Presentation is loading. Please wait.

Presentation is loading. Please wait.

Models and Process of Psychosomatic Medicine

Similar presentations


Presentation on theme: "Models and Process of Psychosomatic Medicine"— Presentation transcript:

1 Models and Process of Psychosomatic Medicine
APM Resident Education Curriculum Robert C Joseph, MD, MS, FAPM Director Consultation-Liaison and Primary Care Behavioral Health Service Program Director, Psychosomatic Medicine Fellowship Cambridge Health Alliance, Cambridge MA Assistant Professor, Harvard Medical School Updated Summer 2011 Robert Joseph, MD, MS Fall 2013 R. Brett Lloyd, MD, PhD

2 Psychosomatic Medicine
Subspecialty at the interface of Medicine and Psychiatry Clinical Service Research Training Psychosomatic Medicine is the name of the accredited subspecialty The terms ‘Consultation-Liaison Psychiatry (C-L) and ‘Psychosomatic Medicine’ (PM) have had a variety of connotations historically. The 2 terms are increasingly used interchangeably One can think of PM as the background body of knowledge and C-L as the clinical service

3 Models of Psychosomatic Medicine Psychiatry
Traditional/Conventional Hospital or Ambulatory Based Consultation Upon Request (reactive) Liaison Psychiatry Mental Health Integration Case Finding/Screening Proactive/Systemic Mental Health Involvement Population Based Programs Disorder Specific Programs Hybrid Models Traditional Models: Classic, hospital based C-L service; Conventional; Common Integration Model: Integration occurs along a spectrum. The degree of integration varies from something that may closely resemble a traditional (reactive) service to a highly structured, multidisciplinary disorder specific management program. Increasingly common More often seen in ambulatory settings Consistent with many aspects of health care reform proposals. Most common inpatient version is seen with delirium prevention and management programs Hybrid Models: Elements of both

4 Traditional Models Consultation Upon Request
Reactive Patient and consultee specific Primary responsibility for patient remains with consutee Liaison Psychiatry Components Education Formal and informal education Support Service, Ward, Nursing Staff Can be Sub-Specialty Specific OB, Oncology, Neurology etc. Consults usually funded by FFS system. Liaison work not supported in FFS system.

5 Types of Patients Complex, co-morbid psychiatric and medical conditions Neurocognitive disorders Somatic symptom and functional disorders Psychiatric disorders secondary to medical conditions or treatments Disorders above are most commonly seen but range of disorders include all DSM Dx The range of disorders seen can present significant challenges to residents early in their training Most common reasons for consult request: Depression, Mental Status Change, Capacity, Safety, Dementia

6 Distinction from Office Based Psychiatry
Services requested by consultee No “self referral” Obligations to consultee as well as patient Patient often unaware of referral Usually ill, uncomfortable or in pain Patient motivation often compromised Limited privacy Visits not scheduled nor time based The working environment presents challenges not generally encountered in the rest of psychiatry. Pt is often less motivated to willingly participate These factors add to the challenge for trainees.

7 Function of Psychiatric Consultation
Doctor-to-doctor communication designed to address the mental health needs of the patient and improve patient care the over-riding concern is the patient’s well-being The primary function cannot be ignored. Addressing any conflict (when present) is difficult but critical to a successful consultation

8 Essential Tasks Complete a comprehensive psychiatric assessment and develop a management plan Remove impediments to medical care Bring a fresh perspective to the clinical dilemma Facilitate a mutual understanding between patient, doctor and treatment team Educate about the emotional and neuropsychological needs of the patient Multiple agendas are present in most consultations.

