Psychiatric Potpourri

From Managing Depression, Substance Use, and Other Psychiatric Disorders in Later Life, presented by the Veterans Affairs Ann Arbor Healthcare System and the University of Michigan Medical School, Ann Arbor

Educational Objectives

The goal of this program is to improve intervention for substance use and the management of mental illness in the pri­mary care setting. After hearing and assimilating this program, the clinician will be better able to:

1.   Define brief interventions for substance use.

2.   Screen patients to determine the extent of their alcohol use or abuse.

3.   Describe the key components of a brief intervention.

4.   Discuss various models of integrated care.

5.   Explain the advantages of integrating mental health services into primary care.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose.

Acknowledgements

Drs. Barry and Post were recorded at Managing Depression, Substance Use, and other Psychiatric Disorders in Later Life, presented September 25-26, 2008, in Ann Arbor, MI, and sponsored by Veterans Affairs Ann Arbor Healthcare System and the University of Michigan Medical School. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Brief Interventions for Substance Use

Kristen L. Barry, PhD, Research Associate Professor, Department of Psychiatry, Addiction Research Center, and Associate Director, Department of Veterans Affairs Serious Mental Illness Treatment Research and Evaluation Center (SMITREC), Ann Arbor MI

Introduction: in general, frequency and quantity of alcohol consumption directly correlated with degree of negative impact on individual’s life; difficult to select patients who will benefit from brief interventions; brief intervention  —  defined as time-limited (lasting from 5 min to 5 sessions); drug- and alcohol-related behaviors can be targeted, but speaker focuses on alcohol; goals of brief interventions  —  to reduce alcohol consumption and facil­itate entry into treatment

Screening techniques: several available; Alcohol Use Disorders Identification Test (AUDIT)  —  used by speaker and Veterans Affairs (VA); developed by World Health Organization; comprised of 10 questions; first 3 ask about quan­tity, frequency, and binge drinking (AUDIT-Consumption [AUDIT-C]); of these, most insight into patient’s drink­ing obtained from question about binge drinking

Interventions: range from prevention to long-term therapy; patient can move among levels as needed (eg, if patient not responding to prevention attempts, therapist can try brief intervention or course of long-term treatment); brief interventions can be used for moderate drinking to dependence, especially for older adults with moderate drinking who take medications with which consumption of alcohol contraindicated

Brief history of interventions: started with smoking trials; having clinician or staff ask at each visit if patient still smoking found to be most effective strategy for encouraging smoking cessation; »5% stopped smoking without ad­ditional intervention; alcohol trials started in Europe in 1980s (later in United States)

United States Preventive Services Task Force: reviewed studies of 12 English-language, multicontact, primary care-based behavioral interventions in nondependent drinkers; 6- to 12-mo follow-up; found mixed results for mor­bidity; for health care utilization, found self-reports of decreased hospitalizations and decreased emergency depart­ment (ED) visits; some improvement reported in quality of life; study with 48-mo follow-up, found no difference in outcomes between those who showed up for booster session and those who did not; number of hospital days and al­cohol consumption decreased in both groups

Additional studies: 2 large trials for older adults (>60 yr of age); results of both show greater reduction in drinking in experimental groups than in control groups

Speaker’s implementation study: done in conjunction with American Society on Aging in San Francisco; looked at effectiveness of brief interventions carried out by social workers in senior centers and senior housing; criteria for inclusion required consumption of >7 drinks per wk, but average much higher (18 to 19 drinks per wk for men, 16 to 19 for women); 260 seniors randomized to experimental or control group; over 6 mo, drinking reduced in both groups; attributed to finding that providers “liked the interventions” and used them for some subjects who had been flagged for control group; providers found intervention easy to do; men in experimental group reduced drinking by »42%; researchers concluded that getting all patients to reduce drinking to targeted guidelines not likely; more re­alistic goal is risk management (eg, may refrain from drinking and driving or from drinking when using certain medications)

Settings for brief interventions: primary care; EDs; psychiatric settings; senior housing; college campuses; venues frequented by adolescents

