Better Together: Mental Wellness as an Effective

Augmentation Strategy in Psychiatry

Bernadette A. DeMuri-Maletic, MDAssistant Clinical ProfessorMedical College of WisconsinMilwaukee, Wisconsin

Adjunct Clinical AffiliateUniversity of Texas at AustinSchool of NursingAustin, Texas

Saundra Jain, MA, PsyD, LPC

Disclosure• The faculty have been informed of their responsibility to disclose to the

audience if they will be discussing off-label or investigational use(s) of drugs, products, and/or devices (any use not approved by the US Food and Drug Administration).

• Applicable CME staff have no relationships to disclose relating to the subject matter of this activity.

• This activity has been independently reviewed for balance.

When Medications Leave Patients Wanting More

Depression: What We Learned from STAR*D

STAR*D = Sequenced Treatment Alternatives to Relieve Depression.Dunner DL. Primary Psychiatry. 2007;14(3). Rush AJ, et al. Am J Psychiatry. 2006;163(11):1905-1917.

Bipolar Depression and Remission Rates: What We Learned from STEP-BD

STEP-BD = Systematic Treatment Enhancement Program for Bipolar Disorder; BUP = bupropion; PAR = paroxetine; PBO = placebo; TEAS = treatment-emergent affective switches; Transient Remission = 1 to 7 consecutive weeks of euthymia; Durable Recovery = Euthymia for at least 8 consecutive weeks.Sachs GS, et al. N Engl J Med. 2007;356(17):1711-1722.

Double-blind, placebo-controlled study, randomly assigned participants (N=366) with bipolar depression to receive up to 26 weeks of treatment with a mood stabilizer plus adjunctive antidepressant therapy or a mood stabilizer plus a

matching placebo.

Take Home: 50% to 80% of

participants DID NOTachieve remission!

Generalized Anxiety Disorder: Are Medications Getting the Job Done?

GAD = generalized anxiety disorder; HAM-A = Hamilton Rating Scale for Anxiety.Baldwin D, et al. BMJ. 2011;342:d1199.

Systematic review of randomized controlled trials (n=27) to appraise the evidence for comparative efficacy and tolerability of drug treatments in patients with GAD.

Pharmacotherapy while helpful in GAD, is still Suboptimum treatment for a Large Number of Patients

Response: ≥ 50% reduction from baseline score on HAM-A

Remission: Final HAM-A score ≤ 7

Compared 9 medications (duloxetine, escitalopram, fluoxetine, lorazepam,

paroxetine, pregabalin, sertraline, tiagabine, and venlafaxine)

CATIE: Medications Leave Us Wanting More

d/c = discontinue; CATIE = Clinical Antipsychotic Trials of Intervention Effectiveness.Lieberman JA, et al. N Engl J Med. 2005;353(12):1209-1223.

Olanzapine 15%Risperidone 27%Perphenazine 25%Quetiapine 28%Ziprasidone 24%

Tx D/C = Lack of Efficacy

N=1493 (Schizophrenia). 74% d/c study medications before 18 months. The majority in each group d/c their assigned treatment owing to inefficacy or intolerable side effects or for other reasons.

TMS Response and Remission Rates

PHQ-9

42 US TMS practice sites; 307 outpatients with MDD, persistent symptoms despite AD pharmacotherapy.

Take Home: More than 2/3 of

participants DID NOTachieve remission!

Categorical response and remission outcomes—stratified by baseline level of treatment resistance (low vs high). TMS = transcranial magnetic stimulation; MDD = major depressive disorder; AD = antidepressant; PHQ-9 = Patient Health Questionnaire.Carpenter LL, et al. Depress Anxiety. 2012;29(7):587-596.

Do we need another augmentation strategy?

Who has the time?

Is it possible there is a hidden epidemic called a Wellness Deficit Disorder?

Data tells us that medications often prove inadequate.

Let’s consider it, and then look at the sciencebehind positive psychiatry and wellness

interventions.

Does a Wellness Deficit Disorder Exist?

~ 350 Diagnoses

What do you think?

Is Wellness Deficit Disorder worthy of our clinical

consideration?

HERO: An Anonymous Online Survey

N=757.

Foundational Elements of Wellness

Anonymous Online Survey ResultsNo Condition Compared to those with a Mental Health Condition

N=757. MH = mental health. Jain S, et al. Presented at: 29th Annual US Psychiatric and Mental Health Congress; October 2016; San Antonio, TX.

