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Psychologists at Health Psych Maine

Nurse Practitioners & Psychologists Collaborating in Primary & Specialty Care Settings April 25, 2013 Jeff Matranga, Ph.D., ABPP Diplomate in Health Psychology M.S. in Clinical Psychopharmacology jeff@hpmaine.com www.hpmaine.com. Psychologists at Health Psych Maine.

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Psychologists at Health Psych Maine

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  1. Nurse Practitioners & Psychologists Collaborating in Primary & Specialty Care SettingsApril 25, 2013Jeff Matranga, Ph.D., ABPPDiplomate in Health PsychologyM.S. in Clinical Psychopharmacologyjeff@hpmaine.com www.hpmaine.com Collaboration: Maine NPs & Psychologists

  2. Psychologists at Health Psych Maine Jeff Matranga, Ph.D., ABPP Jonathan Borkum, Ph.D. Laura Holcomb, Ph.D. Stacy Whitcomb-Smith, Ph.D. David Meyer, Ph.D. Marin Godsoe, Psy.D. Carol Ann Faigin, Ph.D. Farhana Shah, Ph.D. Collaboration: Maine NPs & Psychologists

  3. Financial Disclosure: Nothing. Want copies of PowerPoint or have questions later? jeff@hpmaine.com Collaboration: Maine NPs & Psychologists

  4. Learning Objectives • 3 ways to improve coordination in care between behavioral and medical care. • Paraphrase behavior change strategies for increasing wellness behaviors. • Name 2 efficacious TXs for: • insomnia. • depression. • anxiety. Collaboration: Maine NPs & Psychologists

  5. 1) 3 ways to improve coordination between behavioral and medical care. • Communicate + collaborate. • Communicate + collaborate. • Communicate + collaborate. Collaboration: Maine NPs & Psychologists

  6. 1) 3 ways to improve coordination between behavioral and medical care. • Communication. Send your notes to the behavioral provider and ask the same in return. • Agree on some objective measures, e.g., of A1C, depression scores, etc. • Include the patient as part of team and let patient know how you are coordinating on their behalf, e.g., “I see in Dr. Smith’s note, you recently increased your logging of your food intake. Great!” Collaboration: Maine NPs & Psychologists

  7. 2) Paraphrase 2 Behavior Change Strategies for Increasing Wellness Behavior Tone of self-compassion. Aversion-based change more likely to be short-lived. Join with the patient’s goals, especially any functional goals, e.g., “If you could improve your physical functioning even a modest amount, what would you like to do more of?” Avoid dead person’s goals. Log. Tone of: “Let’s see how many days out of 7 you can record your ____.” 1-to-6-hour rule. Collaboration: Maine NPs & Psychologists

  8. 3) Paraphrase 2 Efficacious Txs for: • Insomnia. • Acute insomnia. May be indication for sedative-hypnotics. • Chronic insomnia: CBT-I (CBT for insomnia) is most efficacious, e.g., stimulus control (leave bed when awake > 15 minutes, no napping, etc.) • Depression. • Anxiety. Collaboration: Maine NPs & Psychologists

  9. 3) Paraphrase 2 Efficacious Txs for: • Insomnia. • Depression. • Response & remission: ADMs (antidepressants) = CBT for initial response rate. • Relapse & recurrence: CBT far superior: 30% relapse for CBT only; 70% for meds only. • Anxiety. Collaboration: Maine NPs & Psychologists

  10. 3) Paraphrase 2 Efficacious Txs for: C. Anxiety. • Panic: most effective tx by far is form of CBT emphasizing interoceptive exposure. Benzos interfere with outcome, but can be tapered in context of CBT. • PTSD: strongest data is for a form of CBT called Prolonged Exposure or PE. If time, will show clip. • Worry/GAD: CBT with worry exposure. • OCD: ERP – exposure + response prevention. Collaboration: Maine NPs & Psychologists

  11. Collaboration: NPs & Psychologists Collaboration in primary care & specialty environments is not only a good idea, it is critical to success. And…we will be financially rewarded for it in the new system by increasing the hit rate for those 32 quality indicators for ACOs. Collaboration: Maine NPs & Psychologists

