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Psychopharmachology

Lecture 5 – Working with Medical Providers and Addresing Medical

Conditions

Primary Care Consult in 5 min Elevator Speach

This brief video (less than 5 minutes) will orient you (the primary care provider) as to how to use a behavioral health consultant in your primary care practice and how to introduce the behavioral health consultant to your patients.

https://www.youtube.com/watch?v=luTrKOeQ4ag

This video presents a vision for redesigning the mental health care delivery system by integrating it into the primary care system as many individual clinics already have.

https://www.youtube.com/watch?v=t0MsDjlTQfo

Anxiety Disorders Overview

300.02 Generalized anxiety disorder

300.21 Panic with agoraphobia 300.01 Without agoraphobia 300.22 Agoraphobia without history of panic disorder

300.29 Specific phobia

300.23 Social phobia

300.3 Obsessive-compulsive disorder

309.81 Posttraumatic stress disorder

308.3 Acute stress disorder

293.84 Anxiety disorder due to a general medical condition

293.89 Anxiety disorder due to... [indicate the general medical condition]

300.00 Anxiety disorder NOS

Paul D. MacLean 1913-2007 coined the concept of the limbic system in 1952 and went on to place the limbic system into an evolutionary context. He proposed that the human brain is really

three brains in one, a "triune brain."

Triune Brain

Autonomic Nervious System

Fear: Short-term and conditioned through classical conditioning principals.

8 mil seconds from trigger to startle response

Anxiety: Long-term and activated in the background. Does not follow conditioned stimulus. Triggerd CRH (e.g. dark ally) make startle more likely.

Talking to Your Client About Medications

Assessment: Assess beliefs, fears and worries about medications. Assess side effects duration, intensity and frequency.

Look up side effects, consult with a provider and develop plan to minimize their impact.

Address Concerns: Normalize and use as opportunity to develop increased self

acceptance. Support client to discuss concerns with clinician. (Clinical

goal: Healthy boundaries and assertiveness). Support cleint to research normal and high risk side effects

and empower them to understand their treatment.

Anxiety Psychopharm Quick Refference

SSRIs: Change serotinin and are the first line of treatment for anxiety.

SNRI’s and Welbutrin: Change norepinephrine (SNRI’s), Change predominantly dopamine (Buproprion).

Buspar: A good treatment for GAD. Buspirone functions as a serotonin 5-HT1Areceptor partial agonist. It is this action that is thought to mediate its anxiolytic and antidepressant effects.

Antipsychotics: Studies as main treatment show effective tx for GAD and social anxiety questions about respiridal as a main treatment. Often used as adjunct tx for anxiety. Has poor adherence due to side effects.

Anxiety Psychopharm Quick Refference

Benzodiazipines: Effect GABA. GABA Is a neurotransmitter associated with overall reduced activation in the brain. It has a sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant

Betablockers: Beta-blockers control some of the physical symptoms of anxiety, such as trembling and sweating.

Trycylics antidepressants can be effective for anxiety. They tend to be sedating.

Case Discussion

Identify clinical cases for case consult at end of training that have a pharmachologcial and a health component of care.

We will have 30 min for case consultation starting at 3:30.

Medication of the Week Presentation

Describe a medication briefly,

Describe what it is used to treat

Describe its side effects

Describe other relivent information.

A Comparison Trial: GAD Treatment Critical Thinking

Approximately two-thirds of the patients who completed the study improved greatly or moderately on all three active drugs.

During the first 2 weeks of treatment, 2′-chlordesmethyldiazepam treatment resulted in the greatest improvement in anxiety ratings. (Slow Acting Benzodiazipine)

Both paroxetine and imipramine treatment resulted in more improvement than 2’-chlordesmethyldiazepam by the fourth week of treatment.

Paroxetine and imipramine affect predominantly psychic symptoms, whereas 2′-chlordesmethyldiazepam affects predominantly somatic symptoms.

DOI: 10.1111/j.1600-0447.1997.tb09660.x

Collaborative Care

Collaborative Care is a diverse set of healthcare protocols that incorporate health, behavioral health and substance abuse services into primary care treatment.

Three Models: The shifted outpatient clinic, The consultation liaison model, and The attached-mental health professional model.

The Attached mental health model: Behavioral Health professionals are attached to a primary care practice and are a part of extended care services.

Medical Complexity

A post-hysterectomy patient on replacement progesterone was treated with Klonopin for post-MVA pain.She had consulted a number of different specialists including me, for pain management.

She came to a session reporting confusion and fatigue, stating that she was “totally out of it.”

A computer check of drug interactions showed that her hormone replacement therapy increased the half-life of Klonopin several fold, effectively resulting in an overdose. This was promptly reported to the prescriber.

Integrating Psychology with Psychopharmacology Joseph J. Zielinski, PhD

Psychological Impacts of Medical Diagnosis

Core beliefes about medical condition.

Change in cognitions: Self, world, future.

Adjustment to the medical diagnosis.

Chronic psychological strain.