Happiness diminished 24% in MH conditions

Enthusiasm diminished 22% in MH conditions

Resilience diminished 18% in MH conditions

Optimism diminished 23%in MH conditions

The Neurobiology of Positive Psychiatry

Positive emotions such as:

Happiness Enthusiasm Resilience Optimism etc.

Regions involved in positive emotions:

Ventral striatum Amygdala Orbital PFC Hippocampus

Neurotransmitters involved in positive emotional processing:GABA, opioid receptors, endogenous opioids, endogenous endocannabinoids

Neurobiology of Positive Emotions

GABA = gamma-aminobutyric acid; PFC = prefrontal cortexBurgdorf J, et al. Neurosci Biobehav Rev. 2006;30(2):173-187.

IFN-γ: An Inflammatory

Cytokine

Higher Perceived Happiness

LOWERIFN-γ levels

HIGHERIFN-γ levels

Lower Perceived Happiness

In addition, touching and warm/positive emotion induction by touch of a loved oneREDUCED IFN-γ levels.

Happiness and Its Relationship to Inflammation

IFN-γ = interferon gamma. Matsunaga M, et al. Neuro Endocrinol Lett. 2011;32(4):458-463.

Wellness Interventions &

Epigenetic Changes

Wellness interventions (such as exercise, mindfulness, sleep hygiene, social connectedness, and optimized nutrition) through epigenetic mechanisms,

promote RESILIENCE in the BRAIN.

Resilience (a Pillar of Mental Wellness) andWellness Interactions

Russo SJ, et al. Nat Neurosci. 2012;15(11):1475-1484.

The Neurobiology of Wellness InterventionsExercise, Mindfulness, Sleep, Social Connectedness, Nutrition

Graph demonstrating an increase in hippocampus volume for the aerobic exercise group and a decrease in volume for the stretching control group. The Time × Group interaction was significant (P<.001) for both left and right regions.

Exercise Increases Hippocampal Volume

Erickson KI, et al. Proc Natl Acad Sci U S A. 2011;108(7):3017-3022.

120 older adults without dementia randomly assigned to an aerobic exercise group (n=60) or to a stretching control group (n=60). The groups did not differ at baseline in hippocampal volume.

Aerobic Exercise Intervention: Increased hippocampalvolume by 2%, reversing age-related loss in volume by 1–2years. Reverses hippocampal volume loss in late adulthood +improved memory function.

Stretching Control Group: Hippocampal volumedeclined but higher pre-intervention fitnesspartially attenuated the decline, suggesting thatfitness protects against volume loss.

Sleep Deprivation Decreases Memory Encoding

IPS = intraparietal sulcus; PCC = posterior cingulate cortex; V1 = primary visual cortex.Krause AJ, et al. Nat Rev Neurosci. 2017;18(7):404-418.

Focusing on neuroimaging studies, this review considered the consequences of Sleep Deprivation onattention and working memory, positive and negative emotion, and hippocampal learning.

Mindfulness Decreases Amygdala Gray Matter Volume

MAAS = Mindful Attention Awareness Scale; MRI = magnetic resonance imaging; GMV = gray matter volume.

Taren AA, et al. PLoS One. 2013;8(5):e64574.

A self-report measure of dispositional mindfulness (MAAS) and structural MRI images were obtainedfrom 145 healthy community adults to determine if higher levels of dispositional mindfulness would beassociated with decreased gray matter volume in the amygdala.

The right amygdala is shown here in red.

• Higher dispositional mindfulness isassociated with decreased GMV in theright amygdala

• Smaller amygdala volumes may reflect apotential neurobiological mechanism forreduced stress reactivity in more mindfulindividuals, and lower negative affect indaily life thus improving psychologicaland physical health

Social Support Increases Gray Matter Volume

PSSS = Perceived Social Support Scale. Che X, et al. Soc Neurosci. 2014;9(2):152-159.

347 healthy undergraduate volunteers (144 men and 203 women; mean age 19.9) completedPSSS to measure subjectively assessed social support, referring to interpersonal exchangesincluding combinations of aid, affirmation, and affection. Voxel-based morphometry used toinvestigate the neural bases of individual differences.

Individuals with perceivedhigh levels of support hadlarger GMV in a cluster thatmainly included areas inposterior parts of posteriorcingulate cortex, bilaterallingual cortex, left occipitallobe, and cuneus. P<.05

Association of scaled dietary foods and vitamins with cortical thickness in regions of interest

MeDi Increases Cortical Thickness

MeDi = Mediterranean diet; CHO = carbohydrate.Staubo SC, et al. Alzheimers Dement. 2017;13(2):168-177.

Higher MeDi score associated with larger frontal, parietal, occipital, and

average lobar cortical thickness.

Higher legume and fish intake associated with larger cortical

thickness.

Higher CHO and sugar intake associated with lower entorhinal

cortical thickness.

Population-based sample of 672 cognitively normal elderly participants, ≥ 70 years

Introducing a Wellness Program That’s Applicable to Psychiatry:

WILD 5 Wellness

A Prescriptive and Proven Wellness Program

Disclaimer

THIS DISCUSSION ABOUT WILD 5 WELLNESS IS IN NO WAY A SOLICITATION.

IT’S ONLY INTENDED TO FURTHER EDUCATE AND REPORT ON EXPERIENCE UTILIZING THIS

WELLNESS INTERVENTION.

WILD 5 WellnessWellness Interventions for Life’s Demands

History of WILD 5 Wellness: Research Timeline

WILD 5 Research

2015N=36

2016N=100

2016Beloit N=84

2016UT AustinOngoing

2017Beloit

First Year

2017/18Beloit

First Year

2018RA

2018 Rutgers Family

Medicine

The WILD 5 Wellness Program Philosophy

All are equally important

No picking & choosing

Positive Psychiatry

Wellness Interventions

Tried & True Practices Perfection is Not the Goal

Wellness Practices Plus Positive Psychiatry

• Optimized Nutrition

• Optimized Sleep

• Mindfulness

• Exercise

• Optimized Socialization

• Optimism

• Enthusiasm

• Happiness

• Resilience

WILD 5 Wellness: A 90-Day Program

Phase 1

Start

30 Days

Phase 3

Sustain

30 Days

Phase 2

Solidify

30 Days

Program Expectations

Exercise Exercise 30 minutes each day for 30 days; aim for at least moderate intensity

Mindfulness Practice mindfulness for at least 10- to 15-minutes each day for 30 days (www.WILD5Meditations.com)

Sleep Implement ≥ 4 of WILD 5’s 6 sleep hygiene practices each day for 30 days

Social Connectedness

Meet, call, or text at least 2 family members or friends each day for 30 days

NutritionLog your daily meals/snacks/beverages/alcohol AND

listen to the WILD 5 Mindful Meal Meditation (1 meal/day) for 30 days

Wellness Practices: Phase 1 – Start

WILD 5 Wellness Components

Program Expectations Remain the Same;Only Frequency Changes

PROGRAM EXPECTATIONS: Phase 1 ‒ START7 Days Per Week

PROGRAM EXPECTATIONS: Phase 3 ‒ SUSTAINAt Least 3 Days Per Week

PROGRAM EXPECTATIONS: Phase 2 ‒ SOLIDIFYAt Least 5 Days Per Week

WILD 5 Wellness Positive Psychology Components

Phases 1–32 Questions Per Day

• Optimism

• Enthusiasm

• Happiness

• ResilienceCan we strengthen these positive

psychology traits?

YES – we will look at the data shortly.

Data Matters

MENTAL HEALTH (N=27)

PARTICIPANTS:Self-reported Axis I condition

Taking a psychotropic medicationCompleted 90 days

Happiness: A state of contentment and satisfaction and is related to an overall sense of well-being. Enthusiasm: A feeling of excitement and interest and is related to an overall sense of well-being. Resilience: The ability to recover from or adapt easily when confronted with a difficult situation and is related to an overall sense of well-being. Optimism: A belief that good things will happen and is related to an overall sense of well-being.Jain S, et al. Presented at: 2018 Psych Congress; October 2018; Orlando, FL.

Impact of 90-Day WILD 5 Wellness Program on HERO Wellness Scale Scores

Positive Psychology Traits Can Be Strengthened Enthusiasm

PRE POST

P=.0002

Mean:4.2

Mean:6.4

N=27

Resilience

PRE POST

P=.00004

Mean:3.9

Mean:6.4

N=27

Optimism

PRE POST

P=.00003

Mean:4.1

Mean:6.6

N=27

Happiness

PRE POST

Mean:4.7

Mean:7.2

N=27

P<.00001

% Improvement

= 53% % Improvement

= 52% % Improvement

= 64% % Improvement

= 61%

Even though this is a wellness program, what about the impact on disease markers?

Impact of 90-Day WILD 5 Wellness Program on Disease Markers

PHQ-9 is a 9-item scale; scores range from 0 to 27. Lower score denotes improvement. GAD-7 is a 7-item scale; scores range from 0 to 21. Lower score denotes improvement. SCI is an 8-item scale; scores range from 0 to 32. Higher score denotes improvement. Jain S, et al. Presented at: 2018 Psych Congress; October 2018; Orlando, FL.

Anxiety (GAD-7)

PRE POST

Mean:7.5

Mean:4.2

N=27

P=.0005

Sleep Condition Indicator (SCI)

PRE POST

Mean:14.5

Mean:22.5

N=27

P<.00001

Depression (PHQ-9)

PRE POST

Mean:10.2

Mean:5.2

N=27

P=.00002

% Improvement

= 49% % Improvement

= 44% % Improvement

= 55%

Impact of 90-Day WILD 5 Wellness Program on Impairment and Functional Markers

SDS is a 5-item scale; scores range from 0 to 30. Lower score denotes improvement. SCS is an 8-item scale; scores range from 8 to 48. Higher score denotes improvement. BPI Short Form; scores range from 0 to 10. Lower score denotes improvement. Jain S, et al. Presented at: 2018 Psych Congress; October 2018; Orlando, FL.

Sheehan Disability Scale (SDS)

PRE POST

Mean:11.4

Mean:5.9

N=27

P<.001

Social Connectedness Scale (SCS)

PRE POST

Mean:31.7

Mean:40.2

N=27

P<.001

Brief Pain Inventory –Average Pain (BPI)

PRE POST

Mean:2.2

Mean:1.6

N=27

P=.05

% Improvement

= 48% % Improvement

= 27% % Improvement

= 27%

Impact of 90-Day WILD 5 Wellness Program on Impairment and Functional Markers

EADES is a 24-item subscale; scores range from 24 to 120. Higher score denotes improvement. CPFQ is a 7-item scale; scores range from 1 to 42. Lower score denotes improvement. MAAS is a 15-item scale; scores range from 15 to 90. Higher score denotes improvement.Jain S, et al. Presented at: 2018 Psych Congress; October 2018; Orlando, FL.

Cognitive & Physical Functioning Questionnaire

(CPFQ)

PRE POST

Mean:26.3

Mean:14.8

N=27

P<.00001

Mindful Attention Awareness Scale (MAAS)

PRE POST

Mean:53.3

Mean:66.2

N=27

P=.0005

Eating & Appraisal Due to Emotions & Stress (EADES)

PRE POST

Mean:62.2

Mean:75.2

N=27

P=.003

% Improvement

= 21% % Improvement

= 44% % Improvement

= 24%

Better Together:Patient – Psychiatrist – Psychotherapist

LR

Clinical Presentation Prior to Wellness Program – LR• 29-year-old single unemployed female living at home with parents• History of Persistent Depressive Disorder, Social Anxiety Disorder,

and Obsessive-Compulsive Disorder• SSRI and Atypical Antipsychotic • Psychotherapy for over 9 months

Let’s Bring it Full Circle and Check-in with LR

W5W = WILD 5 Wellness.LR

My thoughts about W5W after

the 90-day program.

W5W: LR Check-in Post 90-Day ProgramPatient – Psychiatrist – Psychotherapist

LR

What impact did W5W have on

your day-to-day functioning?

W5W: LR Check-in Post 90-Day ProgramPatient – Psychiatrist – Psychotherapist

LR

How do you think you’ve

benefited from W5W?

W5W: LR Check-in Post 90-Day ProgramPatient – Psychiatrist – Psychotherapist

What changes did you notice in LR as a result of

using W5W?

Jennifer Cicero, LCSW

W5W: LR Check-in Post 90-Day ProgramPatient – Psychiatrist – Psychotherapist

Better Together:

The Power of Collaborative

Care!

Jennifer Cicero, LCSW

Will we see changes?

What about LR’s disease and functional markers?

