#APAAM2016
psychiatry.org/annualmeeting
ANNUAL MEETINGMay 14-18, 2016 • Atlanta
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PRIMARY CARE SKILLS FOR PSYCHIATRISTSAmerican Psychiatric Association Annual Meeting
Atlanta, Georgia
May, 2016
Primary Care Skills for Psychiatrists
APA/AMP 2014: Primary Care Skills for Psychiatrists 2
a collaboration of:
APA Workgroup on Integrated CareLori Raney, MD (chair)Medical Director, Axis Health Systems Dolores, Colorado
Aniyizhai Annamalai, MDInternal Medicine/Psychiatry
Jae Han, MDFamily Medicine/Psychiatry
Robert McCarron, DO Internal Medicine/Psychiatry
Jeffrey Rado, MD Internal Medicine/Psychiatry
Erik Vanderlip, MD MPHFamily Medicine/Psychiatry
Martha Ward, MD Internal Medicine/Psychiatry
Faculty
Disclosures…
New resources are available now!
&
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Agenda
• 9-9:50:
• 10-1020 hr:
• 1020-1040hr:
• 1040-1100 hr:
• 1100 to 1200 hr:
• 1200 to 1 PM hr:
• 100 – 120
• 120 - 140 hr:
• 140-200 hr:
• 2-3 PM hr:
• 3-4 PM hr:
APA/AMP 2014: Primary Care Skills for Psychiatrists 4
• Introduction, background
• HTN
• Obesity
• Cholesterol
• Cases on HTN, Obesity, Cholesterol
• Lunch
• Diabetes
• Tobacco
• Preventive Medicine
• DM, Tobacco, Prevention cases
• Collective group discussion
First: Survey!
APA/AMP 2014: Primary Care Skills for Psychiatrists 5
Lastly: Survey!
APA/AMP 2014: Primary Care Skills for Psychiatrists 6
Same Number!!!
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INTRODUCTION AND BACKGROUNDLori Raney, MD Medical Director, Axis Health Systems Dolores, Colorado
Erik R. Vanderlip, MD MPHUniversity of Oklahoma School of Community [email protected]
Integrated Care is a Two-Way Street
Mental Health Services
Mental Health Services
Primary Care Services
Primary Care Services
“reverse integration”
This Talk Focuses on Part II
1. Why?
2. What?
3. When?
4. Where?
5. Who?
Mental Health Services Primary Care Services
“reverse integration”
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Why?
1. History
2. Morbidity
3. Access
DECADE OF THE BRAIN
1990 – 1999July 17, 1990
Now, Therefore, I, George Bush, President of the United States of America, do hereby proclaim the
decade beginning January 1, 1990, as the Decade of the Brain.
Decade of the Brain from the Trenches
AntidepressantsSecond Generation
Antipsychotics
• 1987 –fluoxetine
• 1989 – citalopram
• 1989 - bupropion
• 1992 – sertraline
• 1992 - paroxetine
• 1993 – venlafaxine
• 1993 – fluvoxamine
• 1991 – clozaril
• 1994 – risperidone
• 1994 – olanzapine
• 1995 – quetiapine
• 2001 – zisprazidone
• 2002 – aripiprazol
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“First, Do No Harm”
*4–6 week pooled data (Marder SR et al. Schizophr Res. 2003;1;61:123-36; †6-week data adapted from Allison DB,Mentore JL, Heo M, et al. Am J Psychiatry. 1999;156:1686-1696; Jones AM et al. ACNP; 1999.
Estimated Weight Change at 10 Weeks on “Standard” Dose
6
We
igh
t C
ha
ng
e (
kg
)
54
3
21
0
-1-2
-3
13.2
We
igh
t Ch
an
ge
(lb)
11.08.8
6.64.42.20-2.2-4.4-6.6
*
ADA/APA Screening Guidelines for Second Generation Antipsychotics
American Association of Clinical Endocrinologists, North American Association for the Study of Obesity: Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004; 27:596–601
History: The Beginning
Circa: 2006
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History: The Beginning
National Association of State Mental Health Program DirectorsOctober 2006
Why?
1. History – How we got here…
2. Morbidity
3. Access
Cardiovascular Disease Is Primary Cause of Death in Persons with Mental Illness
*Average data from 1996-2000. Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited].
Per
cen
tag
e o
f d
eath
s
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Nasralla, et al Schizophrenia Research 2006
Rates of Non‐treatment
Cardiometabolic Risk in Patients With First‐Episode Schizophrenia Spectrum Disorders: Baseline Results From the RAISE‐ETP StudyChristoph U. Correll, MD et al.JAMA Psychiatry. Published online October 08, 2014.
• 394‐patients with schizophrenia, prospective enrollment
• – mean age 24 –
• half were overweight or obese,
• nearly 60% had abnormal lipid levels,
• half had above‐normal blood pressure or overt hypertension,
• Even though “some of these factors were likely related to antipsychotic medications patients had taken, the researchers concluded that the illness itself and associated ‘unhealthy lifestyles’ also played major roles.”
Predicting Cardiovascular Risk
PRIMROSE: Osborn et al JAMA Psych 2015 72(2): 143‐51.
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High Medical Burden of Disease
• Persons with SMI have an accelerated mortality and medical burden compared with the general population– Some estimates are 10-25 years (Colton & Manderscheid, 2006)
– For all adults with any mental illness, it is 8 years (Druss, Zhao, & Esenwein, 2011)
• This mortality gap between those with SMI appears to be widening over time in some groups– In Sweden they’ve found an overall 1.7 fold increase from 1976 to
1995 for men, and 1.3 fold increase for women with schizophrenia (Osby, Correia, Brandt, Ekbom, & Sparén, 2000)
Mental Illness and Mortality
Mortality Risk:
2.2 times the general population
10 years of potential life lost
8 million deaths
annually
Walker, E.R., McGee, R.E., Druss, B.G. JAMA Psychiatry. Epub, doi:10.1001/jamapsychiatry.2014.2502
• The leading causes of this w i d e n i n g g a p are:1. Cardiovascular/ischemic heart disease (Osby 2000), (Crump
2013)
2. Cancer (Crump 2013)3. Suicide (Obsy 2000)4. Accidental death (Osby 2000)
• Persons suffering with SMI are at risk for a number of other medical co-morbidities– High risk of infectious/communicable disease (McQuistion 1997,
Pirl 2005)– High risk of respiratory illness (DeHert 2011)– High risk of dental disease (DeHert 2011)
• Very nice review available from DeHert, 2011 and NASMHPD 2006 Mind the gap.
