Specific Behavioral Health Issues that Affect Medical Conditions

Specific Behavioral Health Issues that Affect Medical Conditions

Medical Knowledge for Behavioral Health Providers Miller What Do You See? What Do You Do? Does It Work? A story

Asthma Chronic Pain Hypertension Diabetes The Biggies Medications (side effects and interactions) The basic vitals Height/weight BP

The most common medical conditions and what you can do Diagnoses and underlying physiological processes What might be, but is not a mental health condition Psychological factors affecting medical conditions A Whole Bunch of Numbers If you have a mental health diagnosis, higher likelihood you have physical symptoms or

medical diagnosis (vice versa too) 20-40% patients in primary care reporting fatigue suffer from depression Patients with mental health diagnosis often have longer hospital stay Depression and anxiety associated with increased use of medical services Distilling down THE BUMPER STICKER

BUT, what we do works Psychological interventions lead to Decrease in medical utilization Saving money Increased recovery time (post surgery) Less readmission rates Improved mental AND medical outcomes Get specific Miller

A FEW EXAMPLES Major depressive disorder affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year Cardiovascular Disease is the leading cause of death in United States; approximately 60.8 Americans experience some for of CVD Approximately 10% to 15% of patients diagnosed with

diabetes mellitus meet DSM-IV criteria for major depression (Anderson, Freedland, Clouse, & Lustman, 2001; Katon et al., 2004 ) Conclusions A modest association of baseline depressive symptoms with incident type 2 diabetes existed that was partially explained by lifestyle factors. Impaired fasting glucose and untreated type 2 diabetes were inversely associated with incident depressive symptoms, whereas treated type 2 diabetes showed a positive association with depressive symptoms. Then there is that stress thing

Stress affects health primarily through: Direct physiological mechanisms Decreased resistance to disease (greater incidence of infectious disease) Trigger for cardiovascular events Can alter metabolic activity in diabetes Alteration of health related behaviors Cessation of healthy habits Increase in smoking status

Arguably the most under utilized tool Stress leads to non- adherence of treatment regimens AND diagnosis and symptomatology can lead to psychological distress (Lustman, 1988; Wells, Golding, & Burnam, 1988; Wilkinson, 1991) Another two way street Deep breath

LET THE FUN BEGIN Medical Terminology (prefixes) hyper - above; excessive hypo - deficient; below; under; less than normal a no; not; without ab away from Medical Terminology (meds) prn as needed

bid twice a day q qd qh q4h, q6h.... qid QNS qod Qs/Qt Qt

every (e.g. q6h = every 6 hours) every day every hour every 4 hours, every 6 hours etc. four times a day quantity not sufficient every other day shunt fraction total cardiac output What you need

And how could we forget BUT DOC, SMOKING MAKES ME FEEL RELAXED Smoking 1946 ~1950

Tobacco Use Common 80% of individuals with severe mental illness report using some form of tobacco (Ziedonis & Williams, 2003) 44% of all cigarettes consumed by individuals with a mental illness or substance abuse disorder (Lasser et al., 2000) Nicotine dependence has been well documented among individuals diagnosed with schizophrenia (88%), mania (70%), major depression (49%), and anxiety disorder (47%) (Hughes, Hatsukami, Mitchell,

& Dahlgren, 1986) To complicate these mental health diagnoses, withdrawal from tobacco use can aggravate and increase emotional lability (Glassman, 1993; Wetter et al., 1998) Among current smokers, the most common current (within the last 30 days) mental health diagnoses are (Lasser, 2000): Alcohol abuse Major Depressive Disorder

Anxiety disorders: simple phobias and social phobias Substance Abuse The Five As Ask

Advise Assess Assist Arrange Tobacco Use: What Works* High Marginal Efficacy: Efficacy: Self-help materials

(e.g., books/videos; Lancaster Behavioral Methods: al, to 2005) et Face face counseling (e.g., Lancaster et al, 2005) Ineffective: Telephone counseling (e.g., Quitlines; Stead et al.,

Acupuncture 2006) (White et al., 2006) Hypnosis Computer-tailored (Abbot etinterventions al., 1998) *Everyone has an Aunt Susie Level of Nicotine

The importance of physiology NRT Time Examination of the Evidence Intervention: Pharmacotherapy First-line medications:

Bupropion SR Bupropion SR is an efficacious smoking cessation treatment that patients should be encouraged to use (Strength of Evidence A) Can be used in combination with other nicotine replacement therapies Available exclusively for smoking cessation (Zyban) or depression (Wellbutrin) Estimated abstinence rate: 30.5 Intervention: Pharmacotherapy

First-line: Nicotine Gum (Strength of Evidence A) Estimated abstinence rate: 23.7 13 studies Nicotine Inhaler (Strength of Evidence A) Estimated abstinence rate:

