APNA 25th Annual Conference

October 19, 2011 - Session 1046

Psychopharmacology, Recovery, and Trauma--Informed Care: Opportunities, Trauma Challenges, and Pitfalls Mary Ann Nihart, Nihart, MA, RN, PMHNPPMHNP-BC, PMHCNS PMHCNS--BC Nurse Manager, San Francisco Veterans Administration Medical Center Clinical Faculty, University of California, Davis

Objectives  Identify key principles of recovery as they relate to prescriptive practice.  Explain how common prescriber behaviors conflict with recovery principles.  Utilize methods for implementing recovery principles in prescriptive practice.

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Disclosures  This presenter has no financial relationship or interest in any product discussed in this presentation.  Any incidental mention of off label uses of medication will be identified as “off label” during the lecture. Discussion of specific medication uses is not the primary focus of this presentation. 3

Case Study: “Sara Sara” ”  21 y/o mother of a toddler toddler, living with 2 female roommates attending college in criminal justice and plans on attending law school  Presentation  Wants help concentrating at school, states she is having problems with sleeping and focusing

 Symptoms    

Waking frequently during the night, sometimes can not return to sleep Complains of less energy and enjoyment Feels irritable and “moody” – “I get mad for no reason.” Feels edgy, jumpy, and nervous. C/o racing thoughts and difficulty concentrating 4

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Quick show of hands  How Ho man many people ssuspect spect Sara has      

Bipolar spectrum disorder? Borderline Personality disorder? PTSD? Major Depression? All of the above? Other Diagnosis?

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“Sara Sara” ” continued  History  Spent most of her teens in foster placement and group homes, where she cut herself, ran away, and got into fights  Has been told in the past that she is bipolar and received “a lot” of medication in group homes  When she “aged out” at 18, she stopped all of her meds  Reports “taking up” with a guy she knew, getting pregnant and then feeling like she had no life - “CYC CYC (California Youth Connection) saved my life” life”  She was able to live in a home for single mothers, received her GED and received grants for college ad has been doing well in school  She lives with other women she has met through CYC who help her care for her child 6

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Quick show of hands  How Ho man many people ssuspect spect Sara has      

Bipolar spectrum disorder? Borderline Personality disorder? PTSD? Major Depression? All of the above? Other Diagnosis?

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Discussion  Why is the Diagnosis important?  What happened to Sara?  Would what happened to Sara make the diagnosis difficult or unclear?  Any thoughts about all the medications?  Did Sara’s past treatment help her Recovery?  How would you implement Recovery Principles in response to Sara’s current concerns? 8

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Major Depression

Borderline Personality Disorder

Psychosis

Generalized Anxiety or Panic Disorder

PTSD Impulse Control Disorder or Antisocial

Primary Insomnia

Bipolar Disorder 9

Psychiatric Medication Use on the Rise  73% increase in prescriptions for adults from 1996 to 2006  50% increase in same time period for children  Researchers site increase availability of insurance for psych h meds, d and d  More drugs to treat more psychiatric disorders News Editor, P. (2009). Psychiatric drug use on the rise. Psych Central. Retrieved on October 3, 2011, from http://psychcentral.com/news/2009/05/05/psychiatric-drug-use-on-the-rise/5709.html 10

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Rise in Prescription of Antidepressants  Examined the records of 233,144 adults seen in primary practice office from 1996 to 2007  9.3% of the visits led to prescription of an antidepressant  3rd most commonly prescribed class of medications  3/4ths of the antidepressants prescribed by primary care

Percent of Prescribed without Psychiatric Diagnosis 80 60 40

72.7 72 7

59.5

20 0 1996

2007

Mojtabai & Olfson (2011). Health Affairs, 30, 1434-42 11

Rise in Prescription of Antipsychotics  Stanford researchers found that antipsychotic prescriptions nearly tripled from 1995 to 2008  1 generation antipsychotic use decreased from 5.2 million to 1 million  In 2008, 54% of surveyed prescriptions had i ti h d uncertain t i evidence  $6 billion spent in 2008 on off off-label uses with $5.4 billion with uncertain evidence.

