Download Comprehensive and Coordinated Systems of Care

Integrating Behavioral and Pharmacologic
Interventions: Treating People with Psychiatric
Disorders and IDD
RCPA 2014
Cheryll Bowers-Stephens, M.D.,M.B.A.
Chief Medical Officer PerformCare
System of Care Overview
The goal of this specialized program was to interrupt the cycle
of multiple hospitalizations and institutionalization by promoting
community inclusion and expert care.
The program utilized:
– Expert staff.
– Outpatient Assertive Community Treatment (ACT) program serving ages 2 to 22.
– Specialized inpatient adolescent unit serving ages 13 through 18.
The program was part of the ICF-MR Waiver Demonstration Project,
and included longitudinal data.
2
DNP Service Model
Components of the DNP service model include:
• Utilizing learning-based, structured teaching approaches.
• Encouraging healthy, prosocial behaviors while promoting social
inclusion and reintegration, or stabilization, in the community.
• Adapting therapies to the cognitive abilities and developmental
needs of the individual.
3
DNP Service Model (Continued)
• Fully integrating family and school into the treatment.
• Promoting social skills development, and building upon the
youth’s personal goals, strengths and competencies.
• Promoting interagency support and coordination.
– Community collaboration and support are also key to the success of the program.
4
Evidence-Based Practices Utilized
Some of the therapeutic techniques utilized by the specialized
inpatient unit include:
– Integration of behavioral and pharmacological interventions.
– Functional analysis and behavioral modification (i.e., applied behavioral techniques,
cognitive behavioral therapy and behavioral therapy).
– Continuity of care.
– Modified Linehan approach (dialectical behavioral therapy).
– Relaxation training.
5
Prevalence of Psychotropic Usage by Drug Class
(Prior to admission)
Drug class
Percentage
Neuroleptic
85.0%
Mood stabilizer
73.5%
Antidepressant (non-SSRI)
54.4%
SSRI
55.8%
Antidepressant (combined)
78.2%
Psychostimulant
46.3%
Anxiolytic
24.5%
Anticonvulsant
16.3%
Antihypertensive
36.1%
6
Diagnostic Errors Noted During the Course of Treatment
Diagnosis of psychosis based solely on invalid self-report
of auditory hallucinations.
PTSD was often misdiagnosed as psychosis.
PTSD was sometimes incorrectly diagnosed as conduct disorder.
Bipolar disorder was often diagnosed as conduct disorder.
7
Integrating Pharmacotherapy and
Behavioral Therapy Step-Wise Approach
Applied behavioral analytic approach.
Functional behavioral analysis and identification of target behaviors;
pharmacologic inventory.
Linking target behaviors to DSM-V diagnosis.
Literature review identifying evidenced-based treatments.
Behavioral therapy to target behaviors mediated by environmental
factors.
Pharmacotherapy to target biologically mediated behaviors
8
SEVERE DESTR. BEH./FREQ.
Case Example: 13-Year-Old Presents
with Diagnosis of Schizophrenia
7
Tegretol
6
5
4
3
2
1
0
1
8
15
22
29
36
43
50
57
64
71
78
85
92
99
106
DAY
9
7
6
5
4
M
3
2
M
HH H
H
H
M
H
H H HH
1
498
492
486
480
474
468
462
456
450
444
438
432
426
420
414
408
402
0
396
SEVERE DESTR. BEH./FREQ.
Baseline Assessment: H = Herpetic Lesion, M = Menses
DAY
10
7
6
Clonidine
Depakote
5
4
3
2
1
0
59
6
60
2
60
8
61
4
62
0
62
6
63
2
63
8
64
4
65
0
65
6
66
2
66
8
67
4
68
0
68
6
69
2
69
8
SEVERE DESTR. BEH./FREQ.
Diagnostic Clarification: PTSD/Cyclical Mood Disorder Implementation of
Cognitive Behavioral Therapy and Pharmacotherapy
DAY
11
Additional Programs Supporting the IDD Populations
The following slides will highlight several programs that actively advocate for
higher-quality treatment interventions for the IDD population. It is important
that all programs have the ability to complete the following core competencies:
• Conduct a comprehensive biopsychosocial assessment — typically the first
intervention offered — which can assist the clinician with differential diagnosis,
as well as accurate diagnosis of current symptomatology.
