More than Just a Tummy Ache: Collaborative Primary Care and Behavioral Health Approaches

1. More than Just a Tummy Ache: Collaborative Primary Care and Behavioral Health Approaches Head to Toe 14 Preconference Breakout Session “H” Dan Rifkin, MD & Mary M. Ramos, MD, MPH April 13, 2010 Albuquerque

2. Presenters Mary M. Ramos, MD, MPH, FAAP Office of School and Adolescent Health (NM DOH) Research Assistant Professor of Pediatrics University of New Mexico—School of Medicine Dan Rifkin, MDChild & Adolescent Psychiatrist Envision New Mexico UNM School-Based Health Centers Pediatric Clinic, UNM-Health Sciences Center Asst Professor of Pediatrics and Psychiatry, University of New Mexico School of Medicine

3. Goals Integrated Medical and Mental Health Care Collaborative Assessment and Treatment

4. Objectives 1) Appreciate how the integration of medical and mental health care benefits students 2) Recognize several (9+) ways the mind-body interface presents clinically 3)Anticipate psychiatric comorbiditycommonly found in students 4) Outline three realms of collaborative care 5)Select ways to integrate care involving empirically supported approaches to assessment and treatment of psychiatric comorbidity frequently encountered in youth

5. Integrated Medical & Mental Healthcare Does it really benefit students?1st Objective Appreciate how the integration of medical and mental health care benefits students

6. Valuing the Integration of Health & Behavioral Health Care

7. Who Said so… • The U.S. Surgeon General has stated that the connection between mind and body are closely related (1999). • SBHC Primary Care and Behavioral Health Providers have a lot to say and do about the mind-body connection!!!

8. History • Remote:Ancient Greeks: Hippocrates et al. believed physiologic & mental state determined by mixture (balance/imbalance) of four humors (Black Bile, Phlegm, Yellow Bile, Blood) • Recent:BioPsychoSocial model, ca.1970s-80s, by internist/psychiatrist George Engel, MD Offers explanations for: • Heart Disease, Asthma, and other medical illnesses • Depression, Anxiety, Subst. Abuse/Dep, and other psychiatric disorders

9. Separating Mind from Body • Separation of Mind [“Psyche”] from Body [“Soma”] has become a useful, convenient construct for conceptualizing illness and appropriating care • Separation limits effective health & mental health care! • Without care integration, psychiatric comorbidity can be under-recognized during primary health care and, conversely, medical problems under-recognized during mental health care.

10. Integrating Medical & Mental Health Care • SBHCs aim to integrate medical and mental health care in order to assess and treat youth comprehensively. • Standard of care in SBHCs • Care integration has become the standard set for SBHCs in New Mexico, by OSAH, and nationally, by NASBHC. • NASBHC developing Integrated Care position statement • Beyond our SBHCs, appreciated by school providers, educators, and families • Compatible with the clinically useful BioPsychoSocial model

11. NASBHC Developing Position Statement* on Integrated Care • Integration of primary care and mental health services expected in SBHCs, as standard of care • Expanding traditional roles, sharing competencies across disciplines • Provide operational processes for combining mental health and primary care services regarding documentation, communication, visits, referrals, and shared responsibilities • Insurance (Medicaid, SCHIP, commercial) reimbursement for integrated SBHC services • Integrated practice training for primary care and mental health providers {*2008 Draft being revised}

12. Frequently Seen in SBHCs Conditions/Diagnoses with intertwined medical and psychosocial {BioPsychoSocial} etiologies & risk factors that benefit from integrated care: • Asthma • Overweight • Depression • Anxiety • Pregnancy • Substance Abuse/Dependence

13. ? How does the mind-body interface emerge ?Objective Recognize several (9) ways the mind-body interface presents clinically

14. Preamble • Physiologic regulation is influenced by psychologic state (and vice versa) in humans. • Most organ systems and many medical conditions are stress sensitive (Kazura, Boris, & Dalton). Contrariwise, physiologic disequilibrium and medical illness profoundly impact the psyche.

15. Psychosomatic Syndromes Bodily Symptoms develop during Mental Health Disruption

16. 1) “Classic” psychiatric disorders**{distinguished by prominent physical symptoms} a) Somatoform Disorders--include: Somatization Disorder Conversion Disorder (e.g. pseudoseizures) Hypochondriasis Physical symptoms/complaints without objective “organic” causes/signs Unconscious expression of psychological stress/conflict through body b) Factitious Disorder: a.k.a.“Munchausen Syndrome” Symptoms & signs produced by patient or someone else (“by proxy”) Differs from deceptive Malingering (psychiatric Ddx; DSM-IV, v65.2) **2 of 3 broad categories of psychosomatic disorders distinguished in DSM-IV • Result in medical care seeking, yet… • Rare in school-based health care; following conditions more common in students…

