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20 WAYS TO OVERCOME BARRIERS TO RECOVERY

20 WAYS TO OVERCOME BARRIERS TO RECOVERY. Prof. Courtenay M. Harding Professor of Psychiatry and Director, Center for Rehabilitation and Recovery The Coalition of Behavioral Health Agencies - NYC. Good Morning!.  OVERALL GENERAL INFORMATION FOR TODAY  What’s in the folders?

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20 WAYS TO OVERCOME BARRIERS TO RECOVERY

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  1. 20 WAYS TO OVERCOME BARRIERS TO RECOVERY Prof. Courtenay M. Harding Professor of Psychiatry and Director, Center for Rehabilitation and Recovery The Coalition of Behavioral Health Agencies - NYC

  2. Good Morning! OVERALL GENERAL INFORMATION FOR TODAY What’s in the folders? How to work with this information Take a break for phone & bathroom Ask questions as we go along Evaluations and Certificates at end

  3. THE PRESENTATION PLAN Review 20 obstacles with strategies to get some answers or how to better understand the complications. Lots of resources!

  4. IF RECOVERY AND SIGNIFICANT IMPROVEMENT ARE POSSIBLE………. THEN WHY ARE SO MANY PARTICIPANTS NOT GETTING BETTER? 2.5 2.5 – – 5 MILLION PEOPLE 5 MILLION PEOPLE LANGUISHING IN US ALONE LANGUISHING IN US ALONE

  5. ACKNOWLEDGMENT & APPRECIATION TO ALL THE CLINICIANS & FAMILIES WHO CARE WHO SPEND TIME PROBLEM SOLVING WHO CHALLENGE THE STATUS QUO WHO SPEND TIME GOING THE EXTRA MILE

  6. HOWEVER……….. If your participant seems to be “stuck” on the path to recovery let’s look at some possible reasons and ways to change the Individual Recovery Plan (IRP)……

  7. Learning to play a detective !

  8. LOOKING FOR THE “PERSON UNDER THE DISORDER”  COMPREHENSIVE RE COMPREHENSIVE RE- -EVALUATION NEEDED NEEDED (based on history, careful interview, lab findings & physical exam)  BIO BIO- -PSYCHO PSYCHO- -SOCIAL SOCIAL- -SPIRITUAL APPROACH APPROACH  SYSTEMATIC & SYSTEMATIC & MULTIDISCIPLINARY MULTIDISCIPLINARY EVALUATION SPIRITUAL

  9. YOU NEED TO LOOK AT A PERSON TWICE…… once with your heart and then with your head…….. FIRST TO SEE THE SIMILARITIES AND ONLY THEN CAN YOU APPRECIATE THE DIFFERENCES

  10. QUESTION #1 HAVE OTHER POSSIBLE CAUSES OF SYMPTOMS AND BEHAVIORS BEEN ELIMINATED?

  11. DIAGNOSIS OF EXCLUSION DIAGNOSIS OF EXCLUSION (especially schizophrenia) (especially schizophrenia) 26 other disorders (medical, neurological, and psychiatric) that masquerade with schizophrenia-like symptoms !

  12. DIAGNOSIS OF DIAGNOSIS OF EXCLUSION EXCLUSION (schizophrenia) (schizophrenia) Autism (esp. Asperger’s Syndrome) Temporal Lobe Epilepsy Tumor Stroke

  13. MORE THINGS TO EXCLUDE Brain Trauma Endocrine & Metabolic Disorders (e.g. acute intermittent porphyria (liver enzyme) Homocystinuria (a disorder of amino acid metabolism)

  14. MORE THINGS TO EXCLUDE Vitamin Deficiency (e.g. B 12) Central Nervous System Infectious Processes (e.g. AIDS, neurosyphilis, or herpes encephalitis) Autoimmune Disorders (systemic lupus erthymatosa) Heavy Metal Toxicity (e.g. Wilson’s Disease – too much copper)

  15. EVEN MORE TO EXCLUDE:  Some Drug Induced States (e.g. amphetamines, barbiturate withdrawal, cocaine, digitalis, disulfram)  Mood disorders, schizoaffective disorder,  Personality disorders,  Brief Reactive Psychosis,  OCD