High Medical Burden of Disease
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Why?
1. History
2. Morbidity
3. Access to quality care
Patient Level Factors
Lack of motivation,apathy
Cognitive Impairment Lack of perceived
need for health care
Fear and DistrustPoor social, communication skills
Comorbidity
Provider Level Factors
Lack of Knowledge about specific disorders
Attribute physical sx to mental illness and miss the problems
Why bother?“Just treat the Schizophrenia and leave the rest”.
Fear and Distrust Discomfort
Lester HE. BMJ, doi.1136/bmj.38440.418426.8F 2005
Take too long, high no-show, impacts bottom line
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The Need for Better Medical Care• Persons with SMI frequently do not get the care they
require– CVD:
• Those with schizophrenia post-MI were significantly less likely to get reperfusion therapy or evidence-based pharmacotherapies, accounting for a significant portion of their 1-year mortality (Druss 2001)
• Adults with schizophrenia admitted to a hospital with confirmed MI were 41% as likely to receive a catheterization (Druss, JAMA, 2000)
– Cancer:• Lower screening rates of colorectal, breast, prostate than cervical, but
all low overall (Xiong 2008)
– Infectious Disease:• Lack overall screening (Goldberg 2004)
• Lack overall vaccinations (Druss 2010)
Crump 2013
Women, Schizophrenia WITH a diagnosis of CAD
Women, Schizophrenia WITHOUT dx of CAD
Gap due to recognition
The quality of care may contribute to a significant portion of this mortality gap.
Average Life Expectancy in US: 78.2 years
Life Expectancy in US of those with any Mental Illness: 70 years
Life Expectancy with SMI: 55 years Mortality Gap
Care
Portion of Gap Attributable to Access and
Quality Care
~12 Years
Putting it Together
Intervention
This Talk Focuses on Part II
1. Why?
2. What?
3. When?
4. Where?
5. Who?
Mental Health Services Primary Care Services
“reverse integration”
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What?
1. Overcoming Access Issues to…
2. Lower morbidity
Improving Access to Care: Models
1. PCARE study
2. PBHCI Grantees
3. 2703 Medicaid State Plan Amendments -Missouri
4. HOME study
5. Certified Community Behavioral Health Clinics (Excellence in Mental Health Act)
32
Programs Generally Contain 3 Major Components:
Primary Care Services
Care Management and Tracking
Health Behavior Change
33Kern, in Integrated Care: Working at the Interface of Primary Care and Behavioral HealthLori E. Raney, MD, editor. American Psychiatric Publishing, October 2014
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PCARE: Care Management Roles
• RN/LCSW
• Facilitates patient engagement
• Identification and targeting of high-risk individuals
• Monitoring of health status and adherence –tracking outcomes in registries
• Staff and patient education
• Development of treatment guidelines
• Individualized planning with patients
• Tracks care transitions
PCARE: PC Access, Referral and Eval.
Usual CareIntervention
Group
Preventive Services 21.8% 57.8%
CardiometabolicInterventions 27.7% 34.9%
Have Primary Care Provider 51.9% 71.2%
Framingham Risk Index 9.8% 6.9%
Druss BG, et al. Am J Psychiatry. 2010;167(2):151-159.
PCARE: RCT, Atlanta, GA: 407 SMI over 1 year
Improving Access to Care: Models
1. PCARE study
2. PBHCI Grantees
3. 2703 Medicaid State Plan Amendments -Missouri
4. HOME study
5. Certified Community Behavioral Health Clinics (Excellence in Mental Health Act)
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UT(1)
AZ(1) NM
WY
MT ND
SD
NE (1)
KS
OK(4)
TX(3)
LA(1)
AR
MO
IA
MN
WIMI(1)
IL(5)
IN(6)
KY (1)
WV(2)
OH(7)
MD (1)
OR(2)
CA(11)
AK(2)
HI
NV
ID
WA(3)
CO(4)
NJ (4)
DE
MA (4)
NH (1)
CT (3)
VT
PA (2)
NY(8) RI (3)
ME (2)
ALMS
TN (1) SC (1)
NC (1)
VA(3)
FL(7)
GA(4)
DC
Region 85 Grantees
Region 519 Grantees
Region 415 Grantees
PBHCI Grantees by HHS RegionsRegion 107 Grantees
Region 912 Grantees
Region 212 Grantees
Region 113 Grantees
Region 71 Grantee Region 3
8 Grantees
Region 68 Grantees
As of 03/01/14
PBHCI Approach in CMHC Settings
PCP
Patient
CareManager
Psychiatrist
Core Team
Other Behavioral Health Clinicians Substance Treatment, Wellness Coach
Vocational Rehabilitation
CaseManager
Grant-funded additions to the BH team
Health/and Wellness
Peers, Wellness Coaches
PBHCI RAND Evaluation #1
Lessons Learned from Early Implementation1.Registries not simple to construct – data gathering difficult
2.Recruiting and retaining qualified staff – high primary care provider turnover
3.Patient recruitment
4.Space and licenses to do primary care
Sharf DM, et al. Psychiatric Services. 2013;64(7):660-665
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PCPs who are a “good fit” for this work• Flexible, sense of humor• Adapts well to behavioral health environment• Likes working with patients with mental illnesses –compassion and passion
• Enjoys being part of a team – no lone rangers• Want to make a difference in a health disparity group• Prefer to use data to drive care including utilizing a ‘treat-to-target” approach to meet goals
“My observations are that the key variable is a seasoned/experienced, confident provider who may not fully understand but isn't frightened or put off by issues of mental illness.”
- CMHC PBHCI Grantee
Curriculum designed to to be taught by Psychiatrists or PCPs
30 slides per module• Downloadable• Updateable• Modifiable• Pre and post test questions• Resources
http://www.integration.samhsa.gov/workforce/primary-care-provider-curriculum
Make your own PCP-guide!
