Transcript Mental Health and the Justice System In Nevada

MENTAL HEALTH
AND THE
JUSTICE SYSTEM
IN THE SIERRAS
“Entering an Era of Great Potential
For Positive Change”
Peter Van Houten MD
2015
We Are in This Together
■ Sierra Family Medical Clinic every day works with many of the same people you do in
the justice system. We see people from all over Nevada County, as well as from
Sierra and Yuba counties.
■ Many of our patients have significant behavioral health issues including some who
have a serious mental health condition (MH) or (SMI).
■ We provide integrated medical, behavioral health and substance use services.
■ Since 2004 we have had medical providers working together with behaviorists and
have had substance use treatment onsite working collaboratively since 2009.
■ We make the best use possible of modern medical science to ensure patient
outcomes. Includes medication, tele-psychiatry, on-site counseling all fully
integrated. The “warm handoff” is used for immediate referral.
■ We are a "stigma" free zone for medical and behavioral health problems as well as
substance use treatment.
Medical Patients have
Behavioral Health Vital Signs
■
My first patient of the day is a 55 year old male with high blood pressure and diabetes, who is
a bit overweight but he has an itchy leg rash too that is his main complaint. Here for a routine
3 month follow up visit but is a bit irritable and impatient.
■
As we do at every visit he has filled out his pre-visit form which asks about physical symptoms
like chest pain, shortness of breath, fever, abdominal pain and the like. He will have his
physical vital signs done including weight, blood pressure, temperature, and pulse rate before
I see him.
■
His pre-visit form includes some routine questions about behavioral health which are his
mental health vital signs. One is, “do you feel safe at home?”.
■
What are the other mental health questions on his form? I need these BEFORE actually
seeing the patient.
■
He turned out to be depressed, his diabetes under poor control, and he had started drinking
beer again. We addressed all these issues with myself and our BH staff, and gave him cream
for his leg rash. His entire time at the clinic was under 90 minutes.
Treatment Means Hope
■ Whether someone is seen in the medical system or they dealing with the justice system
people need hope.
■ Offering genuine hope to people (with respect and kindness) is the most important thing
I have to do every day, period.
■ The vast majority of mental health disorders if recognized can be treated.
■ The vast majority of substance use disorders if recognized can be treated.
■ Not treating mental health and substance use disorders dramatically limits a person’s
chances for navigating the legal system successfully.
■ Not treating them also means higher recidivism, higher legal costs, and limits the
possibility of that person having any hope for their future.
■ Adequate treatment requires collaboration of mental health providers, substance use
treatment providers, and medical care with the justice system.
Why do people behave the way they do?
■ Everyone has a brain and central nervous system through which they
express who they are. We will see that unique expression as
demonstrated by that person’s specific behaviors.
■ A person's psychological, spiritual, moral make up are expressed
directly through the brain.
■ Everyone's brain and nervous system is unique. We are all
neurological snowflakes.
■ In the last 25 years we have dramatically improved our understanding
of the brain’s function and its role in behavior. There are still
limitations to our understanding both from imaging with tools like the
MRI and from genetics.
How our brains interpret the world
(or what about the gorilla?)
■ Our brain is our conduit for interacting with our world. It interprets reality for
us.
■ Its ability to tell us about reality is affected by internal and external factors.
■ "What about the gorilla?" and why magicians so easily fool us.
■ Video games, movies, music are all "reality" to our brains.
■ A positive emotional tone of brain function and life's experiences make things
appear positive.
■ Exact same experience may feel negative to someone with a negative brain
emotional tone.
■ External factors such as consuming alcohol, smoking cannabis, or a
threatening environment can greatly affect our interpretation of reality.
Is It Nature or Nurture that
Determines Our Behavior?
■ In this case the term nature refers to our genetic traits that are inherited.
■ Nurture refers to our life experience as we develop and go through life.
■ Both are important in determining how our brain’s function. It depends on the
individual which is predominant.
■ A person who inherits a strong predisposition to alcohol use will be at a
disadvantage as an adult even if they have a perfect upbringing and otherwise
healthy life.
■ Someone who has had a head injury or has suffered through child abuse will be at a
disadvantage even if they have great DNA which they have inherited.
Can People Change?