• Demonstrate the willingness and ability to collaborate with physicians regarding
any secondary medical diagnoses which may complicate treatment.
• Correctly administer and interpret psychological testing with an IDD population.
12
American Academy of Child and Adolescent Psychiatry
(AACAP)
In order to best serve the IDD population, the AACAP advocates for:
• The creation of a Community-Public Psychiatry certification.
• Certification will improve the quality of individual care for people in
community-public settings through training improvements, and by
furthering the development of the field of Community-Public Psychiatry.
Retrieved from https://sites.google.com/site/aacpcertification/home
13
AACAP (Continued)
Additional goals include:
• Increase interest for members in training to pursue careers
or training in public psychiatry.
• Professionally support community-public psychiatrists
through credentialing.
• Define essential knowledge and skills of the field.
– This includes developing standardized treatment protocols for this population.
Retrieved from https://sites.google.com/site/aacpcertification/home
14
AACAP (Continued)
Supplementary goals include:
• Encourage residency training programs to strengthen public and
community psychiatry training.
• Recognize community psychiatrists with years of providing quality
psychiatric services.
• Improve cohesiveness among community psychiatrists through
defined professional identity and community education.
Retrieved from https://sites.google.com/site/aacpcertification/home
15
AACAP Advocacy
AACAP advocates for the following treatment protocols:
• Replacement behavior training.
• Social skills training.
• Psychoeducation on IDD and other atypical developmental needs.
• Individual, group and family therapy.
• Behavioral Interventions that are developmentally appropriate.
• Concrete goals for treatment that are collaboratively developed
by all team members.
• Treatment delivered by clinicians with experience working with this population.
• Interventions that are developmentally appropriate.
Retrieved from https://sites.google.com/site/aacpcertification/home
16
American Journal on Mental Retardation –
Consensus Guidelines (May 2000)
This group published a consensus document that advocated for utilizing
the following therapeutic interventions when treating an IDD population:
•
Applied behavioral techniques.
•
Cognitive behavioral techniques.
•
Behavior therapy.
•
Cognitive therapy.
•
Functional assessment.
•
Identification of antecedents and consequences of undesirable behaviors.
•
Environmental modifications to change, or interrupt, undesirable behaviors.
•
Reinforcement of desirable behaviors.
•
Uses basic tenets of operant and classical conditioning.
Retrieved from
http://www.mhid.org/uploads/assets/16/EAMHID_Practice_Guideline_Assessment_and_Diagnosis_of_Mental_Disorders_in_People_with_IDD_Deb_et_al.__2001.p
df
17
Commonalities that Should Occur in all Therapies
Regardless of theoretical orientation, all treatment should begin with
a comprehensive assessment (symptoms; functional impairment;
history; ethnic and cultural background; cognitive impairment;
learning disabilities; suicide risk; and homicidal ideation).
The therapeutic relationship, or working alliance, is also very
important to the change process and should be evident in all
theoretical orientations.
The lower the cognitive functioning of the individual, the more
behaviorally oriented the intervention should be.
18
Behavioral Treatment for Depression
Behavior modification is the method of changing the way a person reacts
either physically or mentally to a given stimulus.
By using this technique, undesirable behavior can be exchanged with more
appropriate behaviors that can be substituted into the behavioral repertoire of the
individual.
Behavior modification techniques (operant conditioning) include:
– Thorndike Principle.
• Behaviors followed by a satisfying consequence are repeated.
– Shaping.
• Reinforcement for approximations of the desired behavior.
• Generalization of these new skills is likely the next step in treatment.
– Contingency management.
– Reinforcement of desired behavior.
• Given rewards, such as verbal praise, for behavior that is inconsistent with depression.
