It Takes a Village: Mental Health Care and the Role of the Family

1. It Takes a Village: Mental Health Care and the Role of the Family Jeffrey Rakofsky, MD Assistant Professor Emory University Mood and Anxiety Disorders Program

2. Dr. Jeffrey Rakofsky, Personal/Professional Financial Relationships with Industry *Consulting, scientific advisory board, industry-sponsored CME, expert witness for company, FDA representative for company, publishing contract, etc. **Does not include stock in publicly-traded companies in retirement funds and other pooled investment accounts managed by others.

3. Today’s Agenda: I. Mental Health Care and the Role of the Family II. Exciting Research Conducted by Department of Psychiatry faculty at Emory University

4. Mental Health Care and the Role of the Family

5. Learning Objectives • To understand why families must get involved in the psychiatric care of their loved ones 2. To appreciate the different phases of illness and most appropriate behaviors from family members 3. To appreciate the dynamic nature of healthy family involvement throughout the different phases of a loved one’s illness

6. Families must be involved! • Psychiatric illness, unlike medical illness, affects judgment. • - Psychosis • - Depression • - Mania • - Addictions

7. Families must be involved! • Staying well costs money and requires resources: • - Hospitalization • - Doctor’s appointments • - Medications • - Transportation

8. Families must be involved! • Regardless of psychiatric illness, the fewer relapses that occur over time, the better a person will do over the long run….. • So, give your loved one the best chance of staying well by getting involved (appropriately)!

9. Phases of Care: I. BEFORE TREATMENT II. ACUTE TREATMENT III. RECOVERY

10. I. Before Treatment

11. Before Treatment • Getting a loved-one to treatment • Historian Family has 2 essential roles:

12. Getting a loved-one to treatment Involuntary Voluntary Doesn’t meet 1013 criteria • Meets 1013 criteria 1013 Criteria: Has mental illness AND Is an imminentthreat to self or others, OR Is too disorganized to care for self **At this point, firearms should be removed from the house.

13. Involuntary-Options • Call the police (Crisis Intervention Team) • Call Georgia Crisis and Access Line (Mobile Assessment) • Get a court order ……Don’t be handcuffed by threats of suicide. Doing nothing could ultimately be worse…..

14. Voluntary-Options • Talk to the loved-one • Don’t yell or argue or blame • Be empathic • Share your concerns (“I” statements) • Help your loved one identify his/her perceived barriers to getting mental health care

15. Voluntary-Options • Consider hiring an Interventionist • Consider “tough-love” approach • Can wait until rock-bottom, but don’t get pulled down too!

16. Don’t bring stigma home with you • Stigma can be toxic and undermine your loved one’s recovery • Muster up the courage to talk to people you trust (e.g. clergy, your primary care doctor) and ask for help and resources.

17. Know your options! Voluntary Involuntary Medical or psychiatric emergency rooms • Private practices • Day treatment hospitals • Medical or psychiatric emergency rooms

18. Historian • Be ready to provide clinicians with information about the loved-one: • - Behaviors • - Concerns • - Medical history • - Psychiatric history • - Medications

19. II. Acute treatment

20. Facilitating the process • Visit loved-one in the hospital • Provide transportation to outpatient appointments, pharmacy, phlebotomy clinic • Help with medication and outpatient visit co-pays

21. Treatment adherence • Consider dispensing medication to loved one • Consider watching loved-one take medicine daily • Organize daily medicines in a 7-day pill box.

22. Be Vigilant! • Look out for signs of worsening symptoms • Look out for signs of adverse drug reactions • If present, first encourage loved-one to notify doctor

23. Communications with therapist/psychiatrist • Call clinician with concerns/updates but don’t expect clinician to return your call or provide details of the loved-one’s care. • Do not expect the clinician to hold secrets for you about the loved one.

24. STOP YELLING!!!!! • Reduced expressed emotion among families is linked to better outcomes for patients • Consider “Family-Focused Psychotherapy” to help improve communication skills between family members and improve attitudes about mental illness.

25. Avoid avoidable stress • Stress is a trigger for most psychiatric illnesses • Consider the effects on the loved-one of upcoming family events within or outside the home……reschedule!

