(New?) strategies for mental health in primary care

1. (New?) strategies for mental health in primary care Larry Wissow, MD MPH Johns Hopkins School of Public Health, Baltimore, MD

2. Goals • Learn about the importance of alliance (patient-doctor; patient-staff; patient-office) as a platform for delivering mental health care • Learn some techniques for fostering patient-doctor alliance • Building a repertoire of brief interventions as a first step in providing mental health treatment

3. Disclosure • "I have no relevant financial relationships with the manufacturers of any commercial product(s) and/or provider of commercial services discussed in this CME activity.” • "I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.”

4. Acknowledgements • Grateful to funders and collaborators • Duke Endowment (Dr. Jane Foy) • National Institute of Mental Health • Dr. Anne Gadomski (Bassett Research Institute) • Many others!

5. Cases to think about • Foster parent brings in the bag of pills (for “anger management”) and says they aren’t working • A parent seems depressed or has revealed problems on a screening form • In the middle of a short medical visit the family raises (as yet not well articulated) concerns about a teen’s mood

6. What do these cases have in common? • Likely to require longer time to sort out • From the start, some concern that the problem may be outside your range of practice • Uncertain how long you will have to manage the situation pending consultation or a referral

7. Background/philosophy • Pediatric practices see same range of severity as child psychiatrists • But distribution varies • Many different ways to cope • Develop your own skills • Co-locate with mental health • Find an informal coach or consultant

8. Parallel approaches to mental health in primary care • Make a specific psychiatric diagnosis • Then apply a specific treatment (versus) • Identify families experiencing behavioral or emotional problems • Work with them to formulate the problem in terms that make sense to them and you • Develop a plan that includes • An initial response (including identifying emergencies) • Monitoring/follow-up • Further diagnosis, referral and treatment as needed

9. To adopt the alternative… • Core capability for any solution might be called “alliance” with family • Partnership, engagement… • Data from adult primary care studies of depression treatment • Relationship with provider predicted engagement and outcome Van Os TW. J Affect Disord 2005;84:43-51. Frémont P. Encephale 2008;34:205-10.

10. Why start with a focus on alliance? • Advice alone isn’t enough • < 50% of psychosocial concerns disclosed • < 50% of mental health referrals kept • < 50% of children who start mental health treatment finish • Evidence from psychotherapy • Predicts outcome over and above any specific treatment (including medications)

11. Elements of alliance in psychotherapy • Agreement on nature of problem • Agreement on what to do (and when) • “Affective bond” with provider • Trust • Optimism • Relief

12. Why alliance especially with mental health issues? • Particularly stigmatizing • Doubt and equivocation part of the “illness” • Not sure that you’re the one to tell • Afraid to hear the answer

13. What builds alliance? • Evidence that process starts with initial interaction with office • Image of relationship built from staff as a whole, not just the pediatrician • Patients value flexible, open staff who can • pinch hit for each other • help trouble shoot problems • speed things up when needed • realize when the patient’s context has changed Ware NC. Psychiatr Serv. 1999;50:395-400. Pulido R. Arch Psych Nursing 2008;22:277-87.

14. Practice climate predicts patient trust • Adult primary care patients’ trust in provider related to: • Physicians and staff reporting better collaboration with each other, more autonomy, ability to delegate to each other • Trust then relates to: • Attribution of influence over healthy behaviors to provider recommendations Becker ER, Medical Care 2008;46:795-805

15. Alliance building 1:1 • Feeling heard and understood (the bond) • Seeking agreement on a working formulation of the problem • Offering advice after obtaining permission to do so

16. 1. Feeling heard and understood • Open-ended questions • Anything else? • Playing back the story • Asking for clarifications and priorities • “Which one of those is hardest?” • “Pick one of those to start with.”

17. “Enforcing” taking turns - child • [Video example here]

18. Common issues in agenda setting • Parent and child/youth have different priorities • Family priorities not same as yours’ • Opportunities for additional visits are limited • You really do want to accomplish more than you have time for!

19. Skills for agenda setting • Making sure this process is clear to patient/parent • Playing back the list of concerns • Asking for priorities • Getting agreement from all parties • Openly and collaboratively problem solve about limitations on follow-up visits

20. Cases to think about • Foster parent brings in the bag of pills (for “anger management”) and says they aren’t working • A parent seems depressed or has revealed problems on a screening form • In the middle of a short medical visit the family raises (as yet not well articulated) concerns about a teen’s mood

21. 2. Getting to agreement on a working formulation • Why ask for permission to get more information? • What is it that you want to know? • Sensitive but important details • Data related to possibly urgent treatment needs (including overall level of function) • What they think might be the underlying cause

22. Asking about severity/function • Questions from “SDQ” • Do the difficulties you mentioned distress you (teen) or your child (younger child)? • How much? • How much do they interfere with life? • At home • With friends • In school • In other activities

23. Cases to think about • Foster parent brings in the bag of pills (for “anger management”) and says they aren’t working • A parent seems depressed or has revealed problems on a screening form • In the middle of a short medical visit the family raises (as yet not well articulated) concerns about a teen’s mood

24. 3. Asking for permission to offer advice • Summing up your thinking and checking for agreement • May need to cycle back to get more information • Do they still agree that this is something they want to do something about? • If no, what should be monitored, what would it take?

25. When you get to give advice • Ask for permission • Helps patients maintain sense of control • Ask for their ideas • Offer advice as set of choices • Preferably include their ideas among choices • Frame as short and long term plans • What might help now • What diagnostic steps to take

26. Asking about barriers • Easy to skip this step in a quick visit • Evidence suggests even motivated patients appreciate help with logistics • Asking allows people to think through and get more committed to plan • Opportunity to build alliance and anticipate “resistance”

27. Responding to “resistance” • Overall, emphasize choice and time to discuss • Apologize for getting ahead • Agreeing with a twist • What would it take?

28. What would be grounds to act? • [Video example here] Click box to start film clip Gloss2/whatwouldittake2

29. General advice Revisit what the family has thought about Have they thought about a specialist? What would be their threshold for referral?Clarifying environmental risks Current stresses for parent and child What can simply be acknowledged What can get taken off the plate temporarily What concrete assistance would generally make things better

30. The advice itself: “Practice elements” • There are many “evidence-based” treatments for child mental health problems • Though they vary in content and intensity, treatments for any one or related condition have many features in common (hawaii.gov/health/mental-health/camhd/library/pdf/ebs/ebs011.pdf)

31. Practice elements for treating childhood anxiety

32. Practice elements for psychological treatment of ADHD

33. Practice elements for psychological treatment of depression

34. Practice elements for disruptive/oppositional behavior

35. Menu of “common elements” Anxiety Graded exposure, modeling ADHD and oppositional problems Tangible rewards, praise for child and parent, help with monitoring, time out, effective commands and limit setting, parent psychoeducation, response cost Low mood Child psychoeducation, cognitive/coping methods, problem-solving strategies, activity scheduling, behavioral rehearsal, social skills building

36. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents

37. Revisiting the cases to think about • Foster parent brings in the bag of pills and says they aren’t working • A parent seems depressed or has revealed problems on a screening form • In the middle of a short medical visit the family raises a difficult to sort out behavior or mood issue

38. Summing up • Tending to the alliance you build with families is a treatment in itself, and facilitates the impact of other treatment you provide • Clarifying concrete concerns and making it clear that you are working toward addressing those concerns is also therapeutic • A relatively small repertoire of brief advice may help many families while waiting for more definitive diagnosis and treatment

39. Much thanks