Modules
• Module 1: Introduction to Primary and Behavioral Heath Integration
• Module 2: Overview of the Behavioral Health Environment
• Module 3: Approach to the Physical Exam and Health Behavior Change
• Module 4: Psychopharmacology and Working with Psychiatric Providers
• Module 5: Roles for PCPs in the Behavioral Health Environment
• Pre and Post test
• Reflective exercise
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PBHCI RAND Evaluation #2
• Integrated systems of various kinds created
• Limited use of Evidence Based Practices for smoking, obesity in particular
• Not able to identify centers which functioned best
• Small clinical evaluation did not show significant effect on physical health.
43Scharf, et al. 2013 Report to HHS. http://aspe.hhs.gov/daltcp/reports/2013/PBHCIfr.shtm
PBHCI Clinical Outcomes – N of 3, 12 months
Scharf, et al. 2013 Report to HHS. http://aspe.hhs.gov/daltcp/reports/2013/PBHCIfr.shtm
RAND Recommendations
• Needs Assessment - include systematic efforts to understand the types and extent of consumer physical health care needs, preferences, attitudes, and beliefs about integrated care; barriers anticipated, number of clients in need of care, etc
• Improve Program performance through continuous quality improvement initiatives – use data to drive care, PDSA cycles
• Use Evidence-based practices and measure fidelity to the practice if appropriate
• Provide ongoing education to staff about the primary care services being offered to improve recruitment into the program
• Hire staff that are a good fit for Integrated Care
Scharf, et al. 2013 Report to HHS. http://aspe.hhs.gov/daltcp/reports/2013/PBHCIfr.shtml
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Behavioral Weight Loss Interventions
Most likely to be effective:
• Longer duration (24 weeks)• Manualized• Combined education and
physical activity• Both nutrition and physical
exercise• Evidence-based (proven
effective by RCTs)
Less likely to be successful:
• Briefer duration interventions • General wellness or health
promotion education only• Non-intensive, unstructured,
or non-manualized interventions
46
Bartels, Steve
HEALTH PROMOTION RESOURCE GUIDESept 2014, SAMHSA
Improving Access to Care: Models
1. PCARE study
2. PBHCI Grantees
3. 2703 Medicaid State Plan Amendments -Missouri
4. HOME study
5. Certified Community Behavioral Health Clinics (Excellence in Mental Health Act)
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2703 Medicaid State Plan Amendments
• Mechanism of Federal funding through the ACA
• Targets care coordination of vulnerable populations• Many states use for SMI/SED
• 90% Federal Match for first 2 years
• Doesn’t cover actual delivery of primary care
• First awards in 2011, Missouri
2703 Medicaid State Plan Amendments
www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/HH-MAP_v34.pdf. Accessed July 19, 2014.
Health Home Focus
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Six Required Services (no direct Primary Care, More Care Coordination)
Individual and Family Support
Comprehensive Care
Management
Care Coordination
Referral to Community and Social Support
Services
Health Promotion
Comprehensive Transitional
Care
52
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Integrating-Care/Health-Homes/Health-Homes.html
“Consultant” PCP (Missouri Model)
ConsultantPCP
Patient
Nurse Care
Manager
Psychiatrist
Other Behavioral Health Clinicians, Substance Tx, Vocational Rehabilitation
Other Community Resources
Case Manager
PCP
New Role
Offsite
Education, tracking
Core Team
OtherResource
Consultant PCP Duties
• Case Consultation
• Collaboration
• Population management
• Education
**Does this look familiar?
• Looking over your shoulder to make sure adequate care is being provided
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Outcomes
Reducing Hospitalization
Primary Care Health Homes CMHC Healthcare Homes
dmh.mo.gov/docs/mentalillness/18MonthReport.pdf
M5
131.19
121.12
116
118
120
122
124
126
128
130
132
Pre Post
LDL Changes in PCHH Patients with Initially High
Levels
p<.0001
9.89
9.17
8.8
9
9.2
9.4
9.6
9.8
10
Pre Post
HA1c Changes in PCHH Patients with Initially High
Levels
p<.0001
149.75
142.94
138
140
142
144
146
148
150
152
Pre Post
Systolic Blood Pressure Changes in PCHH Patients with
Initially High Values
p<.0001
87.84
83.85
81
82
83
84
85
86
87
88
89
Pre Post
Diastolic Blood Pressure Changes in PCHH Patients with Initially High
Values
p<.0001
dmh.mo.gov/docs/mentalillness/18MonthReport.pdf
Primary Care Provider
Establish Priorities Education
Develop Collaborative Relationships
Case Consultation
Psychiatrist
Medical Leadership
Shared Medical
Oversight
Collaboration with other Team Members
in Comprehensive Care Management
Medical Staff SummitsMissouri 2012 and 2013
Slide 55
M5 Paul and Kit would rather not use this slide based on updated methodology.MUZAC7Y, 12/31/2013
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Improving Access to Care: Models
1. PCARE study
2. PBHCI Grantees
3. 2703 Medicaid State Plan Amendments -Missouri
4. HOME study
5. Certified Community Behavioral Health Clinics (Excellence in Mental Health Act)
58
HOME (Health Outcomes Management and Evaluation) Study
• An RCT Permutation of PCARE
• 300 patients with SMI and at least one chronic condition: DM, HTN, Dyslipidemia, Heart Disease
• Randomized 150/150 usual care or intervention
• Partner with FQHC on site
• ICC: Integrated Community Care• Medical outcomes and budget analysis
Druss, NIMH funded. http://clinicaltrials.gov/ct2/show/NCT01228032
Certified Community Behavioral Health Clinics (CBHC)
Excellence in Mental Health Act – passed March 31, 2014
Scope:
•Primary Care Screenings and Monitoring of Key Health Indicators and Risk
•Care Management
•Partnerships with FQHCs for physical health
•Evidence-Based Practices
•Robust evaluation of 8 pilots – CMS in rule writing phase – due Sept 2015
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Integrating Primary Care Into Behavioral Health Settings: What Works For Individuals with Serious
Mental IllnessMillbank Report 2014
• The use of fully integrated systems or enhancing collaboration through care management enhances outcomes
• The interventions required additional staffing, training and support of care managers
• Cost savings is not clear but early reports from HH is this will be effective
• Integrated data and population health tracking
61
Gerrity, et al: Integrating Primary Care Into Behavioral Health Settings: What Works For Individuals with Serious Mental IllnessMillbank Memorial Fund, NY, 2014
What?