9 Steps in the Consultation (1)
Review chart and consult question Discuss case with consultee To help delineate the manifest question and help identify any latent question(s) To help consultee reformulate the question, in a manner which addresses underlying issues and allows the consultant to be helpful Review all staff notes. Notes from nursing, PT etc often contain valuable information on pt. The stated reason for the consultation often does not reflect the nature of the problem. Discussing the problem with the consultee before seeing the patient is critical to the consultation. The consultant can often help reformulate the question in a way that better describes the nature of the problem and allows one to be the most helpful. For Example “Rule out depression” might be a reflection of other, less defined concerns…. “I have been unable to explain this patients symptoms….it must be something psychological…”

10 Steps in the Consultation (2)
Patient Interview Introduce self Sit down Address patient’s surprise at the arrival of a psychiatrist (if present) Attend to any physical discomfort Identifying oneself as the Psychiatric Consultant is usual but must be weighed against the possibility of premature termination of the interview. Be active in your approach, clarify distortions and misconceptions aggressively (“No one thinks you are crazy”) Personally attend to the patients physical discomfort or obtain nursing assistance if needed. Adjust bed, patient position, obtain drink etc. Conversation should be conversational, polite and respectful Pay attention to personal items, visitors etc Observe personality traits, coping styles without digging Support defenses. The tone should generally be conversational and supportive. ‘Uncovering’ is usually to be avoided

11 Steps in the Consultation (3)
Mental status exam Includes bedside cognitive testing Targeted physical exam (if appropriate) Ancillary history gathering often appropriate Family PCP Other care givers Other MS exam is tailored to the clinical situation. Serial MSE’s are often useful to make diagnosis and document response to treatment Cognitive exams are common and facility with bedside neuropsychological assessment is necessary. Must be comfortable either doing a targeted PE or suggesting that one is necessary. Ancillary informants are often critical and should be considered a routing part of the process.

12 Steps in the Consultation (4)
Written note Verbal communication (feedback) with consultee, regarding your opinion Follow-up visits as appropriate Range can be none to daily The written note largely follows the standard medical write up. Verbal communication with the consultee is critical to confirm that your assessment was understood and to address any remaining question. At least one follow up visit is often important to verify that your recommendations were understood and followed, or, if not, ascertain why not Multiple fu visits are sometimes necessary (persistent suicidal ideation, behavioral disruption, fluctuating MS).

13 Designed to be used by other members of the treatment team
The Written Note (1) Document formally addressed to the physician requesting the consultation Designed to be used by other members of the treatment team May be read by a variety of hospital personnel Consider confidentiality The document is addressed to the consultee but the audience is usually varied. The note should be written with this in mind. Depending on the nature of the problem the target audience could be nursing staff, social workers, lawyers etc…

14 The Written Note (2) TITLE: Psychosomatic Medicine Service
Attending Resident Other NATURE OF THE NOTE Initial Consultation Note Follow-up Consultation Note Given the variety of MD notes in the chart it is important to clearly identify who you are and your role.

15 The Written Note (3) DATE AND TIME: SOURCE IDENTIFYING STATEMENT
Essential when dealing with a fluctuating mental status SOURCE Patient, family, medical record, other IDENTIFYING STATEMENT This lays the groundwork for your formulation and recommendations in a way that helps the readers to understand your note Distinguish the time of the exam from the time the note was written if discrepant Collateral information is often critical and obtaining such is more the norm than an exception. It is also worthwhile to document the total time spent on consultation. May help for reimbursement and demonstrates the amount of effort involved in consultation

16 The Written Note (4) Reason for Consultation
Why did the primary treatment team request a psychiatric evaluation? There is often a difference between what the primary team requests and what they actually want from the psychiatrist Manifest request: R/O depression Latent request: There is nothing wrong with this patient. She is drug seeking and manipulative. Make her stop complaining and behave! The consultant’s understanding of the reason for the consultation evolves in the process of reviewing the chart and talking to the consultee, nurses etc.

