Providing Context at Psychiatric Appointments

1
Providing Context at Psychiatric Appointments

• What Psychiatric Prescribers Need To Know When
  Assessing and Treating Individuals
• With Developmental Disabilities

2
What Is In A Snapshot?

• Psychiatric appointments occur out of context.
• Psychiatric appointments are brief and in the
  moment.
• Sometimes people aim to please when meeting
  with professionals.
• Without context, what is directly observed during
  a psychiatric appointment can be challenging to
  evaluate.

3
Cognitive Delays Provision of Verbal Context

• Abstractions such as time frames, reasons why,
  and relative seriousness of events might be
  distorted.
• Memory gaps and inability to fully describe a
  situation might impact what is shared.
• A patient might not understand questions in a
  diagnostic interview.
• Lack of trust with a clinician or saying Yes as
  a strategy to please might distort what is shared.

4
Deep Listening

• Though psychiatric prescribers necessarily depend
  on others to provide context, it is important
  that patients with developmental disabilities are
  accorded respect and are the central treatment
  focus.

5
Supports to Persons With Developmental
Disabilities

• Family supports.
• Medicaid Personal Care and COPES supports.
• Adult Family Home supports.
• Group Homes and Boarding Home supports.
• Supported Living supports.
• Community Protection supports.

6
Treatment Modalities

• Be sure that physical pain, neurological
  conditions, and other physiological issues are
  being treated.
• Ask if there is a Functional Assessment,
  Positive Behavior Support Plan, and a
  Cross-Systems Crisis Plan for patients with very
  challenging symptoms.
• Address the adequacy of residential, educational,
  and vocational supports.
• Is the patient using counseling therapies?
• Access Speech Therapy, OT and PT when helpful.
• Psychiatric treatment is not a stand alone
  solution.

7
How Systems Skew Psychiatric Assessments and
Treatments

• In frustration, support providers may over-state
  symptoms to effect a strong response.
• Unrealistic expectations are sometimes placed on
  psychiatric prescribers.
• There is a tendency to look for the most powerful
  pill.
• There is the idea that using medicine is the
  easiest (cheapest?) way to fix problems.

8
Changes in Community Mental Health Services

• More money is being spent on pharmaceuticals and
  less money is being spent on mental health case
  management per client.
• Mental health caseloads have essentially doubled
  in Washington State in the past fifteen years.
• Collaboration and consultation between mental
  health case managers and prescribers for each
  client has substantially decreased.

9
Requesting Contextual Information at Appointments

• Psychiatric prescribers depend on families and
  agency staff to provide supports to individuals
  with developmental disabilities at psychiatric
  appointments.
• Patients are better served if families and/or
  support providers understand psychiatric
  treatments.
• Good care requires good sharing of information
  both ways.

10
Psychiatric Appointment Information Sheet - GOALS

• Minimize unnecessary psychotropic medication use.
• Limit the number, dose and toxicity of necessary
  psychotropic medications as possible.
• Obtain as accurate and detailed information as
  possible to make medication decisions.
• Identify treatable psychiatric conditions.
• Identify environmental, social and medical causes
  of concerning behaviors.
• Determine efficacy of existing psychotropic
  therapy.
• Identify any side effects

11
Demographic Information
Patient Name Psychiatric Prescriber Appt.
Date Person(s) Completing Form Relationship to
Patient Who else provided input? Guardian (if
any) Guardian phone Date of last visit
12
General Information

• Who is providing information?
• How well do they know the patient?
• Are there differing opinions or an agenda?
• What is the patients weight and why is it
  important?

13
Basic Medical Information
Recent Weight Date when weighed       Date of
last Blood Draw       Pharmacy Name and Phone
Number Name(s) of other involved medical
specialists (general practitioner, neurologist,
gastroenterologist, dentist, etc.)
14
Medications and Diagnosis
List all current psychiatric meds, dosages,
times administered.   List all current
non-psychiatric meds, dosages, times
administered. Current DSM Diagnosis (if
any) Axis I       Axis II       Axis III
     
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Reasons For The Appointment
Please address the following issue(s)
      Describe other efforts to address symptoms
of concern How is the client doing in
general Great OK Doing Poorly Since the
last appt. is the client doing Better Same
Worse
16
Information From Patients Support System

• How is the patient doing now?
• Has anything changed since the last appointment? 

