Transcript Document

INTEGRATED TREATMENT
OF THE COMPLEX PATIENT
MICHAEL V. GENOVESE, M.D., J.D.
MEDICAL DIRECTOR, SIERRA TUCSON
OVERVIEW
• Integrative Holistic Medicine
• Co-Occurring/Dual Diagnosis
• Professionals As Complicated Patients
• Integrative Holistic Modalities
INTEGRATIVE HOLISTIC MEDICINE
• Reaffirms relationship between practitioner and
patient
• Focuses on the whole person
• Is informed by evidence
• Makes use of all appropriate therapeutic
approaches and disciplines to optimize health and
healing
• Addresses physical, emotional and spiritual aspects
of life
COMPREHENSIVE TREATMENT
• Chemical
Dependency
Pain
• Mood Disorders
• Eating Disorders
• Trauma
• Complex Pain
Mood
Chemical
Dependency
UNIQUE PATIENT NEEDS
Chemical
Dependency
Eating Disorder
Chemical
Dependency
Pain
Mood
Trauma
PREVALENCE
• Approximately 20% of Americans suffer from
diagnosable mental illness each year
• According to the National Institute of Mental Health
major depressive disorder is the leading cause of
disability in United States for individuals aged 15 to
44 years
• 17.5% of adults with psychiatric illness have cooccurring chemical dependency = 7.98 million
FINANCIAL BURDEN
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Forbes: Most Expensive Medical Conditions
Heart Disease
Trauma
Cancer
Depression
Chronic Obstructive Pulmonary Disease
Hypertension
Diabetes
Arthritis
Back pain
BREAKING (OR PREVENTING) THE
CYCLE
Poor
Health
Mood
Addiction
Anxiety
Sleep
Patient
INITIAL EVALUATION
• Establish Rapport & Partnership
• History
• Lab Work
• Initial Treatment Plan
REWARD PATHWAY
NEUROPLASTICITY
EPIGENETICS
PROFESSIONALS AS COMPLEX
PATIENTS
• Stress
• Permissive Cultures
• Fear Induced Avoidance
• Obstacles to Accurate Diagnosis
PERSONALITY
TRAITS
ASSOCIATED
WITH HIGHER
PSYCHIATRIC
MORBIDITY
• Perfectionism
• Indecisiveness
• Self-Criticism
• Low Flexibility
• Highly Disciplined
• Idealism
• High Degree of
Empathy
Graske et al. BMJ 2003
IMPAIRED PHYSICIANS
• Compromise patient safety
• Foster medical errors
• Poor patient satisfaction
• Preventable adverse outcomes
• Undermine individual and team
communication and effectiveness
• Increased the cost of care
• Prevalence
COMMON PHYSICIAN STRESSORS
• Sitting For Exams
• Acute Environments
(ER, ICU)
• Juggling Career and
Family
• Overwork/Fatigue
• English 2nd Language
• Physical Illness
• Authoritarian
Hierarchies Intolerant of
“Weakness or Failure”
• System Issues (Morale,
Funding)
• Increasing Emphasis on
Efficiency
• Increasing
Requirements for
Formalized
Accountability
• Increasing Threats of
Litigation
• Financial Difficulties
COMMON PHYSICIAN STRESSORS
(CONTINUED)
• Decreased Long-Term
Unhurried Relationships
with Patients
• Increasing Emphasis on
“Patient Rights”
• Perceived Decline of
Status of Medicine
• Uncertainty about
Career Options
• Marital Discord
RESIDENCY TRAINING
• “Catastrophic Stress”
• “House Officer Syndrome”
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Depression (1/3 to1/2)
Episodic Cognitive Impairment
Sleep Deprivation
Chronic Anger
Pervasive Cynicism
Family Discord
Female Residents at Significantly Higher Risk of Suicide (2.5
to 5.7)
“APPARENTLY SUCCESSFUL”
• Co-workers unaware
• Other Aspects of Life Secretly Affected
ATTORNEYS AS PATIENTS
DEPRESSION
• University of Arizona Study:
• General Population
3%-9%
• Late Spring of First Year of Law School
32%
• Late Spring of Fourth Year of Law School 40%
A PROGRESSIVE PROBLEM
25
20
15
10
5
0
United States
Attorneys 2 to
Attorneys
20 years
over 20 years
% CHEMICAL DEPENDENCY WITH COOCCURRING PSYCHIATRIC DISORDER
70
60
50
40
30
Attorneys
Health Professionals
Non Professionals
20
10
0
Sweeny et al. (2004)
DR. JONES
Cc: “I feel terrible.”