17 The Written Note (5) Identifying Statement Important
“The patient is a 34 year old female admitted for abdominal pain with a history of multiple medical complaints and pain unresponsive to usual interventions. We are asked to evaluate her for possible depression” A reiteration of the manifest question Reminds us to answer the question Respectful to consultee This statement sets the tone for the consultation and frames the objectives of the consultation Remains nonjudgmental and respectful of affect behind the consultant’s original request Tactfully reformulates original question into one that allows the consultant to address the underlying issue and thus, be more helpful

18 The Written Note (6) HISTORY OF PRESENT ILLNESS
A place to document the essential positive and negative aspects of the history Provides a historical framework for understanding the patient Must include DSM descriptive characteristics and review of systems relevant to diagnosis Consider: The special events of the patient’s life, e.g., losses, illnesses. The precipitant to the current psychological and physical difficulties. The nature of the patient’s reaction to these precipitants. Usual coping mechanisms The written history illustrates what information we judge as being important. This data plus other data should substantiate the ultimate formulation and differential diagnosis.

19 The Written Note (7) Past Medical/Surgical History
Include menstrual and obstetric Past Psychiatric History Medication Prior to admission At time of consultation Recent changes Substance Use History Family History Social History Medication documentation should also distinguish what medications are ordered from what meds are taken

20 The Written Note (8) Physical Exam (as appropriate) Mental Status Exam
Analogous to the physical examination. Reflects a point in time Address the question of the consultation and your formulation within the mental status examination It is an opportunity to teach and to demonstrate how diagnoses are made A tool to gain access to a patients mental life Pertinent Laboratory and Radiologic Findings Should document signs that substantiate one’s diagnostic impression and changes over time

21 The Written Note (9) Impression
Other than recommendation, the most likely part of the consult to be read Should have the components of a good biopsychosocial formulation, but avoid psychiatric jargon whenever possible Include stressors and functional status Know your audience and what you want to accomplish Differential diagnosis, including personality and medical disorders Consider the audience and remember ‘essential tasks’ of consultation in composing this An opportunity to educate the medical community about the patient

22 The Written Note (10) DIAGNOSIS DSM-V DSM IV-TR Multi-axial assessment
Axis III – including disorders relevant to the psychiatric disorder(s) Axis IV – Psychosocial/ environmental problems Axis V – global assessment of functioning DSM-V Axis I-III combined: list relevant diagnoses to consultation List ICD-9-CM V codes related to psychosocial and environmental problems WHODAS – may be used to demonstrate disability Axis I – III merged. Relevant diagnoses that impact case formulation are listed. Consider using ICD-9-CM V codes for factors that may further influence or impact diagnosis. WHODAS may be performed as indicator of overall disability.

23 WHODAS: World Health Organization Disability Assessment Schedule 2.0
The Written Note (10) WHODAS: World Health Organization Disability Assessment Schedule 2.0 Axis V (GAF) was dropped from DSM-V WHODAS is included for further study as an assessment tool for functioning 36-item, self-administered measure used to assess disability in adults (age 18 and older Included in Section III of the DSM-V Domains include: Communication, getting around, self-care, relationships, household activities, school and work activities, participation in society Global Assessment of Functioning (GAF) was dropped in the DSM-V. Lack of conceptual clarity, questionable psychometrics. WHODAS may be performed instead as indicator of overall disability. WHODAS has been included for further study (placed in section III of the DSM-V)

24 The Written Note (11) Recommendation/Plan
Most likely part of the consultation to be read Further work-up suggested Physician management Medication Behavioral approaches with patient Be specific, avoid jargon Nursing management Legal issues Social service needs Aftercare plans Consultant follow-up Inform treatment team of your availability, whether/when you will return and the purpose of your return Tone should be confident, informative and respectful Content should be evidenced based and practical Example “This is not the best time to confront the patient on the possibility of their overuse of prescription drugs. This can wait till the medical crisis passes.”

