Models and Process of Psychosomatic Medicine

1. Models and Process of Psychosomatic Medicine APM Resident Education Curriculum Robert C Joseph, MD, MS, FAPM Director Consultation-Liaison and Primary Care Behavioral Health Service Program Director, Psychosomatic Medicine Fellowship Cambridge Health Alliance, Cambridge MA Assistant Professor, Harvard Medical School Updated Summer 2011 Robert Joseph, MD, MS Fall 2013 Robert Joseph, MD, MS R. Brett Lloyd, MD, PhD

2. Psychosomatic Medicine • Subspecialty at the interface of Medicine and Psychiatry • Clinical Service • Research • Training • Psychosomatic Medicine is the name of the accredited subspecialty

3. Models of Psychosomatic Medicine Psychiatry • Traditional/Conventional • Hospital or Ambulatory Based • Consultation Upon Request (reactive) • Liaison Psychiatry • Mental Health Integration • Hospital or Ambulatory Based • Case Finding/Screening • Proactive/Systemic Mental Health Involvement • Population Based Programs • Disorder Specific Programs • Hybrid Models

4. Traditional Models • Consultation Upon Request • Reactive • Patient and consultee specific • Primary responsibility for patient remains with consutee • Liaison Psychiatry Components • Education • Formal and informal education • Support • Service, Ward, Nursing Staff • Can be Sub-Specialty Specific • OB, Oncology, Neurology etc.

5. Types of Patients Complex, co-morbid psychiatric and medical conditions Neurocognitive disorders Somatic symptom and functional disorders Psychiatric disorders secondary to medical conditions or treatments

6. Distinction from Office Based Psychiatry • Services requested by consultee • No “self referral” • Obligations to consultee as well as patient • Patient often unaware of referral • Usually ill, uncomfortable or in pain • Patient motivation often compromised • Limited privacy • Visits not scheduled nor time based

7. Function of Psychiatric Consultation • Doctor-to-doctor communication designed to address the mental health needs of the patient and improve patient care • the over-riding concern is the patient’s well-being

8. Essential Tasks Complete a comprehensive psychiatric assessment and develop a management plan Remove impediments to medical care Bring a fresh perspective to the clinical dilemma Facilitate a mutual understanding between patient, doctor and treatment team Educate about the emotional and neuropsychological needs of the patient

9. Steps in the Consultation (1) • Review chart and consult question • Discuss case with consultee • To 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 helpful

10. Steps in the Consultation (2) • Patient Interview • Introduce self • Sit down • Address patient’s surprise at the arrival of a psychiatrist (if present) • Attend to any physical discomfort

11. Steps in the Consultation (3) • Mental status exam Includes bedside cognitive testing • Targeted physical exam (if appropriate) • Ancillary history gathering often appropriate • Family • PCP • Other care givers • Other

12. Steps in the Consultation (4) • Written note • Verbal communication (feedback) with consultee, regarding your opinion • Follow-up visits as appropriate • Range can be none to daily

13. The Written Note (1) • Document formally addressed to the physician requesting the consultation • Designed to be used by other members of the treatment team • May be read by a variety of hospital personnel • Consider confidentiality

14. The Written Note (2) • TITLE: Psychosomatic Medicine Service • Attending • Resident • Other • NATURE OF THE NOTE • Initial Consultation Note • Follow-up Consultation Note

15. The Written Note (3) • DATE AND TIME: • Essential when dealing with a fluctuating mental status • SOURCE • Patient, family, medical record, other • IDENTIFYING STATEMENT • This lays the groundwork for your formulation and recommendations in a way that helps the readers to understand your note

16. The Written Note (4) • Reason for Consultation • Why 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 psychiatrist • Manifest request: R/O depression • Latent request: There is nothing wrong with this patient. She is drug seeking and manipulative. Make her stop complaining and behave!

