Self-Management Tools: It's Not Just Patients Who Can Benefit

1. Self-Management Tools: It's Not Just Patients Who Can Benefit Eleanor Davidson, MD Tanya Massey, CNP MaryannMcGlenn PhD Case Western Reserve University

2. Objectives • Introduce the National College Depression Partnership and discuss how it led to our focus on self-management • Describe 3 self-management tools used for patients with depression • Describe 3 self-management tools used for clinicians • Describe a teaching process for clinicians learning to use self-management • Describe how clinician self-management tools can be entered into the medical record

3. Our model

4. So why screen for depression in primary care? • US Preventative Services Task Force Recommendation: • Adult primary care practice settings should screen for depression—but only within the context of a “prepared practice.” • http://www.uspreventiveservicestaskforce.org/

5. Background: Phase I NCDP • College Breakthrough Series-Depression: 2006-07 • NYU, Princeton, Cornell, CUNY (Hunter & Baruch), CWRU, St Lawrence

6. Phase I (CBS-D): challenges • ● How would students react to depression screening in the health service? • ● Could the health service achieve an 80% rate of screening all patients once during a school year? • ● How would clinicians react to screening for depression in primary care? • -Use of Plan-Do-Study-Act cycles • -Start small and grow.

7. Some of us imagined that our biggest challenge was identification of depressed students who would then be referred to the counseling service for treatment.

8. Successes and challenges (our model) • We could achieve 80-90 % screening of all students in primary care (throughout—all visit types). • We could achieve simple self-management goals with a majority of patients (30 min of exercise 2-3 times per week was most common).

9. Successes & challenges (our model) • The majority of our patients were entered from primary care; we had a disproportionate number who did not want either counseling or medication. • Identification was the easy part. The challenge became what do after depression was identified.

10. In other words, if a student did not want to go to counseling, we wanted to initiate treatment without feeling forced to • start medication. • We needed another way to start and self-management seemed like a plausible option

11. What Is Self-Management? Self-management - Goal directed patient behaviors that enhance clinical & functional outcomes: • Medication management and adherence • Self-monitoring of symptoms, treatment status • Managing effects of illness on social role function • Reducing health risks (alcohol misuse, smoking) • Preventive maintenance (e.g., exercise, screening check-ups) • Working with health care professionals

12. NCDP Operational Definition The engagement of patients in a collaborative partnershipwith clinicians to achieve goal-directed behavioral changeandpatient activation.

13. Why Self-Management? • We know it is evidence based • It is simple • Fits well in a college setting. It focuses on a developmental model. For them everything is a self-management tool.

14. Phase II (NCDP) 20 schools 2008-09 • Refined the concept of a prepared practice • Expanded self-management tools to a treatment goal: • - Exercise • - Harm reduction (e.g. alcohol, marijuana) • - Sleep hygiene • - Full session with dietitian: concern for eating • disorder • - Assessment in career services • - Positive activity: spending time with friends • - Medication follow through • - Mindfulness/Stress Management: Friday group • therapy sessions

15. Phase III (NCDP-CAN) 17 schools 2010-11 • Further refine/expand self-management: • -Collaborative treatment planning (educate • about treatment options, elicit feedback, • encourage behavioral activation) by four • weeks • - Personalized self-management • (personalized goal, frequency, duration, • confidence rating, reassessment of goal) • by 8 weeks

16. Findings

17. What Happened? • Self-Management goals/measurement criteria were high • Not enough time to accomplish this in one visit • After obtaining PHQ-9, history, and addressing the patient’s medical concern, we were lucky to have enough time for a self-management goal let alone elicit duration, frequency, and student confidence.

18. Is time the biggest impediment? • We’ll return to something we invented as a bridge to counseling that involved encouraging patient activation, exploring self-management options, and chart documentation of these steps. • One of the psychology post docs created this in consultation with our NCDP team. • [The BRIDGES Program]

19. What if time is not the biggest impediment:The patient’s perspective • May disagree on diagnosis • Believe there is a physiologic etiology such as fatigue due to anemia or thyroid problem • May disagree on treatment plan • May not be ready for counseling • May not be ready for medication • May not be ready for the self-management tools we have in mind.

