1. www.pspbc.ca Adult Mental Health Module An Organized Approach to Mental Health Issues in Realistic Time Learning Session 2 2015 www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

2. 2 Housekeeping www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

3. 3 Learning Session Activities 1.Share experiences 2. Patient feedback 3.Coach report 4.Algorithm tricks 5.DAI 6.Patient advocate 7. Break 8.Anxiety tips 9. ASW MOAs billing and scheduling (30 min) 11.Brief action planning 12.Evaluations, AP review Welcome and Agenda

4. Sharing our experiences www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

5. Questions to consider – 20 min.

6. PSP Coordinator: Participant Feedback on Algorithm

7. Participant Feedback Problem List

8. Participant Feedback Resource List

9. Participant Feedback Problem List Action Plan

10. More algorithm practice Algorithm Tricks -Dr. Egan 10

11. Algorithm Tool Role plays Paired practice 10 min. each round 10 minute highlights from each pair

12. More on using the CBIS Tools

13. Ways to stick with the status quo! Don’t do it until you feel like you have mastered the material Not giving yourself enough time Not having materials at the ready Not having worked out a booking strategy with your MOA Not figuring out how to use billing codes Avoidance as a way of dealing with anxiety

14. Compare to a regular office visit Complex physical Requires planning ahead Takes more time Holds up an exam room Is more involved and complicated Needs forethought to have supplies ready Takes practice to feel comfortable doing Mental health care Requires planning ahead Takes more time Holds up an exam room Is more involved and complicated Needs forethought to have supplies ready Takes practice to feel comfortable doing

15. So why take the time? Complex physical You might miss something if you didn’t schedule the time and do a thorough exam Mental health care You might miss something if you didn’t schedule the time and do a thorough exam

16. Mental health care in the family doc’s office: It’s a balancing act Expediency of handing something out versus Increasing likelihood the patient will follow through and truly benefit

17. Mental health care in the family doc’s office: It’s a balancing act Investing the time to build the supportive relationship at the beginning or Spending the time dealing with patients who feel you don’t get it

18. Am I missing something? Part 1 Could there be a confounding factor in patient’s life? Try problem list to find what else might be going on

19. Am I missing something? Part 2 Am I sure about the diagnosis? Co-morbidities? Try Diagnostic Assessment Interview to find what else might be going on

20. Diagnostic Assessment Interview Structured approach to symptoms of most common mental illnesses Screens for co-morbid disorders

21. S2IGICAPS A2GS P3OMP2 CAGES DAI ACRONYM

22. I don’t have the time! Not for every patient Don’t do it on the fly- book time Can be done in a. 2 counseling visits b. 1 counseling visit finishing off with MH planning visit c. 2 office visits d. 1 office visit finishing off with MH planning visit Practice does make it quicker Be realistic – you are probably spending a lot of time with these patients already- this just makes the time productive

23. What if “stuff comes out”

24. 24  Be empathetic and genuine  “ That helps me understand why you are feeling the way you do”  “ It makes sense that you are struggling with that”  “ How much do you think this is playing a role in your depression/anxiety?” * Rogers, C. A Way of Being, Boston, Mass: Houghton Mifflin: 1980 Hall JA. Roter DL, Katz NR: Meta analysis of correlates of provider behavior in medical encounters. Med Care. 1988;26:657-75 Dorr Goold S, Lipkin M: J Gen Int Med Vol 14, Jan (Supplement 1) 1999The Doctor- Patient RelationshipL Challenges, Opportunities and Strategies Listening and Hearing IS treatment! *

25. Youtube Video Its not about the nail: http://www.youtube.com/watch?v=-4EDhdAHrOg

26. Patient Feedback Patients really said 1.If someone had asked the questions, my bipolar would have been diagnosed 4 years earlier 2.If someone had asked the question about sexual abuse, my PTSD would have been diagnosed 50 years earlier! 3.If I feel heard, I can wait a while for an appointment, I won’t keep pushing for an appointment 4.If someone comes in with chest pain, would you send them home to to their own physical? Family docs are left to manage the patient anyway during the long wait for specialist access Sending to ER rarely resolves the need to manage the patient