  12. Why Medical & Behavioral Integration? 68% of adults with a mental disorder have a medical condition 29% of individuals with a medical condition have a mental disorder Collaboration: Maine NPs & Psychologists

  13. Lifetime Prevalence (2005) • Anxiety disorders (all): 28.8% • Specific phobia: 12.5% • Social phobia: 12.1% • PTSD: 6.8% • Gen. Anx. Dis.: 5.7% • Separation Anx. Dis.: 5.2% • Panic disorder: 4.7% • OCD: 1.6% Replication of earlier comorbidity survey. Face-to-face interviews of 9,282 people interviewed, 2001-2003. Kessler et al. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62 (June), 593-602. Dr. Matranga Anxiety Disorders

  14. Can Help Improve Outcomes • Psychologist with the right training and orientation can improve outcomes. Remember those 32 quality indicators? • Health behavior change. • Evidence-based practices. • Help patients learn self-management strategies for chronic health conditions: • Diabetes • Cardiovascular disease. • Cancer. • Adjustment to health problems. Collaboration: Maine NPs & Psychologists

  15. Comorbidity : Diabetes & Depression • When Type 2 & depression occur together, depression: • Usually unrecognized & untreated. • Course is usually severe. • Up to 80% have depressive relapse within 5 years. • Less likely to adhere to self-care. •  results in worse overall outcomes. Katon, W.J. (2008). The comorbidity of diabetes mellitus and depression. Am. J. Med., 121(11 Suppl 2), S8-15. Diabetes & Depression - Matranga

  16. Comorbidity : Diabetes & Depression • Risk of MDD (major depressive disorder) doubles for those with diabetes. • Depression risk with & without a medical condition present: • Without: 2.8% • With: 4.0%. • Conversely, depressed adults have 37% higher risk of developing type 2 diabetes. Katon, W.J. (2008). The comorbidity of diabetes mellitus and depression. Am. J. Med., 121(11 Suppl 2), S8-15. Diabetes & Depression - Matranga

  17. Comorbidity of Diabetes & Depression • When type 2 & depression occur together  higher health care costs for general medical care. • When the depression is treated: •  healthcare costs. • Cost of treating the depression is offset by the savings in medical care. •  work productivity. Treating the depression decreases economic burden and improves clinical outcomes. Katon, W.J. (2008). The comorbidity of diabetes mellitus and depression. Am. J. Med., 121(11 Suppl 2), S8-15. Diabetes & Depression - Matranga

  18. Psychologist may provide or help with: • On-site consultation, assessment, & intervention. • “Specialty mental health services” off-site to but with communication & collaboration. • Increase patient adherence. • Improved adjustment for patients & families dealing with chronic or catastrophic disease. • Increase healthy behaviors. • Medication adherence. Continued… Collaboration: Maine NPs & Psychologists

  19. Psychologist may provide or help with: • Patients learning self-monitoring and goal-setting. • Screening and primary prevention for mental health conditions. • Educational sessions for patients and staff, e.g., weight loss, disease mgt. • Design & implement program evaluation methods. Collaboration: Maine NPs & Psychologists

  20. Psychologists’ Educ. & Training Doctoral-level training: 5-6 yrs. beyond Bachelor’s. Scientist-practitioner model. Use evidence-based practices. Health psychology, behavioral medicine, interdisciplinary teams. Some: psychopharmacology. Those with extra training prescribing in military for 20 years now. Also prescribe in U.S. Public Health Service, Louisiana, New Mexico. Collaboration: Maine NPs & Psychologists

  21. Increasing Wellness Behaviors Collaboration: Maine NPs & Psychologists

  22. Behavior Change Tips What are the individual’s goals? Avoiding dead person’s goals. Effective goals are… Why change? Why bother? 1-to-6-hour rule. Avoiding deprivation. Preventive eating. 45-minute delay. Use it. Self-acceptance & self-compassion. Batting average vs perfection or all-or-nothing. Keep a log. Dealing with compulsive urges, e.g., riding the wave. Evaluating progress. How friends and family can help. Kelly McGonigal, Ph.D., The Science of Willpower. Diabetes & Depression - Matranga