20. We need to step back and figure out where the patient is. Is the patient ready to make changes?

21. Transtheoretical Model of Change

22. Transtheoretical Model of Change • Where are the CWRU students? • Although many are in pre-contemplation or contemplation, the model does not necessarily describe every student

23. Where are our clinicians? • We noticed that clinicians could quickly figure out a student was likely depressed but the student was nowhere near that conclusion. • We wondered if our team member from mental health could help us understand more about where we might lose patients in the journey.

24. NCDP Team • A group made up of clinicians, a care manager, a women’s health advocate, and a representative from counseling services. • Meet every 2 weeks to discuss patient cases.

25. Mental Health Professional as Team Member • Focus on: • Biopsychosocial/Mind-Body perspective and viewing the person as a whole • Relationship as an important change factor • Interaction between provider and patient can be a help or hindrance towards change • Self care tools – Providers also need them

26. PRECURSORS MODEL OF CHANGE • Adapted from Hanna, F. J. (2001) • Therapy With Difficult Clients: Using the Precursor Model to Awaken Change.

27. Seven Elements Necessary for Therapeutic Change • CLIENT CLINICIAN • 1. Sense of necessity => Sense of necessity to help the client change • 2. Willingness to experience anxiety => Willingness to experience the anxiety or difficulty inherent within the client • 3 . Awareness of the problem => Awareness of the client’s issues and one’s own corresponding issues • 4. Confronting the problem => Confronting the client’s issues • Effort or will toward change => Effort or will to work through issues with the client • Hope for change => Hope for client change • Social support for change => A therapist’s social support for facilitating change

28. Comparing Models of Change

29. Difficult Client or Difficult Therapist? • One-sided View of a Difficult Client • One who is defiant, unruly, stubborn, undermining, ambivalent, apathetic, deceptive (pejorative) • One who fails to make satisfactory progress in treatment • Shared Perspective (of a difficult client) • One for whom change is not forthcoming in spite of therapist and client efforts to achieve it

30. Rating the Clinician on the Precursor Scale • It’s important to examine the clinician’s disposition and reactions to “difficult” clients (aka countertransference) • “Resistance” viewed as client or therapist interference in the change process • Therapist Effectiveness is enhanced by • Building the Relationship and Reducing Interference

31. Relationship Building: Strategies and Techniques • View empathy as a duty not a suggestion • Attend to the unspoken conversation that the client may be having with the therapist (metalog) • Set (mutual) boundaries including asking permission and taking time to reflect before responding • Leave the ego at the door • Work from a strength based approach and validate the client’s abilities and positive qualities • Reframe Negative Behaviors and Attitudes

32. Reducing Therapist Interference • Detach from one’s own agenda • Confront with curiosity, empathy, serenity and the intention to help • Be aware of becoming too rigid, flexible, distant or long-winded • Meet hostility with equanimity and humor and avoid power struggles • Attend to differences in culture and socioeconomic status • Use consultation to regain focus and a sense of control

33. Self Survey for Clinicians(adapted from Kottler, 1992) • What am I doing to exacerbate the situation? • What buttons is this client pushing in me? • Who does this client remind me of from my past? • In what ways am I acting out my impatience? • What are my expectations for this client? • Which of my needs are not being met by this client?

34. So we’ve looked at factors that influence both the patient and the clinician in this change process. • Now let’s examine 3 cases which illustrate how this might apply in the clinical setting.

35. Case Example: Patient M. • 27 y/o Asian male MD/PhD student • Presents with chief complaint of fatigue and headache • Also reports sleeping more, decreased appetite, less energy, trouble focusing, and hand weakness

36. 2 1 3 3 2 0 3 0 0 1 4 9 14 3

37. Case Example: Patient M. • Rejects possibility of depression as the initial diagnosis • Requests blood work to rule out the physiologic first • BMP, CBC, and TSH are all normal • Again discussed counseling. Said he would consider it after exams • 3

