Integrating Mental Health Into Your Primary Care Practice Margaret Bavis, DNP, FNP-BC Sue Murray, RN, MPH In collaborat

1. Bringing Health Care to Schools for Student Success Integrating Mental Health Into Your Primary Care Practice Margaret Bavis, DNP, FNP-BC Sue Murray, RN, MPH In collaboration with Sharon Stephan, PhD Center for School Mental Health NASBHC Training of Trainers September 20-23, 2008

2. Ice-Breaker

3. Workshop Objectives Participants will be able to: • Name at least two strategies for improving primary care-mental health collaboration in school-based health centers. • Identify at least one screening instrument to screen for anxiety, depression, disruptive behavior disorders, and strengths and difficulties. • Identify possible mental health diagnoses based on a list of presenting symptoms.

4. Workshop Objectives (continued) Participants will be able to: • Identify at least two core skills for treating anxiety and depression. • Identify at least two strategies to improve mental health referrals and documentation.

5. Workshop Outline • Mental health and primary care integration and collaboration • Risk and protective factor assessment • Mental health screening tools • Diagnostic review • Treatment, referrals and follow-up • Resources

6. Definitions • Primary Care and Mental Health Integration - integrating mental health practice into primary care services • Collaborative Care – primary care and mental health providers working collaboratively to provide quality health and mental health care • Interdisciplinary Practice - mutual respect and coordination of care between SBHC staff and other health professionals practicing in schools, including nurses, nutritionists, as well as mental health and other counseling professionals, see position statement at: http://www.nasbhc.org/atf/cf/{CD9949F2-2761-42FB-BC7A-CEE165C701D9}/Advocacy%20interdisciplinary%20pos.%20statement.pdf

7. Primary Care Providers – Why should I be doing mental health? • I don’t have time • I’m not trained • I don’t like doing mental health work

8. Importance of Mental Health Services in School-Based Health Centers • In studies of SBHC service utilization, mental health counseling is repeatedly identified as the leading reason for visits by students. • Approximately 1/3 to 1/2 of all visits to SBHCs are related to mental health problems. • Only 16% of all children receive any mental health services. Of those receiving care, 70-80% receive that care in a school setting. • Schools are the “de facto” mental health system for children and adolescents. SOURCE: (1) National Assembly on School-Based Health Care. Creating Access to Care for Children and Youth: School-Based Health Center Census 1998-1999. June 2000. (2) Jellinek M, Patel BP, Froehle MC, eds., Bright Futures in Practice: Mental Health—Volume II. Tool Kit. Arlington, VA: National Center for Education in Maternal and Child Health.(4) Center for Health and Health Care in Schools, Children’s Mental Health Needs, Disparities, and School-Based Services: A Fact Sheet.

9. SBHC Staffing Models(N=1235)

10. Mental Health Services in SBHCs With (n=655) and Without (n=277) Mental Health Providers * P<.01

11. Strategies for Improving Collaborative Care in SBHCs • Collaborative screening and assessment • Chart/documentation • Information sharing between mental health and primary care providers • Interdisciplinary case conferences • Multidisciplinary training • Co-facilitation of student groups • Joint presentation of in-services to school staff • Efficient, reliable, informative referral process

12. Mental Health Problem Identification • Comprehensive Risk and Protective Factor Assessment • Mental Health Screening • Mental Health Diagnosis

13. Assessment and Screening Shouldn’t only mental health providers assess and screen for mental health?

14. Assessment of Risk and Protective Factors

15. What assessment tools is your SBHC using???

17. Risk Assessment • A comprehensive annual risk assessment and biennial physical exam are essential to detecting and addressing all important health concerns of the student. -NASBHC CQI Tool

18. injury safety violence diet and exercise dental substance use and passive exposure abuse family relationships school friends mood and emotional health sexuality Risk Assessment Must be developmentally appropriate and is expected to cover: - NASBHC CQI Tool

19. Guidelines for Adolescent Preventive Services (GAPS) http://www.ama-assn.org/ ama/pub/category/1980.html Bright Futures http://www.brightfutures.org American Academy of Pediatrics http://www.aap.org/policy/periodicity.pdf Risk Assessment Tools