27. Demonstration of DAI Watch for how it is introduced Intentional closed questions Ask patient to help you be as efficient as possible

28. Your turn- Practice DAI in dyads 10 min each Each patient has a reason why they haven’t improved to date Using the DAI- figure out why you and patient are stuck Don’t assume one problem only 20 min for this activity – switch roles half way through Go easy on each other !

29. Diagnostic Assessment Interview

30. 30 www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources Perspective

31. Break (MOAs to ____ )

32. Tips for working with Anxious Patients

33. Clinical pearls Don’t rush to treat anxiety after upsetting events Encourage patient to stay in usual roles and not start to avoid Attempting something new will increase anxiety first

34. You can’t go around anxiety to get over it You have to go through it!

35. Avoider Teach breathing Break activity into very small steps Start with easiest step Stay with the activity until the anxiety has peaked and then goes down

36. Worrier To generate worry and anxiety – tell yourself “For sure something bad will happen and further…I won’t be able to cope…at all!”

37. Help for the worrier Be realistic about the likelihood the feared thing will happen “It’s possible but not definite” And give yourself credit for how you have coped in the past “ I may not like it but I will find a path through somehow”

38. Print from algorithm Print on demand ($10) www.carmha.ca/publications under Self Care Translations: French Chinese Punjabi Versions: Adolescent Workplace 38 CARMHA

39. 39 39 Find a Starting Point

40. 40 40 Free download of relaxation training audiofile: www.comh.ca/pchc/ Pt is anxious/tense Special Bonus Skill: Relaxation

41. Common Steps to Using All Options www.gpscbc.ca/psp-learning/ adult-mental-health/tools-resources Identify appropriate case: PHQ 2,9, GAD 7, PL, PLAP, SAQ, DSM Bipolar? Possible comorbid confounders? Do the DAI Explain the Depression/Anxiety Model and explain SSM

42. www.gpscbc.ca/psp-learning/ adult-mental-health/tools-resources Explaining the depression model Situation

43. 43 43 SITUATIONS Loss Conflict Isolation SITUATIONS Loss Conflict Isolation THOUGHTS Harsh self- criticism Over-pessimistic Catastrophic about future THOUGHTS Harsh self- criticism Over-pessimistic Catastrophic about future PHYSIOLOGY  Altered sleep  Low energy  Δ brain chemistry PHYSIOLOGY  Altered sleep  Low energy  Δ brain chemistry ACTIONS  Withdrawal  Reduced activity  Poor self-care ACTIONS  Withdrawal  Reduced activity  Poor self-care EMOTIONS  Sadness  Despair  Numbness EMOTIONS  Sadness  Despair  Numbness Step 1: Recommend the Workbook Problem Solving Behavioural Activation Realistic Thinking

44. Anxiety Model Magnifying fear = Increased anxiety Minimizing coping Something terrible will happen = Increased Anxiety I won’t be able to cope

45. 45 Steps to using CBIS skills www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources Identify appropriate case: PHQ9, GAD 7, DAI, PLAP, SAQ, symptom driven Introduce self-management, recommending CBIS skills : Explain the Depression Model, anxiety equation Help patient find a starting point: PL, PLAP, Symptoms, SAQs which skills seem most relevant = Activation for patient who has become inactive/isolated Relaxation for patient who is angry, tense, overwhelmed, panicky, anxious etc Anxiety skills for specific anxiety disorders Cognitions or realistic thinking for patient who expresses overly negative evaluation of self, situation and future Lifestyle for patients not sleeping eating exercising enough Set homework eg: Using the antidepressant activity handout, negotiate one small activity goal which patient believes he can do with 75% chance of success. Subsequent visits Subsequent Sessions: “How did the homework go?” Other goals?