38. Case Example: Patient M. • One month later made an appointment for ADHD testing • Canceled appointment and rescheduled with counseling • Attended an initial intake evaluation and then one full counseling session • Two weeks after that met with psychiatry. Wellbutrin prescribed initially. Klonopin added later • On and off meds for the next year. • Never returned for counseling sessions. “Not a talker”

39. Case Example: Patient M. • Returned to UHS sporadically, seeing a different provider each time, often when off meds • Fatigue—concerned with sleep apnea, enlarged tonsils • HA—began one week after stopping antidepressants • Last saw psychiatry Oct 2012. Did not keep 3 month follow up • Last seen at UHS Feb 2013 for travel visit (on med)

40. Case Example: Patient M. • What would we do differently now? • Assign a primary care clinician • Schedule routine follow up at UHS (even if it seemed like he was going to UCS) • Send periodic messages via secure e-mail • Work on relationship and self-management

41. Case Example: Patient M. • We might also be kind to ourselves and realize someone that is not only getting an MD but also a PhD in the sciences might be more focused on identifying a ‘molecular” cause of his distress. • How would this help? • We don’t need to berate ourselves in the process. • We might get a bit more therapeutic distance to help us make observations.

42. Case Example: Patient N. • 19 year old undergraduate studying piano performance seen for women’s health annual physical exam Routine PHQ-2 = 1. • PHQ-9 = 7. Functional score = 1 somewhat difficult. • Counseling information given and also referred to Dr. Davidson. Declined scheduling follow up appointment.

43. Case Example: Patient N. • Seen 5 months later for Depo-Provera shot. • PHQ 9 = 9 with yes to question 9 (suicidal ideation) • Functional score = 2 very difficult • More thorough history taken • Realized she was depressed but admitted to coming from an ethnic background that did not accept mental health treatment--it was looked down upon in her culture. • Had discussed counseling with her parents in high school and was told that counselors would just “mess with her”

44. Case Example: Patient N. • States on the one hand she is interested in counseling but on the other and it is “unnecessary and for the weak”. • Not interested in medication or therapy but interested in other options. • Assessed that she was not in acute danger to herself or others and scheduled a one week follow up appointment • Self-management: safety, enjoyable activity, spend time with friends

45. Case Example: Patient N. • In the next two years, I saw her periodically for sick visits, Depo-Provera shots and annual exams. • During that time I continued to work on the relationship, getting a thorough history, encouraging treatment and working on self-management. • Eventually, she did start counseling at CWRU, started on medication through a home psychiatrist. The last time I had seen her she was on medication and going to counseling.

46. What did we learn? • Removing barriers to treatment • Multiculturalism—she knew she needed treatment but did not have family or cultural support to back her up • Keeping patients in the women’s clinic • Many women would prefer all of their care in one place. Forget about seeing a provider in a different side of campus. We learned they wanted to “stay within the product line” they chose originally. • Benefits of our Women’s Health Advocate • She could do full PHQ-9 if time was an issue • Clinicians felt more comfortable raising these issues if the health advocate was there for back up.

47. Case Example: Patient D. • 19 year old sophomore with chief complaint of chest discomfort/tightness, heart palpitations, and body aches. • Came in realizing that all her symptoms were linked to anxiety provoking situations. • Had been attending counseling weekly for the last 2 months but felt uncertain about returning. Wanted to switch counselors • PHQ-9 = 18 • Functional score = 2 very difficult

48. Case Example: Patient D. • She had already been making changes by going to counseling • She was ready to start medication (Zoloft) and work on her issues • We worked on self management • Finding a counselor that was the right fit for her • Putting herself in situations to work on her social anxiety

49. Case Example: Patient D. • She has stayed on the medication • Has kept regularly scheduled appointments with me • She found a new therapist that she is happy with and sees regularly • PHQ-9 started at 18 and decreased to 6 • Functional score: Very difficult initially to somewhat difficult four months later • Time will be the test

50. Real World Use • Rule out the physiologic • physical exam, lab work, etc • Work on relationship--build rapport, trust • taking the time to listen to their concerns • acknowledging these concerns but also offering alternative diagnoses • Obtain a more thorough psychosocial history • where they were born, grew up, current major, why they came to this school. • family history—health, parent’s occupation, marital status • relationship with family, friends, significant other