1 respect-mil v. september 2007 recognition and management of depression & post-traumatic stress...
TRANSCRIPT
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RESPECT-Mil
V. September 2007
Recognition and Management of Depression & Post-
Traumatic Stress Disorder(Review & PTSD)
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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
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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
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Three Component Model (3CM)
PREPARED PRACTICE
PSYCHIATRIST
PATIENTCARE FACILITATOR
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PTSD
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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
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PTSD DiagnosisIntrusion 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
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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)
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PTSD Diagnosis‘Arousal’ Symptoms Need two (2) or more:
‘Keyed up’ (anger; insomnia)Difficulty concentratingHyper-vigilance; easily startled
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PTSD DiagnosisImpairment & Duration Impairment functioning
Social Psychological Occupational
Persistent (one month)
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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
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INTRUSION1. Images, thoughts2. Nightmares3. Sudden re-experience4. Upset at reminders5. Physical reactionsAVOIDANCE6. Avoid thinking/talking7. Avoid situations8. Memory loss of event9. Loss of interest10. Distant, cut-off11. Emotionally numb12. Future cut short AROUSAL13. Insomnia14. Outbursts15. Low concentration16. Watchful on guard17. Easily Startled
The PTSD Checklist (PCL) Not A little Moderately Quite Extremely at all bit a bit 0 1 2 3 4
Handout #2
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Confirm Diagnosis
Focused History Questions: Suicidal ideation; Symptoms (intrusion, avoidance, arousal); past PTSD,substance use
Document: For continuity of care/handoff
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Establishing RapportKey Issues Mistrust & uncertainty
Frequent self-blame
Sense of isolation (“no one can understand”)
Trauma discussion is distressing
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Establishing RapportHow 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
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Case Example - PVT Andrews Part 1 Scoring PCL
Illustrate efficient suicide evaluation
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Not A little Moder- Quite Extremely at all bit ately a bit 0 1 2 3 4
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
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Not A little Moder- Quite Extreme- at all bit ately a bit ly 0 1 2 3 4
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 &/orNUMBING (need 3 or more)
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Not A little Moder- Quite Extreme- at all bit ately a bit ly 0 1 2 3 4
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
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INTRUSION1. Images, thoughts2. Nightmares3. Sudden re-experience4. Upset at reminders5. Physical reactionsAVOIDANCE6. Avoid thinking/talking7. Avoid situations8. Memory loss of event9. Loss of interest10. Distant, cut-off11. Emotionally numb12. Future cut short AROUSAL13. Insomnia14. Outbursts15. Low concentration16. Watchful on guard17. Easily Startled
Scoring the PCL Not A little Moderately Quite Extremely at all bit a bit 0 1 2 3 4
Subtotals: a x 0 b x 1 c x 2 d x 3 e x 4TOTAL: A + B + C + D + E
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INTRUSION1. Images, thoughts2. Nightmares3. Sudden re-experience4. Upset at reminders5. Physical reactionsAVOIDANCE6. Avoid thinking/talking7. Avoid situations8. Memory loss of event9. Loss of interest10. Distant, cut-off11. Emotionally numb12. Future cut short AROUSAL13. Insomnia14. Outbursts15. Low concentration16. Watchful on guard17. Easily Startled
0 + 2 + 0 + 9 + 24 = 35
Scoring the PCL Not A little Moderately Quite Extremely at all bit a bit 0 1 2 3 4
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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…
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1. Have these symptoms/feelings we’ve been talking about led you to believe that you would be better off dead?
NO YES
2. This past week, have you had any thoughts that life is not worth living or that you would be better off dead?
NO YES
3. What about thoughts of hurting or even killing yourself?
NO YES
4. What have you thought about? Do you have a plan or have you actually tried to hurt your self?
NO YES5. RISK FACTORS:
History of suicide attempt Substance abuse Significant comorbid anxiety Social isolation Hopelessness
Evaluation of Suicide Risk (Question 19)
Handout #5
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Evaluation of Suicide Risk
No current thoughts or risks Low Risk Follow & 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 RiskEmergency (now) MHP
Urgent (48hr) MHP if social support & self control present, no risk factors
Handout #5
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Case Example - PVT. Andrews Part 2Role 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
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Next, PTSD Treatment:Explain the Options & Patient Choice
Psychological Counseling
and/or
Medication Treatment
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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
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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
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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
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Case Example - PVT Andrews Part 3Role 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
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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
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Self-Management PlanHandout #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
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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
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PCP
Typical Frequency of Patient Contacts
PCP
PCP RCFPrimary CareClinician Visit
Care FacilitatorPhone Call
Continuation Phase
WEEK
Acute Phase
RCF
20
RCF
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PCP
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PCP PCP
RCF
1
RCF
4
RCF
8
RCF
12
PCP
RCF
40
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INTRUSION1. Images, thoughts2. Nightmares3. Sudden re-experience4. Upset at reminders5. Physical reactionsAVOIDANCE6. Avoid thinking/talking7. Avoid situations8. Memory loss of event9. Loss of interest10. Distant, cut-off11. Emotionally numb12. Future cut short AROUSAL13. Insomnia14. Outbursts15. Low concentration16. Watchful on guard17. Easily Startled
PVT Andrews - Part 4, f/u PCL Handout #8
Not A little Moderately Quite Extremely at all bit a bit 0 1 2 3 4
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INTRUSION1. Images, thoughts2. Nightmares3. Sudden re-experience4. Upset at reminders5. Physical reactionsAVOIDANCE6. Avoid thinking/talking7. Avoid situations8. Memory loss of event9. Loss of interest10. Distant, cut-off11. Emotionally numb12. Future cut short AROUSAL13. Insomnia14. Outbursts15. Low concentration16. Watchful on guard17. Easily Startled
0 + 3 + 8 + 6 + 0 = 17
PVT Andrews - Part 4, f/u PCL
Not A little Moderately Quite Extremely at all bit a bit 0 1 2 3 4
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PTSD Treatment Modification Table
To SSRIs
PCL Treatment 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
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RemissionThe 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
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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
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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
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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
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Summary PTSD and Major Depressive Disorder are
significant health problems post-deployment
RESPECT-Mil implements a system for the depression &/or PTSD care process
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PTSD Four question
screen
PCL (PTSD Checklist)
Suicide assessment
Parallel Diagnostic ToolsDEPRESSION Two question
screen
PHQ-9
Suicide assessment
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Parallel Management ToolsPTSD 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
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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 QuestionsPHQ-9 &/or PCLSuicide AssessmentInterview
Present Rx OptionsElicit Patient Choice
Key Patient EducationSelf-Management Plan
PHQ-9 or PCL for Rx ResponseInformal or Formal Specialty Referral
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Care Facilitator
Encourage AdherenceProblem Solve Barriers
Measure Treatment Response
Monitor Remission
Com
munic
ate
wi t
h C
l inic
ian
s
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Psychiatrist
Care Facilitator Supervision
Informal Consultation
Formal Consultation / Treatment
Psychological Counseling
Access to mental health
resources will beenhanced
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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