Key components of brief interventions: screening (several instruments available for younger and older adults, and for drugs and alcohol); feedback; motivation to change; strategies for change; behavioral contract (agreement about shared decision making); follow-up

Advantage: not necessary to accomplish everything in one visit (can spread over several visits)

Confrontational vs motivational interviewing: confrontational approach  —  often has individual accept label (eg, alcoholic); motivational interviewing  —  labels eschewed; addresses patient’s concerns; emphasizes personal choice; utilizes “rolling with resistance” (finding ways to accommodate patients objections without arguing); en­courages reflection; negotiates treatment plan with patient

Synopsis: brief interventions known to reduce alcohol use for ³12 mo; effect sizes similar for men and women and for all groups >18 yr of age; overall, »40% of patients reduce drinking over 12-mo period; can explore further treat­ment options for 60% unaffected by brief intervention; studies show hospital days, ED visits, and readmissions for trauma reduced; Canadian study found decrease in outpatient visits; cost-benefit analysis favors brief interventions; billing codes now available

Innovations in brief interventions: computer-driven interventions (currently being compared with therapist-driven interventions); interactive voice-recognition technology; web-based interventions for special populations; tailored audiotape headphone interventions; “Video Doctor”; telephone-based counseling

Conducting brief interventions: speaker and colleagues have developed workbook (not mandatory for use of tech­nique); advantages of workbook  —  gives patient something to take home, think about, and refer to; clinician sits beside patient while discussing contents of workbook, which conveys sense of teamwork; because patient does not have to look at clinician, he or she may experience less fear of stigma and find communication easier

Identify goals: what does patient want to achieve over next 3 mo to 1 yr?; include goals about physical health, activ­ities and hobbies, and relationships

Screening: summary of patient’s health habits, ie, questions about exercise, smoking, nutrition, alcohol use, and (particularly in older adults) medications; ask patient which health habits he or she wants help with (in speaker’s experience, response never about alcohol use)

Discussion: addresses patient’s health concerns, but allows redirection of conversation to alcohol use; ask patient for his or her definition of standard drink, and educate patient about accepted definitions; find out how often and how many drinks patient typically consumes; discuss whether patient fits profile of dependency on alcohol (ex­plain why term “alcoholic” not used); inquire what patient likes about drinking (eg, taste, greater comfort in so­cial situations, reduced stress and/or loneliness); gently inform patient of negative consequences of drinking; discuss reasons for cutting down on alcohol consumption

Drinking agreement: clinician makes suggestion of goal for reducing drinking; may need to negotiate with patient about frequency, timing, and/or quantity of drinking; patient may not agree, but clinician records recommenda­tions and both parties sign agreement

Drinking diary cards: included with workbook; encourage patient to fill out card each day (record how many drinks consumed that day); ask patient to bring cards and workbook to next visit; speaker found that »50% of patients complied with completion of cards; even with no compliance, keep dialogue open

Conclusions: problem drinking defined as >14 drinks per wk or >2 drinks per day for men <65 yr of age, >7 drinks per wk or >1 drink per day for women and for men ³65 yr of age; however, these standards may be modified by in­dividual circumstances, such as pregnancy, medical conditions, medications, etc; if brief interventions do not result in reduction in patient’s drinking, more intense therapy may be necessary; speaker finds that people benefit most from nonjudgmental approaches

Integrating Mental Health Into Primary Care

Edward P. Post, MD, PhD, Assistant Professor of Internal Medicine, University of Michigan Medical School, and National Medical Director, Veterans Affairs Primary Care-Mental Health Integration Program, Ann Arbor, MI

Introduction: many clinical challenges in treating mental and substance use disorders in older adults; goals of inte­grated care  —  finding how best to engage patient; getting best evidence-based treatment to patient; providing pa­tient-centered care; facilitating initiation of care, follow-up, and patient compliance; Veterans Affairs institutions have developed programs to integrate mental health into primary care and improve accessibility of mental health services