30 25

Off Label Uses (millions)

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Total Prescriptions (millions)

10 5 0 1995

2008

Stanford University Medical Center (2011, January 7). ScienceDaily. Retrieved October 3, 12 /releases/2011/01/110107094900.htm 2011, from http://www.sciencedaily.com-

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Consumer Comments about Medications  “The worst bout of them overdoing it on medication l d me to be led b crawling li around d lik like an animal i l on the h hospital floor”  “I was toxic. I couldn’t walk, couldn’t control my legs, couldn’t see – other than the hallucinations”  “When I was on this stuff my IQ just crashed and burned. …having tremendous difficulty with relatively simple tasks tasks. …my my creative stuff went down hill, which is part of the wholeness of who I am”  “I am Buddhist, I love to meditate. When I told the doctor I could not sit still and my legs just keep moving, he thought I would adjust. I didn’t and I never went back.” 13

Consumer comments continued…  “One One time my arms got stiff and my eyes rolled up. up I couldn’t couldn t talk. I didn’t know what was going on. I was so scared. After a couple of hours they gave me a shot and I was okay, but I still don’t know what happened. I think they were just experimenting. I’ve learned to avoid the police so they won’t take me back there.”  “I gained so much weight, I can’t stand myself. The voices are l less and d my thi thinking ki iis b better tt b butt now I h have tto ttake k d drugs ffor my high cholesterol and blood pressure. I feel defeated.”  “I look in the mirror and I do not know who the person is in there. I don’t recognize her. I told my doc that I feel better but I can not stand the weight gain. He said better weight gain than being suicidal. I am not so sure.” 14

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Consumer comments continued…  “After After about a month on Wellbutrin Wellbutrin,, I felt like I was jumping out of my skin. Everything was all mixed up. I had no idea I was yelling at people until a good friend told me. I stopped that drug and never went back to a doctor.”  “ I felt a huge weight on my shoulders. I couldn’t sleep. I was worrying my way through the night. I wanted to talk t lk tto some b body. d My M insurance i company sentt me to t 3 different psychiatrists who all wanted me to take medications. I finally gave up and took them. It has been a few months and I am sleeping, but I still want to just talk with someone.” 15

Consumer Response

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Adherence to Medication Treatment  Average nonnon-adherence rates 50%  CATIE study demonstrated nonnon-adherence rates of 80 to 85% in schizophrenia  Reasons for nonnon-adherence:  Feeling their prescribe was not listening to their concerns  Opposition to the idea of medications  Feeling that medications did not work  Unrealistic expectations

 Side effects 17

Trauma

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

What is Trauma?  Traumatic event - one in which “aa person experienced, witnessed or was confronted with an event(s) that involved actual or threatened death or serious injury or threat to the physical integrity of self or others”  The person person’ss response involved intense fear, helplessness or horror DSM--IV DSM IV--TR (APA, 2000)

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Exposure to Trauma General Population

 Until U il recently, l trauma exposure was thought h h to be unilaterally rare (combat violence, disaster trauma)  Recent research has changed this. Studies done in the last decade indicate that trauma exposure is common even in the middle class  56% of an adult sample reported at least one (Kessler et al., 1995) event 20

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Exposure to Trauma

Mental Health Population  90% off public bli mentall h health l h clients li h have b been exposed d (Muesar et al., 2004; Muesar et al., 1998)

 Most have multiple experiences of trauma  34 34--53% report childhood sexual or physical abuse ((Kessler et al., 1995; MHA NY & NYOMH 1995))

 43 43--81% report some type of victimization

(Ibid)

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Adverse Childhood Events (ACE) Study

Only 34.5% of women and 38% of men had no history of childhood trauma Adapted from http://www.cdc.gov/ace/prevalence.htm 22