17
Stress Related To Life Events
Loss of job Significant change in support
staff Victim of crime or assault Move to a new
residence Death in family Loss of preferred
activity Death or loss of a friend
Change in family circumstance Increased stress at
home Exposed/witness to violence Law enforcement
contact Change in physical health Medical
tests/MD visits/ER visits Other -      
18
Physiological Symptoms
Constipation Nausea/Vomiting Diarrhea Rectal
bleeding/discomfort Abdominal pain Weight
gain/loss Urinary difficulties/excess Edema/swelli
ng Chest pains Tingling/numbness
Dizziness/fainting Slurred speech Rapid or slow
pulse Stumbling/unsteady gait Stiffness Tremor/sha
king/ticks Seizures Fatigue Headache Physical
weakness Injury requiring medical response
19
Physiological Symptoms - II
Unusual facial/ mouth/eye movement Unusual
movements of extremities Drooling Dry
mouth Increased thirst Unusual tastes/smells Appet
ite change Choking on food Dental pain Change in
skin color
Rash/Itching Breast discharge Sexual function
difficulties Menstrual changes Excessive
sleepiness Loud snoring Breathing
abnormalities Wheezing or cough Sweating or
chills Hearing/vision changes Hair loss/unusual
growth Other -      
20
What Physiological Symptoms Can Tell Us

• Is the patient experiencing a medical condition
  as a potential cause of behavioral concerns?
• Is a psychotropic medication causing a
  physiological symptom?
• Is a psychotropic medication causing a medical
  condition?
• What physiological symptoms are associated most
  commonly with what psychotropic medications

21
Behavioral Symptoms
Assaultive Behavior Anger outburst(s) Sleep/awake
change SIB causing self-harm Poor attention to
hygiene Restlessness or anxiety Nightmares Suicida
l behavior Reported hallucinations Intrusive/press
ured Elopement or Wandering
Peculiar rituals Listless, low energy Criminal
activity Has dangerous friends Increased
irritability Pacing/repetitive Obsessively
organized Indiscriminate sexual
activity Excessive neediness/dependent Crying/tear
fulness
22
Behavioral Symptoms II
Substance Abuse Medication refusal(s) Changes in
food/drink intake ? interest in
activities Property destruction Talking about
death/dying Hoarding/stealing/collecting Possible
delusions/paranoia Labile, rapid change in
mood Dramatic reduction in need for sleep Poor
phone use (making 911 calls)
Isolative, withdrawn Low response, flat
affect Repeated police/ER contacts Making false
accusations Work/recreation activity
refusals Pressured/rapid speech Disorganized/tange
ntial speech Stripping/exposing self in
public Change in sexual activity Other -
23
What Behavioral Symptoms Can Tell Us

• Behavioral symptoms as side effects of
  medication.
• Behavioral symptoms associated with various
  psychotropic medications.
• Behavioral symptoms associated with various
  psychiatric diagnoses.
• When is it appropriate to treat behavioral
  symptoms with psychotropic medication?
• Which behavioral symptoms are most likely to
  respond to psychotropic medication and which are
  not?
• Why are changes in circumstance important to
  consider in making decisions about psychotropic
  medications?

24
Team Building

• Accurate psychiatric assessment and treatment of
  individuals with developmental disabilities is
  best done with a team approach.
• Detailed information sharing improves the quality
  of care.
• For a number of reasons there are powerful
  pressures on the mental health system to pursue
  efficiencies, decreasing time resources for
  adequate assessment and monitoring of psychiatric
  services.
• Formalizing ways to share information across
  systems may be a helpful structure for
  collaborations.