  16. Differential Diagnoses for Mood D/O (based on history, careful interview, lab findings & physical exam)  Multiple Sclerosis  Stroke  Hyper & Hypothyroidism  Bereavement  Dementia  Cancer (esp. of Pancreas)  Spinal Cord Injury  Peptic Ulcer  Mononucleosis  Huntington’s Disease  AIDS  End-stage Renal Disease  Head Injury  Parkinson’s Disease  Lupus  Hyper & Hypo parathyroidism  Hepatitis

  17. SUGGESTED INSTRUMENT Basis-24  “a leading behavioral health assessment”  Comprehensive  Cuts across diagnostic categories  Provides weighted average  Overall score plus 6 subscales  (sub abuse, symptoms and functioning, relationships, self harm, emotional liability, psychosis, and depression)

  18. SUGGESTED INSTRUMENT SCID –THE STRUCTURED CLINICAL INTERVIEW FOR DSM-IV TR CLINICAL VERSION

  19. HOW TO DO BETTER……… Take the time get Take the time get triangulated information triangulated information Get the lab tests done Get the lab tests done Reassess over time Reassess over time Pay attention to comorbid Pay attention to comorbid d/o d/o

  20. Treat or refer other diagnoses  Establish links and a little black book with other medical colleagues across the local community  Work with your colleagues in other fields to understand what happened and how to understand your participant who may still appear to them to have a psychiatric disorder  Health Homes are coming as networks of partnerships treating person in a holistic way  Partners include hospital, primary care docs, mental health and addiction services + + +

  21. OR IF PSYCHIATRIC DIAGOSIS IS RE-ESTABLISHED All diagnosis are cross-sectional working hypotheses Not lifetime labels Not able to predict long-term outcome Write enough evidence to “convict” person of the diagnosis into the case record

  22. REMEMBER TO LOOK FOR & RECORD STRENGTHS  Strengths of your participant ( e.g. insight? Manage meds? Manage S/S ? Uses strategies to recognize oncoming prodrôme? Uses coping to reduce anxiety? Computer skills? Has driver’s license? ETC  Working with the strengths rather than deficits, problems and disabilities – that is what helps people get better

  23. EBP:WELLNESS MANAGEMENT AND RECOVERY PROGRAM-1  CLINICIAN BENEFITS: A comprehensive step by step approach Ready-to-use materials Skills is using motivational , cognitive behavioral and educational strategies   Satisfaction to see   outcomes

  24. EBP: WELLNESS MANAGEMENT AND RECOVERY PROGRAM-2  CLINICIANS RECEIVE:  guide with practical tips  handouts, checklists, planning sheets  intro video  info brochures  fidelity scale  outcome measures

  25. EBP: WELLNESS MANAGEMENT AND RECOVERY PROGRAM-3 • reducing • relapses • using meds • effectively • coping with • stress • coping with • problems & symptoms • getting your • needs met in the mh system • Recovery strategies • Practical facts about mi • Stress- Vulnerability & treatment strategies • Building social supports

  26. EBP: ILLNESS (WELLNESS) MANAGEMENT AND RECOVERY PROGRAM-4  RESOURCES:  Wellness Self-Management & Plus by Columbia University – Paul Margolies and Tony Salerno  http://www,mentalhealth.samhsa.gov/cmhs/co mmunitysupport/toolkit  http://www.mentalhealthpractices.org/imr_mlpl . html  Liberman RL et al, describing UCLA Models, Innovations & Research, Vol2(2), 1993  P.A. Garrety et al , Schiz Bull, 2000

  27. QUESTION #2 Is there an additional additional neurological neurological impairment? impairment? Is there an

  28. THE DEFICIT THE DEFICIT SYNDRÔME SYNDRÔME  +/- S/S of Schizophrenia Come and Go (esp. + symptoms)  Attempts to find primary, enduring stable negative symptoms  Subtype or Additional D/O  Neurological Impairments ( sensory integration, stereognosis, graphesthesia, right-left confusion, the face-hand test, & audiovisual integration)

  29. THE DEFICIT THE DEFICIT SYNDRÔME SYNDRÔME - - 2 2  Poor premorbid social functioning  Reduced glucose uptake in the frontal cortex, parietal & thalamic areas on PET scans  Increased anhedonia and fewer psychotic events  Earlier onset, seems to be unremitting, suffer spontaneous movement d/o, severe cognitive impairments

