUILD THERAPEUTIC RELATIONSHIPS BUILD THERAPEUTIC RELATIONSHIPS

96 QUESTION # 11 WHAT MYTHS AND MISINFORMATION ARE STRESSING THE PERSON? WHAT MYTHS AND MISINFORMATION ARE STRESSING THE PERSON?

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98 ASSESSMENT OF UNDERSTANDING THE ILLNESS AND MEDICATIONS “Knowledge is power” “Knowledge is power” Collaboration and education Collaboration and education Helps change the stressful valence – can reduce relapse rates Helps change the stressful valence – can reduce relapse rates Teaches how to manage symptoms Teaches how to manage symptoms Promotes competency and empowers Promotes competency and empowers Increases self-esteem Increases self-esteem

99 QUESTION # 12 WHO DEPENDS ON THE CLIENT FOR HELP? WHO DEPENDS ON THE CLIENT FOR HELP?

100

101 SOCIAL SUPPORTS CONNECTION BETWEEN KIND AND AMOUNT OF SOCIAL SUPPORTS AND RECOVERY FROM AND PREVENTION OF ILLNESS OF ALL KINDS CONNECTION BETWEEN KIND AND AMOUNT OF SOCIAL SUPPORTS AND RECOVERY FROM AND PREVENTION OF ILLNESS OF ALL KINDS NETWORKS = TYPE, AMOUNT, DENSITY, SIZE, DEGREE OF INTERDEPENDENCE, CLUSTERING, DEGREE OF INTIMACY NETWORKS = TYPE, AMOUNT, DENSITY, SIZE, DEGREE OF INTERDEPENDENCE, CLUSTERING, DEGREE OF INTIMACY

102 SOCIAL SUPPORTS - 2 Social Skills Training (Promising Rehab Practice) Social Skills Training (Promising Rehab Practice)  Reading social cues  Acting appropriately  Practicing acceptable social behaviors  (e.g. eye contact, small talk etc)  Decrease loneliness  Increase possibility of finding friends and significant others.

103 More resources………… Robert Liberman’s Social & Independent Living Skills Modules at UCLA Robert Liberman’s Social & Independent Living Skills Modules at UCLA See Innovations & Research See Innovations & Research Vol2 (2) 1993 Vol2 (2) 1993 Harding’s Star Chart (Social Network) Harding & Keller, 1998 Harding’s Star Chart (Social Network) Harding & Keller, 1998

104 QUESTION #13 WHAT IS THE PERSON’S WORLD VIEW? WHAT IS THE PERSON’S WORLD VIEW?

105

106 CULTURAL SENSITIVITY ONLY RECENTLY APPRECIATED ONLY RECENTLY APPRECIATED DIVERSITY IS HALLMARK OF WORLD DIVERSITY IS HALLMARK OF WORLD NEED TO UNDERSTAND AT INTAKE ONWARD NEED TO UNDERSTAND AT INTAKE ONWARD WHAT IS IMPORTANCE OF RELIGIOUS THINKING versus RELIGIOSITY? WHAT IS IMPORTANCE OF RELIGIOUS THINKING versus RELIGIOSITY? SENSE OF TIME? SENSE OF TIME? DISPLAYED AFFECT? DISPLAYED AFFECT?

107 CULTURAL SENSITIVITY-2 Disorganized sounding speech - a linguistic variation? Disorganized sounding speech - a linguistic variation? Importance of family, community and church? Importance of family, community and church? Is the interpreter asking the same questions you are? (see Utah DMH video) Is the interpreter asking the same questions you are? (see Utah DMH video)

108 CULTURAL SENSITIVITY-2 SAMHSA’s only approved standards for anything SAMHSA’s only approved standards for anything Benchmarks Benchmarks Guidelines Guidelines Outcome Measures Outcome Measures Lit Review Lit Review For everyone and for the core 4 minority groups For everyone and for the core 4 minority groups

109 Question # 15 IS THERE ANY COHESION IN THE SYSTEM OF CARE? IS THERE ANY COHESION IN THE SYSTEM OF CARE?

110

111 LINKAGES - 1 Coordination and linkage between all the players are critical Coordination and linkage between all the players are critical Need semi-permeable membranes for information sharing, flexibility, coordination, continuity and integration Need semi-permeable membranes for information sharing, flexibility, coordination, continuity and integration Clear and consistent policies from the top down Clear and consistent policies from the top down The more we have our act together the better the participants become The more we have our act together the better the participants become