Integrated care models: colocated, collaborative care  —eg, White River model; care management  —  eg, Translat­ing Initiatives in Depression into Effective Solutions (TIDES model); nurse-based; now being expanded to diseases other than depression; behavioral health laboratory  —  structured computer-aided telephone interview; basic as­sessment operationalized into assessment with primary care physician (PCP); wraparound oversight provided by mental health professionals, who give feedback to PCPs; blended models  —  customized mixes of other models; tar­geted conditions — affective disorders (depression and anxiety), alcohol misuse and abuse, and posttraumatic stress disorder (PTSD; limited primarily to screening and referral)

Why integrate primary care and mental health? improves access to mental health evaluation, prevention, and treatment; fosters continuity of care; institutional memory allows optimization of each episode of care; popula­tion-based approach accommodates patients reluctant to seek specialty care; broadens identification of patients with mental health needs and provides convenient and evidence-based treatment at point of identification

Outcomes: large body of evidence shows that primary care-mental health integration improves engagement with and adherence to mental health treatment (75% in integrated care models vs 35%-50% in referral model); other studies show improvement in time to remission, quality of life, and mortality; integrated care shows substantial patient acceptance and satisfaction; studies show that older patients desire to have mental health treatment in pri­mary care venue

Depression and medical comorbidities: literature mixed, but possible that depression can lead to nonadherence to medical regimens; literature shows that patients with diabetes and comorbid depression have poorer outcomes than those without depression; studies show that optimizing treatment of depression can lead to improved glu­cose control

Depression and cardiovascular disease: mixed results from studies of treating depression in patients with this co­morbidity; speaker posits that these results may be due to heterogeneity of cardiovascular conditions studied (ie, depression interacts differently with different forms of cardiovascular disease and/or with cardiovascular disease of different durations)

Depression and mortality: studies show that depression has independent effect on all-cause mortality; mechanisms not understood, but finding consistent across all causes of mortality; Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) confirmed independent effect on mortality, and that patients with major depres­sion in integrated care arm of trial had lower all-cause mortality over 5 yr than those receiving standard care

Integrated care in VA: does not eliminate specialty mental health care, but facilitates more efficient use of resources (allows patients more appropriately treated by mental health specialists to receive intensity of treatment needed); survey of program directors indicated that integrative approach added value to both primary care and mental health programs

Suggested Reading

Alexopoulos GS et al: PROSPECT Group. Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study. Am J Psychiatry 166:882, 2009; Barry KL et al: Use of alcohol screening and brief interventions in primary care settings: Implementation and barriers. Subst Abus 25:27, 2004; Blow FC et al: The efficacy of two brief intervention strategies among injured, at-risk drinkers in the emergency de­partment: impact of tailored messaging and brief advice. J Stud Alcohol 67:568, 2006; Blow FC, Barry KL: Older patients with at-risk and problem drinking patterns: new developments in brief interventions. J Geriatr Psychiatry Neurol 13:115, 2000; Collins SE et al: A new decisional balance measure of motivation to change among at-risk col­lege drinkers. Psychol Addict Behav 23:464, 2009; Cunningham JA et al: A randomized controlled trial of an inter­net-based intervention for alcohol abusers. Addiction 104:2023, 2009; Felker BL et al: Developing effective collaboration between primary care and mental health providers. Prim Care Companion J Clin Psychiatry 8:12, 2006; Field CA et al: Ethnic differences in drinking outcomes following a brief alcohol intervention in the trauma care set­ting. Addiction Nov 17, 2009 [Epub ahead of print]; Gunn WB Jr, Blount A: Primary care mental health: a new frontier for psychology. J Clin Psychol 65:235, 2009; Kilbourne AM et al: Translating evidence-based depression management services to community-based primary care practices. Milbank Q 82:631, 2004; Lee HS et al: Harm re­duction among at-risk elderly drinkers: a site-specific analysis from the multi-site Primary Care Research in Sub­stance Abuse and Mental Health for Elderly (PRISM-E) study. Int J Geriatr Psychiatry 24:54, 2009; Milner KK et al: Brief interventions for patients presenting to the psychiatric emergency service (PES) with major mental illnesses and at-risk drinking. Community Ment Health J Mar 4, 2009 [Epub ahead of print]; Mundt MP et al: Brief physician advice for problem drinking among older adults: an economic analysis of costs and benefits. J Stud Alcohol 66:389, 2005.