Retrieved from http://operationmeditation.com/discover/8-useful-behavior-modification-techniques-for-adults/
19
Behavioral Treatment for Depression
Example of Behavioral Therapy in the treatment of depression
• Behavior Therapy postulates that depression can result from a stressor which disrupts
normal behavior patterns causing a low rate of response contingent positive
reinforcement. The rate of reinforcement is functionally related to the availability of
reinforcing events, personal skills to act on the environment, or the impact of certain
types of events.
• If an individual cannot reverse the negative balance of reinforcement, a heightened state
of self-awareness will follow that can lead to self-criticism and behavioral withdrawal.
• The resulting behavioral therapy involves helping patients increase the frequency and
quality of pleasant activities.
• It has been found that depressed people have low rates of pleasant activities and
obtained pleasure.
• Research suggests that depressed individuals experience moodiness in response to both
pleasant and aversive activities (as compared to the general population).
• It is hypothesized that depressed individuals lack social skills, at least during the
depressed phase, and this negative view contributes to the depression.
20
Behavioral Treatment for Depression
Treatment consists of:
• Psychoeducation
• Introducing techniques and strategies to cope with the problems that are assumed to be
related to the depressive episode
• Improving social skills
• Addressing depressogenic thinking
• Increasing pleasant activities
• Relaxation training
• Reinforcement at various success points
• Education regarding basic communication, negotiation, and conflict-resolution skills
All of the above techniques are modified, as needed, in order to “meet” the individual at
the emotional and cognitive level that was noted during the initial (comprehensive)
assessment
Antonuccio, D.O. (1998). The coping with depression course: A behavioral treatment for depression. The Clinical Psychologist, 51 (3), 3-5
21
Behavioral Techniques Useful When Treating Depression
Techniques for treating depression include:
• Mood logs.
• Self-statements.
• Social skills training.
• Frequent reinforcement for desirable behaviors.
• Differential reinforcement of other behavior.
– Positive reinforcement when the person has not made the typical
(or undesired response).
22
Modified Daily Mood Log
Sad Thoughts
Happy Thoughts
Nobody likes me.
I guess when I think about it, there
may be some people who do like me.
(List friends.)
I don’t have any friends.
I’m fat and ugly.
Other people say these things are
nice about me:
• My hair and eyes are nice.
• I’m pretty when I smile.
• I have a great personality.
23
Behavioral Treatments of Anxiety Disorders
In general, anxiety disorders are best treated with a combination
of medication and behavioral therapy.
Behavioral techniques shown to be effective in the treatment
of anxiety disorders:
– Exposure-based behavioral therapy is the treatment of choice, and has been
used for many years to treat anxiety, specific phobias, and response to trauma.
Techniques include:
– Collaboratively developing an hierarchy that outlines the least
to most fearful situations.
Retrieved from http://www.nimh.nih.gov/health/publications/anxiety-disorders/index.shtml#pub7
24
Behavioral Treatments of Anxiety Disorders
Techniques continued
•
Collaboratively developing an exposure plan, clearly stating how the stimuli will be
presented.
•
Depending on the level of impairment, exposure may occur in-vivo, by showing a
picture of the fear-inducing scenario or object, or other less threatening methods.
•
At this same time, a competing response is introduced and practiced during
therapy sessions with the person.
•
This response is one that is incompatible with the anxiety response.
•
Relaxation
•
Evoking relaxing or soothing images.
•
The entire process of exposure and response prevention is called systematic
desensitization.
•
This technique would be quite amendable to people of differing cognitive abilities.
Retrieved from http://www.nimh.nih.gov/health/publications/anxiety-disorders/index.shtml#pub7
25
Behavioral Treatment for Obsessive Compulsive Disorder
As is true with other anxiety disorders, OCD is often best treated
with a combination of medication and behavioral therapy.
People with obsessive-compulsive disorder (OCD) have persistent,
upsetting thoughts (obsessions) and use rituals (compulsions) to
control the anxiety these thoughts produce.
– Most of the time, the rituals end up controlling daily routines and significant
amounts of time are spent engaging in ritualistic behaviors.