1. Overcoming Access Issues to…2. Lower morbidity
• Evaluation is ongoing• Overall weaker evidence for
exact model of “reverse integration”
• Some patients will not get access.
PRIMARY CARE SKILLS FOR PSYCHIATRISTSAmerican Psychiatric Association Annual Meeting
Toronto, Canada
May, 2015
5/10/2016
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This Talk Focuses on Part II
1. Why?
2. What?
3. When?
4. Where?
5. Who?
Mental Health Services Primary Care Services
“reverse integration”
US?
US?
• A Framework for Intervention
• Basic Requirements• First, do no harm
• Second, do KNOW harm screen appropriately, limit risk
• Counsel to mitigate risk
• Tobacco Cessation in everyone
• Be aware of basic chronic disease guidelines for evidence-based management
• Intervene when necessary
Pro
gre
ssiv
e in
tens
ity,
risk
Nature of Problem
Access to Care
Medical Training, Medico‐
Legal Scope
System Capacity of
BHO
Patient Preference
Routine
Domain Spectrum Action
Urgent EmergentEmergent Referral
Poor/Refuses
Inconsistent Good
Sufficient, CoveredInsufficient, Not
Covered
Adequate Systems in Place, Monitoring and Follow‐Up
Limited Systematic Capacity
Prefers BHO, Psychiatrist
Prefers Traditional Primary Care
Psych Manages with PCP Support
Refer to PCP, Triage Barriers to Access to Care
1
2
3
4
5
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Roles for Psychiatrists
Co-Management
• Each provider has their own caseload
• PCP manages all medical problems
• Psychiatrist manages all mental health problems
• Work together to re-enforce treatment plans
• Psychiatrist screens for medical problems
• Same site or different• Facilitated referral
Manage with Primary Care
Consult
• Psychiatrist works with a nurse care manager
• Manages a caseload of patients for BOTH mental health and basicmedical problems
• Utilize protocols from PCP
• PCP available for consultation and stepped care as needed
• Outside PCP care continued
Comprehensive Management
• Typically dually trained psychiatrist
• One provider manages both medical and mental health problems
• Limited number of providers have this expertise
All psychiatrists are responsible for “not making people sicker”.
Basic Requirements• Knowledge of Management and Screening of Chronic Diseases, Modifiable CVD Risk Factors
• Treatment of Tobacco Use Disorders• Evidence-based Health/Wellness Activities:• Diet• Exercise
• Knowledge of Recommended Preventive Health Screening Practices as patient advocates at the very least
US?
• A Framework for Intervention
• Basic Requirements• First, do no harm
• Second, do KNOW harm screen appropriately, limit risk
• Counsel to mitigate risk
• Tobacco Cessation in everyone
• Be aware of basic chronic disease guidelines for evidence-based management
• Intervene when necessary
Pro
gre
ssiv
e in
tens
ity,
risk
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Do No Harm: Psychiatrists Prescribing SGAs
Agents with higher cardiometabolic risk were prescribed to over 75% of individuals with cardiometabolic disorders
• Primary Reasons Cited Upon Interview included:• *Efficacy• *Less sedation/more sedation• *Patient preference• Low incidence of extra pyramidal symptoms• Low incidence of tardive dyskinesia• Cannot tolerate alternatives
Psych Services, 2013, Hermes, et al. Prescription of Second Generation Antipsychotics: Responding to Treatment Risk in Real World Practice
US?
• A Framework for Intervention
• Basic Requirements• First, do no harm
• Second, do KNOW harm screen appropriately, limit risk
• Counsel to mitigate risk
• Tobacco Cessation in everyone
• Be aware of basic chronic disease guidelines for evidence-based management
• Intervene when necessary
Pro
gre
ssiv
e in
tens
ity,
risk
ADA/APA Guideline Revised for Non-fasting Labs
72
Monitoring Protocol For Patients on Atypical Antipsychotics
Assessment Parameter
Cut-offs Baseline 4 wks 8 wks 12 wks Quarterly Annually
Medical and Family History, Including CVD
n/a x
Weight, BMI (kg/m2)
>7% gain over baseline or >25
kg/m2 x x x x x
Waist Circumference
Men: 40 in., Women: 35 in.
x x
Hemoglobin A1cPre-DM: >5.7%,
DM: >6.5%x x x
Random Plasma Glucose
Pre-DM: > 140 mg/dL, DM: > 200
mg/dLx x x
Blood Pressure >140/90 mmHg x x x
Non-Fasting TC and HDL
Non-HDL: >220mg/dL; or 10-yr
risk > 7.5%x x X
Nonfasting Screening for Cardiovascular Risk Among Individuals Taking Second Generation Antipsychotics. Vanderlip et al. Psychiatric Services, Vol. 65 No. 5. 573 - 576
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Non-Fasting Labs: Detail
APA/AMP 2014: Primary Care Skills for Psychiatrists73
US?
• A Framework for Intervention
• Basic Requirements• First, do no harm
• Second, do KNOW harm screen appropriately, limit risk
• Counsel to mitigate risk
• Tobacco Cessation in everyone
• Be aware of basic chronic disease guidelines for evidence-based management
• Intervene when necessary
Pro
gre
ssiv
e in
tens
ity,
risk
• Smoking contributes to half the deaths in SMI population, DSM V diagnosis
• Psychiatrists counsel patients less frequently regarding cessation – <15% vs 90% for PCPs
• Education issue? Reluctance? Belief not interested in quitting?
Williams, et al Psychiatric Services Oct 2014
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US?
