Providing Context at Psychiatric Appointments

1. Providing Context at Psychiatric Appointments What Psychiatric Prescribers Need To Know When Assessing and Treating Individuals With Developmental Disabilities

2. What Is In A Snapshot? • Psychiatric appointments occur out of context. • Psychiatric appointments are brief and in the moment. • Sometimes people ‘aim to please’ when meeting with professionals. • Without context, what is directly observed during a psychiatric appointment can be challenging to evaluate.

3. Cognitive Delays & Provision of Verbal Context • Abstractions such as time frames, reasons why, and relative seriousness of events might be distorted. • Memory gaps and inability to fully describe a situation might impact what is shared. • A patient might not understand questions in a diagnostic interview. • Lack of trust with a clinician or saying “Yes” as a strategy to please might distort what is shared.

4. Deep Listening • Though psychiatric prescribers necessarily depend on others to provide context, it is important that patients with developmental disabilities are accorded respect and are the central treatment focus.

5. Supports to Persons With Developmental Disabilities • Family supports. • Medicaid Personal Care and COPES supports. • Adult Family Home supports. • Group Homes and Boarding Home supports. • Supported Living supports. • Community Protection supports.

6. Treatment Modalities • Be sure that physical pain, neurological conditions, and other physiological issues are being treated. • Ask if there is a Functional Assessment, Positive Behavior Support Plan, and a Cross-Systems Crisis Plan for patients with very challenging symptoms. • Address the adequacy of residential, educational, and vocational supports. • Is the patient using counseling therapies? • Access Speech Therapy, OT and PT when helpful. • Psychiatric treatment is not a stand alone solution.

7. How Systems Skew Psychiatric Assessments and Treatments • In frustration, support providers may over-state symptoms to effect a strong response. • Unrealistic expectations are sometimes placed on psychiatric prescribers. • There is a tendency to look for the most powerful pill. • There is the idea that using medicine is the easiest (cheapest?) way to fix problems.

8. Changes in Community Mental Health Services • More money is being spent on pharmaceuticals and less money is being spent on mental health case management per client. • Mental health caseloads have essentially doubled in Washington State in the past fifteen years. • Collaboration and consultation between mental health case managers and prescribers for each client has substantially decreased.

9. Requesting Contextual Information at Appointments • Psychiatric prescribers depend on families and agency staff to provide supports to individuals with developmental disabilities at psychiatric appointments. • Patients are better served if families and/or support providers understand psychiatric treatments. • Good care requires good sharing of information – both ways.

10. Psychiatric Appointment Information Sheet - GOALS • Minimize unnecessary psychotropic medication use. • Limit the number, dose and toxicity of necessary psychotropic medications as possible. • Obtain as accurate and detailed information as possible to make medication decisions. • Identify treatable psychiatric conditions. • Identify environmental, social and medical causes of concerning behaviors. • Determine efficacy of existing psychotropic therapy. • Identify any side effects

11. Demographic Information Patient Name Psychiatric Prescriber Appt. Date Person(s) Completing Form Relationship to Patient Who else provided input? Guardian (if any) Guardian phone # Date of last visit

12. General Information • Who is providing information? • How well do they know the patient? • Are there differing opinions or an agenda? • What is the patient’s weight and why is it important?

13. Basic Medical Information Recent Weight & Date when weighed Date of last Blood Draw Pharmacy Name and Phone Number Name(s) of other involved medical specialists (general practitioner, neurologist, gastroenterologist, dentist, etc.)

14. Medications and Diagnosis List all current psychiatric meds, dosages, & times administered.   List all current non-psychiatric meds, dosages, & times administered. Current DSM Diagnosis (if any): Axis I:       Axis II:       Axis III:

15. Reasons For The Appointment Please address the following issue(s): Describe other efforts to address symptoms of concern: How is the client doing in general Great OK Doing Poorly Since the last appt. is the client doing: Better Same Worse

16. Information From Patient’s Support System • How is the patient doing now? • Has anything changed since the last appointment? 

17. Stress Related To Life Events Loss of job Significant change in support staff Victim of crime or assault Move to a new residence Death in family Loss of preferred activity Death or loss of a friend Change in family circumstance Increased stress at home Exposed/witness to violence Law enforcement contact Change in physical health Medical tests/MD visits/ER visits Other -    

18. Physiological Symptoms Constipation Nausea/Vomiting Diarrhea Rectal bleeding/discomfort Abdominal pain Weight gain/loss Urinary difficulties/excess Edema/swelling Chest pains Tingling/numbness Dizziness/fainting Slurred speech Rapid or slow pulse Stumbling/unsteady gait Stiffness Tremor/shaking/ticks Seizures Fatigue Headache Physical weakness Injury requiring medical response

19. Physiological Symptoms - II Unusual facial/ mouth/eye movement Unusual movements of extremities Drooling Dry mouth Increased thirst Unusual tastes/smells Appetite change Choking on food Dental pain Change in skin color Rash/Itching Breast discharge Sexual function difficulties Menstrual changes Excessive sleepiness Loud snoring Breathing abnormalities Wheezing or cough Sweating or chills Hearing/vision changes Hair loss/unusual growth Other -      

20. What Physiological Symptoms Can Tell Us • Is the patient experiencing a medical condition as a potential cause of behavioral concerns? • Is a psychotropic medication causing a physiological symptom? • Is a psychotropic medication causing a medical condition? • What physiological symptoms are associated most commonly with what psychotropic medications

21. Behavioral Symptoms Assaultive Behavior Anger outburst(s) Sleep/awake change SIB causing self-harm Poor attention to hygiene Restlessness or anxiety Nightmares Suicidal behavior Reported hallucinations Intrusive/pressured Elopement or Wandering Peculiar rituals Listless, low energy Criminal activity Has dangerous friends Increased irritability Pacing/repetitive Obsessively organized Indiscriminate sexual activity Excessive neediness/dependent Crying/tearfulness

22. Behavioral Symptoms II Substance Abuse Medication refusal(s) Changes in food/drink intake ↓ interest in activities Property destruction Talking about death/dying Hoarding/stealing/collecting Possible delusions/paranoia Labile, rapid change in mood Dramatic reduction in need for sleep Poor phone use (making 911 calls) Isolative, withdrawn Low response, flat affect Repeated police/ER contacts Making false accusations Work/recreation activity refusals Pressured/rapid speech Disorganized/tangential speech Stripping/exposing self in public Change in sexual activity Other -

23. What Behavioral Symptoms Can Tell Us • Behavioral symptoms as side effects of medication. • Behavioral symptoms associated with various psychotropic medications. • Behavioral symptoms associated with various psychiatric diagnoses. • When is it appropriate to treat behavioral symptoms with psychotropic medication? • Which behavioral symptoms are most likely to respond to psychotropic medication and which are not? • Why are changes in circumstance important to consider in making decisions about psychotropic medications?

24. Team Building • Accurate psychiatric assessment and treatment of individuals with developmental disabilities is best done with a team approach. • Detailed information sharing improves the quality of care. • For a number of reasons there are powerful pressures on the mental health system to pursue efficiencies, decreasing time resources for adequate assessment and monitoring of psychiatric services. • Formalizing ways to share information across systems may be a helpful structure for collaborations.