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Public Health Detailers Training NYC Department of Health and Mental Hygiene
Ann M. Sullivan, M.D. Regional Director of Psychiatry for the Queens Health Network New York City Health and Hospitals Corporation
Depression Treatment
Psychotherapy
Alone or as adjunctive therapy
Pharmacotherapy
Effective for major depression and dysthymia Questionable effectiveness in minor depression
Primary care
Education Supportive Counseling Care Management
Psychotherapy
Sometimes referred to as counseling or talk therapy As effective as medication for treating mild to moderate depression. In more severe cases, should be used in conjunction with medication A therapist listens, talks and helps you find new ways of thinking about yourself, the world, your relationships, and the future.
Therapist can be a trained psychologist, social worker, psychiatrist, nurse practitioner, or counselor
*Judy Stein
Psychotherapy
Psychotherapy for depression is not necessarily talking about your childhood More often focused on current concerns and ways to address them Modes of treatment
Individual, group, family or marriage therapy
Evidence-based Psychotherapies
Cognitive-behavioral Therapy (CBT)
Helps to change negative styles of thinking and behaving often associated with depression
Interpersonal Therapy
Clarifies and resolves interpersonal difficulties, ie. role disputes, social isolation, prolonged grief, role transition
*Judy Stein
Evidence-based Psychotherapies
Problem-solving therapy
Teaches patients to address current life difficulties by breaking larger problems into smaller pieces and identifying specific steps toward change
*Judy Stein
*Judy Stein
*Judy Stein
Primary Care
Education Supportive Counseling Care Management:
Self-management Adherence Monitoring Progress Monitoring
Patient Education
Dispel negative perceptions/address stigma:
Explain the causes, mechanisms, and impact Compare to other treatable medical illnesses (ie. high blood pressure) Inform patients that antidepressant medication helps correct imbalances in brain chemicals
*Judy Stein
Patient Education
Educate about medical treatment options Effectiveness Onset of action of meds Potential adverse side effects
If patients know what to expect will be less likely to discontinue meds prematurely
*Judy Stein
Patient Education
Inform patients about non-pharmacologic options
Psychotherapy Self management techniques, incl. physical activity nutrition/diet, social supports, etc.
Type of treatment recommended depends on the type of symptoms, the severity of symptoms and the patients personal preferences
*Judy Stein
*Judy Stein
*Judy Stein
PCPs can further facilitate a relationship with the patient through use of supportive therapy techniques, ie. BATHE pneumonic
Techniques for gathering information and responding to patient emotions that make the patient feel validated and comfortable communicating openly about their condition
*Judy Stein
BATHE pneumonic
Used to elicit information from patients and address mental health concerns in a busy practice
Allows physician to reinforce effective coping strategies and provide general support
*Judy Stein
BATHE pneumonic
Background
Ask open-ended questions to encourage open dialogue
Affect
Ask questions such as How do you feel about that? to encourage patient to talk about his/her feelings
*Judy Stein
BATHE pneumonic
Trouble
Ask What about the situation troubles you most? helps the physician elicit the meaning to the patient of a specific situation Asking How are you handling that? will help the physician assess the patients coping skills and level of functioning
Legitimize a pts reaction to a situation by comments such as That must be very difficult for you.
Handling
Empathy
*Judy Stein
Self Management
The individuals ability to manage the symptoms, treatment, physical and social consequences, and lifestyle changes inherent in living with a chronic condition.
*Judy Stein
Self Management
Empower and prepare patients to manage their health and health care Self management support (SMS): emphasize the patients central role in managing their illness use of effective SMS strategies, ie. assessment, goal setting, action planning, problem-solving, and follow-up organize internal and community resources to provide ongoing self management support to patients
*Judy Stein
Self Management
Self management support goal-setting:
Encourage patient to select one or two small, achievable goals to work on each week for the next several weeks to alleviate some symptoms Goals can include physical activity, pleasurable activities, spending time with supportive people, or relaxing activities Ask how confident patient is on a scale of 1 to 10 that they can accomplish selected goal and address barriers
*Judy Stein
The care manager supports the PCC (Primary Care Clinician by (1) delivering patient education (2) eliciting patient preferences (3) monitoring patient adherence to treatment and response (4) provides feedback to the PCC about patient progress so that any needed changes in management are made in a timely manner. B.
5.
If medication prescribed: Verify meds prescribed. Prescription filled? Taking meds? Adverse side effects?
If referred to psychological counseling: Appointment made? First visit kept? Adverse feelings about referral?
If self-management were set: Practicing? If not, need new goals? If no goals set with PCC, assist in setting goals
If patient education materials provided: Reviewed? Any questions? If not provided, get mailing address and send Facilitate next action steps: If does is being titrated upward or mental health appointment not completed, schedule additional adherence contact(s)
* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual
Telephone Contact at 4 weeks: Assessment of Initial Treatment Response Administer and score PHQ-9. Report results of PHQ-9 to patient, PCC and psychiatrist (before next PCC visit) PCC may request additional care manager contacts if treatment modified. Supervising psychiatrist may also suggest additional visits or make informal consultation contact with PCC. (This holds true for all subsequent calls)
* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual
* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual
Five Stages of Change: 1. 2. 3. 4. 5. Precontemplation (unaware, not interested in change) Contemplation (thinking about change in the near future) Preparation (making plans to change) Action (actively modifying behavior) Maintenance (Continuation of new healthier behavior)
EXPLORE BY ASKING:
What do you think is going on?
* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual
Explaining to the patient that their primary care clinician believed they are depressed and that treatment would be helpful.
Explore what is uncomfortable about the diagnosis (do they know someone who is depressed or seriously mentally ill and perhaps this is frightening to them).
Explore what they believe having depression means and dispel some of the myths.
If a patient continues to be adamant that they do not have depression, acknowledge their stance and focus more on what symptoms they have.
* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual
* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual
CARE MANAGEMENT PLUS PROBLEM SOLVING TECHNIQUES BREAK DOWN BARRIERS* (Continued)
Concerned about addiction PATIENT MIGHT SAY: I dont want to be on the medicine forever. I dont want to become addicted to it. EXPLORE BY ASKING: Have you heard or known about someone who had trouble with the medication being addictive? INTERVENE BY: Informing the patient that the depression medication is not addictive. Explain that it is common for people to be on the medication for six months to a year and in some cases longer. Be sure to say that the decision about how long to stay on the medication should be made with their primary care clinician.
* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual
CARE MANAGEMENT PLUS PROBLEM SOLVING TECHNIQUES BREAK DOWN BARRIERS* (Continued)
Emphasize that they should not stop or change their medication dose without talking to their primary care clinician first. Mention that often people go off of their medication too soon because they are feeling better. By stopping medication too soon, they are running the risk of a relapse.
* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual