MANAGING PARTICIPANTS WITH PSYCHIATRIC AND CO … · PTSD, CHILDHOOD TRAUMA, ACUTE STRESS DISORDER SYMPTOMS A diagnosis of PTSD requires exposure to an upsetting traumatic event

MANAGING PARTICIPANTS WITH PSYCHIATRIC AND CO-OCCURRING DISORDERS IN ALTERNATIVE TO DISCIPLINE PROGRAMS

NOAP MARCH 28, 2018

2 | MAXIMUS V. MATTHEWS: NOAP MARCH 2018

GINNY MATTHEWSRN, BSN, MBA

MAXIMUS

CALIFORNIA DIVERSION PROGRAM

[email protected]

PHOTO

PLACEHOLDER



REVIEW OF COMMON PSYCHIATRIC AND CO-OCCURRING

DISORDERS

THEIR IMPACT ON HEALTHCARE PRACTICE

RECOVERY AGREEMENT TERMS WITH MENTAL HEALTH FOCUS

TOPICS OF DISCUSSION


� IDENTIFY COMMON PSYCHIATRIC DISORDERS

� IDENTIFY THE IMPACT OF PSYCHIATRIC DISORDERS ON HEALTHCARE

PRACTICE

� RECOGNIZE CO-OCCURRING DISORDERS

� DEVELOP RECOVERY AGREEMENT TERMS TO ACCOMMODATE MENTAL

HEALTH ISSUES

LEARNING OBJECTIVES



IDENTIFICATION OF THE NATURE OF THE DISORDER LEADS TO

�APPROPRIATE INTERVENTION

�APPROPRIATE TREATMENT

�DEVELOPMENT OF A MEANINGFUL RECOVERY AGREEMENT

�RETURN TO SAFE PRACTICE WITH APPROPRIATE LEVEL OF OVERSIGHT

ASSESSMENT: CO-OCCURRING DISORDER,

SUBSTANCE-RELATED, OR MENTAL ILLNESS?


� The disorder shows the same distinct symptoms of a mental disorder

� Symptoms stop within days or weeks after drug or medication was last used

� Prior health history/exam/lab results demonstrate the following:

�Began during or within 1 month of intoxication or withdrawal

�Substance or medication that was used is known to cause the disorder

� Determine the disorder is due to a separate mental D/O dx (not substance-

related) with evidence of the following:

�Symptoms started before the severe intoxication, withdrawal or exposure

�Full D/O lasted at least 1 month after the severe exposure ended

� Not part of a delirium (confusion, reduced attention) caused by intoxication

� Disorder causes temporary distress and problems with social, work or daily

functions

SUBSTANCE-RELATED PSYCHIATRIC

DISORDERS


Substance or medication Psychiatric symptoms

Sedating substances:

sedative, hypnotics,

alcohol, marijuana

Psychotic symptoms, depression, sleep disorders,

sexual dysfunction

Withdrawal can lead to panic and anxiety

Stimulants: cocaine,

amphetamines

Psychotic symptoms, manic symptoms, anxiety, sleep

disorders

Anesthetics,

antihistamines,

antihypertensives,

gabapentin

Neurocognitive problems: forgetfulness, memory

impairment, confusion, disorganization

Cardiovascular

medications, steroids

Psychotic symptoms

SUBSTANCE-RELATED PSYCHIATRIC

DISORDERS


� Co-occurring disorders must be expected when evaluating any person, and

clinical services should incorporate this assumption into all screening,

assessment, and treatment planning




� As many as 6 in 10 substance abusers also have at least one other mental

disorder. (NIDA)

� Co-occurring disorders were previously referred to as dual diagnoses. According

to SAMHSA’s 2014 National Survey on Drug Use and Health (NSDUH) (PDF | 3.4

MB), approximately 7.9 million adults in the United States had co-occurring

disorders in 2014. (SAMHSA)

� Co-occurring disorders, such as post-traumatic stress disorder (PTSD) and

substance use, is prevalent among veterans and the military community.

According to the Veterans Affairs Department (VA), approximately one-third of veterans seeking treatment for substance use disorders also met the criteria for

PTSD. (SAMHSA)




� For persons with COD, symptoms of either disorder may vary over time. It is

possible for the person to be effectively managing one set of symptoms while the

other set causes significant impairment. The interactive nature of COD requires

each disorder to be continually assessed and treatment plans adjusted

accordingly

� Within the treatment context, both co-occurring disorders are considered primary




CO-OCCURRING DISORDERSSUBSTANCE USE DISORDER AND PSYCHIATRIC DISORDERFEATURES


CO-OCCURRING DISORDERSSUBSTANCE USE DISORDER AND PSYCHIATRIC DISORDER

IMPACT ON HEALTHCARE PRACTICE



NEURODEVELOPMENTAL DISORDERS

SYMPTOMS


NEURODEVELOPMENTAL DISORDERS



PSYCHOTIC DISORDERSSchizophrenia; Schizoaffective D/O; Delusional D/O

SYMPTOMS


PSYCHOTIC DISORDERS



BIPOLAR DISORDERS

DEFINITIONS


BIPOLAR DISORDERS

SYMPTOMS


BIPOLAR DISORDERS



DEPRESSIVE DISORDERS

SYMPTOMS


DEPRESSIVE DISORDERS



ANXIETY DISORDERS

SYMPTOMS


ANXIETY DISORDERS



TRAUMA AND STRESS DISORDERS

PTSD, CHILDHOOD TRAUMA, ACUTE STRESS

DISORDERSYMPTOMS



PTSD, CHILDHOOD TRAUMA, ACUTE STRESS

DISORDERSYMPTOMS

A diagnosis of PTSD requires exposure to an

upsetting traumatic event. However, exposure

could be indirect rather than first hand. For

example, PTSD could occur in an individual

who learns that a close family member or friend

has died accidentally or violently.



SYMPTOMS





NEUROCOGNITIVE, DEMENTIA AND MEMORY DISORDERSSYMPTOMS


NEUROCOGNITIVE, DEMENTIA AND MEMORY DISORDERSIMPACT ON HEALTHCARE PRACTICE


CLUSTER A-marked by odd or eccentric

thoughts, feelings or behaviors

PARANOID

SCHIZOID

SCHIZOTYPAL

CLUSTER B-appear dramatic, emotional

or erratic. Extreme shifts in feelings,

frequent changes in behavior

ANTISOCIAL

BORDERLINE

HISTRIONIC

NARCISSISTIC

CLUSTER C-anxious or fearful, marked

by fear or worry

AVOIDANT

DEPENDENT

OBSESSIVE-COMPULSIVE

PERSONALITY DISORDERS

BY DSM-5 CLUSTERS



SYMPTOMS/FEATURES






ELIGIBILITY AND ASSESSMENT

•Baseline Poly-drug Urine Screen

•Based on history, consider hair test for longer window of detection

•Report from current treating psychiatrist with Comprehensive or

DSM-5 Diagnosis

•Safety Assessment: Suicidality, Homicidality, Medical

complications, Risk of withdrawal

•Therapeutic drug levels (if available)

•Clinical assessment by MD psychiatrist, psychologist, psychiatric

RN, LCSW, MFT

RECOVERY AGREEMENT


ADMISSION CRITERIA

•PARTICIPANT ACKNOWLEDGES THAT A PROBLEM EXISTS

•PARTICIPANT WILLING TO FOLLOW REHABILITATION PLAN

•PARTICIPANT VOLUNTARILY REQUESTS TO ENTER PROGRAM

•PARTICIPANT SIGNS RELEASE OF INFORMATION

SPECIFICALLY FOR PSYCHIATRIC RECORDS

•PARTICIPANT AGREES TO ABSTAIN FROM ALCOHOL OR

OTHER DRUGS NOT PRESCRIBED

RECOVERY AGREEMENT


Four-Quadrant Model of Care for Co-occurring DisordersI

Psychiatric

Disorder

LOW

Severity

Substance Use

Disorder

LOW

Severity

II

Psychiatric

Disorder

HIGH

Severity

Substance Use

Disorder

LOW

Severity

III

Psychiatric

Disorder

LOW

Severity

Substance Use

Disorder

HIGH

Severity

IV

Psychiatric

Disorder

HIGH

Severity

Substance Use

Disorder

HIGH

Severity

LOC: Client served by primary care

clinic

LOC: Client served by mental

health center/clinic

LOC: Client served by SUD treatment

program

LOC: Client served by mental

health center integrated Co-

occurring disorders program

Source: National Advisory Council, Substance Abuse and Mental Health Services Administration: Improving Services for Individuals at Risk of, or With co-occurring Substance-Related and Mental Health Disorders. Rockville, MD, SAMHSA, 1997.


TREATMENT

•INITIAL TREATMENT AT LEAST RESTRICTIVE LEVEL OF CARE

•ONGOING TREATMENT AND MEDICATION MANAGEMENT WITH

TREATMENT PROVIDER WHO AGREES TO SUBMIT MONTHLY OR QUARTERLY REPORTS, INCLUDING:

•COMPLIANCE WITH TREATMENT & MEDICATION MANAGEMENT

REGIMEN

•NOTIFICATION TO PROGRAM OF ANY CHANGES TO TX PLAN

•PARTICIPANT AGREES TO ABSTAIN FROM ALCOHOL OR OTHER DRUGS NOT PRESCRIBED

•IMMEDIATE REPORT OF ANY ESCALATION OR CHANGE IN

SYMPTOMS

RECOVERY AGREEMENT


PHARMACOLOGICAL TREATMENT

RECOVERY AGREEMENT

DIAGNOSIS COMMON TREATMENT SAFER WITH SUD

ANXIETY BENZODIAZEPINES SSRI, GABAPENTIN

ADHD AMPHETAMINE SALTS ATOMOXETINE (Strattera)

PTSD CANNABIS SERTRALINE, NALTREXONE, DISULFIRAM

PSYCHOTIC SX 2ND GEN ANTIPSYCHOTICS(Clozapine)

2ND GEN ANTIPSYCHOTICS(Clozapine)

BIPOLAR D/O TOPIRAMATE, LITHIUM,

GABAPENTIN, VALPROIC ACID, LAMICTAL

TOPIRAMATE, LITHIUM,

GABAPENTIN, VALPROIC ACID, LAMICTAL


SELF-HELP /COMMUNITY SUPPORT GROUPS

• DBSA-Depression and Bipolar Support Alliance (Live and Online) www.dbsalliance.org

• ADAA-Anxiety and Depression Association of America (Live, chat, online) www.adaa.org/supportgroups#

• NAMI-National Alliance for the Mentally Ill NAMI Connection

www.nami.org

• EA-Emotions Anonymous (Live, chat, skype and phone) www.emotionsanonymous.org

• RI-Recovery International (Live, chat, phone, online)

www.Recoveryinternational.org/meetings/

RECOVERY AGREEMENT


NURSE/HEALTH PROFESSIONAL PEER SUPPORT GROUPS

� REMOVE FROM GROUPS IF DISRUPTIVE OR UNABLE TO HANDLE THE SITUATION

�DISCUSSION WITH FACILITATOR BEFORE PARTICIPANT JOINS GROUP

� PEER SUPPORT HELPS TO NAVIGATE PROGRAM REQUIREMENTS

� PEER SUPPORT HELPS TO GIVE PARTICIPANT FEEDBACK ON BEHAVIORS

� FACILITATOR AND GROUP PROVIDE EARLY DETECTION OF CHANGES IN

THOUGHT PROCESSES OR BEHAVIORS

�NEED TO MAINTAIN EXPECTATION OF CONSISTENT ATTENDANCE-NOT

SPECIAL TREATMENT

RECOVERY AGREEMENT


DRUG TESTING COMPONENTS

Continue random drug testing on a limited basis

To ensure participant is not engaged in “self-medicating”

To ensure participant is not presenting with a missed

co-occurring substance use disorder

Consider limited or varied test panel

RECOVERY AGREEMENT


WORK RESTRICTIONS

•PRIOR TO RELEASE TO WORK, OBTAIN TREATMENT PROVIDER REPORT

FROM PSYCHIATRIST OR THERAPIST, SPECIFICALLY

•STABILITY ON MEDICATION

•JUDGEMENT

•LOGICAL THOUGHT PROCESSES

•ABILITY TO WORK UNDER STRESS

•ABILITY TO FOLLOW DIRECTIONS

•INTERACTIONS WITH OTHERS

•RECOMMENDATION TO RETURN TO PRACTICE

RECOVERY AGREEMENT


WORK RESTRICTIONS

•Gradual return to practice to ensure stress of work schedule and responsibilities are not overwhelming

•Start with non-direct patient care or in position with limited clinical decision-making (advice nurse, blood donations, dialysis, utilization management, case management, insurance reviews)

•Consider restriction on work hours, less than full time

•Limit overtime, night shift, home-based positions, Home Health, Registry or traveler positions, Float, or unstable shift schedule

•Each case must be considered individually, for participant’s ability to practice safely

•If not co-occurring disorder, may return to medication privileges sooner

RECOVERY AGREEMENT


CRITERIA FOR UNSUCCESSFUL COMPLETION

•FAILURE TO RESPOND TO TREATMENT PLAN

•FAILURE TO ACHIEVE A LEVEL OF STABILITY

•INABILITY TO MAINTAIN SUCCESSFUL EMPLOYMENT

•DEMONSTRATED FAILURE TO DERIVE BENEFIT DUE TO

•CHRONIC AND SERIOUS NATURE OF THE DISEASE

PROCESS

•INABILITY TO COMPLY WITH PROGRAM REQUIREMENTS

RECOVERY AGREEMENT


CRITERIA FOR SUCCESSFUL COMPLETION

•2 YEARS OF GOOD COMPLIANCE, INCLUDING:

•MAINTAIN THERAPEUTIC REGIMEN AS PRESCRIBED BY TREATMENT PROVIDER

•TAKING MEDICATIONS AS PRESCRIBED

•SUBMISSION OF LETTERS OF SUPPORT FOR SUCCESSFUL

COMPLETION FROM TREATMENT PROVIDERS, SPONSOR OR

“BUDDY”, SPOUSE/S.O./GROUP FACILITATOR

•NEGATIVE RANDOM DRUG TESTS OF NON-PRSECRIBED

MEDICATIONS OR ALCOHOL

RECOVERY AGREEMENT


CRITERIA FOR SUCCESSFUL COMPLETION

•DEMONSTRATED STABIILTY IN DAILY LIVING CHARACTERIZED BY:

•ABILITY TO RECOGNIZE ESCALATION OF SYMPTOMS

•ABILITY TO EXPRESS SELF-AWARENESS OF MENTAL HEALTH

AND DIAGNOSIS

•NO EVIDENCE OF PSYCHIATRIC SYMPTOMS

•IF SYMPTOMS ARE IDENTIFIED, SEEKS PROMPT,

APPROPRIATE TREATMENT

RECOVERY AGREEMENT


Neurodevelop-

mental D/OPsychotic D/O BiPolar D/O;

Depressive D/OAnxiety D/O Trauma and

Stress D/ODementia and Memory D/O

Personality D/O

IMPACT

Judgement

Distraction

Relationships

IMPACT

Judgement

Distraction

Relationships

Thought disorder

Safety

IMPACT

Judgement

Distraction

Relationships

Labile

IMPACT

Judgement

Distraction

Relationships

Avoidance

Labile

IMPACT

Judgement

Distraction

Relationships

Avoidance

Labile

IMPACT

Judgement

Distraction

Relationships

Errors

IMPACT

Judgement

Distraction

Relationships

Labile

AGREEMENT TERMS

Work Monitor

Peer support group

Psych assessment

and reporting

Basic drug testing

AGREEMENT TERMS

Work Monitor

May not be appropriate for

peer support group

Psych assessment

and reporting

Basic drug testing, higher risk of self-

medicating

AGREEMENT TERMS

Work Monitor

Peer support group

Psych assessment

and reporting

Basic drug testing,

higher risk of self-medicating

AGREEMENT TERMS

Work Monitor

Peer support group

Psych assessment

and reporting

Basic drug testing,

higher risk of self-medicating

AGREEMENT TERMS

Work Monitor

Peer support group

Psych assessment

and reporting

Basic drug testing,

higher risk of self-

medicating

Ensure Pt/WSM notifies program of

workplace risks

AGREEMENT TERMS

Work Monitor

May not be appropriate for

peer support group

Psych assessment

and reporting

Basic drug testing

Consider if progressive, may

not be appropriate to return to work

AGREEMENT TERMS

Work Monitor

May be disruptive in peer support

group

Psych assessment

and reporting

Basic drug testing, higher risk of self-

medicating

SUMMARY

Documents

MANAGING PARTICIPANTS WITH PSYCHIATRIC AND CO … · PTSD, CHILDHOOD TRAUMA, ACUTE STRESS DISORDER SYMPTOMS A diagnosis of PTSD requires exposure to an upsetting traumatic event