COPD and Anxiety

“COPD is associated with a higher risk of anxiety. Once anxiety develops among patients with COPD, it is related to poorer health outcomes.”

Participants with COPD (n=1202) and matched controls without COPD (n=302). doi:10.1136/thx.2009.126201

Both CBT group treatment and COPD education can achieve sustainable improvements in QoL for COPD patients experiencing moderate-to-severe symptoms of depression or anxiety.

Adjustment to Medical Diagnosis

Grief Stages: 1. Deniel and Isolation, 2. Anger, 3. Bargining, 4. Depression and 5. Acceptance.

Developing Adaptations: Living with a chronic illness or dissability requires adapting life and building tools to make our life a good life for us.

Understanding diagnosis and how to work with it: Often medical information is confusing and overwhelming. Psychologists can be invaluable to catch missunderstandings and develop realistic apprasials of current abilities.

Dealing with Ablism: Bigotry is real. It impacts how safe we feel with each other. However developing a positive identity can support the transformation of an impediment to a stregnth.

Tammy Duckworth, a disabled Iraq War veteran who was elected yesterday to represent the 8th congressional district of Illinois in the U.S. House of Representatives.

Physiological Impacts of Diagnosis

Impacts of diagnosis on stress response: Asthma, COPD, Diabetes, and chronic pain.

Impacts of diagnosis on mood: Lack of exercise, impacts concentration, impacts cognitive functioning.

Impacts of diagnosis on sleep, eating, breathing, self-care and other basic functions. (Aleostatic load)

Impacts of diagnosis on ability to do things one enjoys and have ease daily living.

Impacts of diagnosis on cognitive functions (Thoughts, cognitions, awareness, delirium or dementia).

Living with IBS

IBS sufferers often feel betrayed by their body.

They can fee like it acts up stopping them from leading the life they want to live.

Irritable bowel syndrome (IBS) Cramp pain in gut, gassiness, bloating and changes in bowel

habits. IBS-C have constipation (difficult or infrequent bowel

movements) Sometimes the person with IBS has a crampy urge to move the bowels but cannot do so.

IBS-D Diarrhea (frequent loose stools, often with an urgent need to move the bowels).

Also alternating IBS-A, Mixed IBS-M, Unspecified IBS-U

Copyright © American Psychiatric Association. All rights reserved.

From: Anxiety Disorders and Comorbid Medical Illness Focus. 2008;6(4):467-

485.

Rome III Guidelines for the Medical and Psychological Treatment of IBS.

Figure Legend:

Date of download: 10/21/2012

Copyright © American Psychiatric Association. All rights reserved.

From: Anxiety Disorders and Comorbid Medical Illness

Focus. 2008;6(4):467-485.

Number of 30-Day Role Impairment Days Associated With Comorbid DSM-III-R Mental Disorders Among NCS-R Respondents With Chronic Physical Disorders

Figure Legend:

Anxiety and Irritable Bowl Syndrome

Co-morbid IBS and anxiety corealtes with increased severity of GI symptoms and more dissability.

CBT has several studies but limited double blind studies but is considered effective.

Tricyclic antidepressants (TCAs) more effective than SSRI (central analgesic actions of norep.)

SSRIs are effective for underlying anxiety and depression, and possibly for IBS sufferers without psychiatric disorders.

The benzodiazepines have some studies showing efficacy for reducing anxiety and limited for effecting the IBS sympt. but due to tolerance and addiction not recommended.

Buspar: May be effective but no clear data exists to date.

Activation of CRF1 signaling pathways and IBS-like manifestations, which can be blocked by CRF1 receptor antagonists.

Social Impacts of Disease

Change in ability to socialize through reduced energy, focus, stamina and ability.

Poor understanding of disease by friends and family (get over it, or poor them).

Change in physical appearience.

Change in role in family system.

Change in ability to engage sexually or romatically.

Asthma and Anxiety

“Panic disorder, panic attacks, GAD and phobias appear to be the anxiety disorders most strongly associated with asthma.”

“In youth: a significant correlation between anxiety sensitivity and asthma severity.”

“One study found that adolescents with a history of life-threatening asthma attacks are more likely to have symptoms of PTSD due to asthma attacks.”

“Comorbid anxiety and depressive disorders are only accurately diagnosed in approximately 40% of asthmatic patients in primary care.”

doi:10.1080/02770900701840238

Asthma and Anxiety

Psychological Treatments: (data on efficacy inconclusive at this time)

“Relaxation therapy reduced the need for rescue bronchodilators.”

“CBT improved quality of life in two other studies.”

“Spirometry measures improved following bio-feedback in two studies, but not with relaxation therapy in four studies.”

doi:10.1080/02770900701840238

Pharmacological Interventions a Dissorder

Based Approach

Detailed and clear diagnosis as route to best possible treatment (Differential diagnosis and co-morbidity).

Symptoms cluster to dissorder if you treat the main causes you treat the dissorder.

Dissorder Based treatment matches the diagnosis with proper treatment protocol. Depression – CBT, SSRI. Seizure dissorder – Neurontin (or other

anticonvulsent), identifing prodromals, safety planning, increased self-care and stress reduction.