  23. Diabetes & Depression - Matranga

  24. Collaboration: Maine NPs & Psychologists

  25. Insomnia Collaboration: Maine NPs & Psychologists

  26. Insomnia Tx Overview • Acute insomnia. Meds  acute changes, not maintained after DC. • Problematic for chronic insomnia. • Chronic insomnia: CBT-I is tx of choice. Behavioral  longer term gains, sustained at 1-2 yr follow-ups. • CBT-I helpful for insomnia comorbid with various conditions. • Combo of Rx & CBT-I: • Short-term outcomes: = or slightly better than either monotx. • Long-term outcomes: mixed. Morin, 2010; Smith et al., 2005. Collaboration: Maine NPs & Psychologists

  27. CBT-I vs. temazepam vs. combo. Morin et al., 1999, JAMA Collaboration: Maine NPs & Psychologists

  28. Insomnia: Rx v CBT-I? Tx Effect Sizes Dr. Matranga Anxiety Disorders

  29. Insomnia: CBT-I Empirical support for: • Relaxation training. • Stimulus control therapy (SCT): only go to bed when sleepy; get up if awake >15 minutes; only use bedroom for sleep & sex; get up same time each morning; no naps. • Sleep restriction therapy (SRT):  time in bed to actual sleep time, creating mild sleep deprivation   sleep consolidation & efficiency. • Cognitive therapy: change unrealistic thoughts, beliefs about sleep, fear of consequences of sleep deprivation, etc. • Worry exposure: for fear of functional decline with sleep deprivation. • Sleep hygiene: • Dietary:  caffeine, nicotine, alcohol, spicy foods. • Lifestyle: exercise, but not close to bedtime. • Environment: dark, quiet, comfortable. Morin, 2001, Combined treatments of insomnia. Behavior & Insomnia: Chickens & Eggs

  30. Cost of Meds for Sleep According to epocrates/drugstore.com: • Eszopiclone (Lunesta): $203/mo. • Zolpidem (Ambien) CR: $180/mo. • Ramelteon (Rozerem): $160/mo. • Mirtazapine (Remeron), 15 mg: $50/mo. • Quetiapine (Seroquel), 25 mg: $182/mo. • Trazodone, 50 mg. X 30 tabs = $12/mo. • Diphenhydramine (Benedryl): $4/mo. Seroquel is 45 times more expensive than Benedryl. Dr. Matranga Anxiety Disorders

  31. Collaboration: Maine NPs & Psychologists

  32. Depression Collaboration: Maine NPs & Psychologists

  33. Diabetes & Depression - Matranga

  34. Response & Relapse Rates Diabetes & Depression - Matranga

  35. Depression Treatments? • Efficacy: CBT = meds for efficacy. ~50% response rate. • Durability/Relapse: clear advantage for CBT for resistance to relapse. • Meds without CBT: ~70% relapse in 1 year. • CBT relapse: ~30% relapse in 1 year. • Cost: Lines cross at 8 mo. Meds initially cheaper, then CBT is. • Dropouts: higher with meds due to side effects. • Time commitment: CBT requires 8-20 hours. Med checks then add up over time. Collaboration: Maine NPs & Psychologists

  36. CBT for Depression • Behavioral activation. Get people moving, engaged, solving problems, avoiding avoidance. • Activity menu. • Activity log with mood ratings. • Cognitive. Challenging and changing negative thought patterns. Collaboration: Maine NPs & Psychologists

  37. Diabetes & Depression - Matranga

  38. Mindfulness & Depression Relapse 6 RCTs (n=593) of MBCT vs tx as usual (TAU) for recurrent major depression. • 43% risk reduction for those with 3 or more episodes. • No risk reduction for those with only 2 episodes. • In 2 studies, MBCT = maintenance ADMs for relapse prevention. Piet, J. & Hougaard, E. (2011). The effect of MBCT for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis. Clinical Psychology Review, 31, 1032-1040. 3 ½ min. video clip explaining this from Mark Williams, Ph.D., Oxford researcher: http://www.youtube.com/watch?v=8GVwnxkWmSM Diabetes & Depression - Matranga

