Transcript Document

Setting the Stage for Change
Behavioral Health Regional Training
Chad Morris, PhD
June 20, 2012
Santa Rosa, CA
Behavioral Health & Wellness
Program (BHWP)
Education
Evaluation
Research
Policy
Change
BHWP
Clinical
Care
www.bhwellness.org
A Wellness Philosophy
Leading a meaningful and fulfilling life through
conscious and self-directed behaviors, focused
upon living at one’s fullest potential
A Wellness Philosophy
Wellness is a multifaceted approach
made up of eight dimensions.
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Emotional
Environmental
Financial
Intellectual
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Occupational
Physical
Social
Spiritual
This is a Critical Issue
What is killing the
majority of us is not
infectious disease,
but our chronic and
modifiable behaviors
This is a Critical Issue
On average, persons
diagnosed with mental
illnesses and addictions
have higher rates of
disease and disability, and
die up to 25 years earlier
than the general population
Modifiable Behaviors
TOBACCO USE
Burden of Tobacco
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443,000 tobacco-related deaths in the U.S.
each year
 6 million tobacco-related deaths worldwide
each year
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8.6 million people living with tobacco-related
chronic illness
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50,000 deaths each year in the U.S. due to
second-hand smoke exposure
U.S. Trends in Adult Smoking
Males
19.3% of adults
are current
smokers
Females
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population
Survey; 1965–2007 NHIS. Estimates since 1992 include some-day smoking.
California Smoking Prevalence
70
63.5
Percentage of Population
60
50
40
30
20
23.4
13.1
10
0
Smoking Status
Current
BRFSS 2009
Former
Never
Adult Cigarette Use
But …
There were no changes for persons with
behavioral health conditions
Behavioral Causes of Annual Deaths
in the United States
450
435
400
365
350
* Persons with behavioral
health disorders
300
250
200
*
150
85
100
50
43
20
29
*
17
0
Sexual
Behavior
Alcohol
Motor
Vehicle
Guns
Drug
Obesity/ Smoking
Induced Inactivity
Cause of Death
1
Tobacco Use Among Persons with
Behavioral Health Conditions
Persons with behavioral health conditions are:
 Are nicotine dependent at rates 2-3 times
higher;
 Represent over 44% of the U.S. tobacco
market;
 Consume over 34% of all cigarettes smoked.
Tobacco Use by Diagnosis
Schizophrenia
62-90%
Bipolar disorder
51-70%
Major depression
36-80%
Anxiety disorders
32-60%
Post-traumatic stress disorder
45-60%
Attention deficit/ hyperactivity disorder
38-42%
Alcohol abuse
34-80%
Other drug abuse
49-98%
Contributing Factors
TOBACCO USE
Dopamine Reward Pathway
Prefrontal
cortex
Dopamine release
Stimulation of nicotine
receptors
Nucleus
accumbens
Ventral
tegmental area
Nicotine enters
brain
Nicotine Effects
Receptor Activation
Withdrawal Symptoms
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Increase arousal
Heighten attention
Influence stages of sleep
Produce states of pleasure
Decrease fatigue
Decrease anxiety
Reduce pain
Improve cognitive function
Mentally sluggish
Inattentive
Insomnia
Boredom and dysphoria
Fatigue
Anxiety
Increase pain sensitivity
Decrease cognitive function
Most symptoms:
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Appear within the first 1–2 days
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Peak within the first week
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Decrease within 2–4 weeks
Medications Known or Suspected To Have Their Levels
Affected by Smoking and Smoking Cessation
ANTIPSYCHOTICS
Chlorpromazine (Thorazine)
Olanzapine (Zyprexa)
Clozapine (Clozaril)
Thiothixene (Navane)
Fluphenazine (Permitil)
Trifluoperazine (Stelazine)
Haloperidol (Haldol)
Ziprasidone (Geodon)
Mesoridazine (Serentil)
ANTIDEPRESSANTS
MOOD STABLIZERS
ANXIOLYTICS
OTHERS
Amitriptyline (Elavil)
Fluvoxamine (Luvox)
Clomimpramine (Anafranil)
Imipramine (Tofranil)
Desipramine (Norpramin)
Mirtazapine (Remeron)
Doxepin (Sinequan)
Nortriptyline (Pamelor)
Duloxetine (Cymbalta)
Trazodone (Desyrel)
Carbamazepine (Tegretol)
Alprazolam (Xanax)
Lorazepam (Ativan)
Diazepam (Valium)
Oxazepam (Serax)
Acetaminophen
Riluzole (Rilutek)
Caffeine
Ropinirole (Requip)
Heparin
Tacrine
Insulin
Warfarin
Rasagiline (Azilect)
Tobacco Use Affects Treatment
& Recovery from Addiction
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Addressing tobacco dependence
during treatment for other substances
is associated with a 25% increase in
long-term abstinence rates from
alcohol and other substances.