112 LINKAGES - 2 Clear and consistent policies from the top down Clear and consistent policies from the top down Use community resource checklist (cmhcs, extension serv, consumer groups, nat support) Use community resource checklist (cmhcs, extension serv, consumer groups, nat support) The more we have our act together the better the participants become The more we have our act together the better the participants become

113 QUESTION # 14 – RISK MANAGEMENT - 2 Research has found the following risk factors for minor and serious violence: Research has found the following risk factors for minor and serious violence:  PERSECUTORY IDEATION  SUBSTANCE ABUSE  CHILDHOOD CONDUCT D/O  VICTIMIZATION

114 #14 – WHAT TO DO WITH AN OUT OF CONTROL PERSON?

115

116 RISK MANAGEMENT Relapse Prevention Strategies Relapse Prevention Strategies Try Paul and Lentz Social Learning Environments (behavioral) Try Paul and Lentz Social Learning Environments (behavioral) Tony Menditto’s program for forensic participants Tony Menditto’s program for forensic participants Individualized Token Behavioral Programs which tend to generalize to other environments Individualized Token Behavioral Programs which tend to generalize to other environments Reduce Restraint and Seclusion with other psychological strategies first Reduce Restraint and Seclusion with other psychological strategies first

117 QUESTION #16 WHERE DO THE CLINICIAN AND CONSUMER BEGIN TO START BUILDING THE RECOVERY PROCESS? WHERE DO THE CLINICIAN AND CONSUMER BEGIN TO START BUILDING THE RECOVERY PROCESS?

118

119 ASSESSMENT OF STRENGTHS REHAB IS BUILT ON STRENGTHS NOT PROBLEMS OR DEFICITS REHAB IS BUILT ON STRENGTHS NOT PROBLEMS OR DEFICITS STRENGTHS OF: PERSON, SYSTEM OF CARE, FAMILY, CASE MANAGER, THE DOC ETC STRENGTHS OF: PERSON, SYSTEM OF CARE, FAMILY, CASE MANAGER, THE DOC ETC SENSE OF HUMOR, DRIVERS LICENSE, COMPUTER SKILLS, CARE OF OTHERS, WATERING PLANTS AND EVEN THE MANIPULATION OF SYSTEMS SENSE OF HUMOR, DRIVERS LICENSE, COMPUTER SKILLS, CARE OF OTHERS, WATERING PLANTS AND EVEN THE MANIPULATION OF SYSTEMS

120 New questions 17) AT SOME POINT WE NEED TO FIND OUT ABOUT PREVIOUS TRAUMATIC EXPERIENCES 17) AT SOME POINT WE NEED TO FIND OUT ABOUT PREVIOUS TRAUMATIC EXPERIENCES Avoidance, hypervigilance, emotional difficulties, and recall behaviors, anxiety, depression, probs sleeping, and sometimes hopeless Avoidance, hypervigilance, emotional difficulties, and recall behaviors, anxiety, depression, probs sleeping, and sometimes hopeless Use SCID-D for assessment Use SCID-D for assessment

121 # 17 – WHAT ABOUT TRAUMA?

122

123 Predictors of the Emergence of PTSD LACK OF SOCIAL SUPPORT LACK OF SOCIAL SUPPORT LACK OF EDUCATION LACK OF EDUCATION TOUGH FAMILY BACKGROUND TOUGH FAMILY BACKGROUND PRIOR PSYCHIATRIC HISTORY PRIOR PSYCHIATRIC HISTORY DISSOCIATIVE REACTION DISSOCIATIVE REACTION (Berwin et al 2000, Ozer et al, 2003) (Berwin et al 2000, Ozer et al, 2003)

124 Some Trauma Studies 50-60% of US have a traumatic experience 50-60% of US have a traumatic experience 10% - 17 % Chronic PTSD (Galea et al, 2002) 10% - 17 % Chronic PTSD (Galea et al, 2002) In community 1 in 10 women/girls and 1 in 20 men/boys have PTSD (Kessler et al, 1995) In community 1 in 10 women/girls and 1 in 20 men/boys have PTSD (Kessler et al, 1995) Most do not. Not pathological! (Bonanno et al, 2002) Most do not. Not pathological! (Bonanno et al, 2002)