Retrieved from http://www.nimh.nih.gov/health/publications/anxiety-disorders/index.shtml#pub7
26
Behavioral Treatment for Obsessive Compulsive Disorder
Therapeutic techniques would also be similar to other anxiety
disorders, and include:
– Exposure and response prevention.
– Most types of exposure therapy.
– Introducing competing responses.
All of these techniques would be amendable to people
with cognitive limitations.
Retrieved from http://www.nimh.nih.gov/health/publications/anxiety-disorders/index.shtml#pub7
27
The Use of CBT with the IDD Population
There are some indications that the use of cognitive-behavioral
approaches for people with intellectual disabilities is becoming
more widely accepted.
Lindsay (1999) showed that although some procedures may need to
be adapted and simplified, people with intellectual disabilities and a
variety of behavioral health problems can benefit from interventions
that retain all the key elements of cognitive behavioral therapy.
Retrieved from http://nrl.northumbria.ac.uk/1124/1/CBT%20for%20People%20with%20Intellectual%20Disabilities.pdf
28
The Use of CBT with the IDD Population
Several studies have shown that people with intellectual disabilities
(ID) have suitable skills to actively participate in cognitive behavioral
therapy (CBT).
Case studies have reported the successful use of CBT techniques
(with adaptations) when treating people with ID.
Modified CBT may be a feasible and effective approach for the
treatment of depression, anxiety and other mood disorders in
people with cognitive or other limitations.
Retrieved from dhs.sd.gov/ddc/documents/CognitiveBehaviorTherapy.pdf
29
The Use of CBT with the IDD Population
To date, two studies have reported successful group-based
manualized cognitive behavioral treatment programs for depression
in people with mild ID.
– Currently, there is not a widely accepted manualized program for anxiety
or depression for people impacted by an intellectual impairment.
– Most researchers (e.g., Hatton, 2002) conclude that CBT-based treatments,
appropriately modified, may be a feasible intervention option for people
impacted by an intellectual disability.
Retrieved from dhs.sd.gov/ddc/documents/CognitiveBehaviorTherapy.pdf
30
The Use of CBT with the IDD Population
Current research teams are providing empirical support, published
in a multitude of journals, noting that practitioners are beginning to
offer CBT interventions routinely to people with intellectual
disabilities who are also experiencing emotional problems.
While the evidence base is still limited, researchers continue to offer
meaningful contributions to the literature base regarding treatment
of this population.
– For most individuals this includes a modified version of CBT.
Retrieved from dhs.sd.gov/ddc/documents/CognitiveBehaviorTherapy.pdf
31
The Use of CBT with the IDD Population
Behaviors that have the most robust support and response
to CBT interventions include:
– Self-management approaches.
– Emotional labelling.
– Recognition of the mediating role of cognitions.
– Understanding the mediating role of cognitions.
Retrieved from dhs.sd.gov/ddc/documents/CognitiveBehaviorTherapy.pdf
32
The Use of CBT with the IDD Population
Willner (2005) found CBT interventions utilizing cognitive-skills
training show promising results.
These include:
– Self-management.
– Self-monitoring.
– Self instruction and training.
Retrieved from http://nrl.northumbria.ac.uk/1124/1/CBT%20for%20People%20with%20Intellectual%20Disabilities.pdf
33
Borderline Personality Disorder
Marcia Linehan is the primary authority in treating individuals
diagnosed with borderline personality disorder.
– Linehan’s intervention, dialectical behavior therapy (DBT), is a type of therapy
that balances therapeutic validation and acceptance of the person.
– (DBT) is closely aligned with cognitive and behavioral change strategies.
Lew, M., Matta, C., Tripp-Tebo, C., & Watts, D. (2006). Dialectical Behavioral Therapy with Individuals with Intellectual Disabilities 9(1), 1 – 13.
34
Borderline Personality Disorder
The emphasis of the DBT model is on teaching the individual to:
– Modulate extreme emotions and reduce negative behaviors
that result from those emotions.
– Trust his or her own emotions, thoughts and behaviors.