46. 46  Steps to using Bounce Back Program www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources Identify appropriate case: PHQ9, DSM, PL, PLAP, SAQs Bipolar? Comorbid confounders? Do the DAI Explain the CBT Model and SSM Introduce Bounce Back program Hand out BB DVD, schedule visit to discuss and see if patient is interested in the telephone coaching component Use referral form to refer to Bounce Back program, tell patient that patient will be contacted by coach and started Consult with BB coach as needed

47. 47 Steps for using the ASW www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources Identify appropriate case: PHQ9, DSM, PL, PLAP, SAQs Bipolar? Comorbid confounders? Do the DAI Explain the CBT Model and SSM If higher functioning, more literate, recommend the ASW Help patient find a starting point which skill seems most relevant = Behavioural Activation Problem Solving Realistic Thinking Set homework patient believes he can do with 75% chance of success.. Subsequent sessions: “How did the homework go?” Other goals?

49. PHQ-9 “ Are you heading in the right direction?”  If Question 1 and 2 are both not “more than half the days” you cannot make the criteria for major depressive disorder… you may consider a different diagnosis or screening tool

50. Top ten tips measure “D and A”  1. phq-9 numbers are useful feed  back for patient... Tell them we have  2 minutes to answer all the questions  please give me your best guess..  Do not elaborate,immediately ask the  next question before there is time to  deliberate previous answer... It is easy  to move to gad-7 afterwards by saying  another quiz same “best guess”

51. 2. Major depression disorder and Generalised Anxiety Disorder

52. NO. 2 D and A “system wide crash”  You made a diagnosis of depression and anxiety.... no time to take it much further......  Use as check list..  Depression “ system wide crash” or anxiety “system wide explosion” check positives off give it to them and empathise that you can see they are having a tough time and would like to set up another appointment to do more work on this..........Validation and Empathy powerful support.

53. No. 3 high anxiety  For anxiety and Panic type of symptoms  Use box breathing... Get good at it and teach them how to do it and to practice it.

54. NO.4 Resources  Your patient is..”burnt out” and overwhelmed and not coping very well....  Use resource list have them list qualities which defines them..Internal and external make it personal.. Fill it out with them and give it to them to take home and read every time they are “ stuck/overwhelmed”

55. No6. Safety first

56. No.5  Suicide safety plan  Get them started on it and make them bring it home and share it with their main support person

57. No 6.  When our Patient needs “activation”  The antidepressant activities log.. This is brilliant....simple very easy and very effective  Always ask to review it

58. N0. 7  Negative thinker  Realistic thinking work sheet  -thought change worksheet-  The driving and stop sign analogy

59. NO. 8  Sleep  Lifestyle sleep hand out  Get up same time 7 days a week use calendar to log and rate quality and review  Try to get to bed before certain agreed time.. Document  Animal alphabet

60. No.9  For selective populations  Bounce back, antidepressant skills work book and mood gym moodshift app are fantastic  Explain the resource briefly and honestly and then ask how committed they are to pursuing this resource out of 10............ 7 or higher is needed...  Your interest in them trying this may be higher than theirs

61. No. 10 “ Doctor- patient relationship”  Listening and hearing IS treatment

62. No.10  As their gp.. Remind them you are invested in their physical emotional and social well being you are in their “corner” and routing for them.  You have history and an established longitudinal and caring relationship and are in a very strong and privileged position to engage and get buy in...use this. Believe in yourself,your patients trust and believe in you.  You are set up to be successful

63. Finally “The Mental Health Algorithm”  Get to know your algorithm well it is a fantastic resource and it will do an enormous amount of good work and provide you with tremendous feedback and professional satisfaction.

