Models and Process of Psychosomatic Medicine - PowerPoint Presentation

1. Models and Process of Psychosomatic MedicineAPM Resident Education CurriculumRobert C Joseph, MD, MS, FAPMDirector Consultation-Liaison and Primary Care Behavioral Health ServiceProgram Director, Psychosomatic Medicine FellowshipCambridge Health Alliance, Cambridge MAAssistant Professor, Harvard Medical SchoolUpdatedSummer 2011Robert Joseph, MD, MSFall 2013Robert Joseph, MD, MSR. Brett Lloyd, MD, PhD

2. Psychosomatic MedicineSubspecialty at the interface of Medicine and PsychiatryClinical ServiceResearchTrainingPsychosomatic Medicine is the name of the accredited subspecialty2

3. Models of Psychosomatic Medicine PsychiatryTraditional/Conventional Hospital or Ambulatory BasedConsultation Upon Request (reactive)Liaison PsychiatryMental Health IntegrationHospital or Ambulatory BasedCase Finding/ScreeningProactive/Systemic Mental Health InvolvementPopulation Based ProgramsDisorder Specific ProgramsHybrid Models3

4. Traditional ModelsConsultation Upon RequestReactivePatient and consultee specific Primary responsibility for patient remains with consuteeLiaison Psychiatry ComponentsEducationFormal and informal educationSupportService, Ward, Nursing StaffCan be Sub-Specialty SpecificOB, Oncology, Neurology etc.4

5. Types of PatientsComplex, co-morbid psychiatric and medical conditionsNeurocognitive disordersSomatic symptom and functional disordersPsychiatric disorders secondary to medical conditions or treatments5

6. Distinction from Office Based PsychiatryServices requested by consulteeNo “self referral”Obligations to consultee as well as patientPatient often unaware of referralUsually ill, uncomfortable or in painPatient motivation often compromisedLimited privacyVisits not scheduled nor time based6

7. Function of Psychiatric ConsultationDoctor-to-doctor communication designed to address the mental health needs of the patient and improve patient carethe over-riding concern is the patient’s well-being7

8. Essential TasksComplete a comprehensive psychiatric assessment and develop a management planRemove impediments to medical careBring a fresh perspective to the clinical dilemmaFacilitate a mutual understanding between patient, doctor and treatment teamEducate about the emotional and neuropsychological needs of the patient8

9. Steps in the Consultation (1)Review chart and consult questionDiscuss case with consulteeTo help delineate the manifest question and help identify any latent question(s)To help consultee reformulate the question, in a manner which addresses underlying issues and allows the consultant to be helpful9

10. Steps in the Consultation (2)Patient InterviewIntroduce selfSit downAddress patient’s surprise at the arrival of a psychiatrist (if present)Attend to any physical discomfort10

11. Steps in the Consultation (3)Mental status exam Includes bedside cognitive testingTargeted physical exam (if appropriate)Ancillary history gathering often appropriateFamilyPCPOther care giversOther11

12. Steps in the Consultation (4)Written noteVerbal communication (feedback) with consultee, regarding your opinionFollow-up visits as appropriateRange can be none to daily 12

13. The Written Note (1)Document formally addressed to the physician requesting the consultationDesigned to be used by other members of the treatment teamMay be read by a variety of hospital personnelConsider confidentiality 13

14. The Written Note (2)TITLE: Psychosomatic Medicine ServiceAttendingResidentOtherNATURE OF THE NOTEInitial Consultation NoteFollow-up Consultation Note14

15. The Written Note (3)DATE AND TIME: Essential when dealing with a fluctuating mental status SOURCEPatient, family, medical record, otherIDENTIFYING STATEMENTThis lays the groundwork for your formulation and recommendations in a way that helps the readers to understand your note15

16. The Written Note (4) Reason for ConsultationWhy did the primary treatment team request a psychiatric evaluation?There is often a difference between what the primary team requests and what they actually want from the psychiatristManifest request: R/O depressionLatent request: There is nothing wrong with this patient. She is drug seeking and manipulative. Make her stop complaining and behave!16

17. The Written Note (5)Identifying StatementImportant“The patient is a 34 year old female admitted for abdominal pain with a history of multiple medical complaints and pain unresponsive to usual interventions. We are asked to evaluate her for possible depression”A reiteration of the manifest questionReminds us to answer the question Respectful to consultee17

18. The Written Note (6)HISTORY OF PRESENT ILLNESS A place to document the essential positive and negative aspects of the historyProvides a historical framework for understanding the patientMust include DSM descriptive characteristics and review of systems relevant to diagnosis Consider: The special events of the patient’s life, e.g., losses, illnesses.The precipitant to the current psychological and physical difficulties.The nature of the patient’s reaction to these precipitants.Usual coping mechanisms18

19. The Written Note (7)Past Medical/Surgical HistoryInclude menstrual and obstetric Past Psychiatric HistoryMedicationPrior to admissionAt time of consultationRecent changesSubstance Use HistoryFamily HistorySocial History19