These goals are accomplished through multiple treatment
modalities (i.e., individual therapy, skills training, coaching and
environmental interventions).
Lew, M., Matta, C., Tripp-Tebo, C., & Watts, D. (2006). Dialectical Behavioral Therapy with Individuals with Intellectual Disabilities 9(1), 1 – 13.
35
Borderline Personality Disorder
DBT can be modified in the following ways when working
with an IDD population:
– Reduce the use of metaphors and acronyms that are peppered
throughout the manual.
– Allow more time for problem solving and skill acquisition.
Accept that people with borderline personality disorder
and IDD are extremely challenging, even to seasoned clinicians.
Lew, M., Matta, C., Tripp-Tebo, C., & Watts, D. (2006). Dialectical Behavioral Therapy with Individuals with Intellectual Disabilities 9(1), 1 – 13.
36
Borderline Personality Disorder
Multiple repetitions may be necessary to ensure
understanding of lessons.
Readiness to participate in group sessions should be carefully
assessed by the interdisciplinary team.
Participants may show initial, and sometimes protracted,
regression prior to demonstrating treatment progress.
– It is hypothesized that due to the complexity of the DBT program, some of the
dually diagnosed participants took longer to learn the program, internalize the
coping and self-management skills, and to become their own coach.
The researchers concluded DBT has significant potential to meet
the behavioral health needs of people impacted with an IDD.
Lew, M., Matta, C., Tripp-Tebo, C., & Watts, D. (2006). Dialectical Behavioral Therapy with Individuals with Intellectual Disabilities 9(1), 1 – 13.
37
AACAP Work Group Commentary (1999)
• Some clinicians target symptom suppression without
regard for habilitative functioning.
• Informed consent is often overlooked.
• Medication often is not integrated as part of comprehensive
treatment plans.
• Medications often don’t match diagnosis.
• Polypharmacy is overused.
• There is often no active monitoring for side effects.
38
Outcomes
• Patients served — 207.
• Served inpatient — 184.
• Served outpatient — 60.
• Outpatient only — 23.
• Inpatient only — 123.
• Both inpatient and outpatient — 37.
39
Outcomes
• Male - 56%
• Female - 44%
• Mean age at admission - 15
• At admission 50% state custody
40
Diagnosis
• MR - 75%
• Autism, PDD, LD, or met federal definition of DD - 25%
• Autism or a PDD - 14%
• Mood disorder - 35%
• Anxiety disorder with PTSD - 25%
• ADHD - 23%
• Thought disorder - 4%
41
Level of care
Initial (177)
Current (131)
Supported/IND
6 (3%)
27 (21%)
Parent/family
86 (49%)
51 (39%)
Foster family
25 (14%)
5 (4%)
Group home
34 (19%)
21 (16%)
Residential
6 (3%)
6 (5%)
Hospital
6 (3%)
5 (4%)
Detention
3 (2%)
4 (3%)
ICF-MR
7 (4%)
11 (8%)
Eloped
4 (2%)
0
Deceased
0
1 (1%)
42
Outcomes
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
43
Juvenile Justice Involvement in DNP Youth
147 inpatients
Pre-treatment
Post-treatment
Legal involvement
57%
36%
Arrests
46%
26%
44
Mental Health Treatment can Reduce Arrest Rates in this Population
Post treatment
90%
of these youth had either no
jail time or jail time less than
30 days.
45
Lessons Learned
• These youth are at risk for substance abuse and dependence.
They need specialized services.
• These youth are at risk of entering the juvenile justice system and
adult corrections.
• These youth are institutionalized as adults.
• Failure to meet the needs of these youth is the most costly
mistake that policymakers at both the state and federal level
make.
46
This Presentation may present links to other Internet web
sites for the convenience of users in locating information
and services that may be of interest. These sites are
maintained by organizations over which PerformCare
exercises no control, and PerformCare expressly disclaims
any responsibility for the content, the accuracy of the
information and/or quality of products or services provided
by or advertised on these third-party sites. PerformCare
does not control, endorse, promote, or have any affiliation
with any other web site unless expressly stated herein.
47
48