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Trauma and Medications  Force or coercion are rere-traumatizing  Involuntary medications carry the largest risk  Problem Prescriber Behavior  If you don’t…  “I can’t see you as a patient”  “I will have to hospitalize you”  “I am not responsible for what might happen”

 “I was angry and yes I raised my voice, but does that mean three big guys should grab me, take me to an empty room, hold me down on a dirty mat, and shove a needle in me. I cried for an hour on that cold mat. I had been raped once again.” 23

Recovery and Trauma--Informed Care Trauma

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Defining Recovery “Recovery is rediscovering meaning and purpose after f a series i off catastrophic hi events which hi h mentall illness is. It is a process, a way of life, an attitude, and a way of approaching the day’s challenges. It is not a perfectly linear process. At times our course is erratic and we falter, slide back, regroup and start again. . . .The need is to meet the challenge of the disability and to reestablish a new and valued sense of integrit integrity and purpose within and beyond be ond the limits of the disability; the aspiration is to live, work, and love in a community in which one makes a significant contribution.” contribution.” Patricia Deegan is a psychologist and ex ex--patient who is now director of training at the National Empowerment 25 Center in Lawrence, Massachusetts.

Defining Recovery " Recovery is a deeply personal, personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness. illness "

26 of the Boston Center for Psychiatric Rehabilitation (1993) William Anthony, Director

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Defining Recovery Recovery refers to the process in which people are able to live, work, learn, and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete remission of symptoms. symptoms Science has shown that having hope plays an integral role in an individual’s recovery. Achieving the Promise: Transforming Mental Health Care in America. 27 The President’s New Freedom Commission Report on Mental Health

SAMSHA 10 Fundamentals of Recovery  Self S Selflf- Direction Di ti

 Strengths St Strengthsth -based b d

 Individualized & Person--Centered Person

 Peer Support  Respect

p  Empowerment

 Responsibility

 Holistic

 Hope

 Non Non--linear 28

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Trauma--Informed Care Trauma  Recognizes the frequency of trauma histories among the individuals served  Uses interventions based on current literatures  Is informed by research and effectiveness of practice  Understands that coercive interventions cause traumatization and re re--traumatization and are to be avoided  Based on respect for all individuals served  Operates on the belief that individuals served are more important than rules 29

Applying the Principles to Practice

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Role of Medication in Recovery  Recovery is a unique, unique individual process, process the role of medication is different for each person  A tool to achieve personal recovery goals  A way to achieve stability to use other tools of recovery  Medications can interfere with recovery through untoward effects  Adverse effects can be worse than the problem they intended to relieve  Need a balanced view of benefits and costs 31

Relationship with Mental Health Provider  Being listened to and understood  Choice, including access to alternative treatments and therapies  Feeling part of the decisiondecision-making process  Having access to reliable information  Being supported in making their own choices  Careful monitoring of medication  Trust

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

What all Nurses Can Do  Be aware many persons served do not feel able to be honest about their experience of medication because they fear the consequences  Give the message that people can take control of their medication use  Share recovery stories from people who have reduced medication or used it in a targeted way

 Explore people’s experiences taking medication  Take their concerns seriously and explore ways to address them 33

What all Nurses Can Do (continued)

 Explored preferred way of understanding their challenges and how medications fit  Discuss how medications support their recovery goals, e.g., feeling calmer, improved sleep, etc.  Support people in getting and understanding adequate information  Encourage a range of sources, such as personal accounts, results of research, and manufacturer’s information  Support understanding limitations and biases to all sources of knowledge 34

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

What all Nurses Can Do (continued)

 Support connections with peers around their experiences with medication  Support people to access expertise in medication so they have an opportunity to talk  Workers might share their own experience with medication, briefly y with focus on the p person served

 Support people to prepare for meetings with prescribers  Identify concerns and questions in advance 35

