michael v. genovese, m.d., j.d. medical director, sierra tucson integrated treatment of the complex...

M I C H A E L V . G E N O V E S E , M . D . , J . D .M E D I C A L D I R E C T O R , S I E R R A T U C S O N

INTEGRATED TREATMENT OF THE COMPLEX PATIENT

OVERVIEW

• Integrative Holistic Medicine

• Co-Occurring/Dual Diagnosis

• Professionals As Complicated Patients

• Integrative Holistic Modalities

INTEGRATIVE HOLISTIC MEDICINE

• Reaffirms relationship between practitioner and patient• Focuses on the whole person• Is informed by evidence• Makes use of all appropriate therapeutic

approaches and disciplines to optimize health and healing• Addresses physical, emotional and spiritual

aspects of life

COMPREHENSIVE TREATMENT

• Chemical Dependency

• Mood Disorders

• Eating Disorders

• Trauma

• Complex Pain

Chemical Dependency

Mood

Pain

UNIQUE PATIENT NEEDS

Mood

Chemical Dependency

Eating Disorder

Trauma

Pain

Chemical Dependency

PREVALENCE

• Approximately 20% of Americans suffer from diagnosable mental illness each year • According to the National Institute of Mental

Health major depressive disorder is the leading cause of disability in United States for individuals aged 15 to 44 years• 17.5% of adults with psychiatric illness have co-

occurring chemical dependency = 7.98 million

FINANCIAL BURDEN

• Forbes: Most Expensive Medical Conditions • Heart Disease• Trauma • Cancer• Depression• Chronic Obstructive Pulmonary Disease • Hypertension • Diabetes • Arthritis • Back pain

BREAKING (OR PREVENTING) THE CYCLE

Mood

Anxiety

Sleep

Addiction

Poor Health

Patient

INITIAL EVALUATION

• Establish Rapport & Partnership

• History

• Lab Work

• Initial Treatment Plan

REWARD PATHWAY

NEUROPLASTICITY

EPIGENETICS

PROFESSIONALS AS COMPLEX PATIENTS

• Stress

• Permissive Cultures

• Fear Induced Avoidance

• Obstacles to Accurate Diagnosis

• Perfectionism• Indecisiveness• Self-Criticism• Low Flexibility•Highly Disciplined• Idealism•High Degree of Empathy

PERSONALITY TRAITS ASSOCIATED WITH HIGHER PSYCHIATRIC MORBIDITY

Graske et al. BMJ 2003

IMPAIRED PHYSICIANS

• Compromise patient safety

• Foster medical errors

• Poor patient satisfaction

• Preventable adverse outcomes

• Undermine individual and team communication and effectiveness

• Increased the cost of care

• Prevalence

COMMON PHYSICIAN STRESSORS

• Sitting For Exams• Acute Environments

(ER, ICU)• Juggling Career and

Family• Overwork/Fatigue• English 2nd Language• Physical Illness • Authoritarian

Hierarchies Intolerant of “Weakness or Failure”

• System Issues (Morale, Funding)• Increasing Emphasis

on Efficiency• Increasing

Requirements for Formalized Accountability• Increasing Threats of

Litigation• Financial Difficulties

COMMON PHYSICIAN STRESSORS (CONTINUED)

• Decreased Long-Term Unhurried Relationships with Patients• Increasing Emphasis

on “Patient Rights”• Perceived Decline of

Status of Medicine• Uncertainty about

Career Options• Marital Discord

RESIDENCY TRAINING

• “Catastrophic Stress”

• “House Officer Syndrome”• Depression (1/3 to1/2) • Episodic Cognitive Impairment• Sleep Deprivation• Chronic Anger• Pervasive Cynicism• Family Discord• Female Residents at Significantly Higher Risk of Suicide

(2.5 to 5.7)

“APPARENTLY SUCCESSFUL”