Impact of 90-Day WILD 5 Wellness Program on LR’s Disease Markers

Depression (PHQ-9)

PRE POST

Mean:19

Mean:7

Anxiety (GAD-7)

PRE POST

Mean:16

Mean:6

Sleep Condition Indicator (SCI)

PRE POST

Mean:5

Mean:14

Eating & Appraisal Due to Emotions & Stress (EADES)

PRE POST

Mean:27

Mean:66

% Improvement

= 63% % Improvement

= 63% % Improvement

= 180% % Improvement

= 144%

Impact of 90-Day WILD 5 Wellness Program on LR’s Impairment and Functional Markers

Cognitive & Physical Functioning Questionnaire

(CPFQ)

PRE POST

Mean:31

Mean:18

Mindful Attention Awareness Scale (MAAS)

PRE POST

Mean:72

Mean:73

Sheehan Disability Scale (SDS)

PRE POST

Mean:10

Mean:5

Social Connectedness Scale (SCS)

PRE POST

Mean:14

Mean:38

% Improvement

= 42% % Improvement

= 1% % Improvement

= 50% % Improvement

= 171%

Was she able to improve her happiness, enthusiasm, resilience, and optimism?

What about LR’s HERO scores?

W5W: LR Check-in Post 90-Day ProgramHERO Wellness Scale Scores

Happiness

% Improvement

= 400%

Enthusiasm

% Improvement

= 300%

Resilience

% Improvement

= 300%

Optimism

% Improvement

= 300%

LR

Implementing WILD 5 Wellness into a Busy Clinical Practice

“You can’t manage what you don’t measure”

~Peter Drucker

Measurement Matters

Scores range from 0–50.

Higher scores indicate higher

levels of wellness.

The HERO Wellness ScaleA Validated Wellness Scale

The HERO Wellness Scale allows the

patient to become an active member in their treatment by tracking their own

wellness.

www.JainTexasinfo.com(Password: resources)

Tracking Matters

Participant Tracking FormWellness and Positive Psychiatry Practices

Resources Matter

Library of Enduring Materials

www.JainTexasInfo.com(Password: resources)

Exercise Social Connectedness Nutrition

www.bemindfulonline.com/the-course/.www.wild5meditations.com.

www.psychcongress.com/saundras-corner/apps/meditation-apps.

CBT-I = Cognitive Behavioral Therapy-Insomnia.Erman MK. Primary Psychiatry. 2007;14(11).

www.psychcongress.com/saundras-corner/apps/sleep-apps.www.clevelandclinicwellness.com/programs/Pages/Sleep.aspx.

WILD 5 Mindfulness Meditations

www.JainTexasinfo.com(Password: resources)

1. Five-Minute Breathing Space (6:45)2. Mindful Breathing (15:00)3. Body Scan (15:00)4. A Moment of Gratitude (9:58)5. Happiness Meditation (11:37)6. Pain Meditation (13:00)7. Introduction to Mindful Meal

Meditation (5:19)8. Mindful Meal Meditation (23:31)9. Mindful Moment with a Raisin (9:57)

Share with Patients

How to Start Meditating?A Frequently Asked Question

www.JainTexasinfo.com(Password: resources)

WILD 5 Patient Educational Booklets

www.JainTexasinfo.com(Password: resources)

Want to educate patients about the importance of exercise, mindfulness, sleep, social

connectedness, or nutrition?

Appropriate

Moderate to Highly Motivated

Both Women and Men

All Education Levels

Mood and Anxiety Disorders

Assess Motivation and Engagement

WILD 5 Wellness – Not Appropriate for All

Not Appropriate

Non-Adherent

Lacks Motivation

Suicidal

Psychotic

Challenges

My participation isn’t perfect. I want to quit!

Pain stops me from exercising.How do I fill out the tracking form?

I can’t disengage from electronics 90 minutes before bedtime!

I don’t have time to mindfully meditate!

Logging food and snacks is a hassle!

Solutions

Negotiate intensity and duration based on your health.

Negotiate fewer days per week. Observe your quality of sleep.

Decide on a time; put it on your calendar; set an alarm.

This practice promotes consumption of fewer calories.

Perfection is not the goal. Do your best to practice daily.

Perfection is Not the Goal

Proactively Address Potential Barriers

A variety of patient educational resources are available at:

www.jaintexasinfo.com

Password: resources (all lower case)

Practical Take-Aways• Wellness strategies are effective augmentation strategies and

should be part of our mental health treatment plans • The science behind wellness and positive psychology traits can

be powerful patient motivators • Integrating wellness strategies into a busy clinical practice is

feasible and effective