HPI: Dr. Jones is a 46-year-old male who
presented with complaints of
depressed mood, anhedonia, low
energy, insomnia, feelings of guilt,
decreased appetite and generalized
anxiety. Symptoms have been present
for “several years” exacerbated over
the past six months in the context of
marital and occupational stress.
PΨH: No history of psychiatric
hospitalizations. Was treated in the
past by self with Effexor XR 75 mg QD
for anxiety and depression. Was
referred by friend to psychiatry three
years ago but never followed through.
Saw a marital therapist “three or four
times about two years ago.” No other
psychiatric history reported.
FΨH: Father, who was also a surgeon,
may have suffered with, but was never
treated for depression. Sister has
reported anxiety symptoms and Dr.
Jones believes she is engaged in
psychotherapy.
PMH: Hypercholesterolemia, Chronic
Headache, Back Pain
Soc. Hx: Dr. Jones has been married for
twenty two years and resides with his
wife, 20-year-old son and 18-year-old
daughter. He is self employed and on
staff at a local hospital. He has never
missed work due to the symptoms
referenced above. She reports social
Etoh, denies tobacco, denies illicit drug
use.
Current Medications:
Lipitor 20 mg PO QD
Ambien CR 12.5 mg PO HS PRN Sleep
Percocet 10/325 PRN Headache, Back
Pain
Previous Medications: Effexor XR as
above.
Allergies: NKDA
MSE: Dr. Jones is a 45-year-old neatly
dressed male who appears slightly
older than his stated age. His speech is
normal in rate and tone. He is coherent
but easily distracted. His mood is
“rotten” and affect is angry. He denies
any auditory or visual hallucinations.
He denies suicidal or homicidal
ideation. His short term memory is
intact as is his long term memory. His
attention is impaired, insight and
judgment are fair.
Assessment/Plan: Dr. Jones is suffering
with Major Depressive Disorder, Severe,
Recurrent, without psychotic features.
He also meets criteria for Generalized
Anxiety Disorder. Rule out Opioid
Dependence.
We discussed the following treatment
options:
BUILDING A BIGGER TOOLBOX
TREATMENT CONSIDERATIONS
• Diet
• Supplementation
• Exercise
• Pharmacology
• Psychotherapy
• Acupuncture
• Massage
• Reiki
• Neuromodulation
• Equine Therapy
• Alternative Setting
FOOD AS MEDICINE
• Individualized
• Excellent Safety Profile
• Treat and Prevent Disease
• Empowers the Patient
SUPPLEMENTS
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Vitamin D
Vitamin B
S-Adenosylmethionine
Rhodiola
Passion Flower
Melatonin/Ashwagandha
Kudzu
EXERCISE
PHARMACOLOGY
• Individualized to
Every Patient
• Education
PSYCHOTHERAPY
ACUPUNCTURE
• Depression
• Anxiety
• Pain
MASSAGE
REIKI
The root chakra is in relation
to the adrenal gland. The
navel chakra to the ovaries
or testicles. The solar plexus
chakra is related to the
pancreas. The heart
chakra belongs together
with the thymus. The throat
chakra corresponds to the
thyroid gland. The third eye
chakra has a connection to
the pituitary gland. The
crown chakra is usually
connected to the pineal
gland.
EQUINE THERAPY
NEUROMODULATION
• Neurofeedback
• Transcranial Magnetic Stimulation
• Electroconvulsive Therapy
ZERO BALANCING
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