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RESPECT-Mil

V. September 2007

Recognition and Management of Depression & Post-

Traumatic Stress Disorder(Review & PTSD)

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Today’s Learning Objectives Use of PTSD Symptom Checklist (PCL) Diagnostic process including suicide

assessment Understand new resources for primary

care RESPECT-Mil Care Facilitator (RCF) RCF Supervision Process Informal Behavioral Health Consultations

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Overview of Three Component Model Care Process Screening as a routine Assessing screen positives For those with a potential diagnosis

Assess suicide risk Relevant history Share diagnosis with Soldier

Use new resources Tools Care facilitation Informal psychiatric advice

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Three Component Model (3CM)

PREPARED PRACTICE

PSYCHIATRIST

PATIENTCARE FACILITATOR

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PTSD

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PTSD Diagnostic Concept Traumatic experience

Threat of death/serious injury Intense fear, helplessness or horror

Symptoms Reexperiencing the trauma Numbing & avoidance Physiologic arousal

Impaired functioning Persistence

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PTSD DiagnosisIntrusion or ‘Reexperiencing’ Symptoms

Need one (1) or more:

Intrusion of disturbing Memories or Images; Nightmares; Flashbacks

Reminders of trauma resulting in upset feelings; physical reactions

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PTSD Diagnosis‘Numbing/Avoidance’ Symptoms Need three (3) or more:

Avoidance of trauma reminders (thoughts or feelings or talking; activities or situations; memories)

Numbing of responsiveness (loss of interest; detached; reduced affect; future cut short)

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PTSD Diagnosis‘Arousal’ Symptoms Need two (2) or more:

‘Keyed up’ (anger; insomnia)Difficulty concentratingHyper-vigilance; easily startled

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PTSD DiagnosisImpairment & Duration Impairment functioning

Social Psychological Occupational

Persistent (one month)

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Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month,you…

1. Have had nightmares about it or thought about it when you did not want to? …………….....Yes No

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? …………………………………………………………......Yes No

3. Were constantly on guard, watchful, or easily startled? …………………………………….…………......Yes No

4. Felt numb or detached from others, activities, or your surroundings? ………………………….....Yes No

If YES to two or more proceeds to further assessment

From MEDCOM Form 774

RESPECT-Mil Routine Office Visit Screening Form

Handout #1

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INTRUSION1. Images, thoughts2. Nightmares3. Sudden re-experience4. Upset at reminders5. Physical reactionsAVOIDANCE6. Avoid thinking/talking7. Avoid situations8. Memory loss of event9. Loss of interest10. Distant, cut-off11. Emotionally numb12. Future cut short AROUSAL13. Insomnia14. Outbursts15. Low concentration16. Watchful on guard17. Easily Startled

The PTSD Checklist (PCL) Not A little Moderately Quite Extremely at all bit a bit 0 1 2 3 4

Handout #2

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Confirm Diagnosis

Focused History Questions: Suicidal ideation; Symptoms (intrusion, avoidance, arousal); past PTSD,substance use

Document: For continuity of care/handoff

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Establishing RapportKey Issues Mistrust & uncertainty

Frequent self-blame

Sense of isolation (“no one can understand”)

Trauma discussion is distressing

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Establishing RapportHow to Do It Acknowledge difficulties

Avoid judgment – “I’m sorry this happened to you…you definitely didn’t deserve this.”

Address symptoms & circumstances (Don’t talk about the trauma)

Seek continuity among providers

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Case Example - PVT Andrews Part 1 Scoring PCL

Illustrate efficient suicide evaluation

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Not A little Moder- Quite Extremely at all bit ately a bit 0 1 2 3 4

PCL

1. Repeated, disturbing memories, thoughts, or images of a stressful experience?

2. Repeated, disturbed dreams of a stressful experience from the past?

3. Suddenly acting or feeling as if a stressful experience were happening again?

4. Feeling very upset when something reminded you of a stressful experience?

5. Having physical reactions (e.g. heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience from the past?

INTRUSION need 1 or more

Handout #3

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Not A little Moder- Quite Extreme- at all bit ately a bit ly 0 1 2 3 4

PCL

6. Avoid thinking or talking about a stressful experience or avoid having feelings related to it?

7. Avoid activities or situations because they remind you of a stressful experience?

8. Trouble remembering important parts of a stressful experience?

9. Loss of interest in things you used to enjoy?

10. Feeling distant or cut off from other people?

11. Feeling emotionally numb or being unable to have loving feelings for those close to you?

12. Feeling as if your future will somehow be cut short?

AVOIDANCE &/orNUMBING (need 3 or more)

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Not A little Moder- Quite Extreme- at all bit ately a bit ly 0 1 2 3 4

PCL

13. Trouble falling or staying asleep?

14. Feeling irritable or angry outbursts?

15. Having difficulty concentrating?

16. Being “super alert” or watchful on guard?

17. Feeling jumpy or easily startled?

AROUSAL (need 2 or more)

18. How difficulty have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult Somewhat Very difficult Extremely at all difficult difficult