• Co-workers unaware

• Other Aspects of Life Secretly Affected

ATTORNEYS AS PATIENTS

DEPRESSION

• University of Arizona Study:

• General Population 3%-9%

• Late Spring of First Year of Law School 32%

• Late Spring of Fourth Year of Law School 40%

A PROGRESSIVE PROBLEM

United States Attorneys 2 to 20 years

Attorneys over 20 years

0

5

10

15

20

25

% CHEMICAL DEPENDENCY WITH CO-OCCURRING PSYCHIATRIC DISORDER

Series10

10

20

30

40

50

60

70

AttorneysHealth ProfessionalsNon Professionals

Sweeny et al. (2004)

DR. JONES

Cc: “I feel terrible.” HPI: Dr. Jones is a 46-year-old male who presented with complaints of depressed mood, anhedonia, low energy, insomnia, feelings of guilt, decreased appetite and generalized anxiety. Symptoms have been present for “several years” exacerbated over the past six months in the context of marital and occupational stress. PΨH: No history of psychiatric hospitalizations. Was treated in the past by self with Effexor XR 75 mg QD for anxiety and depression. Was referred by friend to psychiatry three years ago but never followed through. Saw a marital therapist “three or four times about two years ago.” No other psychiatric history reported.

FΨH: Father, who was also a surgeon, may have suffered with, but was never treated for depression. Sister has reported anxiety symptoms and Dr. Jones believes she is engaged in psychotherapy.  PMH: Hypercholesterolemia, Chronic Headache, Back Pain Soc. Hx: Dr. Jones has been married for twenty two years and resides with his wife, 20-year-old son and 18-year-old daughter. He is self employed and on staff at a local hospital. He has never missed work due to the symptoms referenced above. She reports social Etoh, denies tobacco, denies illicit drug use.

Current Medications:

Lipitor 20 mg PO QD

Ambien CR 12.5 mg PO HS PRN Sleep

Percocet 10/325 PRN Headache, Back Pain Previous Medications: Effexor XR as above. Allergies: NKDA 

MSE: Dr. Jones is a 45-year-old neatly dressed male who appears slightly older than his stated age. His speech is normal in rate and tone. He is coherent but easily distracted. His mood is “rotten” and affect is angry. He denies any auditory or visual hallucinations. He denies suicidal or homicidal ideation. His short term memory is intact as is his long term memory. His attention is impaired, insight and judgment are fair. Assessment/Plan: Dr. Jones is suffering with Major Depressive Disorder, Severe, Recurrent, without psychotic features. He also meets criteria for Generalized Anxiety Disorder. Rule out Opioid Dependence.We discussed the following treatment options:

BUILDING A BIGGER TOOLBOX

TREATMENT CONSIDERATIONS

• Diet• Supplementation• Exercise• Pharmacology• Psychotherapy• Acupuncture• Massage• Reiki

• Neuromodulation• Equine Therapy• Alternative Setting

FOOD AS MEDICINE

• Individualized

• Excellent Safety Profile

• Treat and Prevent Disease

• Empowers the Patient

SUPPLEMENTS

• Vitamin D• Vitamin B• S-Adenosylmethionine• Rhodiola• Passion Flower• Melatonin/Ashwagandha• Kudzu

EXERCISE

PHARMACOLOGY

• Individualized to Every Patient

• Education

PSYCHOTHERAPY

ACUPUNCTURE

• Depression

• Anxiety

• Pain

MASSAGE

REIKIThe root chakra is in relation to the adrenal gland.The navel chakra to the ovaries or testicles.The solar plexus chakra is related to the pancreas.The heart chakra belongs together with the thymus.The throat chakra corresponds to the thyroid gland.The third eye chakra has a connection to the pituitary gland.The crown chakra is usually connected to the pineal gland.

EQUINE THERAPY

NEUROMODULATION

• Neurofeedback

• Transcranial Magnetic Stimulation

• Electroconvulsive Therapy

ZERO BALANCING