20. The Written Note (8)Physical Exam (as appropriate)Mental Status ExamAnalogous to the physical examination.Reflects a point in timeAddress the question of the consultation and your formulation within the mental status examinationIt is an opportunity to teach and to demonstrate how diagnoses are madeA tool to gain access to a patients mental lifePertinent Laboratory and Radiologic Findings20

21. The Written Note (9)ImpressionOther than recommendation, the most likely part of the consult to be readShould have the components of a good biopsychosocial formulation, but avoid psychiatric jargon whenever possibleInclude stressors and functional statusKnow your audience and what you want to accomplishDifferential diagnosis, including personality and medical disorders21

22. The Written Note (10)DSM IV-TRMulti-axial assessmentAxis III – including disorders relevant to the psychiatric disorder(s)Axis IV – Psychosocial/ environmental problemsAxis V – global assessment of functioning22DSM-VAxis I-III combined: list relevant diagnoses to consultationList ICD-9-CM V codes related to psychosocial and environmental problemsWHODAS – may be used to demonstrate disabilityDIAGNOSIS

23. The Written Note (10)Axis V (GAF) was dropped from DSM-VWHODAS is included for further study as an assessment tool for functioning36-item, self-administered measure used to assess disability in adults (age 18 and older23Included in Section III of the DSM-VDomains include: Communication, getting around, self-care, relationships, household activities, school and work activities, participation in societyWHODAS: World Health Organization Disability Assessment Schedule 2.0

24. The Written Note (11)Recommendation/PlanMost likely part of the consultation to be readFurther work-up suggestedPhysician managementMedicationBehavioral approaches with patientBe specific, avoid jargonNursing managementLegal issuesSocial service needsAftercare plansConsultant follow-upInform treatment team of your availability, whether/when you will return and the purpose of your return24

25. Mental Health Integration (1)Collaboration with Multidisciplinary TeamMental Health (MH) and non-Mental Health (non-MH) providersPsychiatrist, other MD’s, Psychologists, Social Workers, Nurses, Case Managers, Support StaffElements of IntegrationMissionOptimal care for behavioral problems in non-MH settingTarget PopulationPatients with co-morbid medical and psychiatric problemsPatients with MH problem but no other MH careLocationGenerally involves co-location of MH staff in medical siteCommunicationTeam meetings, shared, medical record and treatment plansAdministrative Shared or coordinated between MH and non-MH staffFiscalIntegrated budget for MH and medical staff vs. separate25

26. Mental Health Integration (2)General Hospital Based Tends to be disorder specific E.g., delirium, transplant or substance use disorders Ambulatory Primary careMedical/Surgical Specialty clinicsOB, Oncology, Neurology, Transplant etc26

27. Mental Health Integration (3)Rationale Prevalence of mental health (MH) issues in medical settingLack of access to conventional MH servicesPatient’s reluctance to go to MH clinicExtensive co-morbidity of medical and MH disordersBidirectional adverse effect of co-morbid disordersAssociated morbidity and cost of disordersMethod/StructureWide rangeReactive Programs Mimic traditional consult services except, perhaps for co-locationPlanned ProgramsHighly Structured, oriented toward “Disease Management”27

28. Mental Health Integration (4)Value addedDelirium prevention programsDepression, Anxiety and Substance Abuse Management in primary careCo-morbid MH and medical disordersdepression, diabetes, cardiac disordersMedically Unexplained Physical Symptoms (MUPS)28

29. Mental Health Integration (5)Planned Care for Behavioral Health Disorders in Medical ClinicsDerivative of chronic disease management programsProven efficacy in multiple studiesAKA Collaborative Care, Stepped CareMethodsProactive Screening/Case Finding, Registry, Team Management, Algorithm directed, Consultation and Supervision, Case Management, Teamwork29

30. REFERENCES Garrick TR, & Stotland NL. How to write a Psychiatric Consultation. Am J Psychiatry 139:7, 1982. Meyer F, Joseph RC, Peteet JR. Models of Care for Co-occurring Mental and Medical Disorders. Harvard Review of Psychiatry, In press. Gilbody S et al; Collaborative Care for Depression, Accumulative Meta-analysis and Review of Longer-term Outcomes. Arch Intern Med. 2006;166:2314-2321. Williams J et al; Systematic Review of Multifaceted Interventions to Improve Depression Care. General Hospital Psychiatry 29 (2007) 91-116. Kathol R et al; Psychiatrists for Medically Complex Patients: Bringing Value at the Physical Health and Mental Health/Substance-Use Disorder Interface. Psychosomatics 50:2, March-April 2009. Kontos N; Querques J. Psychiatric Consultation to Medical and Surgical Patients. In: Stern TA, Rosenbaum JF, Fava M, et al. eds: Massachusetts General Hospital Comprehensive Clinical Psychiatry. Philadelphia: Mosby-Elsevier. 2008; p. 749-760. Smith G; Clarke D. Assessing the Effectiveness of Integrated Interventions: Terminology and Approach. Med Clin N Am 90 (2006) 533-548. Katon W et al. Collaborative Care for Patients with Depression and Chronic Illnesses. N Engl J Med 2010; 363:2611-262030