Pharmacological Interventions a Symptom

Based Approach Identify core symptoms effecting paitient (e.g. sleep,

lack of hunger, lethargy, social anxiety, impulsivity, irritability, difficulty concentraiting).

Consider bodily system driving the symptom and its context to assess ways to possibly address symptom (e.g. chronic pain leading to nocturnal rousals - long acting pain medication at night combined with tricyclic).

Consider psychopharacological intervention to reduce symptoms impact on quality of life.

Small Group ExerciseTreatment Planning

Each group will discuss these key issues: Key assessment questions to follow

up on in next session. Major treatment goals. Interventions to reach those goals. A short treatment plan – six sessions. Report back to group briefly.

Treatment Planning

A 56-year old caucasion vice-principal has been working at her job for 12 years. She currently reports gut pain, lower back pain, and has become more impulsive. She reportedly has missed multiple days of work due digestion.

Her desperate husband attending session describing to you in privatre bizarre, out of character behavior, such as talking to strangers in restaurants, poor overall hygiene, eating nothing but junk food, resulting in 12 dental caries.

Psychologists as Pharmacology Consultant

Psychologists have begun to realize just how valuable psychopharmacological training can be.

Psychopharmacological training for psychologists is the new face of psychology.

It can prepare the psychologist to (a) Collaborate with physicians in order to craft the right

psychopharmacological regimen for their mutual patients. (b) Recognize which symptoms are likely to benefit from the use

of medications. (c) Examine possible drug–drug interactions. (d) Make sure that the prescription decisions being made are

actually in the best interest of the patient.

Psychologists as Pharmacology Consultant

Prescribing (Louisianna, New Mexico, Navey) Significant post graduate training.

Colaborating – Actively engage with support and dialog about paitient care and medication selection.

Providing Information – Discuss medication information, identify client concers, support adherence, identify side effects and communicate concerns with providers.

Working with Medical Providers

People become doctors to help. Medical providers want their patients to do well.

Basic Prinicipals of Clinical Consult with Medical Provider: Listen to the consulting question. Be cofortalble with the limits of your knowledge but speak

the providers language. They are the provider you “make a recommendation for a

medication evaluation.” Be focused and direct. Say concerns in 3 sentenses or less. Give suggestions through questions.

Psychologist Role in Medical Collaboration

Psychologist Role in Medical Collaboration: Develop clinical team and facilitate communication. Support secure attachment between client and health

provider. Support client to be assertive with questions and needs. Provide direct understanding of impact of medical

intervention on client (side effects, medication complience and changes in condition).

Provide neuanced understanding of psychological conditions for medical providers.

Support treatment adherence and know when treatment is not working and urge team to change treatment.

Working with Psychiatrists

Psychologists see their cleints more often then psychiatrists and our input can be vital.

Many issues require a tag team approach working from both angles (e.g. medication adherence, moving from pre-contemplative to contemplative).

Keep medical explinations on the radar.

Important: Building clinical relationship, recognizing and accepting higherarchy, one down position, effective questions and listen well.

Good statement: “I have been noticing ___ have you noticed it?” and follow, “what do you think about it?”

Good questions: What would help your work? What would you like the client to know about their medcations?

Working with Primary Care Physiscians

Psychologists see paitients more oftenthan PCP.

Psychologists can communicate about psychological symptoms and support neuanced decisions about psychopharmacological treatment.

Develop the collaboration with individual providers.

Build care team. Identify the appropraite range of services. Keep members informed. Address concerns. Be willing to call for team meetings.

Support attachment between medical provider and their patients.

Working With Nursing Staff

Nursing staff are the backbone of the organization. They make everything happen. Many medical errors are caught by nurses.

Nurses in some areas prescribe with a physician supervisor.

Nursing as a culture tends to be practical, direct and results focused.

Nurses provide a large amount of direct information and are integral to patient care.

Defference to their knowledge and expertise as well and seeking their input can increase you knowledge and efficacy as well as your direct impact on patients.

Types of Nurses and Their Training

CNA Certified Nursing Assistant - The education and experience for a CNA is limited, therefore so are the job responsibilities (not considered a nurse).

A Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN): Perform all job duties of a CNA, plus more in-depth care, such as administering medications, injections, starting Ivs, develop patient care plans. LPNs/LVNs cannot fill doctor's orders directly, they must take their orders from higher level nurses.

A Registered Nurse (RN) can perform all tasks of CNAs, LPNs, and LVNs and can take orders directly from doctors. They also operate medical equipment, administer IVs, give medications and injections, assist in surgery, administer care plans and sign off another nurse's work.

Master of Science in Nursing (MSN) programs, RN to MSN programs, and graduate specialty diploma programs are available, as well as PhD doctorates for students who wish to pursue advanced nursing work and/or research.

Advanced Practical Registered Nurse (APRN) specializes in certain types of complex nursing care.

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CasCase Consultation

Closing Questions

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