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1 RESPECT-Mil V. September 2007 Recognition and Management of Depression & Post-Traumatic Stress Disorder (Review & PTSD)

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Presentation on theme: "1 RESPECT-Mil V. September 2007 Recognition and Management of Depression & Post-Traumatic Stress Disorder (Review & PTSD)"— Presentation transcript:

1 1 RESPECT-Mil V. September 2007 Recognition and Management of Depression & Post-Traumatic Stress Disorder (Review & PTSD)

2 2 Today’s Learning Objectives  Use of PTSD Symptom Checklist (PCL)  Diagnostic process including suicide assessment  Understand new resources for primary care  RESPECT-Mil Care Facilitator (RCF)  RCF Supervision Process  Informal Behavioral Health Consultations

3 3 Overview of Three Component Model Care Process  Screening as a routine  Assessing screen positives  For those with a potential diagnosis  Assess suicide risk  Relevant history  Share diagnosis with Soldier  Use new resources  Tools  Care facilitation  Informal psychiatric advice

4 4 Three Component Model (3CM) PREPARED PRACTICE PSYCHIATRIST PATIENT CARE FACILITATOR

5 5 PTSD

6 6 PTSD Diagnostic Concept  Traumatic experience  Threat of death/serious injury  Intense fear, helplessness or horror  Symptoms  Reexperiencing the trauma  Numbing & avoidance  Physiologic arousal  Impaired functioning  Persistence

7 7 PTSD Diagnosis Intrusion or ‘Reexperiencing’ Symptoms  Need one (1) or more:  Intrusion of disturbing Memories or Images; Nightmares; Flashbacks  Reminders of trauma resulting in upset feelings; physical reactions

8 8 PTSD Diagnosis ‘Numbing/Avoidance’ Symptoms  Need three (3) or more:  Avoidance of trauma reminders (thoughts or feelings or talking; activities or situations; memories)  Numbing of responsiveness (loss of interest; detached; reduced affect; future cut short)

9 9 PTSD Diagnosis ‘Arousal’ Symptoms  Need two (2) or more:  ‘Keyed up’ (anger; insomnia)  Difficulty concentrating  Hyper-vigilance; easily startled

10 10 PTSD Diagnosis Impairment & Duration  Impairment functioning  Social  Psychological  Occupational  Persistent (one month)

11 11 Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month,you… 1.Have had nightmares about it or thought about it when you did not want to? …………….....Yes No 2.Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? …………………………………………………………......Yes No 3.Were constantly on guard, watchful, or easily startled? …………………………………….…………......Yes No 4.Felt numb or detached from others, activities, or your surroundings? ………………………….....Yes No If YES to two or more proceeds to further assessment From MEDCOM Form 774 RESPECT-Mil Routine Office Visit Screening Form Handout #1

12 12 INTRUSION 1. Images, thoughts 2. Nightmares 3. Sudden re-experience 4. Upset at reminders 5. Physical reactions AVOIDANCE 6. Avoid thinking/talking 7. Avoid situations 8. Memory loss of event 9. Loss of interest 10. Distant, cut-off 11. Emotionally numb 12. Future cut short AROUSAL 13. Insomnia 14. Outbursts 15. Low concentration 16. Watchful on guard 17. Easily Startled The PTSD Checklist (PCL) Not A little Moderately Quite Extremely at all bit a bit Handout #2

13 13 Confirm Diagnosis  Focused History Questions: Suicidal ideation; Symptoms (intrusion, avoidance, arousal); past PTSD,substance use  Document: For continuity of care/handoff

14 14 Establishing Rapport Key Issues  Mistrust & uncertainty  Frequent self-blame  Sense of isolation (“no one can understand”)  Trauma discussion is distressing

15 15 Establishing Rapport How to Do It  Acknowledge difficulties  Avoid judgment – “I’m sorry this happened to you…you definitely didn’t deserve this.”  Address symptoms & circumstances (Don’t talk about the trauma)  Seek continuity among providers