■ Yes, but it depends on what they're changing and also their
motivation for change.
■ Internal thought patterns (positive and negative) can cause
changes over time brain function. This is a place where
counselling can help.
■ External factors such as substance use, associating with others
(positive or negative people), head trauma, and life stress,
prescription medications can all cause change.
■ The brain is at the center of our ability to change.
The Brain is Highly Changeable:
Neuroplasticity
■ Since the early 1980s we have known the brain is highly changeable
over time.
■ Who do you want to be in six months? At two weeks cellular changes
are occurring and change accelerates, at two months structural
change can be seen on scanning, at six months changes are more
permanent.
■ Throughout our lives we are constantly creating new neurons, rewiring
our brains' nerve pathways, reassigning brain cell function depending
on need.
Neuroplasticity
■ Psychoactive substances include prescribed psychiatric medications, environmental
toxins, and recreational substances can change brain function in short and sometimes
long term ways.
■ Behavioral counseling or talk therapy helps change the brain but using different
pathways than medication.
■ Meditation 12-15 minutes a day works in yet a different way on the brain. It improves
prefrontal lobe function, quiets the limbic system, has many other health benefits. It
works on different brain pathways than counselling and medication.
■ Some brain changes are almost immediate. Think of a trauma inducing PTSD or head
injury for examples of immediate negative change. Abrupt positive change can occur as
well. Some epiphanies are real.
■ Everyone’s mirror neurons are always active. Remember, this a key to helping others
respond in the best way.
Genetic Factors
■ Tendencies toward a host of mental health disorders exist including depression,
anxiety, bipolar disorder and schizophrenia. Multiple genes may be involved in each
of these as well as external factors. There's not a single gene in our DNA for
depression, autism or schizophrenia. Understanding how genetic factors actually
express themselves is still considered very murky.
■ Multi-gene issues may play a role in “spectrum disorders”. Bipolar disorder is an
excellent example with irritability and anger issues at one end and full blown classic
bipolar at the other. Even within a family grouping there may be different levels of
expression of a specific mental health problem. Many behavioral health issues are
spectrum disorders.
■ Many chronic health issues such as diabetes, asthma, high blood pressure, bipolar,
schizophrenia have multiple genes involved and so it makes gene oriented
treatment and counselling more difficult.
Epigenetics and
Biological vs Chronological Age
■
Over the last five years we've discovered that the genes of our DNA are not all fixed in their
function. Some can change function depending on our behavior and lifestyle. This new field is
called epigenics or epigenetics. Some genes for illnesses like alcoholism, depression and
diabetes, in fact, have "on or off" positions that can be influenced by lifestyle and medical
treatment.
■
Our biological age does not necessarily equal our chronological age. The health of our DNA can be
determined by looking at the telomere endcaps on our DNA and their robustness. This can be
directly measured now.
■
Those who live in extremely unsafe environments and poverty have short telomeres and are
biologically old at age 20. A healthy 60-year-old may have telomeres that are like those of a much
younger person if they have a very healthy lifestyle. The life expectancy of white males in US is
falling. Why?
■
Those with serious mental health conditions have expected life spans into only mid 50’s. If the
have a co-occurring substance use issue it is down to mid 40’s. Effect on genetic material and
very unhealthy lifestyles contribute to this, including epigenetic factors.
The Microbiome
■ Just to make it even more complicated, our bacterial microbiome or gut
bacteria affect our physical and mental health. The significance of our
microbiome has increased over recent years.
■ The genetic material of the bacteria in our gut interact with the DNA in our
cells and can affect its function.
■ Our gut microbiome can affect mental health issues by messaging the brain
through the vagus nerve. It can also create chemical messengers that affect
the brain and other organs. It’s not clear how this all works yet. Another
place where diet and lifestyle may matter.
■ We now know that the effects of some medications are primarily because
they affect the gut microbiome. Metformin used in diabetes is a good
example.
Key Brain Structures
■ There are over 100 billion brain cells. Currently, we don't know what
about half of them do.
■ For simplicity, we will look at two specific regions of the brain and their
attendant structures. They appear to impact our behavior and
decision-making.
■ The prefrontal lobes are in the forehead and are a highly refined area
of the brain and part of the frontal lobes. Key to what differentiates
our brain from other primates, such as a chimpanzee.