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INTRUSION1. Images, thoughts2. Nightmares3. Sudden re-experience4. Upset at reminders5. Physical reactionsAVOIDANCE6. Avoid thinking/talking7. Avoid situations8. Memory loss of event9. Loss of interest10. Distant, cut-off11. Emotionally numb12. Future cut short AROUSAL13. Insomnia14. Outbursts15. Low concentration16. Watchful on guard17. Easily Startled

Scoring the PCL Not A little Moderately Quite Extremely at all bit a bit 0 1 2 3 4

Subtotals: a x 0 b x 1 c x 2 d x 3 e x 4TOTAL: A + B + C + D + E

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INTRUSION1. Images, thoughts2. Nightmares3. Sudden re-experience4. Upset at reminders5. Physical reactionsAVOIDANCE6. Avoid thinking/talking7. Avoid situations8. Memory loss of event9. Loss of interest10. Distant, cut-off11. Emotionally numb12. Future cut short AROUSAL13. Insomnia14. Outbursts15. Low concentration16. Watchful on guard17. Easily Startled

0 + 2 + 0 + 9 + 24 = 35

Scoring the PCL Not A little Moderately Quite Extremely at all bit a bit 0 1 2 3 4

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Diagnosis & Initial Treatment Presumptive diagnosis at a glance ≥ six

symptoms ≥ moderate severity ≥ 1 month, functional impairment: ≥ 1 Intrusion/Re-experience ≥ 3 Avoidance/Numbing ≥ 2 Arousal

Score 13 to 32 = mild or subthreshold Patient Choice: Active Rx vs. Education & watchful waiting

Score ≥ 33 = moderate to severe Push harder for initial active treatment

Handout #4

& we’ll use Severity Score for Treatment Response Monitoring…

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1. Have these symptoms/feelings we’ve been talking about led you to believe that you would be better off dead?

NO YES

2. This past week, have you had any thoughts that life is not worth living or that you would be better off dead?

NO YES

3. What about thoughts of hurting or even killing yourself?

NO YES

4. What have you thought about? Do you have a plan or have you actually tried to hurt your self?

NO YES5. RISK FACTORS:

History of suicide attempt Substance abuse Significant comorbid anxiety Social isolation Hopelessness

Evaluation of Suicide Risk (Question 19)

Handout #5

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Evaluation of Suicide Risk

No current thoughts or risks Low Risk Follow & monitor

Current thoughts, no plans

(Questions 2&3=yes 4=no; few risk factors)

Intermediate Risk

F/U each visit;

Pt to call if change;

Consult Mental Health Professional (MHP)

Current thoughts & plans

(Question 4=yes; several risk factors)

High RiskEmergency (now) MHP

Urgent (48hr) MHP if social support & self control present, no risk factors

Handout #5

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Case Example - PVT. Andrews Part 2Role Play to demonstrate:

Using the PCL & focused questions to make and present a diagnosis Establish rapport Mention support from PCL Put in context (“we see this often in people with similar

experiences”) Describe in terms of changes in the brain

Illustrate efficient suicide evaluation

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Next, PTSD Treatment:Explain the Options & Patient Choice

Psychological Counseling

and/or

Medication Treatment

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Medication Treatment SSRIs – treatment of choice Randomized Trials

citalopram (Celexa, Lexapro) paroxetine (Paxil) fluoxetine (e.g. Prozac) fluvoxamine (Luvox) sertraline (Zoloft) venlafaxine (Effexor)

FDA-approved: sertraline, paroxetine Manageable in deployed environment

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Psychological Counseling At least as effective as medication

Cognitive Behavioral Treatment (CBT) Connect thoughts to feelings Challenge & change thoughts

Exposure Therapy Careful, gradual, repeated imagining of trauma Relaxation and desensitization techniques

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Administrative Issues Participation in RESPECT-Mil program does

not start the Chapter Discharge or Medical Board process

Can redeploy Reasons for specialist referral –

low motivation chronic/recurrent (> 6 months) treatment refractory occupational problems (absenteeism, fail to

deploy, supervisor complaints, misconduct) high suicide risk

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Case Example - PVT Andrews Part 3Role Play to demonstrate:

Presenting treatment options

Give key messages if medication prescribed

Explain & offer RCF care facilitation

Discuss primary care clinic continuity

Encourage self-management

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Key Educational Messages Antidepressants only work if taken every day. Antidepressants are not addictive. Benefits from medication appear slowly. Continue antidepressants even after you feel

better. Mild side effects are common, and usually improve

with time. If you’re thinking about stopping the medication,

call clinic first. The goal of treatment is complete remission;

sometimes it takes a few tries.