16 16 Case Example - PVT Andrews Part 1  Scoring PCL  Illustrate efficient suicide evaluation

17 17 Not A little Moder- Quite Extremely at all bit ately a bit PCL 1.Repeated, disturbing memories, thoughts, or images of a stressful experience? 2.Repeated, disturbed dreams of a stressful experience from the past? 3.Suddenly acting or feeling as if a stressful experience were happening again? 4.Feeling very upset when something reminded you of a stressful experience? 5.Having physical reactions (e.g. heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience from the past? INTRUSION need 1 or more Handout #3

18 18 Not A little Moder- Quite Extreme- at all bit ately a bit ly PCL 6. Avoid thinking or talking about a stressful experience or avoid having feelings related to it? 7. Avoid activities or situations because they remind you of a stressful experience? 8. Trouble remembering important parts of a stressful experience? 9. Loss of interest in things you used to enjoy? 10. Feeling distant or cut off from other people? 11. Feeling emotionally numb or being unable to have loving feelings for those close to you? 12. Feeling as if your future will somehow be cut short? AVOIDANCE &/or NUMBING (need 3 or more)

19 19 Not A little Moder- Quite Extreme- at all bit ately a bit ly PCL 13. Trouble falling or staying asleep? 14. Feeling irritable or angry outbursts? 15. Having difficulty concentrating? 16. Being “super alert” or watchful on guard? 17. Feeling jumpy or easily startled? AROUSAL (need 2 or more) 18. How difficulty have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult Somewhat Very difficult Extremely at all difficult difficult

20 20 INTRUSION 1. Images, thoughts 2. Nightmares 3. Sudden re-experience 4. Upset at reminders 5. Physical reactions AVOIDANCE 6. Avoid thinking/talking 7. Avoid situations 8. Memory loss of event 9. Loss of interest 10. Distant, cut-off 11. Emotionally numb 12. Future cut short AROUSAL 13. Insomnia 14. Outbursts 15. Low concentration 16. Watchful on guard 17. Easily Startled Scoring the PCL Not A little Moderately Quite Extremely at all bit a bit Subtotals: a x 0 b x 1 c x 2 d x 3 e x 4 TOTAL : A + B + C + D + E

21 21 INTRUSION 1. Images, thoughts 2. Nightmares 3. Sudden re-experience 4. Upset at reminders 5. Physical reactions AVOIDANCE 6. Avoid thinking/talking 7. Avoid situations 8. Memory loss of event 9. Loss of interest 10. Distant, cut-off 11. Emotionally numb 12. Future cut short AROUSAL 13. Insomnia 14. Outbursts 15. Low concentration 16. Watchful on guard 17. Easily Startled = 35 Scoring the PCL Not A little Moderately Quite Extremely at all bit a bit

22 22 Diagnosis & Initial Treatment  Presumptive diagnosis at a glance ≥ six symptoms ≥ moderate severity ≥ 1 month, functional impairment :  ≥ 1 Intrusion/Re-experience  ≥ 3 Avoidance/Numbing  ≥ 2 Arousal  Score 13 to 32 = mild or subthreshold  Patient Choice: Active Rx vs. Education & watchful waiting  Score ≥ 33 = moderate to severe  Push harder for initial active treatment Handout #4 & we’ll use Severity Score for Treatment Response Monitoring…

23 23 1. Have these symptoms/feelings we’ve been talking about led you to believe that you would be better off dead? NOYES 2. This past week, have you had any thoughts that life is not worth living or that you would be better off dead? NOYES 3. What about thoughts of hurting or even killing yourself? NOYES 4. What have you thought about? Do you have a plan or have you actually tried to hurt your self? NOYES 5. RISK FACTORS:  History of suicide attempt  Substance abuse  Significant comorbid anxiety  Social isolation  Hopelessness Evaluation of Suicide Risk (Question 19) Handout #5