Smoking cessation has no negative
impact on psychiatric symptoms and
smoking cessation may even lead to
better mental health and overall
functioning.
Pictures property of Eric Belluche
Cessation Concurrent with
Mental Health Treatment
Smoking Prevalence Among
Mental Health Providers
30% - 35% of mental health providers smoke as
compared to:
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Primary Care Physicians 1.7%
Emergency Physicians 5.7%
Psychiatrists 3.2%
Registered Nurses 13.1%
Dentists 5.8%
Dental Hygienists 5.4%
Pharmacists 4.5%
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Boredom
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Self-identity
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Lack of recovery
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Expectation of failure
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Fear of withdrawal symptoms
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Coping with tension and anxiety
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Fear of gaining weight
Pictures property of Eric Belluche
Barriers to Tobacco Interventions –
Personal Factors
Tobacco Industry Targeting
 Tobacco companies sought out individuals
with limited resources to cessation services.
 Promoted smoking in treatment settings.
 Monitored or directly funded research
supporting the idea that individuals with
schizophrenia need to smoke to manage
symptoms.
Why Community Treatment
Settings?  Experts in behavioral change
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Duration of treatment
Therapeutic alliances
Co-occurring treatment
Integrated and health home models
Access to high risk populations
Community-based and patientdirected
 Complements other prevention and
wellness activity
 Performance measure
Why Community Treatment
Settings?
Services should be integrated at
the point of delivery, actively
involve patients as partners in their
care, and be coordinated with other
community resources.
-CBHC, 2010
The Limits to Knowledge
© 2012 Behavioral Health and Wellness Program, University of Colorado
Creating
Habits
Cue
Routine
Reward
© 2012 Behavioral Health and Wellness Program, University of Colorado
Integrated Health Care Continuum
Autonomy
(Separation of Parts)
Coordination
Integration
(Relation of Parts)
(Combination of Parts)
Policy + Co-Location ≠ Integration
Wellness as a Cultural Bridge
Where Does Behavioral Health Fit?
Health
Plans
Medicaid
Primary
Care
Hospitals
CMS
Federal
Legislation
State HIT Plan/
Other Infrastructure
Health
Homes
FQHCs
Employers
REC
Behavioral
Health?
ACOs
Chronic Care Model
Community
Resources and Policies
SelfManagement
Support
Informed,
Activated
Patient
Health System
Health Care Organization
Delivery
System
Design
Decision
Support
Productive
Interactions
Outcomes
Improved Outcomes
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Rapid Improvement
Find a Process to Improve
Organize to Improve the Process
Clarify Knowledge of the Process
Understand Sources of Process Variation
Select the Process Improvement
Act
Plan
Study
Do
F.O.C.U.S. Questions
AIM: What are we trying to
accomplish?
MEASURES: How will we
know that a change is an
improvement?
IDEAS: What changes can
we make that will result in an
improvement?
Contact Information
Chad Morris, PhD
Director, BHWP
303.724.3709
[email protected]
University of Colorado
School of Medicine
1784 Racine Street
Mail Stop F478
Aurora, CO 80045