20. Risk Assessment Tools • Pediatric Symptom Checklist http://www.massgeneral.org/psc • Child Health and Illness Profile (CHIP) http://chip.jhu.edu

21. HEADSS interview • Home • Education • Activity • Diet • Safety • Sexuality

22. The Asset Checklist • Self-report • 40 developmental assets • Identifies qualities in youth that can be enhanced to promote resiliency. • http://www.search-institute.org/assets/assetlists.html

23. Stress-Risk Factor Assessment • Ask • “What 3 things do you think are causing you the most stress lately?”; • “What 3 things do you think are causing your family the most stress lately?” • “What 3 things do you think are most stressful about your school?” • “What 3 things do you think are most stressful about your neighborhood?”

24. Considerations In Assessment Selection • Be sensitive to age, sex, language, and culture • Be relevant to their needs or risk factors • Practicality of implementing in your practice • Instruments should be “user friendly” • Capture the information you need • Be measurable • Fit with your style of practice • There is no best way

25. How do you conduct the risk assessment? • Paper and pencil – done by student • Computer based • Provider interview of student at the time of the examination • Provider interview of student at a time apart from the examination What works in your setting?

26. Documentation of Risk and Protective Factors • Documentation may take many forms… • Inclusion of strengths/assets/protective factors in intake evaluation, progress notes, and/or treatment plan • Checklist of risk and protective factors • Assessment instruments (e.g., comprehensive risk assessment, asset checklist, etc.)

27. Getting the assessment done: Distribution of work • Identifying components of the work • Identifying team roles • Shared Responsibility • Staff Training

28. Screening Instruments

29. Screening Instruments – public domain (aka FREE) • General Mental Health – Strengths and Difficulties • Strengths and Difficulties Questionnaire • Disruptive Behavior Disorders/ADHD • Parent/Teacher Disruptive Behavior Disorders Rating Scale • Vanderbilt Scales • Disruptive Behavior Disorders Structured Parent Interview • Depression: • Center for Epidemiological Studies Depression Scale for Children (CES-DC) • Anxiety: • The Spence Children’s Anxiety Scale (SCAS)

30. Strengths and Difficulties Questionnaire • 25-item self-report screening of strengths and difficulties for 3-16 year olds • 5 subscales: • Emotional symptoms • Conduct Problems • Hyperactivity/inattention • Peer relationship problems • Prosocial Behavior • Used as initial screener and/or measure of treatment progress • FREE! – available at http://www.sdqinfo.com/

31. Parent/Teacher Disruptive Behavior Disorders Rating Scale • Disruptive Behavior Disorders • 45 items • FREE! – available at http://128.205.76.10/DBD.pdf • Parent and Teacher report • Subscales for: • ADHD, ODD, CD

32. Vanderbilt Scales • Parent and teacher versions • Also screens ODD, Conduct Disorder, and Anxiety/Depression • Easy to score • FREE! – available at http://www.nichq.org/resources/toolkit/

33. Disruptive Behavior Disorders Structured Parent Interview • Based on DSM criteria • FREE! – available at http://128.205.76.10/DBDInterv.pdf • Subscales for: • ADHD, ODD, CD

34. Center for Epidemiological Studies Depression Scale for Children (CES-DC) • 20-item self-report depression inventory • Used as initial screener and/or measure of treatment progress • FREE! – available at http://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf

35. Center for Epidemiological Studies Depression Scale for Children (CES-DC) • Possible scores ranging from 0-60 • Scale from 0 (Not at all) – 3 (A lot) • Developers indicate a cutoff score of 15 as suggesting depressive symptoms in children and adolescents. • Scores over 15 may be indicative of significant levels of depression

36. The Spence Children’s Anxiety Scale (SCAS) • 38 anxiety items • Overall measure of anxiety with 6 subscales tapping specific aspects of anxiety • Panic attack/agoraphobia • Separation anxiety • Physical injury fears • Social phobia • Obsessive compulsive • Generalized anxiety/overanxious disorder • FREE! – available athttp://www2.psy.uq.edu.au/~sues/scas/ • Parent and Child versions available

37. Screening Discussion • In your SBHC, what factors would you need to consider if you were to implement mental health screening? • Who would do the screening? • When? • Who would score? • Who can diagnose?