24 24 Evaluation of Suicide Risk No current thoughts or risks Low RiskFollow & monitor Current thoughts, no plans (Questions 2&3=yes 4=no; few risk factors) Intermediate Risk F/U each visit; Pt to call if change; Consult Mental Health Professional (MHP) Current thoughts & plans (Question 4=yes; several risk factors) High Risk Emergency (now) MHP Urgent (48hr) MHP if social support & self control present, no risk factors Handout #5

25 25 Case Example - PVT. Andrews Part 2 Role Play to demonstrate:  Using the PCL & focused questions to make and present a diagnosis  Establish rapport  Mention support from PCL  Put in context  (“we see this often in people with similar experiences”)  Describe in terms of changes in the brain  Illustrate efficient suicide evaluation

26 26 Next, PTSD Treatment: Explain the Options & Patient Choice Psychological Counseling and/or Medication Treatment

27 27 Medication Treatment  SSRIs – treatment of choice  Randomized Trials  citalopram (Celexa, Lexapro) paroxetine (Paxil)  fluoxetine (e.g. Prozac)  fluvoxamine (Luvox)  sertraline (Zoloft)  venlafaxine (Effexor)  FDA-approved: sertraline, paroxetine  Manageable in deployed environment

28 28 Psychological Counseling  At least as effective as medication  Cognitive Behavioral Treatment (CBT)  Connect thoughts to feelings  Challenge & change thoughts  Exposure Therapy  Careful, gradual, repeated imagining of trauma  Relaxation and desensitization techniques

29 29 Administrative Issues  Participation in RESPECT-Mil program does not start the Chapter Discharge or Medical Board process  Can redeploy  Reasons for specialist referral –  low motivation  chronic/recurrent (> 6 months)  treatment refractory  occupational problems (absenteeism, fail to deploy, supervisor complaints, misconduct)  high suicide risk

30 30 Case Example - PVT Andrews Part 3 Role Play to demonstrate:  Presenting treatment options  Give key messages if medication prescribed  Explain & offer RCF care facilitation  Discuss primary care clinic continuity  Encourage self-management

31 31 Key Educational Messages Antidepressants only work if taken every day. Antidepressants are not addictive. Benefits from medication appear slowly. Continue antidepressants even after you feel better. Mild side effects are common, and usually improve with time. If you’re thinking about stopping the medication, call clinic first. The goal of treatment is complete remission; sometimes it takes a few tries. Handout #6

32 32 Self-Management Plan Handout #7 1. Stay physically active. 2. Make time for pleasurable activities. 4. Practice relaxing. 5. Simple goals and small steps. 3. Spend time with people who can support you 6. Eat balanced meals and avoid alcohol

33 33 Follow-up  Establish preferred mode and time of facilitator contact  RCF calls –  Initial call one week after treatment started  Minimum calls at 4 week intervals  Follow-up PCL at 4 week intervals  RCF reviews PCL score changes with psychiatrist for possible treatment change recommendations

34 34 PCP Typical Frequency of Patient Contacts PCP RCF Primary Care Clinician Visit Care Facilitator Phone Call Continuation Phase WEEK Acute Phase RCF 20 RCF 32 PCP 36 PCP RCF PCP RCF 40

35 35 INTRUSION 1. Images, thoughts 2. Nightmares 3. Sudden re-experience 4. Upset at reminders 5. Physical reactions AVOIDANCE 6. Avoid thinking/talking 7. Avoid situations 8. Memory loss of event 9. Loss of interest 10. Distant, cut-off 11. Emotionally numb 12. Future cut short AROUSAL 13. Insomnia 14. Outbursts 15. Low concentration 16. Watchful on guard 17. Easily Startled PVT Andrews - Part 4, f/u PCL Handout #8 Not A little Moderately Quite Extremely at all bit a bit