17. 2) Somatic features of common psychiatric disorders: a) Depressed and Anxious youth often present with headache, GI upset, backache, and fatigue b) Generalized anxiety disorder (GAD) causing muscle tension and fatigability (DSM) c) Panic attack symptoms: palpitations, SOB/smothering, chest tightness or pain, sweating, trembling, paresthesias, nausea/abdominal distress, feeling of choking, feeling dizzy, lightheaded, unsteady, or faint, etc (DSM); in panic disorder, PTSD, depression d) Eating disorders: multiple physiologic problems due to anorexia, binging, and purging

18. How frequent are somatic symptoms among adolescents? Headache? Stomachache? Backache? Morning fatigue?

19. Symptoms Frequently Reported*US Adolescent Girls Headache 29% Stomachache 21% Backache 24% Morning fatigue 31% *More than once/week (Arch Pediatr Adolesc Med 2004;158:797-803)

20. Are somatic symptoms related to social stressors?YES ! Very low parent support Very low teacher support Bullying at least once/wk Associated with: Headache, Stomachache, Backache, Morning fatigue (Arch Pediatr Adolesc Med 2004;158:797-803)

21. How do somatic symptoms among adolescent males compare to females?

22. Frequent Somatic Symptoms During Previous 6 Months--Finnish Students, 16-18 years old Females (%)Males (%) Headache 227 Abdominal Pains 13 5 Fatigue or Weakness 38 22 Lethargy 34 24 Difficulty Sleeping 22 16 (Pediatrics 1995;96:59-63)

23. Life Events associated with Higher Somatic Symptom Scores – Female Students Serious illness or injury in family Increased number of arguments between parents Failing an examination Breaking up with boyfriends or girlfriends Also associated: Depression/Anxiety trait High relief alcohol or drug use (Pediatrics 1995;96:59-63)

24. Life Events associated with Higher Somatic Symptom Scores – Male Students Increased absence of a parent from home Trouble with siblings Failing an examination Also associated: Depression/Anxiety trait High relief alcohol or drug use (Pediatrics 1995;96:59-63)

25. Recurrent Abdominal Pain, Anxiety, and Depression in Primary Care • Recurrent abdominal pain (RAP) associated with anxiety and depression in youth. • Students who present with RAP in (school-based health) care deservecareful assessment for anxiety and depressive disorders. • Campo JV, Bridge J, Ehmann M, Altman S, Lucas A, Birmaher B, Di Lorenzo C, Iyengar S, Brent DA (2004), Recurrent Abdominal Pain, Anxiety, and Depression in Primary Care.Pediatrics 113(4):817-24 (Western Psychiatric Institute and Clinic; Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center)

26. RECURRENT ABDOMINAL PAIN, HEADACHE AND LIMB PAINS IN CHILDREN AND ADOLESCENTSPediatrics, Sep 1972; 50: 429 - 436 • prevalence of recurrent abdominal pain 14.4% headache 20.6% growingpains15.5% • eight-year long longitudinalstudy • nonselected population of school children Jakob Øster M.D. Department of Pediatrics, The Central Hospital, Randers, Denmark

27. 3)“Psychophysiologic”syndromes Preamble:From the bronchial constriction in asthma to the weal and flare skin response in uticaria (hives), there are many examples of chronic and recurring conditions whose physiologic course is related to psychologic adjustment. (Kazura, Boris, & Dalton)

28. 3) Psychophysiologic syndromes • Medical illness affected by psychosocial stressors Examples: asthma; headaches; eczema; irritable bowel syndrome • “Psychological Factors Affecting Medical Condition” (316) **3rd broad DSM-IVcategory of Psychosomatic disorders** “[Specified Psychological Factor]Affecting[Indicate the General Medical Condition]” Psychologically meaningfulfactor(s) temporally related to the initiation or exacerbation of a specified physical/medical condition. Varieties: chosen name based on the nature of the psychological factors: -Psychological Symptoms Affecting… e.g. anxiety precipitating tension headache or recurrence of a migraine -(Psychosocial) Stress-Related Physiologic Response Affecting… e.g. break-up with boy/girlfriend during final exams exacerbating asthma (precipitating “asthma attack”) -Personality Traits or Coping Style Affecting… -Maladaptive Health Behaviors Affecting… e.g. overeating; no exercise; unsafe sex -Other psychological factors: e.g. interpersonal, cultural, or religious factors

29. “Somatopsychic” Syndromes Mental Health Disruption develops during Medical & Physiologic Conditions

30. 4) “Medical Mimics” Preamble: Myriad of (a) medical conditions and (b) medications produce psychiatric disorders in youth, including depression, anxiety, psychosis, and disruptive behaviors

31. 4) Medical Mimics a) a.k.a.Psychiatric Disorder Due to a General Medical Condition (DSM-IV293.xx) Depressive Disorder Endocrine (e.g. hypo/hyperthyroidism) Anxiety Disorder….. Metabolic Psychotic Disorder Infections Hematologic (e.g. anemia) Neoplastic (cancer) Neurologic (e.g. seizures) Examples: Depressive Disorder due to hypothyroidism (relatively common) Anxiety Disorder due to hyperthyroidism, tumors (pheochromocytoma-rare), cardiovascular disease (arrhythmias)