• A Framework for Intervention
• Basic Requirements• First, do no harm
• Second, do KNOW harm screen appropriately, limit risk
• Counsel to mitigate risk
• Tobacco Cessation in everyone
• Be aware of basic chronic disease guidelines for evidence-based management
• Intervene when necessary
Pro
gre
ssiv
e in
tens
ity,
risk
Psychiatric Oversight of all Health“Doctor Up”
77
Section
Obesity
Hypertension
Cholesterol
Diabetes
Tobacco Use
Prevention
Presenter
Aniyizhai Annamalai, MD
Robert McCarron, DO
Erik Vanderlip, MD MPH
Martha Ward, MD
Jae Han, MD
Jeff Rado, MD
APA/AMP 2014: Primary Care Skills for Psychiatrists 78
Primary Care Skills for Psychiatrists
123456
5/10/2016
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Nature of Problem
Access to Care
Medical Training, Medico‐
Legal Scope
System Capacity of
BHO
Patient Preference
Routine
Step Spectrum Action
Urgent EmergentEmergent Referral
Poor/Refuses
Inconsistent Good
Sufficient, CoveredInsufficient, Not
Covered
Robust Systems in Place, Monitoring and Follow‐Up
Limited Systematic Capacity
Prefers BHO, Psychiatrist
Prefers Traditional Primary Care
Psych Manages with PCP Support
Refer to PCP, Triage Barriers to Access to Care
1
2
3
4
5
Build the Team and the Supports
• Consider the models presented earlier
• Find your PCP friend and “take them to lunch”• Roger Kathol, MD
• Be systematic, and prepared to follow-up and treat to target
• Remember that everyone needs good primary care – working on collaborations/partnerships is essential
Programs Generally Contain 3 Major Components:
Primary Care Services
Care Management and Tracking
Health Behavior Change
81Kern, in Integrated Care: Working at the Interface of Primary Care and Behavioral HealthLori E. Raney, MD, editor. American Psychiatric Publishing, October 2014
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Registry for Tracking and Analyzing
Psychiatrist as Behaviorist
Two Cultures, One Patient84
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Integration Scores for 53 PBHCI Grantees
Collaboration on Tx Plans
Collaboration on Goals
Overall Leadership Collaboration
Overall Provider Collaboration
Psychiatrists as Leaders
• Champions of improving all medical care• Training non-medical workforce
• Help design programs with strong medical component
• Perform needs analysis
• Determine quality metrics
• Use of registries
• Targeted educational efforts
Psychiatrist’s Duty
• “A forerunner of integration, leading discussions on both physical and behavioral health risks at team meetings, monitoring health indicators in addition to BH progress, promoting wellness and smoking cessation, looking for drug interactions and metabolic side effects. We are trained to be integrated providers but many may have left this calling. “
Psychiatrist in PBHCI grantee site2014
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PCP responses
• “If psychiatrists have buy-in it will trickle down more freely to the patients in terms of full participation in visits and health improvement groups “
• “I would like to have a better relationship with the other psych providers as I often have questions related to side effects of medications and interactions. “
PCP SurveyPBHCI Grantee Summit2014
Resources
• APA Website: www.psych.org and list serve [email protected]
• AIMS Center: http://aims.uw.edu
• Center for Integrated Health Solutions: http://www.integration.samhsa.gov/
• ARHQ Integration Academy: http://integrationacademy.ahrq.gov/
• Books/E-books: Integrated Care: Working at the Interface of Primary Care and
Behavioral Health – edited by Lori Raney, MD
Prevention in Psychiatry – Edited Robert McCarron et al
PRIMARY CARE SKILLS FOR PSYCHIATRISTSAmerican Psychiatric Association Annual Meeting
Toronto, Canada
May, 2015
5/10/2016
31
Primary Care Skills for Psychiatrists
APA/AMP 2014: Primary Care Skills for Psychiatrists 91
a collaboration of:
APA Workgroup on Integrated CareLori Raney, MD (chair)Medical Director, Axis Health Systems Dolores, Colorado
Aniyizhai Annamalai, MDInternal Medicine/Psychiatry
Jae Han, MDFamily Medicine/Psychiatry
Robert McCarron, DO Internal Medicine/Psychiatry
Jeffrey Rado, MD Internal Medicine/Psychiatry
Erik Vanderlip, MD MPHFamily Medicine/Psychiatry
Martha Ward, MD Internal Medicine/Psychiatry
Faculty
Agenda
• 9-9:50:
• 10-1020 hr:
• 1020-1040hr:
• 1040-1100 hr:
• 1100 to 1200 hr:
• 1200 to 1 PM hr:
• 100 – 120
• 120 - 140 hr:
• 140-200 hr:
• 2-3 PM hr:
• 3-4 PM hr:
APA/AMP 2014: Primary Care Skills for Psychiatrists 92
• Introduction, background
• HTN
• Obesity
• Cholesterol
• Cases on HTN, Obesity, Cholesterol
• Lunch
• Diabetes
• Tobacco
• Preventive Medicine
• DM, Tobacco, Prevention cases
• Collective group discussion
• Preventive Medicine Curriculum for Psychiatrists
• 25% Royalties go to APA RFM support
• Preventive Medicine in Psychiatry: General Principles
• Cardiovascular and Pulmonary Disorders
• Endocrine and Metabolic Disorders
• Infectious Disorders
• Oncologic Disorders
• Special Topics– Pain
– Geriatric
– Child Psychiatry
5/10/2016
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Section
Hypertension
Obesity
Cholesterol
Diabetes
Tobacco Use
Prevention
Presenter
Robert McCarron, DO
Aniyizhai Annamalai, MD
Erik Vanderlip, MD MPH
Martha Ward, MD
Jae Han, MD
Jeff Rado, MD
APA/AMP 2014: Primary Care Skills for Psychiatrists 94
Primary Care Skills for Psychiatrists
123456
HYPERTENSION
Edited by:Robert McCarron, DOAssociate Professor Director, Integrated Medicine and PsychiatryDirector, Pain Psychiatry Departments of Anesthesiology, Division of Pain Medicine, Psychiatry and Behavioral Sciences and Internal MedicineUniversity of California, Davis
APA/AMP 2014: Primary Care Skills for Psychiatrists
Presented by:Robert McCarron, DO
1
Nothing to disclose
APA/AMP 2014: Primary Care Skills for Psychiatrists 96
5/10/2016
33
Meet Bill…
• 46 yo single, white, male w/ schizophrenia
• Stable psychiatrically w/
• Intensive case management
• Long acting Risperidone shot
• Olanzapine 20mg (added s/p his hospitalization 18m ago)
• Eats at local fast food restaurants
• Smokes cigarettes and marijuana
• Sees his psychiatrist monthly but refuses to see a primary care doctor
APA/AMP 2014: Primary Care Skills for Psychiatrists 97
With regards to Bill…
• Upon further investigation, you notice Bill’s blood pressure on three prior clinic visits ranged between:
• Does Bill need treatment for his blood pressure???