36 36 INTRUSION 1. Images, thoughts 2. Nightmares 3. Sudden re-experience 4. Upset at reminders 5. Physical reactions AVOIDANCE 6. Avoid thinking/talking 7. Avoid situations 8. Memory loss of event 9. Loss of interest 10. Distant, cut-off 11. Emotionally numb 12. Future cut short AROUSAL 13. Insomnia 14. Outbursts 15. Low concentration 16. Watchful on guard 17. Easily Startled = 17 PVT Andrews - Part 4, f/u PCL Not A little Moderately Quite Extremely at all bit a bit

37 37 PTSD Treatment Modification Table To SSRIs PCLTreatment Response Treatment Plan Drop of  5 pts from baseline Adequate No treatment change needed. F/u in 4 weeks Drop of 3-4 pts from baseline Possibly Inadequate May warrant an increase in SSRI; informal consult Drop of 1-2 pts or no change or increase Inadequate Increase dose; Switch drugs; informal or formal psychiatric consultation; add psychological counseling Handout #9

38 38 Remission The goal of PTSD treatment is remission: a PCL score less than 11 and no functional impairment To obtain remission, you will often be advised to do one or more of:  increase the dose of medication  switch to another medication  add a medication  recognize and treat a co-occurring disorder  consider a different diagnosis  refer for counseling or mental health evaluation  be sure counseling is PTSD specific Attaining and maintaining remission  ongoing contact with primary care as well as the RCF  usually takes at least 12 weeks to achieve and may take longer  often tougher than depression

39 39 Logistics – Screenings, Referrals & Communications  All AD patients are being screened starting (date)  Return Dark or Light Blue folders  Soldiers with a Dx of depression &/or PTSD offered treatment & care facilitation (RCF)  Refer to RCF via AHLTA

40 40 Referrals & Communications  Face-to face introductions with RCF are okay and often helpful if possible (AHLTA still required!)  Ask for more frequent or earlier initial call (e.g. 48 hours) when you have concern about pt. follow through on treatment

41 41 PTSD Skills Practice  Those handed a blue folder partner with someone without a folder  Twenty minutes to practice  Scoring PCL  Suicide assessment  Treatment recommendation & RCF referral  Key medication instructions & Self-management

42 42 Summary  PTSD and Major Depressive Disorder are significant health problems post-deployment  RESPECT-Mil implements a system for the depression &/or PTSD care process

43 43 PTSD  Four question screen  PCL (PTSD Checklist)  Suicide assessment Parallel Diagnostic Tools DEPRESSION  Two question screen  PHQ-9  Suicide assessment

44 44 Parallel Management Tools PTSD  Key messages for drug adherence  Care facilitation calls  Self-management  Psychiatric supervision for treatment changes  Informal psychiatric consultation always available DEPRESSION  Key messages for drug adherence  Care facilitation calls  Self-management  Psychiatric supervision for treatment changes  Informal psychiatric consultation always available

45 45 Primary Care Provider & the Prepared Practice Recognition & Diagnosis Patient Treatment Selection and Education Initiate Treatment & Care Management Continue or Change Treatment Continuation / Maintenance Phase Relapse / Recurrence Prevention Screening Questions PHQ-9 &/or PCL Suicide Assessment Interview Present Rx Options Elicit Patient Choice Key Patient Education Self-Management Plan PHQ-9 or PCL for Rx Response Informal or Formal Specialty Referral

46 46 Care Facilitator Encourage Adherence Problem Solve Barriers Measure Treatment Response Monitor Remission Communicate with Clinicians

47 47 Psychiatrist Care Facilitator Supervision Informal Consultation Formal Consultation / Treatment Psychological Counseling Access to mental health resources will be enhanced

48 48 WE WANT THIS TO WORK FOR YOU!  Please take a moment now and complete our brief evaluation form Your feedback is important to this implementation effort. Thank you! Evaluation Handouts


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