■ The limbic system is deep inside the brain, is very primitive, and even
be found in much simpler animals such as reptiles.
The Prefrontal Lobes
■ The prefrontal lobes which is a subset of the frontal lobes contain the structures
that show association with the following attributes (based on brain scans, head
injury changes, among others):
■ Concentration on a task
■ Mental alertness
■ Will and perseverance
■ Cooperating with others
■ Sense of humor
■ Moral values
■ Analytical reasoning and decision-making
■ Empathy, forgiveness and kindness (may need to include anterior cingulate gyrus)
The Limbic System
■ Attendant structures include amygdala and hippocampus
■ The amygdala encodes memory based on emotion at the time recorded. This
is why we remember both positive and negative episodes if they are strongly
emotionally charged. Remember that PTSD can be an example.
■ Hippocampus extremely important in short-term memory. Think of
Alzheimer's disease.
■ Limbic system is associated with the following states:
• Primitive emotions like rage and panic
• Instinctive responses like self-preservation (fleeing a burning building)
• Is it just a foe or is it a friend too? Reward Circuitry.
Brain Structures Collaborate
to Yield Behavior
■ The prefrontal lobes have an inhibitory effect on the limbic system. They make limbic
system harder to arouse (remember rage and panic).
■ External factors can shift the focus of our function from the prefrontal lobes to limbic
system with unfortunate results. Alcohol, cannabis, methamphetamine, head
injuries all examples.
■ Being in a frightening or crisis situation can hijack our brain function. Particularly
true in PTSD. Shuts off our prefrontal lobes and can cause the limbic system to take
over function.
■ Both the prefrontal lobes and limbic system affect our hormonal system including
production of stress hormones and our autonomic nervous system including flight
and fight and the relaxation response. They contribute to a whole body response.
Age and The Brain:
How Teens are Different
■ Why rental car companies won't rent their cars to someone under 25. Increased
risk because of risk-taking and judgement issues.
■ From puberty through a person's early 20s the brain is undergoing a remarkable
restructuring that affects their behavior while this is happening. For almost
everyone this has concluded by age 25.
■ The issue of the adolescent brain functioning differently than in adults explains
much of the behavior we see in teens. Their brains are dragging them through a
transition.
■ The prefrontal lobes begin restructuring and are less effective and so normal
decision-making can be interfered with. Often their judgment will just be poorer
because of this.
■ 50% of mental health conditions begin to show symptoms prior to the age of 14.
Teens Have Different Brain Issues
■ Learning to form close interpersonal relationships is a key part of the
neurology of the teen brain. It is part of why peer approval may be more
important than parental or adult cultural approval.
■ The reward system (including dopamine) is very strong in teens and so many
forms of risky behavior are more attractive. Their thrill “high” is higher than it
will be later in life. Their decision making is somewhat impaired already
because of ongoing prefrontal lobe changes.
■ Cannabis and alcohol used casually can make serious permanent changes
in teen brain while adult brains are just transiently affected. Drugs affect
teen brains differently.
■ Suicide risk in teens only exceeded by older males. Poor prefrontal lobe
function in teens may play a role in this. Increased impulsivity a factor
particularly with starting some psychiatric medications like Zoloft.
The Aging Brain
■ For those over 60, remember their brains are aging and mild
symptoms brain aging are common. Significant short term memory
issues or new anger management can be early signs of early
dementia. Often symptoms fluctuate so initially one may only see
illness or fatigue. Remember they may need slightly more time to
process questions and hearing may be slightly decreased.
■ For everyone over 50, prescribed medications become a more
common risk for behavioral changes. A diabetic can easily end up on
over 10 medications some of which can have behavioral side effects.
■ Suicide risks are highest for males over 60 with chronic health
conditions. Often little overt warning they are considering this. Over
half use a gun to complete a suicide.
Basic Neurochemistry
■ The cells in the brain use primarily neurotransmitters which are small chemical
messengers to communicate with one another. The primary language of the brain is
chemical.
■ Several of these neurotransmitters are worth discussing because of their suspected
effects on behavior including serotonin, dopamine and the opiate receptors. There are
many, many more.