APA/AMP 2014: Primary Care Skills for Psychiatrists 98
155-174
93-105
HYPERTENSION
APA/AMP 2014: Primary Care Skills for Psychiatrists 99
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HYPERTENSION
APA/AMP 2014: Primary Care Skills for Psychiatrists 100
Cardiovascular Risk Factors: Overview
BMI = body mass index; TC = total cholesterol; DM = diabetes mellitus; HTN = hypertension.Wilson PWF et al. Circulation. 1998;97:1837–1847.
0
2
4
6
8
10
12
14
HTNDMSmokingBMI >27 TC >220
Single Risk Factors
Multiple Risk Factors
Odds ratios
Smoking+ BMI
2
Smoking+ BMI
+ TC >220
3
Smoking+ BMI
+ TC >220+ DM
4
Smoking+ BMI
+ TC >220+ DM + HTN
5
The Framingham Study
APA/AMP 2014: Primary Care Skills for Psychiatrists 101
APA/AMP 2014: Primary Care Skills for Psychiatrists 102
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Mental Illness and Hypertension
• Those with severe mental illness (SMI) are more likely to be obese and therefore more likely to have HTN
• Those with SMI are more likely to have HTN and not be diagnosed or treated
• People who are chronically depressed are more likely to have HTN
• HTN is a key contributor to the significant decreased life span in those who have SMI!
Schizophrenia Research 2006(86)
APA/AMP 2014: Primary Care Skills for Psychiatrists 103
Schizophrenia Research 2006(86)
Hypertension --- We Are Missing the Target
APA/AMP 2014: Primary Care Skills for Psychiatrists 104
Hypertension…Past Definitions (JNC 7)
APA/AMP 2014: Primary Care Skills for Psychiatrists 105
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How We Treat NOW…
General Population
(no diabetes or CKD)
≥ 60 years
SBP <150 mmHgDBP <90 mmHg
< 60 years
SBP <140 mmHgDBP <90 mmHg
Diabetes or CKD present
All agesDiabetes present
No CKD
SBP <140 mmHgDBP <90 mmHg
All agesCKD present with
or without diabetes
SBP <140 mmHgDBP <90 mmHg
Set BP Goal and Treat
(JNC-8 2013 Guidelines)
APA/AMP 2014: Primary Care Skills for Psychiatrists 106
CKD: Chronic Kidney Disease
The Best Treatment is Prevention…
•Screen if normal blood pressure every 2 years
•Consider checking blood pressure at every visit
•Diagnosis of hypertension is made after 3 abnormal readings, made on separate visits
APA/AMP 2014: Primary Care Skills for Psychiatrists 107
Initiate BP Lowering-Medication
No CKD
Nonblack
Thiazide-type diuretic or ACEI or ARB or CCB, alone or in combination
Black
Thiazide-type diuretic or CCB,
alone or in combination
CKD present
ACEI or ARB, alone or in
combination with other drug classes
JNC-8 JAMA Dec 2013
Based on Age, Diabetes, CKD
APA/AMP 2014: Primary Care Skills for Psychiatrists 108
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Drug treatment titration strategy
A. Maximize first medication before adding second or
B. Add second medication before reaching maximum dose of first medication or
C. Start with 2 medication classes separately or as fixed-dose combination.
JNC-8 JAMA Dec 2013
APA/AMP 2014: Primary Care Skills for Psychiatrists 109
Common Medication DetailsMedication Class Dose
RangeFreq. Common Side
EffectsLab Monitoring
Amlodipine CCB 5-10 mg QDSwelling, constipation
None
HCTZ Thiazide 12.5-50 mg QDIncreased urination
Hypokalemia
Chlorthalidone Thiazide 12.5-25 mg QDIncreased urination
Hypokalemia
Lisinopril ACE 5-40 mg QD CoughHyperkalemia,Renal Function
Enalapril ACE 2.5-40 mgQD to BID
CoughHyperkalemia, Renal Function
Losartan ARB 25-100 mg QD --Hyperkalemia, Renal Function
Atenolol BB 25-100 mg QD Bradycardia --
APA/AMP 2015: Primary Care Skills for Psychiatrists 110
Class 1Class 1
Class 2Class 2
Class 3Class 3
APA/AMP 2014: Primary Care Skills for Psychiatrists 111
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APA/AMP 2014: Primary Care Skills for Psychiatrists 112
APA/AMP 2014: Primary Care Skills for Psychiatrists 113
Common Drug Class Interactions Antihypertensive Medication Class
Psychotropics Caution
Diuretics Lithium Watch for dehydration and increased serum lithium level
Multiple taken at the same time
Venlafaxine Potential for increased blood pressure
Multiple taken at the same time
Psychotropics with high α‐1 blockade
Potential for hypotension
Any class MAOI’s 1)Hypotension (α‐1 block)2)Hypertension (food with tyramine might cause a catecholamine surge and hypertensive crisis)
Any class Stimulants Potential for increased blood pressure
APA/AMP 2014: Primary Care Skills for Psychiatrists 114
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For Bill’s Blood Pressure
• You decide to:• Start Hydrochlorathiazide (HCTZ) 12.5mg
• If he had DM, you would have started an ACE Inhibitor
• Two weeks later his BP is 148/93• Increase his HCTZ to 25mg
• One month later, his BP is 141/90 but his K+ is 3.3mg/dL• Add in an ACE inhibitor to help w/ BP control and help spare his
potassium
• Two weeks later, BP is 130/85- Goal!• Creatinine and Potassium are normal
• He uses a pill box to help him manage his new medications
APA/AMP 2014: Primary Care Skills for Psychiatrists115
Any Questions…?
APA/AMP 2014: Primary Care Skills for Psychiatrists 116
Thank You For Listening…
5/10/2016
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Section
Hypertension
Obesity
Cholesterol
Diabetes
Tobacco Use
Prevention
Presenter
Robert McCarron, DO
Aniyizhai Annamalai, MD
Erik Vanderlip, MD MPH
Martha Ward, MD
Jae Han, MD
Jeff Rado, MD
APA/AMP 2014: Primary Care Skills for Psychiatrists 118
Primary Care Skills for Psychiatrists
123456
OBESITY
Edited by:Aniyizhai (Ani) Annamalai, M.D.Assistant ProfessorYale UniversityDepartment of Psychiatry
Presented by:Ani Annamalai, M.D.Yale University
APA/AMP 2014: Primary Care Skills for Psychiatrists 119
2
Nothing to disclose
APA/AMP 2014: Primary Care Skills for Psychiatrists 120
5/10/2016
41
Today in clinic…
• Looks like Bill has been gaining weight
• Currently 287lbs w/ BMI of 37.9
• On chart review, you see he was 210lbs b/f starting Olanzapine w/ BMI of 27.7 (18 mo ago)
• You ask yourself:
• Just how bad is his BMI?