25 Mental Health Integration (1)
Collaboration with Multidisciplinary Team Mental Health (MH) and non-Mental Health (non-MH) providers Psychiatrist, other MD’s, Psychologists, Social Workers, Nurses, Case Managers, Support Staff Elements of Integration Mission Optimal care for behavioral problems in non-MH setting Target Population Patients with co-morbid medical and psychiatric problems Patients with MH problem but no other MH care Location Generally involves co-location of MH staff in medical site Communication Team meetings, shared, medical record and treatment plans Administrative Shared or coordinated between MH and non-MH staff Fiscal Integrated budget for MH and medical staff vs. separate No one definition or model for integrated care Tends to involve teamwork and multiple providers at various levels Seen most often in primary care but also done in specialty clinics (OB, Oncology etc) Responsibility for care is usually shared between MH and non MH providers Shared Record and Co-location tend to be minimal elements of integration Many models are easily adaptable to proposals for health care reorganizaion including the “medical home”

26 Mental Health Integration (2)
General Hospital Based Tends to be disorder specific E.g., delirium, transplant or substance use disorders Ambulatory Primary care Medical/Surgical Specialty clinics OB, Oncology, Neurology, Transplant etc General Hospital based tend to have screening or structured case finding, assessment and management program Ambulatory Integration runs from co-location of fairly traditional reactive consultation to full service MH care thoroughly integrated into medical clinic Planned Care: AKA ‘Collaborative Care’, ‘Stepped Care’, other

27 Mental Health Integration (3)
Rationale Prevalence of mental health (MH) issues in medical setting Lack of access to conventional MH services Patient’s reluctance to go to MH clinic Extensive co-morbidity of medical and MH disorders Bidirectional adverse effect of co-morbid disorders Associated morbidity and cost of disorders Method/Structure Wide range Reactive Programs Mimic traditional consult services except, perhaps for co-location Planned Programs Highly Structured, oriented toward “Disease Management” Prevalence, co morbidity, cost, documented in many studies Access to MH services especially problematic in rural areas and with lower SES and immigrant populations Many patients are willing to be seen in medical clinic but not willing to go to MH clinic Stigma less for MH care received within medical clinic Growing evidence of affect of mental disorders on medical outcomes and vice versa

28 Mental Health Integration (4)
Value added Delirium prevention programs Depression, Anxiety and Substance Abuse Management in primary care Co-morbid MH and medical disorders depression, diabetes, cardiac disorders Medically Unexplained Physical Symptoms (MUPS) Evidence exists for the efficacy and cost efficiency for programs for each of these disorders

29 Mental Health Integration (5)
Planned Care for Behavioral Health Disorders in Medical Clinics Derivative of chronic disease management programs Proven efficacy in multiple studies AKA Collaborative Care, Stepped Care Methods Proactive Screening/Case Finding, Registry, Team Management, Algorithm directed, Consultation and Supervision, Case Management, Teamwork Recognition that many Behavioral Disorders are chronic/intermittent and require long tem management similar to many medical illnesses Proven outcome benefits in many studies Improved outcomes generally correlate with the number of interventions. Case Management and Psychiatric Consultation/Supervision seem to be most critical elements

30 REFERENCES Garrick TR, & Stotland NL. How to write a Psychiatric Consultation. Am J Psychiatry 139:7, 1982. Meyer F, Joseph RC, Peteet JR. Models of Care for Co-occurring Mental and Medical Disorders. Harvard Review of Psychiatry, In press. Gilbody S et al; Collaborative Care for Depression, Accumulative Meta-analysis and Review of Longer-term Outcomes. Arch Intern Med. 2006;166: Williams J et al; Systematic Review of Multifaceted Interventions to Improve Depression Care. General Hospital Psychiatry 29 (2007) Kathol R et al; Psychiatrists for Medically Complex Patients: Bringing Value at the Physical Health and Mental Health/Substance-Use Disorder Interface. Psychosomatics 50:2, March-April 2009. Kontos N; Querques J. Psychiatric Consultation to Medical and Surgical Patients. In: Stern TA, Rosenbaum JF, Fava M, et al. eds: Massachusetts General Hospital Comprehensive Clinical Psychiatry. Philadelphia: Mosby-Elsevier. 2008; p Smith G; Clarke D. Assessing the Effectiveness of Integrated Interventions: Terminology and Approach. Med Clin N Am 90 (2006) Katon W et al. Collaborative Care for Patients with Depression and Chronic Illnesses. N Engl J Med 2010; 363:


Download ppt "Models and Process of Psychosomatic Medicine"

Similar presentations


Ads by Google