What Prescribers Can Do  Adopt a shared decision making approach to prescribing  Make people aware of all the options available including costs and benefits

 Give people an opportunity to think about options and ask questions, possibly over several meetings  Respect the person’s choices  Be clear about the circumstances under which it will no longer be possible to respect their choices

 Treat people’s choice to stop medication or change dose as an experiment  Introduce a simple measuring scale or developing on with the person to track their experience over time. 36

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Prepare for When the Person Can Not Make Choices for Themselves  Develop Advanced Directives, develop a WRAP plan, develop a Crisis Plan include de de--escalation preferences  Communication and record the plan

 Even when having difficulty they should be involved in making choices  Support to understand concerns, give information about options, ask what they find helpful, involve in choice

 Find someone who can act as an advocate  Following the crisis, discuss the action taken with the person and how this can inform how they use medication and manage crisis in the future 37

Informed Consent  To give “Informed Informed Consent” Consent a person must have:  Explanation of diagnosis/prognosis with and without medications  Information on proposed medications, purpose, methods, dosage, side effects, and benefits  How to manage the side effects  Adverse Ad effects ff t including i l di Tardive T di Dyskinesia D ki i  Interactions with other medications  Information on alternative treatments and nontreatment,, including risks, benefits, side effects nontreatment 38

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Best Practice in Prescribing  Listen mindfully  Make sure the diagnosis is accurate and don’t be afraid to change  Discuss possible side effects in as open and complete manner as possible; then discuss them again…and i d again; i answer any and d all ll questions ti  Increase trust and a strong therapeutic relationship  Make sure to discuss alternatives to medications 39

T l ffor D Tools Developing l i Recovery Oriented Practice

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Agency for Healthcare Research and Quality (AHRQ)

http://www.effectivehealthcare.ahrq.gov/index.cfm/what-is-the-effective-health-care-program1/ 41

WRAP Planning Key Elements  Wellness Toolbox  Daily Maintenance Plan  Identifying Triggers and an Action Plan  Identifying Early Warning Signs and an Action Plan  Identifying When Things Are Breaking Down and an Action Plan  Crisis Planning  Post Crisis Planning.

http://www.mentalhealthrecovery.com/wrap/ 42

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Wellness Toolbox Examples              

eat three healthy meals per day t k a nap take exercise stretch watch my fish play with my dog write in a journal make my bed do something g nice for someone else watch a video listen to music see my counselor ask for a medication check make music 43

Programs for Improving Medication Adherence

www.AdultMeducation.com

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

NMHA resources  Consumer information for preparing for office visit  Medication checklists for monitoring side effects  Help paying for prescriptions http://www.mentalhealthamerica.net/go/help/ho w-to to--pay pay--for for--treatment/prescription treatment/prescription--assistance assistance-programs  Contact information for Major Pharmaceutical companies http://www.nmha.org/go/med_info 45

A program to encourage consumers to develop a collaborative relationship with their provider

From the National Mental Health Association

www.nmha.org

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

Pfizer Settlement:

$21 million Consumer and Prescriber Education Program

administered by a special committee of the State Attorneys General pursuant to the Oregon Court Order

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

CommonGround  A web based application to help individuals prepare for their visit with their mental health prescriber and arrive at a shared, supported and best decisions for their treatment and recovery  Developed by Patricia Deegan and Associates  http://www.patdeegan.com/commonground htt // td / d

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Clinical Examples of Application

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

A Final Hope Story The human body experiences a powerful gravitational pull in the direction of hope. That is why the patient's hopes are the physician's secret weapon. They are the hidden ingredients in any prescription. i i - Norman N C Cousins i