■ Serotonin has been called the "rest and fulfillment" neurotransmitter. Many
medications used in depression are SSRIs like Prozac, Lexapro, Paxil, Zoloft and
Celexa, and affect serotonin in the brain. Cymbalta, Effexor, Pristiq also effect
serotonin as well as other key neurotransmitters and have better anti-anxiety effects
and some pain relief compared to SSRIs.
■ Dopamine has been called the "reward" neurotransmitter. Release in brain is highly
pleasurable. Released when we anticipate a reward. “Romance” neurotransmitter.
Released with many addictive substances like cocaine and nicotine. Also involved in
addictive behaviors like gambling. Wellbutrin which affects dopamine works for
nicotine use and has been tried with gambling addiction.
■ Opiate receptors respond to medications like morphine, oxycodone and Vicodin. We
have internally produced opiates the beta endorphins.
Substance Use Neurochemistry
■
In medicine, we treat substance use disorders (SUD) as chronic brain diseases. Genetic and mental
health issues often underlie someone's drug use.
■
Hallucinogens like peyote and LSD cause serotonin surge throughout the brain. Tend not to be
overused.
■
Opiates like hydrocodone (Vicodin), Oxycodone (Oxycontin), morphine, hydromorphone (Dilaudid) are
highly addictive and ripe for overuse. Effect opiate receptors and dopamine. Potentially deadly.
Medical system and unexpected consequences. $4 a dose heroin available.
■
Alcohol and benzodiazepine (sedative/hypnotic drugs like Valium and Xanax) are habituating some
dopamine effects as well as antianxiety. Two alcoholic drinks a day in men and one a day in women
is the health risk threshold.
■
Methamphetamines affect multiple neurochemical pathways and are powerful stimulants.
■
The combination of opiates, alcohol and benzodiazepine can cause the central nervous system to
shut down and can be deadly (respiratory arrest.) All have withdrawal issues.
■
Most recreation drugs cause some deactivation of frontal lobes and hijacking of the limbic system.
Brain and Behavior
Many external factors can affect the brain and change behavior:
■ Head injuries can cause cognitive issues, mental health problems, and an increase
of 60% in criminal behavior. Even very minor head trauma can cause persistent
problems.
■ Substance use including alcohol, cannabis, methamphetamines, opiates and more.
■ Prescribed medications with side effects: Antihistamines, some antidepressants,
late effect from sleep medications, even local anesthetics can be sedating.
Chemotherapy brain injury can occur. Cortisone (steroid) shots for joints or back
and oral prednisone can cause unexpected manic symptoms or extreme irritability
or anger.
■ “Are you taking any medication that could affect your functioning?”
■ Lack of adequate sleep can be highly significant. Poor night’s sleep effect like mild
alcohol intoxication in its effects on driving and function. May contribute to
developing many mental health disorders.
■ Homelessness, poverty, unsafe relationships all dramatically degrade behavior.
Cheaper to provide safe housing based with services available on site?
Brain and Behavior
The are many internal health issues that can effect the brain:
■ Chronic illnesses such as diabetes where low blood sugar can make one appear
intoxicated and irritable. High blood sugars increase depression risk and lifetime risk
depression is 50%.
■ Sleep apnea (poor breathing during sleep) can cause poor mental functioning,
depression and may effect up to 20% of people to some degree. Being overweight
and older add risk and highly underdiagnosed.
■ Degenerative brain illnesses like MS, Parkinson's disease, Alzheimer dementia, and
vascular dementia as seen in diabetics and heart patients can have multiple effects
on mood and cognition. Poor impulse control and irritability common in part
because of prefrontal lobe function impairment.
■ Stroke patients seemingly fully recovered have about 70-80% chance of depression
in first year.
■ Post MI (heart attack) patients have %50+ chance of depression in first year.
■ Inflammatory conditions and the brain: Are depression, dementia and many other
mental health disorders caused by inflammatory response in brain?
■ “Do you have any health issues that could affect your functioning like diabetes?”
Legal System and The Brain
■ A life long criminal’s brain can show poor function of prefrontal lobes and an over
activity of limbic system and contributes to recidivism.
■ Area of brain concerned with empathy can be underactive.
■ Terrorists, both religious and political, can show similar patterns to what is seen in
chronic criminals.
■ Head injuries and chronic substance use related brain changes can worsen
tendencies.
