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
ACADEMY OF PSYCHOSOMATIC MEDICINE Psychiatrists Providing Collaborative Care for Physical and Mental Health Psychosomatic Medicine Subspecialty at the interface of Medicine and Psychiatry Clinical Service Research Training Psychosomatic Medicine is the name of the accredited subspecialty Academy Of Psychosomatic Medicine 2 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 Academy Of Psychosomatic Medicine 3 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. Academy Of Psychosomatic Medicine 4
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 Academy Of Psychosomatic Medicine 5 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 Academy Of Psychosomatic Medicine 6 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 patients well-being Academy Of Psychosomatic Medicine
7 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 Academy Of Psychosomatic Medicine 8 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 Academy Of Psychosomatic Medicine 9 Steps in the Consultation (2) Patient Interview Introduce self
Sit down Address patients surprise at the arrival of a psychiatrist (if present) Attend to any physical discomfort Academy Of Psychosomatic Medicine 10 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 Academy Of Psychosomatic Medicine 11 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 Academy Of Psychosomatic Medicine
12 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 Academy Of Psychosomatic Medicine 13 The Written Note (2) TITLE: Psychosomatic Medicine Service
Attending Resident Other NATURE OF THE NOTE Initial Consultation Note Follow-up Consultation Note Academy Of Psychosomatic Medicine 14 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 Academy Of Psychosomatic Medicine 15 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!
Academy Of Psychosomatic Medicine 16 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 Academy Of Psychosomatic Medicine 17
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 patients life, e.g., losses, illnesses. The precipitant to the current psychological and physical difficulties. The nature of the patients reaction to these precipitants. Usual coping mechanisms
Academy Of Psychosomatic Medicine 18 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
Academy Of Psychosomatic Medicine 19 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 Academy Of Psychosomatic Medicine
20 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 Academy Of Psychosomatic Medicine 21
The Written Note (10) DIAGNOSIS 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 Academy Of Psychosomatic Medicine 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 22 The Written Note (10) WHODAS: World Health Organization Disability Assessment Schedule 2.0 Axis V (GAF) was dropped from DSM-V Included in Section III of the DSM-V WHODAS is included for
further study as an assessment tool for functioning Domains include: Communication, getting around, self-care, relationships, household activities, school and work activities, participation in society 36-item, self-administered measure used to assess disability in adults (age 18 and older Academy Of Psychosomatic Medicine 23
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 Academy Of Psychosomatic Medicine 24 Mental Health Integration (1) Collaboration with Multidisciplinary Team Mental Health (MH) and non-Mental Health (non-MH) providers Psychiatrist, other MDs, 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 Academy Of Psychosomatic Medicine 25 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 Academy Of Psychosomatic Medicine 26
Mental Health Integration (3) Rationale Prevalence of mental health (MH) issues in medical setting Lack of access to conventional MH services Patients 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 Academy Of Psychosomatic Medicine 27 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) Academy Of Psychosomatic Medicine 28
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 Academy Of Psychosomatic Medicine
29 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 Academy Of Psychosomatic Medicine 30
Again, it's important to stress that knowing your audiences(s) is the first step to determining which media are most appropriate to use. Activity: Distribute the Communications Channel Matrix worksheet.
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