32. 5) Psychiatric disorder exacerbated by physiologic factors • Milder version of 4a) Medical Mimics • Examples: Depression (MDE) associated with subclinical hypothyroidism {high nl. TSH (+/- low nl FT4)} Depression following pregnancy (postpartum depression); perhaps alleviated during pregnancy

33. Combined “Psyche” -and- “Soma” Factors

34. 4) Medical Mimics b) Medication-induced: Examples: Rx dextroamphetamine-induced psychosis associated with, GI upset, headaches, decreased appetite & weight, and elevated pulse & BP Rx propranolol-induced depression associated with psychomotor slowing and lower pulse & BP

35. 6) Substance-Induced Disorders • Drugs & Alcohol can produce psychiatric and medical illness • Substance-Induced Psychiatric Disorders: mood, anxiety, psychosis, delirium, sleep • Methamphetamine dependence resulting in psychotic and depressive features, HCV infection, malnutrition, skin lesions, dental decay

36. 7) Physiologic states with intertwined health and mental health vulnerability • Pregnancy • Puberty • Malnutrition (acute or chronic; not due to eating do) • Sleep deprivation

37. 8)Seemingly Unrelated Health/Medical Need • Depression &/or anxiety revealed during sports physical • Psychosis (audio hallucinations & paranoid ideation) found when seen for musculoskeletal discomfort

38. 9) Comorbid/Co-existing Medical and PsychiatricConditions • Asthma, overweight, and other medical conditions often co-occur with psychiatric disorders in youth • Examples: -Asthma co-existing with anxiety disorder {chronic psychophysiologic syndrome} {Cf. Asthmatic exacerbation (“asthma attack”) presenting with panic attack (2c above)} • Can co-exist with depressive disorder -Overweight student with depression

39. Psychiatric Conditions in Children with Asthma • More behavioral/emotional problems in asthmatic children than healthy children -and- those with other chronic illness. • Metaanalysis of 26 studies, involving 4923 children, 4-19 yrs • McQuaid (2000), Society Developmental & Behavioral Peds Annl Mtg • Parent reports indicated significant increases in both internalizing symptoms (depression & anxiety) –and- externalizing symptoms (aggression and oppositionality) • both proportional to asthma severity (7 studies examined)

40. Psychiatric Conditions in Children with Asthma • Metaanalysis of 26 studies, involving 4923 children, 4-19 yrs • McQuaid (2000), Society Developmental & Behavioral Peds Annl Mtg • Difference between children’s and parental perceptions/reports • No increased anxiety or depression found in children’s self-reports of internalizing symptoms (8 studies examined) • Suggests/implies importance of always asking parents/guardians about asthmatic students’ behavior and moods

41. 9 ways the mind-body interface presents clinically 1) “Classic” Psychosomatic Syndromes 2) Somatic features of common psychiatric disorders 3) “Psychophysiologic” syndromes 4) “Medical Mimics”– a) medical conditions and b) medications 5) Psychiatric disorder exacerbated by physiologic factors {milder version of 4a) Medical Mimics} 6) Drugs and Alcohol can produce psychiatric and medical illness 7) Physiologic states with intertwined health & mental health vulnerability 8) Seemingly Unrelated Health/Medical Need 9) Comorbid /co-existing medical and psychiatric conditions

42. ? Do psychiatric conditions commonly co-exist ?Objective Anticipate psychiatric comorbidity commonly found in students

43. Depression is Common! • One of the most serious and common problems encountered by youth of all ages. • E.g, in the 2007 NM Youth Risk and Resiliency Survey (YRRS), of students in grades 9-12: • 30.8% had persistent feelings of sadness or hopelessness • 19.3% seriously considered attempting suicide • 14.3% attempted suicide one or more times

44. Depression can be present in students with: Headaches, stomach aches, and other somatic complaints (especially elem. & middle school) Chronic/recurrent medical illness, e.g. asthma and diabetes Obesity/overweight (inextricable association) Substance abuse Suicidal thoughts (major depressive episode symptom) ADHD and other conditions causing distractibility, impulsivity, and hyperactivity Experienced trauma and important loss

45. Frequent Depression Comorbidity • Anxiety Disorders, including PTSD • Substance abuse/dependence • Often co-occurs with depression in youth • Also, with ADHD, bipolar disorder, PTSD, other anxiety disorders, conduct disorder, etc. • More than in adults!!! • Anticipate comorbid/coexisting psychiatric disorders!!

46. Don’t have to be…

47. ? Who collaborates on care for student success ?Objective Outline three realms of collaborative care >Need to begin with Cooperation !!!

48. SBHC Collaborative Care Overview • Integration within our SBHC • Collaboration with the School • Coordination with Community Providers/Agencies

49. Collaborative Care Overlapping care domains! SchoolCommunity Provider/Agency /Program SBHCenter

50. Collaborative Care Summary • Integration within our SBHC • Care integrationinvolving PCP, therapist, consulting psychiatrist et al. SBHC team • Collaboration with School providers • with school team {nurse, counselor(s), social worker(s), psychologist(s), others} • Coordination with Community Providers/Agencies Team meeting process vital to assessment & tx!!