26. Shoulder the burden… • Consider taking over some of the loved-one’s tasks around the house • May have to take on extra work to compensate for loved-one’s inability to work • Consider hiring a caretaker/housekeeper to help compensate

27. Stay Healthy! • Individual psychotherapy/NAMI support groups • Exercise • Take a break and engage in activities that you enjoy • Remind yourself that you’re not to blame for your loved one being ill or not healing quickly enough. • Keep an eye on the health of other family members as well

28. III. Recovery

29. Reduce Vigilance • Too much for too long can be taxing for you and loved-one • Need to restore power-balance • The loved-one needs to learn self-monitoring • May develop naturally for you

30. Support a return to work/school • The loved one (and their families) have to learn what patients can and can’t do by trial and error • Crucial for a patient’s self esteem and sense of competence

31. Communications with therapists/psychiatrists • Time to stop! • Continuing may undermine the loved one’s recovery and jeopardize the doctor-patient relationship

32. Model healthy behaviors • Avoid drinking/drug use in front of loved-one • Regularly attend your own doctor’s appointments • Keep regular sleep/wake cycle

33. Loss of caretaker identity • Monitor for your own emotional reactions • May be unconscious for some • Individual psychotherapy

34. Beware of your resentments • This is usually when they tend to emerge • Understandable given the disruption to your life/work/family but can be very toxic • Couple’s therapy/Individual therapy

35. Stay Healthy! • So you’ll be emotionally and physically ready to respond if there’s a relapse • Individual psychotherapy • Exercise • Thank yourself for your efforts and sacrifices to keep your loved-one safe and healthy

36. Conclusion • Families matter! • Stay healthy so you can endure the ups and downs • Phase-appropriate behavior from family members is key to the success of your loved one!

37. Exciting Research Opportunities at Emory University!

38. Emory Psychiatry is a Translational Research Enterprise

39. …..Throughout Atlanta

40. ….Unlocking the mysteries behind the most severe mental illnesses! • Schizophrenia • Bipolar disorder • Major depressive disorder • Specific phobias • Autism • Generalized Anxiety Disorder • Post-traumatic stress disorder

41. Our Stats….. • The Emory University Department of Psychiatry has received $22 million in research funding for the first 11 months of the 2012-2013 fiscal year • Ranked # 19 among all (@120) psychiatry departments nationwide in NIH research funding

42. Here’s a sampling….

43. Bipolar disorder 2 clinical trials using a sublingual form of Ramelteon: • Is it better than placebo in the treatment of bipolar depression? • 2. Can it prevent new episodes of depression or mania better than a placebo?

44. Major Depression 4 clinical trials (neurostimulation): • Does Deep Brain Stimulation (DBS) improve treatment-resistant depression? • 2) Does Transcranial Direct Current Stimulation (tDCS) improve depression? • 3) Does Rapid Low FrequencyMagnetic Stimulation (RLFMS) improve treatment-resistant depression? • 4) Does RepetativeTranscranial Magnetic Stimulation (rTMS) improve depression?

45. Major Depression Biological study: • What markers of inflammation and hormonal changes are associated with major depression, sleep problems and cognition?

46. Posttraumatic Stress Disorder 2 Clinical trials: • Is a medication that blocks the Cortisol-Releasing Hormone receptors in the brain better than placebo for women with PTSD? Is a psychotherapy approach that involves skills training, affective regulation and narrative therapy better than treatment as usual for women with PTSD?

47. Posttraumatic Stress Disorder Biological study: What genetic markers are associated with PTSD among patients living in inner-city Atlanta?

48. Autism • 5 year, $9.5 million grant to study Oxytocin: 1) What is the impact of oxytocin on brain activity, social perception and attunement on rhesus monkeys? 2) What is the impact of oxytocin on brain activity and social cognition in patients with Autism?

49. Generalized Anxiety Disorder Clinical trial: • Is 6 weeks of Swedish massage therapy better than light touch in the treatment of Generalized Anxiety Disorder? • 2) What changes in markers of inflammation and oxytocin occur as a result of massage therapy?

50. Specific phobia Clinical trial: • 1) Is 8 weeks of prolonged exposure therapy using • virtual reality technology effective in reducing a fear of flying? Does a genetic marker associated with learning and memory predict who will improve?