22.8 4 studies Nasal Spray (Strength of Evidence A) Estimated abstinence rate: 30.5 3 studies

Nicotine Patch (Strength of Evidence A) Estimated abstinence rate: 17.7 27 studies Intervention: Pharmacotherapy Second-line: Clonidine (Strength of Evidence A) Estimated abstinence rate:

25.6 5 studies Nortriptyline (Strength of Evidence B) Estimated abstinence rate: 30.1 2 studies

Intervention: Pharmacotherapy Not Recommended: Antidepressants other than Bupropion SR and Nortriptyline Anxiolytics/Benzodiazepine/Beta-Blockers Silver Acetate Mecamylamine What is being done? In 2000, 1.3.% of smokers making a quit

attempt used a behavioral treatment - 21.7% used a pharmacologic treatment (Cokkinides et al., 2005) Shiffman et al., 2008 found that behavioral treatments are rarely used without medication (2.9%), while medications are often used without behavioral treatments (26.3%) The Role of Stress Why take away the Pt only way of coping with

stress? Stress management important prior to a quit attempt YerkesDodson, 1908 Assessment Arguably the most important element in cessation remains the assessment The Art of Scaling: 0-10 Assessment Tool On a scale of 0-10, how important is it that you

quit smoking? On a scale of 0-10, how confident are you in your ability to quit smoking? Insomnia The best cure for insomnia is to get a lot of sleep. - W. C. Fields

Chronic Insomnia Prevalence ~10-15% (Costa et al., 1996, Morin et al., 1994) Direct costs - $13.9 billion a year (Walsh, 2004) More frequently seen in Women Older Pt

Pt with chronic medical dx Pt with psychiatric disorders May follow episodes of acute insomnia Definitions Insomnia difficulty with the initiation, maintenance, duration, or quality of sleep that results in the impairment of daytime functioning, despite adequate opportunity and circumstance for sleep (Silber, 2005,

Morin et al., 1999, Costa et al., 1996) Chronic Insomnia Consequences Enter Primary Care Pt often initiate treatment on their own Insomnia often unrecognized Not always Pt presenting problem Assessment Take a careful history Bed partners are an excellent source of

information (e.g., Sleep Apnea) Sleep diary Polysomnography Rarely needed unless suspicion of periodic limb movement, possible sleep disorder breathing problem, or insomnia does not respond to typical treatment Assessment Tools The Pittsburgh Sleep Quality Index (PSQI; Buysse et al., 1989)

Measures the quality and patterns of sleep in adults It differentiates poor from good Measures seven areas:

subjective sleep quality sleep latency sleep duration habitual sleep efficiency sleep disturbances use of sleeping medication daytime dysfunction Scoring of answers is based on a 0 to 3 scale, whereby 3 reflects the negative extreme on the Likert Scale. A global sum of 5 or greater indicates a poor sleeper.

Treatment? 2 4 1 6 5 3

Treatment Medicinal * Multiple options varying in efficacy Behavioral *IMPORTANT NOTE: Try first before combining with medicinal trial studies have shown this reduces the long-term benefit of CBT CBT Addresses several factors that often

perpetuate insomnia (Silber, 2005) RCT have demonstrated efficacy in treating primary insomnia meta analyses (Morin et al., 1994; Murtagh et al., 1995) ~50% of Pt show clinical improvement (Epsie et al., 2001) BHC in primary care treat insomnia well (Goodie, Isler, Hunter & Peterson, 2009) Types of CBT Stimulus-control therapy

Sleep and sex Go to bed only when sleepy 20 minute rule; repeat Regular sleep time No napping Types of CBT Sleep-restriction therapy Reduce/Increase time in bed Relaxation therapy

PMR Biofeedback Guided imagery Meditation Teachable? CBT Cognitive therapy Change beliefs, attitudes about sleep (e.g., But Doc, I know it is medically necessary to obtain

over 8 hours of sleep) Cognitive Physical Environment Behavior Emotions CBT

Sleep Hygiene Pets (Scruffy only covers my face once in a while.) Smoking (It just relaxes me.) Alcohol (All I need is one glass of wine!) Bed Partner (I swear, if only John wouldnt snore like a chainsaw, I would sleep better.)