  39. A quiet moment between Richie and his longtime personal friend His Holiness the Dalai Lama, who attended CIHM’s 2010 Grand Opening Celebration. Mindfulness & Exposure

  40. Mark Williams, Ph.D., Oxford MM and  recurrence of depression in people with severe, recurring depression. Mindfulness & Exposure

  41. Davidson’s Summary of Benefits of Short Course, e.g., 8 weeks of MBSR (2012, p. 224) •  left PFC activation, associated with greater resilience following stressful challenge. •  selective attention. • Strengthens PFC regulation of brain networks involved in attention. • Strengthens connections between PFC and other regions important for attention. • 33% improvement on “attentional blink” tests from pre to post. • Compassion meditation: • Nudge towards more positive outlook. • Strengthens connections between PFC and brain regions important for empathy. • Seems to facilitate social intuition. Mindfulness & Exposure

  42. Mindfulness Meditation – Overview – Benefits with...  anxiety.  depression.  relapse rate – 50% less relapses even when added to tx for those with severe recurrent depression. Substance abuse. Eating disorders Chronic pain Improved immune function.  BP  cortisol levels.  telomerase activity (helps with replacement of short bits of DNA – telomeres – in turn maybe helpful with aging, some cancers, heart disease, diabetes, and QOL). Enhanced cognitive functioning (memory, ?ADHD).  inflammation. Mindfulness & Exposure

  43. Meditation, HRV, & Substance Use? “Together, these results suggest that the increased HF-HRV that has been observed during meditation may reflect increased self-regulation capacity or replenishment of depleted self-control resources, which may in turn contribute to the positive effects of mindfulness-based interventions in the treatment of substance-use disorders.” “Meditation-induced changes in HF-HRV, on the other hand, may be indicative of the capacity to actively modulate reactivity during stressful states such as during cravings for cigarettes.” [i.e., ability to step back from habitual S-R chain] Libby et al. (2012). Meditation-induced changes in high-frequency heart rate variability predict smoking outcomes. Frontiers in Human Neuroscience, 6. http://www.frontiersin.org/Human_Neuroscience/10.3389/fnhum.2012.00054/full Mindfulness & Exposure

  44. Collaboration: Maine NPs & Psychologists

  45. CBT for Anxiety Disorders CBT for anxiety disorders is hands down the 1st-line tx. More effective than meds and other psychotherapies. ~70% - 80% response rate. Collaboration: Maine NPs & Psychologists

  46. Anxiety Disorders & Treatments • Overview • Generalized Anxiety Disorder (GAD) • Panic Disorder & Agoraphobia (PDA) • Posttraumatic Stress Disorder (PTSD) • Obsessive Compulsive Disorder (OCD) • Social Phobia/Social Anxiety Disorder • Health anxiety. Dr. Matranga Anxiety Disorders

  47. Health Anxiety • Preoccupation with false belief or idea that one has, or is in, significant danger of having a serious illness • Prevalence: 4-6% in outpatient medical clinics. • Ineffective and inefficient use of health care system. • Reassurance: persists over time, despite significant evaluation, testing & frequent reassurance. • In some cases, it may be the reassurance that is inadvertently reinforcing the health concern, in an OCD-like fashion. Collaboration: Maine NPs & Psychologists

  48. Health Anxiety – possible overlap OCD: compulsive reassurance-seeking that inadvertently reinforces sensitivity to internal sensations? Worry/GAD: proneness to worry partly focused on medical issues? Panic = phobia of internal sensations; hypervigilance and hyperreactivity to changes in internal environment. PTSD: prior “trauma” of illness or medical event  hypervigilance to sensations. Collaboration: Maine NPs & Psychologists

  49. Health Anxiety Conceptualization Hypervigilance to and misappraisals of various bodily sensations reinforced and maintained by behavioral responses to those misappraisals. There may be features of or overlap with: • OCD • Worry/GAD • Panic • PTSD Collaboration: Maine NPs & Psychologists

  50. Health Anxiety Heuristic

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