38. Diagnosis Who me?… Diagnose?

39. Diagnosis • DSM IV-TR (Diagnostic and Statistical manual, fourth edition, text revised) • Contains mental health diagnoses, as well as all the criteria needed to make the diagnosis • Created by a panel of experts who reach a consensus on what makes a diagnosis - based on their experience and evidence based research • Often see a certain number of symptoms needed to make a diagnosis, i.e. 5 of 9 for depression.

40. Diagnosis cont. • Need some sort of impairment in an arena of patient’s life in order to make diagnosis • So, need to see impairment in social interactions, school functioning, interpersonal interactions, etc. • DSM is updated every so often to indicate any prevalent changes in the field of psychiatry in regards to different diagnoses • Good for “common language”

41. Diagnosis – Primary Care • DSM-IV-PC (Diagnostic and Statistical manual, fourth edition, primary care) • Primary Care Adaptation • emphasizes only those psychiatric disorders that regularly present in primary care settings

42. Diagnosis – Primary Care cont. • Simplified Diagnostic Technique • Nine algorithms, headed by presenting symptoms, for the most common psychiatric concerns encountered in primary care • concise description of disorders as they clinically appear in primary care settings • provides differential diagnoses as they relate to general medical conditions, substance abuse and more severe psychiatric disorders

43. Memorizing the DSM-IV • Daniel Carlat’s, “The Psychiatric Interview” • Memorize the 7 Major Diagnostic Categories • Organized by category for memorization (not organized this way in DSM-IV) • Focus on Positive Criteria

44. Anxiety • Panic Disorder • Agoraphobia • Obsessive Compulsive Disorder • Specific Phobias • Separation Anxiety Disorder • Posttraumatic Stress Disorder • Generalized Anxiety Disorder • Anxiety Disorder NOS

45. What type of anxiety??? • Marcus has come for a follow-up appointment at the School-Based Health Center (SBHC). He reported several anxiety symptoms during his comprehensive risk assessment, and screened positively for panic attacks during the Diagnostic Predictive Scales. Marcus indicates that the panic attacks are triggered by a fear of being called on in class. He experiences symptoms of panic (heart palpitations, nervousness, sweating, etc) on the way to school, while sitting in class, and even just thinking about being in class.

46. Panic Disorder - Diagnostic Criteria I. Recurrent unexpected Panic Attacks Criteria for Panic Attack: A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: (1) Palpitations, pounding heart, or accelerated heart rate (2) Sweating (3) Trembling or shaking (4) Sensations of shortness of breath or smothering (5) Feeling of choking (6) Chest pain or discomfort (7) Nausea or abdominal distress (8) Feeling dizzy, unsteady, lightheaded, or faint (9) Derealization (feelings of unreality) or depersonalization (being detached from oneself) (10) Fear of losing control or going crazy (11) Fear of dying (12) Parenthesis (numbness or tingling sensations) (13) Chills or hot flushes

47. Panic Disorder - Diagnostic Criteria II. At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: (1) Persistent concern about having additional attacks (2) Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy") (3) A significant change in behavior related to the attacks

48. What type of anxiety??? • Philip’s mother came to school to talk to her son’s teacher (Ms. Chalk) because of Philip’s recent absences from school. Upon talking with Philip’s mother, Ms. Chalk learned that Philip had a fear of animals, and was increasingly scared to go outside of his house because he did not want to come into contact with any animals. His mother reported that he even gets nervous when seeing animals on television, even though he knows they cannot hurt him.

50. Specific Phobias • Marked and persistent fear of a specific object or situation with exposure causing an immediate anxiety response that is excessive or unreasonable • In children, anxiety may be expressed as crying, tantrums, freezing, or clinging. • Adults recognize that their fear is excessive. Children may not. • Causes significant interference in life, or significant distress. • Under 18 years of age – symptoms must be > 6 months