125 Psychophysiological Sequelae of Stress and Trauma Psychogenic Stress of all kinds can be Genotoxic in Cellular Structures Psychogenic Stress of all kinds can be Genotoxic in Cellular Structures Changes in both internal and external environments can lead to ± changes in gene structures Changes in both internal and external environments can lead to ± changes in gene structures The Brain is a Plastic Organ as well The Brain is a Plastic Organ as well Healing is possible Healing is possible

126

127 Mnemonic for PTSD FEARS Fears Fears Ego construction (numbing & withdrawal) Ego construction (numbing & withdrawal) Anger Anger Repetition (Flashbacks & nightmares) Repetition (Flashbacks & nightmares) Sleep disturbance Sleep disturbance Jean GoodwinJean Goodwin

128 Mnemonic for COMPLEX PTSD FEARS Fugue & Other Dissociative states Ego fragmentation Antisocial Behaviors Re-enactment Suicidality & Somatitization Jean GoodwinJean Goodwin

129 # 18 – CAN THIS PERSON READ?

130

131 Realizing that admitting you can’t read is more embarrassing to a person than talking about symptoms! Realizing that admitting you can’t read is more embarrassing to a person than talking about symptoms! Receiving information in the way a person can understand Receiving information in the way a person can understand Learning to read might improve self- esteem and reduce symptoms Learning to read might improve self- esteem and reduce symptoms Helps close the gap in healthcare disparities Helps close the gap in healthcare disparities Assessment of the level of functional literacy

132 REALM-R Rapid Estimate of Adult Literacy in Medicine, Revised (a 5 minute 11 word list for English speakers which provides a quick measure of literacy) Bass et al 2003

133 Ways to enhance understanding in persons with low level literacy-1 Slow down speech fluency Slow down speech fluency Use “living room” language instead of medical terminology Use “living room” language instead of medical terminology Show or draw pictures to enhance understanding and subsequent recall Show or draw pictures to enhance understanding and subsequent recall

134 Ways to enhance understanding in persons with low level literacy-2 Limit amount of information given at each interaction and repeat instructions Limit amount of information given at each interaction and repeat instructions Use a “teach back” or “show me” approach to confirm understanding Use a “teach back” or “show me” approach to confirm understanding Be respectful, caring, and sensitive thereby empowering people to participate in their own health care. Be respectful, caring, and sensitive thereby empowering people to participate in their own health care. – –Williams, Davis, Parker & Weiss. Fam Med. 2002, 34:387)

135 # 19 Does this person believe in something bigger than self?

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137 USE OF SPIRITUALITY Research shows that about half of every sample relies on some sort of faith (Western formal, informal, nature, Eastern, personal) to provide help and supports Research shows that about half of every sample relies on some sort of faith (Western formal, informal, nature, Eastern, personal) to provide help and supports Need to ask and talk about it if person is interested Need to ask and talk about it if person is interested

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

139

140 CHERYL GAGNE’S LIST from peers: Loss of self, connection, & hope Loss of roles and opportunities devaluing and disempowering programs, practices, and environments Prejudice and discrimination in society Internalized oppression and shame !

141 WHAT MADE THE DIFFERENCE ACCORDING TO THOSE INTERVIEWED?  Decent food, clothing and housing  People with whom to be  A way to be productive  A way to manage s/s and meds  Individualized rx  Case management  Psycho- education  Integrated back into the community

142 WHAT DID THE VERMONTERS SAY MADE THE DIFFERENCE? Hope! “Someone believed in me” “Someone believed in me” “Someone told me i had a chance to get better” “Someone told me i had a chance to get better” “My own persistence” “My own persistence” Hope connects with natural self- healing capacities Hope connects with natural self- healing capacities

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

144 “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)

145 BEING SYSTEMATIC CREATIVE, & STRUCTURED IN YOUR APPROACH YOURSELF AND YOUR RELATIONSHIP ARE THE BEST TOOLS IN YOUR KIT BAG

146

147 SHOW ME THE EVIDENCE AND MANY THANKS FOR COMING!


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