Exercise (The only time I have to exercise is right before I go to bed or I just dont have time to exercise.) Other Environmental Cues (Falling asleep with the news on isn't a problem is it?) YOU CANT EDUCATE IF YOU DONT ASSESS Pharmacologic Therapies Classes Benzodiazepines Benzodiazepine-receptor agonists

Sedating antidepressants Data to support use No studies extend beyond six months Pharmacologic Therapies zolpidem (Ambien) zaleplon (Sonata) eszopiclone (Lunesta) ramelteon (Rozerem) sedating antidepressants

Pharmacologic Therapies Bottom Line Short-acting agents have greatest effect on sleep latency Agents with intermediate or long-acting have greatest effect on total sleep time Pharm vs. CBT CBT vs. triazolam (Halcion - benzo w/ short half-life; McClusky et al., 1991)

Compared to CBT Shorter sleep latency w/ triazolam at 2 weeks, but equal latencies at 4 weeks CBT vs. zolpidem (Ambien - non-benzo; Jacobs et al, 2004) CBT superior throughout Follow up at 4-6 weeks after medication d/c and CBT completed showed sustained benefit of only CBT Pharm vs. CBT CBT w/ RXP vs. CBT alone (Morin et al., 1999;

Jacobs et al., 2004; Hauri, 1997) 10-24 months f/u improvements are maintained for CBT alone, but not for combined therapy Explanation? Pt less committed to learning and practicing CBT skills if they can control insomnia w/ medications More Evidence AASM EBP (non-pharmacologic tx for insomnia) the following were recommended: Stimulus-control

PMR CBT Insufficient evidence exists to support the use of the following interventions alone: sleep hygiene education ImageryWhat training about me? Cognitive therapy

Take Home Message Assess, Assess, Assess Identify secondary causes first CBT first then meds Medication helpful in short-term (limited studies >6 months)

Insomnia is treatable Resources http://www.aasmnet.org/ http://www.absm.org/PDF/ICSD.pdf

http://www.absm.org/ http://www.sleepfoundation.org http://www.sleepforkids.org/ Ouch CHRONIC PAIN American Pain Society Chronic pain Defined as pain that lasts six months or longer, well past the normal healing period one

would expect for its protective biological function. 50 76 million million (15%-20% Children) Need $100 billion per year

Definitions Acute pain is usually indicative of tissue damage, and it is characterized by momentary intense noxious sensations (i.e., nociception) Chronic pain is defined as pain that lasts six months or longer, well past the normal healing period one would expect for its protective biological function

Recurrent pain refers to intense, episodic pain, reoccurring for more than three months. Recurrent pain episodes are usually brief (as are acute pain episodes); however the reoccurring nature of this type of pain makes it similar to chronic pain in that it is very distressing to patients. Occurs in 15-20% of US population

annually Only 1 out of 4 postsurgical patients are adequately treated 50 million sufferers in US 40% with moderate to severe pain cannot get relief

Nociceptive pain Ongoing activation of nociceptors in response to noxious stimuli (injury, disease, inflammation) Visceral Somatic Superficial Deep Neuropathic pain Caused by aberrant signal

processing in the CNS due to trauma, inflammation, metabolic diseases, infection, tumors, toxins, etc. Allodynia Hyperalgesia Duration Associated pathology

Acute Pain Chronic Chronic Cancer Noncancer Pain Pain Hrs - days Months - yrs Present

Often little or none Usually present Unpredictable Predictable Unpredictable Inc pain with possibility of

disfigurement or fear of dying Associated problems Uncommon Depression, anxiety

Many, especially fear of loss of control Social effects Minimal Profound Profound

Treatment Analgesics Multimodal; largely behavioral Multimodal; drugs play major role

Prognosis Treatment Options Acute Pain Provide rapid and effective relief Treat the cause Chronic Pain Reduce pain to a level that is appropriate for the patient May not be able to eliminate

Improve functioning and quality of life Manage comorbidities Address psychosocial issues How sweet DIABETES What is Type 2 Diabetes? A Chronic endocrinological

disorder characterized by abnormalities in glucose metabolism due to abnormalities in the production and/or utilization of the hormone insulin (Gonder-Frederick, Cox, & Ritterband, 2002) Type I vs Type II T1DM: (insulin dependent) ~5% (think born

with it, onset usually during youth age) Body has insufficient production of insulin (a protein hormone) that helps metabolize carbs T2DM: (non-insulin dependent) 90-95% Gestational diabetes (2-5%) disappears after pregnancy T2DM Statistics Chronic illnesses such as diabetes account for approximately 80% of the deaths in Western countries (Maes, Leventhal, and

DeRidder, 1996) Diabetes is the 7th leading cause of death in the United States (Centers for Disease Control and Prevention, 2002) Diabetes affects approximately 17 million Americans (American Diabetes Association, 2001) Direct and indirect costs related to diabetes range from 57$ to 98$ billion dollars (American Diabetes Association, 1998) T2DM is strongly related to obesity (80%), age, and over 2/3 have a first or second cousin with the disease (Haffner, 1998) Additionally, Haffner (1998) found that the risk for T2DM is higher in minority groups, but T1DM is higher in Caucasians

Thump thump BLOOD PRESSURE AND THE HEART Blood Pressure Systolic <130 Normal 130-139 High Normal 140-159 Hypertension 160-179 (stage II)

>180 (stage III) Diastolic <85 85-89 90-99 100-109 >110 Summary


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