• What can I do to help Bill with his weight?
APA/AMP 2014: Primary Care Skills for Psychiatrists 121
Review impact of obesity among persons with SMI
Understand the efficacy of behavioral and pharmacologic treatment of obesity among persons with SMI
Consider risks and benefits for bariatric surgery for patients with SMI--given the evidence for the health benefits of bariatric surgery in the general population
Objectives
APA/AMP 2015: Primary Care Skills for Psychiatrists
Allison DB et al. J Clin Psychiatry. 1999;60:215-220.
< 18.518.5-20 20-22 22-24 24-26 26-28 28-30 30-32 32-34 > 34
0
10
20
30
No schizophrenia
Schizophrenia
Obese Overweight Acceptable Underweight
BMI Range
BMI Distribution
APA/AMP 2014: Primary Care Skills for Psychiatrists
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Obesity Related Complications
APA/AMP 2014: Primary Care Skills for Psychiatrists 124
• CMHC populations• Dyslipidemia
• 45% with TG > 150 mg/dl;
• 35% with cholesterol > 200
• Diabetes• 33% with Impaired Fasting Glucose
• Hypertension• 51% with BP > 130/85
Correll CU et al. Psychiatr Serv 2010; 61(9): 892-898
Screening for Obesity
Measure weight and calculate BMI Every 4 weeks initially and then at least every 6 months*
Measure waist circumference(independent risk factor for diabetes and other metabolic complications)
At least yearly*
APA/AMP 2014: Primary Care Skills for Psychiatrists 125
*APA/ADA 2004 guidelines but clinical situation often warrants more frequent monitoring
Weight Classification by BMIAPA/AMP 2015: Primary Care Skills for Psychiatrists
Ideal 18.5-24.9
Overweight 25-29.9
Class I Obesity 30-34.9
Class II Obesity 35-39.9
Class III Obesity >=40
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Waist CircumferenceAPA/AMP 2015: Primary Care Skills for Psychiatrists
Males 102cm*
Females 88cm*
* Cut-off for metabolic syndrome criteria
Management of Obesity
Prevention
• Patient education
• Periodic screening
• Choice of antipsychotic
APA/AMP 2015: Primary Care Skills for Psychiatrists 128
Treatment
• Behavioral counseling• Peer support
• Weight loss interventions
• Pharmacologic
• Surgical
Behavioral Weight Loss Interventions
Most likely to be effective:
• Longer duration (24 weeks)• Manualized• Combined education and
activity• Both nutrition and physical
exercise• Evidence-based (proven
effective by RCTs)
Less likely to be successful:
• Briefer duration interventions • General wellness or health
promotion education-only• Non-intensive, unstructured,
or non-manualizedinterventions
APA/AMP 2015: Primary Care Skills for Psychiatrists
Bartels S, et al. SAMHSA-HRSA Center for Integrated Health Solutions, 2012
5/10/2016
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ACHIEVE
RCT (n= 291) 18 months: individual + group exercise and nutrition 57% with schizophrenia; 82% on SGA Baseline BMI = 36.3
% >
5%
Wt l
oss
Daumit GL et al. N Engl J Med 2013; 368: 1594-1602
37.8% lost >5% IBW at 18m(compared to 22.7% of control, p = 0.0009)
STRIDE
• RCT (n = 200)• 12 months (6 +6
months): physical exercise, food records, personalized plans, cognitive strategies
• 69% bipolar disorder and affective psychoses
• Baseline BMI 38.3• 40% lost >5% BW c/w
17% controls (p=0.001) at 6 months
131
Green CA et al. Am J Psychiatry 2014; Epub ahead of print
Other Health Promotion Programs
APA/AMP 2015: Primary Care Skills for Psychiatrists
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Mean Weight Change With Antipsychotic Medications
*4–6 week pooled data (Marder SR et al. Schizophr Res. 2003;1;61:123-36; †6-week data adapted from Allison DB,Mentore JL, Heo M, et al. Am J Psychiatry. 1999;156:1686-1696; Jones AM et al. ACNP; 1999.