64. Case examples

65. Background and context….. How are you?....................Terrible.!  Self employed IT guy builds web sites and makes multimedia promotions advertisements…weddings etc  Business is slow….. Very few repeat customers.. He is swimming in debt.. Living month to month does not know where his next monthly rent will come from.. Married with family of three wife stay at home mom looks after their autistic child. She is very caring supportive and a great mom..  He feels anxious all the time cant sleep well poor motivation, cranky, tired no energy

66. Assessing and planning  Got to the point that he really didn’t care any more..  He snores and his wife has to sleep with their autistic child he is restless and she cannot sleep with the loud snoring.  He has not seen a physician in five years  Bp is 130/80 bmi is 29 pulse is 80/min  General physical exam is normal  Phq -9 is 19 with 1 on q9 gad -7 is 16  Order routine bloods cbc, fbs, lipids, tsh, urine acr

67. Lets get down to business……  Also over night oximiter booked …? Osa  Provisional dx gad (over 6 months and depression meets the axis 1if medical tests are ok)  Plan  Supportative psychotherapy..validation and empathy….(postural mirror)  Collaboration on plan..-involve wife with cbis tools- a/s  Cbis tools …. Anxiety system wide crash.. And thought change and realistic thinking tools..  Also started on sertraline 50mg a day.. Follow up in 2 weeks  As he left he had tears welling up and he smiled and said how grateful he felt…..

68. 68 Impact of using the tools: Dr. Egan’s Renewed Practice Visit 1 PHQ9/GAD & PL/RL Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year Visit 2 Review PL/RL & create Action Plan, choose Skill sheet Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year Visit 3 Review and add ASW (pt may choose Bounce Back too) Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year Visit 4 May need more in depth Diagnostic Assessment Interview

69. 69  Visit 4 May need more in depth Diagnostic Assessment Interview Bill 14043 MH planning fee, and after this is billed, this generates 4 more counseling visits giving access to 8 prolonged visits in one calendar year in addition to the planning visit 14043 worth $100 once a year. Plan must include a screening assessment and a planning document to keep on chart. If you take 2 sessions to do this bill 00120 for first and 14043 for second giving you the time to discuss with patient easily. More about Visit 4 69

70. 70 DAI 2 counseling visits 00120 x 2 1 counseling visit finish with MH planning fee 00120, 14043 Problem List Action Plan Counseling visit 00120 Skills Office Visit 00100 Tel Fup 14079 Telephone Consultation with Community professional or BB coach 14077 or 14016 MSP Compensation

71. Confirm patient population Locate tools on algorithm Begin trying out tools Review use of MH Log Sheet Confirm MOA role Billing questions/tech assistance Review Log Sheet progress Use of DAI Use of other resources Discuss optimal office flow (include MOA) Overview of aims, CBIS, ASW Bounceback and practice finding the tools (Scavenger Hunt) Log sheet/AP requirements Billing and EMR optimization Develop an action plan Share experiences (good & bad) w peers DAI Use of tools Log sheet/AP requirements Update action plan Share experiences Use of tools Community Resource Cafe Troubleshoot issues for sustainability & improvement Sustainability Plan AP1AP2Pre-visit Month 0Month 7-8 Sustain Survey-barriers, desires Orientation to Algorithm, Review use of MH Log Sheet Location of tools on algorithm Confirm use of EMR Ongoing Support CME Post Module Reflective Questionnaire (mid-March) Plan Your Pathway

72. Planning: Action Period 2 Replace this box: With your practice ideas: Scheduling options Create/Review patient registry Select specific patient criteria…complex care, migraine, others? Organize relevant resources – forms, booklets, other materials Identify changes to work processes and office re-design Record overall progress on log sheets MOA could do check in calls to see if patients have completed PL/RL

73. Successful planning for achieving Action Period activities Successful planning for achieving Action Period activities

74. PSP Mental Health Log

76. Paperwork Learning Session Evaluation KEEP Invoices to FAX to Doctors of BC (FAX # at lower R side)

77. 77 www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources ACTION PERIOD PLANNING

78. Thank you www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

79. 79