■ Functioning made worse by current substance use, poverty, homelessness, life
stressors, and mental health problems.
■ Will brain imaging ever be useful in the legal system? Needs to be much better
quality and better understood to allow this.
■ Dealing with the legal system even on routine matters can be very stressful and
worsen underlying behavioral health issues. For those with mental health and/or
substance issues “cognitive intent” or “conscious intent” can become impaired by
this stress.
Behavioral Health Disorders
■
These are quite common, particularly the milder forms.
■
We screened every adult for multiple mental health issues in 2004 for a year. Sobering
results.
■
Almost 30% screened positive for depression or anxiety and often both were present
simultaneously.
■
Untreated excessive alcohol use was around 10%.
■
Bipolar screening tests used in clinics like ours are usually positive about 10% of the time.
Most have less prominent symptoms and often see 5 or more providers before getting a
diagnosis.
■
Currently, in our clinic, serious mental health conditions (MHC) undergoing treatment is about
10% including bipolar disorder, schizophrenia, treatment resistant depression and others. In
jail population MHC is likely closer to 20%.
■
In jail population those with behavioral health disorder, a substance use problem or both is
around 80%. In juvenile hall about 1/3 third of youth are prescribed psychotropic
medications.
■
Anosognosia: the unfortunate fact that as many as 50% of bipolar and schizophrenia (MHC)
sufferers have very poor insight into their abnormal behavior. Also elevated in dementia. Part
of why we have Laura’s law where they are ordered into treatment.
■
Bipolar patients can need 5-7 medications, sometime less; patients with schizophrenia can
need two or more.
Co-occurring Disorders (COD)
■ Not surprisingly many people with behavioral health issues use substances to self
medicate even it is a legal substance like alcohol. The person’s “drug of choice” may tell
you something about their underlying behavioral health issue.
■ When you first diagnose someone with a mental health disorder they may be dealing
with a substance use disorder as well and both need to be treated. It may be easier to
start treatment of their depression or bipolar problem first and then address substance
issue.
■ Their mental health problem likely started first and substance use followed later.
■ Surprisingly, some mental health care providers will simply refuse to see patients with
co-occurring substance use issues.
■ Many behavioral health care providers may ask their patients to get their substance use
treatment elsewhere even if they do treat the person’s mental health disorder and SUD
providers refer patients to other providers for mental health treatment.
■ Serious mental health condition (MHC) and co-occurring disorders hurting our local
emergency room capacity. Four fold increase in last four years for psychiatrically related
cases. Recently 10 of 18 beds in ER occupied by patients with psychiatric issues.
Importance of Screening
for Behavioral Health Issues
■ At every medical visit we screen for depression, anxiety, alcohol use, safety at home, as
well as tobacco use.
■ A simple screen for depression includes two questions. Have you felt depressed or down
in the last two weeks? Have you had less interest or pleasure in your normal activities in
the last two weeks. (PHQ 2)
■ The MINI is a more comprehensive questionnaire which includes questions about
depression, anxiety, social anxiety, anxiety attacks and alcohol use. We have modified it
to include additional questions about other substance use.
■ The most common screening tool for bipolar disorder is the mood disorder questionnaire
(MDQ).
■ Many advanced substance use screening questionnaires including the DAST.
■ Many screens for cognitive function including the SLUMS form.
Substance Use Treatment:
the Orphan of Behavioral Health
■ Mental Health and Substance Use treatment grew rather differently
and often separately.
■ Providers in these two areas frequently do not cross over: substance
use stays with substance use and behavioral health stays with
standard mental health issues. Most medical providers treat very little
except the simplest substance use issues and know little about the
options.
■ Important to get mental health provider, substance use treatment
provider, and medical provider all working together. Often there are cooccurring behavioral health problems and/or medical problems that
can complicate treatment.
Substance Use Treatment
with Targeted Medications
■ We now have improved medications for promoting abstinence in substance use
treatment of many different drugs including alcohol, opiates, nicotine, and cannabis.
■ The individual’s motivation for quitting may be the most important factor. Clearly
assessing that early in the process with motivational interviewing is key (SBIRT).
■ First, be sure to identify and begin to address any mental health issues like depression
or anxiety.