Handout #6

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Self-Management PlanHandout #7

1. Stay physically active.

2. Make time for pleasurable activities.

4. Practice relaxing.

5. Simple goals and small steps.

3. Spend time with people who can support you

6. Eat balanced meals and avoid alcohol

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Follow-up Establish preferred mode and time of

facilitator contact RCF calls –

Initial call one week after treatment started Minimum calls at 4 week intervals

Follow-up PCL at 4 week intervals RCF reviews PCL score changes with

psychiatrist for possible treatment change recommendations

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PCP

Typical Frequency of Patient Contacts

PCP

PCP RCFPrimary CareClinician Visit

Care FacilitatorPhone Call

Continuation Phase

WEEK

Acute Phase

RCF

20

RCF

32

PCP

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PCP PCP

RCF

1

RCF

4

RCF

8

RCF

12

PCP

RCF

40

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INTRUSION1. Images, thoughts2. Nightmares3. Sudden re-experience4. Upset at reminders5. Physical reactionsAVOIDANCE6. Avoid thinking/talking7. Avoid situations8. Memory loss of event9. Loss of interest10. Distant, cut-off11. Emotionally numb12. Future cut short AROUSAL13. Insomnia14. Outbursts15. Low concentration16. Watchful on guard17. Easily Startled

PVT Andrews - Part 4, f/u PCL Handout #8

Not A little Moderately Quite Extremely at all bit a bit 0 1 2 3 4

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INTRUSION1. Images, thoughts2. Nightmares3. Sudden re-experience4. Upset at reminders5. Physical reactionsAVOIDANCE6. Avoid thinking/talking7. Avoid situations8. Memory loss of event9. Loss of interest10. Distant, cut-off11. Emotionally numb12. Future cut short AROUSAL13. Insomnia14. Outbursts15. Low concentration16. Watchful on guard17. Easily Startled

0 + 3 + 8 + 6 + 0 = 17

PVT Andrews - Part 4, f/u PCL

Not A little Moderately Quite Extremely at all bit a bit 0 1 2 3 4

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PTSD Treatment Modification Table

To SSRIs

PCL Treatment Response

Treatment Plan

Drop of 5 pts from baseline Adequate

No treatment change needed. F/u in 4 weeks

Drop of 3-4 pts from baseline Possibly

Inadequate

May warrant an increase in SSRI; informal consult

Drop of 1-2 pts or no change or increase

Inadequate

Increase dose; Switch drugs; informal or formal psychiatric consultation; add psychological counseling

Handout #9

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RemissionThe goal of PTSD treatment is remission:

a PCL score less than 11 and no functional impairment

To obtain remission, you will often be advised to do one or more of: increase the dose of medication switch to another medication add a medication recognize and treat a co-occurring disorder consider a different diagnosis refer for counseling or mental health evaluation be sure counseling is PTSD specific

Attaining and maintaining remission ongoing contact with primary care as well as the RCF usually takes at least 12 weeks to achieve and may take longer often tougher than depression

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Logistics – Screenings, Referrals & Communications All AD patients are being screened starting (date)

Return Dark or Light Blue folders

Soldiers with a Dx of depression &/or PTSD offered treatment & care facilitation (RCF)

Refer to RCF via AHLTA

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Referrals & Communications Face-to face introductions with RCF are okay

and often helpful if possible (AHLTA still required!)

Ask for more frequent or earlier initial call (e.g. 48 hours) when you have concern about pt. follow through on treatment

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PTSD Skills Practice Those handed a blue folder partner with

someone without a folder

Twenty minutes to practice Scoring PCL Suicide assessment Treatment recommendation & RCF referral Key medication instructions & Self-management

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Summary PTSD and Major Depressive Disorder are

significant health problems post-deployment

RESPECT-Mil implements a system for the depression &/or PTSD care process

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PTSD Four question

screen

PCL (PTSD Checklist)

Suicide assessment

Parallel Diagnostic ToolsDEPRESSION Two question

screen

PHQ-9

Suicide assessment

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Parallel Management ToolsPTSD Key messages for drug

adherence

Care facilitation calls

Self-management

Psychiatric supervision for treatment changes

Informal psychiatric consultation always available

DEPRESSION Key messages for drug

adherence

Care facilitation calls

Self-management

Psychiatric supervision for treatment changes

Informal psychiatric consultation always available

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Primary Care Provider &the Prepared Practice

Recognition & Diagnosis

Patient Treatment Selection and Education

Initiate Treatment & Care Management

Continue or Change Treatment

Continuation / Maintenance Phase Relapse / Recurrence Prevention

Screening QuestionsPHQ-9 &/or PCLSuicide AssessmentInterview

Present Rx OptionsElicit Patient Choice

Key Patient EducationSelf-Management Plan

PHQ-9 or PCL for Rx ResponseInformal or Formal Specialty Referral

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Care Facilitator

Encourage AdherenceProblem Solve Barriers

Measure Treatment Response

Monitor Remission

Com

munic

ate

wi t

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ian

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Psychiatrist

Care Facilitator Supervision

Informal Consultation

Formal Consultation / Treatment

Psychological Counseling

Access to mental health

resources will beenhanced

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WE WANT THIS TO WORK FOR YOU! Please take a moment now and complete

our brief evaluation form

Your feedback is important to this implementation effort.

Thank you!

Evaluation Handouts