17. The Written Note (5) • Identifying Statement • Important • “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 question • Reminds us to answer the question • Respectful to consultee

18. The Written Note (6) HISTORY OF PRESENT ILLNESS • A place to document the essential positive and negative aspects of the history • Provides a historical framework for understanding the patient • Must 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 mechanisms

19. The Written Note (7) • Past Medical/Surgical History • Include menstrual and obstetric • Past Psychiatric History • Medication • Prior to admission • At time of consultation • Recent changes • Substance Use History • Family History • Social History

20. The Written Note (8) • Physical Exam (as appropriate) • Mental Status Exam • Analogous to the physical examination. • Reflects a point in time • Address the question of the consultation and your formulation within the mental status examination • It is an opportunity to teach and to demonstrate how diagnoses are made • A tool to gain access to a patients mental life • Pertinent Laboratory and Radiologic Findings

21. The Written Note (9) • Impression • Other than recommendation, the most likely part of the consult to be read • Should have the components of a good biopsychosocial formulation, but avoid psychiatric jargon whenever possible • Include stressors and functional status • Know your audience and what you want to accomplish • Differential diagnosis, including personality and medical disorders

22. The Written Note (10) DIAGNOSIS • DSM-V • Axis I-III combined: list relevant diagnoses to consultation • List ICD-9-CM V codes related to psychosocial and environmental problems • WHODAS – may be used to demonstrate disability • DSM IV-TR • Multi-axial assessment • Axis III – including disorders relevant to the psychiatric disorder(s) • Axis IV – Psychosocial/ environmental problems • Axis V – global assessment of functioning

23. The Written Note (10) WHODAS: World Health Organization Disability Assessment Schedule 2.0 • Included in Section III of the DSM-V • Domains include: Communication, getting around, self-care, relationships, household activities, school and work activities, participation in society Axis V (GAF) was dropped from DSM-V WHODAS is included for further study as an assessment tool for functioning 36-item, self-administered measure used to assess disability in adults (age 18 and older

24. The Written Note (11) • Recommendation/Plan • Most likely part of the consultation to be read • Further work-up suggested • Physician management • Medication • Behavioral approaches with patient • Be specific, avoid jargon • Nursing management • Legal issues • Social service needs • Aftercare plans • Consultant follow-up • Inform treatment team of your availability, whether/when you will return and the purpose of your return

25. Mental Health Integration (1) • Collaboration with Multidisciplinary Team • Mental Health (MH) and non-Mental Health (non-MH) providers • Psychiatrist, other MD’s, Psychologists, Social Workers, Nurses, Case Managers, Support Staff • Elements of Integration • Mission • Optimal care for behavioral problems in non-MH setting • Target Population • Patients with co-morbid medical and psychiatric problems • Patients with MH problem but no other MH care • Location • Generally involves co-location of MH staff in medical site • Communication • Team meetings, shared, medical record and treatment plans • Administrative • Shared or coordinated between MH and non-MH staff • Fiscal • Integrated budget for MH and medical staff vs. separate

26. Mental Health Integration (2) • General Hospital Based • Tends to be disorder specific • E.g., delirium, transplant or substance use disorders • Ambulatory • Primary care • Medical/Surgical Specialty clinics • OB, Oncology, Neurology, Transplant etc

27. Mental Health Integration (3) • Rationale • Prevalence of mental health (MH) issues in medical setting • Lack of access to conventional MH services • Patient’s reluctance to go to MH clinic • Extensive co-morbidity of medical and MH disorders • Bidirectional adverse effect of co-morbid disorders • Associated morbidity and cost of disorders • Method/Structure • Wide range • Reactive Programs • Mimic traditional consult services except, perhaps for co-location • Planned Programs • Highly Structured, oriented toward “Disease Management”

28. Mental Health Integration (4) • Value added • Delirium prevention programs • Depression, Anxiety and Substance Abuse Management in primary care • Co-morbid MH and medical disorders • depression, diabetes, cardiac disorders • Medically Unexplained Physical Symptoms (MUPS)

29. Mental Health Integration (5) • Planned Care for Behavioral Health Disorders in Medical Clinics • Derivative of chronic disease management programs • Proven efficacy in multiple studies • AKA Collaborative Care, Stepped Care • Methods • Proactive Screening/Case Finding, Registry, Team Management, Algorithm directed, Consultation and Supervision, Case Management, Teamwork

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; 363:2611-2620