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References  Canady, y, V. ((2011). ) Involuntary y medication and mental health recovery: y are they incompatible? Mental Health Weekly, Aug. 22, 22, downloaded Sept. 5, 2011, http://www.mentalhealthweeklynews.com/sample--articles/involuntaryhttp://www.mentalhealthweeklynews.com/sample articles/involuntarymedication--mental medication mental--healthhealth-recovery. recovery.aspx aspx  Curtis, L. C., Wells, S. M., Penney, D. J., Ghose, Ghose, S. S., Mistler Mistler,, L. A., Mahone Mahone,, I. H., Delphin Delphin--Rittmon Rittmon,, M., del Vecchio ,P. & Lesko Lesko,, S. (2010). Pushing the envelope: shared decision making in mental health. Psychiatric Rehabilitation Journal, 34, 14 14--22.  Deegan, Deegan, P.E. P E (2010). (2010) A description of a web application to support shared decision making. making. Psychiatric Rehabilitation Journal, 34, 34, 2323-8  Drake, R.E., Deegan Deegan,, P.E., & Rapp, C. (2010). The promise of shared decision making in mental health. Psychiatric Rehabilitation Journal Journal,, 34 34,, 77-13.  Deegan, Deegan, P.E., Rapp, C., Holter Holter,, M., Riefer Riefer,, M. (2008). A program to support shared decision making in an outpatient psychiatric medication clinic. Psychiatric Services, 59, 59, 603603-605. 52

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APNA 25th Annual Conference

October 19, 2011 - Session 1046

References (continued)  Drake, R R.E., E , Deegan Deegan,, P.E., P E , Woltmann Woltmann,, E E.,, Haslett, W W.,, Drake, T T.,, & Rapp, C. (2010). Comprehensive electronic decision support systems. Psychiatric Services, 61, 61, 714– 714–717.  Hamera, Hamera, E., Pallikkathayil Pallikkathayil,, L., Baker, D., & White, D. (2010). Descriptive study of shared decision making about lifestyle modifications with individuals who have psychiatric disabilities. Journal of the American Psychiatric Nurses Association, 16, 16, 280--287 280  Mojtabai, Mojtabai, R. & Olfson Olfson,, M. (2011). Proportion of antidepressants prescribed without a psychiatric diagnosis is growing. Health Affairs, 30, 30, 14341434-1442 doi: doi: 10.1377/hlthaff.2010.1024  Jacobson, N, & Greenley, Greenley, D. (2001). What is recovery? A conceptual model and explication. Psychiatric Services, 52, 482 482--485. 53

References (continued) 

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Kreyenbuhl J, Nossel IR, Dixon LB (2009). Disengagement ffrom rom mental health treatment among individuals di id l with schizophrenia hi h i and d strategies t t i for f facilitating f ilit ti connections ti to t care care:: a review of the literature. literature. Schizophrenia Bulletin, 35 35,, 696696-703. Lysaker,, P. H. & Buck, K.D. (2008). Is recovery from schizophrenia possible? An Lysaker overview of concepts, evidence, and clinical implications. Primary Psychiatry, 15, 15, 60 60--65. News Editor, P. (2009). Psychiatric drug use on the rise. rise. Psych Central. Central. Retrieved on October 3, 2011, from http://psychcentral.com/news/2009/05/05/psychiatrichttp://psychcentral.com/news/2009/05/05/psychiatric-drug drug-use--on use on--the the--rise/5709. rise/5709.html html Ptasznik,, A (2011). The person in Personal Medicine: Moving consumers from Ptasznik periphery to centre of decision making. making. Journal of Addiction and Mental Health, Spring, 14, 14, 3. Stanford University Medical Center (2011, January 7). Evidence lacking for widespread use of costly antipsychotic drugs, study suggests. ScienceDaily ScienceDaily.. Retrieved October 3, 2011, from http://www.sciencedaily.com http://www.sciencedaily.com-- /releases/2011/01/110107094900.htm /releases/2011/01/110107094900.htm Torrey, W. C., Drake, R. E. (2010). Practicing shared decision making in the outpatient psychiatric care of adults with severe mental illnesses: redesigning care for the future. Community Mental Health Journal, 46, 46, 433433-40. 54

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