■ All of these are much more effective if substance use counseling (either individual or
group) is provided as well as medication. Remember these likely affect different
pathways in the brain than medication so there is an additive effect.
■ Teens and young adults may have different needs. May benefit from counselors more
there own age even if just peer counselors. Expected brain development changes in this
age group may present additional challenges. May not be readily employable and not
welcome at home.
■ For alcohol users there is naltrexone both an oral generic form and long-acting injectable
form (Vivatrol) which reduce the desire for alcohol. They can be administered while the
person is still drinking heavily. There are also multiple medications to help with
symptoms of alcohol withdrawal if needed in the initial phase including the
benzodiazepines like Valium.
Substance Use Treatment Medications
■ For alcohol users need to be on opiates for pain issues topiramate (Topamax) is a
surprisingly good alternative for decreasing desire for alcohol. Antabuse is a mild
medication which causes nausea if you drink alcohol and we use on occasionally.
■ For opiate abstinence Suboxone (buprenorphine) is very effective. Needs a medical
provider who has been certified to prescribe this. The certification process and
maintenance of certification makes this a hassle for medical providers and they
tend not to want to do it or really limit the size of their practice.
■ The patient has their opiates weaned somewhat if possible beforehand. They
actually come in for "Suboxone induction" having been in withdrawal for about 24
hours. The first dose of Suboxone ends the withdrawal within the first hour.
■ Patients look and feel dramatically improved within their first week of Suboxone
therapy. Very gratifying for medical providers to see people get their lives back.
Suboxone offers some pain relief which is helpful in patients that got started on
opiates because of pain management.
An Obese Diabetic
with Knee Pain
■ This is a 62 year old 300lb male with severe knee osteoarthritis who really needs
knee replacements because of worsening pain. His orthopedist will not do his
surgery until he loses 50 lbs and has excellent control of his diabetes. He really
can’t exercise. Today he tells me he has been reducing his pain with 6-9 beers a day
for the last 4 months. Vicodin works but he can’t afford to buy on street. He feels
hopeless and very depressed. What do I do?
■ Counselling including suicide risk prevention done today. Start an antidepressant
like Cymbalta today. Ask him to hold drinking to a 6 pack per day. Add hydrocodone
tablets three times a day for pain. I will see him weekly as will or BH staff.
■ At next visit he is more comfortable, less depressed, and drinking 4 beers a day.
Can’t use naltrexone so start topiramate and titrate dose until he is off alcohol.
■ At week 4 he is off alcohol, on 4 hydrocodone daily, losing weight. Diabetes is doing
well. No longer depressed. Has been going to AA and has met with substance use
counsellor. Smiles for the first time.
Substance Use Treatment
■ Methadone maintenance therapy with high-dose methadone is still used but is being
replaced by Suboxone. US is behind in this transition. Basically the high-dose
methadone given daily overwhelms the opiate receptors and makes other opiates
less likely to have an effect. (Methadone is a high risk medication to work with and
very long acting.)
■ Naltrexone also works as a good abstinence drug (blocks effects of opiates) for low
risk individuals with occasional impulsive use. Opiates will have no effect when
someone is on naltrexone.
■ Methamphetamine use is difficult to treat. Naltrexone has shown promise in at least
one study. Using a mild stimulant like Provigil (mondafinil) is reasonable as a
replacement. Wellbutrin which has dopamine effects can also be tried.
■ People using cannabis can often be helped with anxiety specific agents like Valium
to help transition off cannabis.
Where Do We Go
From Here?
■ Mental health and substance use treatment must be considered necessary support of
the justice system.
■ Full time behavioral health provider on justice system staff for triage and advice. Best
consultations are “real time”.
■ Directly addressing mental health and substance use issues in individuals:
■ Will make working with them easier
■ Will make the system more efficient (medical providers find about 10% improvement in
efficiency when these are addressed regularly.)
■ It will reduce costs.
■ Collaboration is the key. All pertinent stakeholders should be involved in planning.
Remember, sometimes smaller organizations may offer more and should be kept at the
table.
Contact Information
Peter Van Houten MD
Sierra Family Medical Clinic
530-292-3478
Main Number
[email protected]
Welcome questions as well as feedback on today’s talk
Follow me on Twitter: Peter Van Houten MD
Lael Walz can be contacted at our main number