  30. THE DEFICIT SYNDRÔME - 3  Deficit PARTICIPANTs in comparison to NonDeficit  PARTICIPANTs show:  Equal positive symptoms (hallucinations, delusions, and formal thought d/o)  Less severe dysphoric symptoms (e.g. depressive mood, anxiety, guilt, & hostility)  Less severity of suspiciousness  Similar duration of illness  Brain architecture seems to be more intact in some areas

  31. THE DEFICIT THE DEFICIT SYNDRÔME SYNDRÔME - - 4 4  Need longitudinal information  Use SDS or PDS Criteria  Exclude: drug effect & demoralization  Need 2 of of the following for more than a year:  restricted affect,  diminished emotional range,  poverty of speech,  curbing of interests,  diminished sense of purpose and social drive

  32. THE DEFICIT THE DEFICIT SYNDRÔME SYNDRÔME - - 5 5 USE SCREENING TOOL: THE Neurological Evaluation Scale (NES) TRY: Atypical Neuroleptics Cognitive Remediation Other Aggressive Rehab

  33. Some Resources: Brian Kirkpatrick et al, 1989, (SDS - The Schedule for the Deficit Syndrome), 1993, 2001 PDS : Proxy for Deficit Syndrome Kirkpatrick 1996 (core deficit + no dysphoria) Robert W. Buchanan et al, 1990, 1993,1994, 1996

  34. QUESTION # 3 QUESTION # 3 DOES THIS PERSON DOES THIS PERSON HAVE OTHER HAVE OTHER MEDICAL PROBLEMS MEDICAL PROBLEMS ABOUT WHICH TO ABOUT WHICH TO WORRY? WORRY?

  35. OVERVIEW OF OVERVIEW OF SITUATION SITUATION  40-60 % with medical co-morbidity  Not recognized nor treated  Participants get “turfed” back to psychiatry or not referred at all  Need primary care, eye & hearing exams, OB etc  Need physical by nurse practitioner, a health history questionnaire and basic lab tests

  36. LABORATORY TESTS LABORATORY TESTS TO ORDER TO ORDER  BIOCHEM 23 BIOCHEM 23  TOX SCREEN TOX SCREEN  COMPLETE COMPLETE BLOOD COUNT BLOOD COUNT  URINALYSIS URINALYSIS  THYROID THYROID FUNCTION FUNCTION TESTS (T4 & TESTS (T4 & TSH) TSH)  B B- -12  FOLATE FOLATE  VDRL (for VDRL (for syphilis) syphilis)  HIV HIV _______________ _______________  CT or CT or  MRI (if MRI (if indicated) indicated) 12

  37. Some Suggested Strategies Collaboration and linkages Have a case manager or other person who knows person well go armed with information and written questions and take notes Rescheduling missed appt.s Get outside prescriptions into record

  38. Medical Algorithm for Detecting Physical Disease in Psychiatric Patients Harold C. Sox, Jr. et al: Hospital and Community Psychiatry, vol.40 (12) 1270-1276

  39. Some Suggested Strategies Offer preventive programs: e.g. Weight Watchers, Jazzercise, other exercise programs, nutrition, cooking and grocery shopping skills, meditation, other relaxation techniques, walking, blood pressure and diabetes monitoring. Health and Wellness Education Classes

  40. PAYING ATTENTION PAYING ATTENTION GETS ……… GETS ……… Finding strengths in self Finding strengths in self care management care management Healthier people Healthier people Reduced mortality rates Reduced mortality rates Avoids confounding Avoids confounding diagnosis diagnosis And contraindicated And contraindicated medications medications

  41. QUESTION #4 QUESTION #4 WHO IS THIS WHO IS THIS PERSON PERSON UNDER A COAT UNDER A COAT OF ILLNESS? OF ILLNESS?

  42. ASSESSMENT OF ADULT DEVELOPMENT  PSYCHIATRIC PROBLEMS DISRUPT A LIFE  NEED TO GRIEVE FOR LOSS OF TIME AND OPPORTUNITIES  THE “REHABILITATION CRISIS” (McCRORY, 1982)  ASSESSMENT OF PREMORBID LEVELS OF FUNCTIONING (PEER RELATIONS, SCHOOL PERFORMANCE AND DATING etc)

  43. What to do when people deny they have an illness?  Can get better without any insight or admission that they have a diagnosis  Usually aware that something is holding them back from getting a life they want  If want to recapture their dreams and accept some kind of help from others or  Focus on what the person thinks is distressing or getting in the way of dream  Listening and engaging – L. Davidson, 2012

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