Estimated Weight Change at 10 Weeks on “Standard” Dose
6
We
igh
t C
ha
ng
e (
kg
)
54
3
21
0
-1-2
-3
13.2
We
igh
t Ch
an
ge
(lb)
11.08.8
6.64.42.20-2.2-4.4-6.6
†
*
APA/AMP 2015: Primary Care Skills for Psychiatrists
Switch to Reduce Metabolic Risk (CAMP)
-4
-3.5
-3
-2.5
-2
-1.5
-1
-0.5
0
StaySwitch
0
-0.5
-1.0
-1.5
-2.0
-2.5
-3.0
-3.5
-4
Week of visit
Wei
ght
chan
ge (
kg)
4 8 12 16 20 24
Stroup TS, et al. Am J Psychiatry 2011; 168: 947-956
APA/AMP 2015: Primary Care Skills for Psychiatrists
Pharmacotherapy
Agent Evidence in schizophrenia
Metformin 3 kg weight loss at 16 weeks1
*Phenteramine-Topiramate
Topiramate: 5 kg weight loss
*Orlistat +/-
*Lorcaserin None*Naltrexone/Bupropion +/-
* FDA approval for weight lossJarskog LF, et al. Am J Psychiatry 2013; 170:1032-1040Das C, et al. Annals of Clinical Psychiatry 2012; 24(3): 225-239
APA/AMP 2015: Primary Care Skills for Psychiatrists
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Bariatric Surgery
• Indications based on current guidelines1
• Class III obesity (BMI > 40 kg/m2)
• Class II obesity (BMI = 35-39.9) with medical complication (DM, Sleep apnea)
• Class I obesity with poorly-controlled T2 DM
APA/AMP 2015: Primary Care Skills for Psychiatrists
1 NHLBI, NIH Publication No. 98-4083, 1998
Adjustable Gastric Band (AGB)
Sleeve Gastrectomy (SG)
Roux-en-Y Gastric Bypass (RYGB)
Bariatric Surgery ProceduresAPA/AMP 2015: Primary Care Skills for Psychiatrists
Benefits: Weight Loss
APA/AMP 2015: Primary Care Skills for Psychiatrists 138
-12
-10
-8
-6
-4
-2
00 3 6 9 12
MedicalRYGBSG
Cha
nge
in B
MI
Months
Schauer PR, et al. N Engl J Med 2012; 366: 1567-1576
5/10/2016
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Benefits: Diabetes
• Improved diabetes control among those with A1c > 7• 12-months: 42% vs 12% of control had A1c < 6 (p=0.002)1
• Higher rates of remission of diabetes at 6 years • (62% vs 8% and 6%); OR = 16.5 (95% CI 4.7-57.6)2
• Prevention of Type 2 Diabetes (15 year follow-up) • Adjusted HR =0.17 (0.13, 0.21)3
APA/AMP 2015: Primary Care Skills for Psychiatrists
1Schauer PS et al. N Engl J Med 2012; 366: 1567-15762Adams TD et al JAMA 2012; 308 (11): 1122-11313Carlsson LMS et al. N Engl J Med 2012; 367: 695-704
Bariatric Surgery and Bipolar Disorder
Surgical Outcomes
• Retrospective study of Roux-en Y at single site (n=120)
• Bipolar (n=33) compared to other psych (n= 45) compared to no psych (n= 42)
• 1 year: no difference in follow-up, mean weight,% weight loss, mean BMI
Psychiatric Outcomes
• N= 144 severely obese patients with bipolar disorder who underwent bariatric surgery (compared to 1440 patients with bipolar disorder who met criteria for referral)
• Hospitalization 9% vs 10.6%; HR = 1.03 (95% CI 0.83-1.23)
• Outpatient psychiatric service utilization also not different
APA/AMP 2015: Primary Care Skills for Psychiatrists
Steinmann WC, et al Obesity Surgery 2011; 21(9): 1323-1329Ahmed AT et al. Bipolar Disord online Aug 5 2013
• Effectiveness with respect to health benefits in this vulnerable population
• Maintenance of weight loss with use of SGA How assess for appropriateness of surgery? No uniform guidelines
• Impact on course of psychiatric illness after bariatric surgery
• Impact of fat malabsorption on medication dose
• Impact on cognition and functional status
• Impact of body image and altered social role
Unique Considerations
Steinmann WC et al. Obes Surg 2011; 21: 1323-1329
APA/AMP 2015: Primary Care Skills for Psychiatrists
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• Individuals with SMI are at greatly increased risk of obesity and related complications
• Mental health providers can and should provide treatment for obesity• Regular screening
• Counseling/lifestyle modification
• Switching to antipsychotic medications with lower metabolic liability
• Metformin?
• Consider bariatric surgery for class III obesity
Summary
APA/AMP 2015: Primary Care Skills for Psychiatrists
What You Can Do As A PsychiatristWeigh all patients!
Provide office based counseling Specific targets for behavior change with periodic monitoring more helpful than general advice
Develop weight loss intervention programs in your center
Models exist and lay educators are effective
Choose antipsychotics with lesser metabolic risk
Start appropriate agent and switch when feasible
Consider medications to promote weight loss
Ex. Metformin, especially if other metabolic risks
Assess for appropriateness of bariatric surgery in all severely obese patients
Can be effective for seriously mentally ill patients
Monitor for complications from obesity! Screen periodically for diabetes, hypertension, lipid disorders
APA/AMP 2015: Primary Care Skills for Psychiatrists 143
So… For Bill’s BMI of 37
• Consider switching his olanzapine
• Encourage lifestyle modifications• Ask him to walk to his CMHC visits
• Stress substituting soda pop with low or no calorie beverages
• Encouraging cooking or healthy options at the fast food restaurant
APA/AMP 2015: Primary Care Skills for Psychiatrists 144
5/10/2016
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Questions?
APA/AMP 2014: Primary Care Skills for Psychiatrists 145
Section
Hypertension
Obesity
Cholesterol
Diabetes
Tobacco Use
Prevention
Presenter
Robert McCarron, DO
Aniyizhai Annamalai, MD
Erik Vanderlip, MD MPH
Martha Ward, MD
Jae Han, MD
Jeff Rado, MD
APA/AMP 2014: Primary Care Skills for Psychiatrists 146
Primary Care Skills for Psychiatrists
123456
CHOLESTEROL
Edited by:Erik Vanderlip, MD MPHAssistant ProfessorUniversity of OklahomaSchool of Community Medicine
APA/AMP 2014: Primary Care Skills for Psychiatrists
3
Presented by:Erik Vanderlip, MD MPH
5/10/2016
50
Nothing to disclose
APA/AMP 2014: Primary Care Skills for Psychiatrists 148
What to look for.
APA/AMP 2014: Primary Care Skills for Psychiatrists 149
4 40 1
Cholesterol Objectives
1. Properly assess cardiovascular (CVD) risk in patients
2. Apply appropriate screening guidelines to patients
3. Interpret a fasting and non-fasting lipid panel
4. Utilize the non-fasting lipid profile for screening
5. Select the appropriate cholesterol-lowering therapy based on CVD risk
6. Monitor and follow-up that therapy to ensure risk is lowered
APA/AMP 2014: Primary Care Skills for Psychiatrists 150
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2013: Out with the old, in with the new
APA/AMP 2014: Primary Care Skills for Psychiatrists 151
NCEP ATPIII:
• LDL (bad cholesterol) was the focus
• Treat to pre-specified target LDL based on risk
• Calculate risk on Framingham cohort
• Add drugs to treatment regimen until the target was met
ACC/AHA
• Appropriate placement on a statin is target
• Calculate risk based on pooled cohort equations
• Ensure that therapy is effective (patients adherent) by checking cholesterol panels
• No evidence for alternative lipid-lowering treatments
2013!
Screening: Who and When?
• US General Population at Average Risk
• Males: Every 5 years, beginning age 35
• Females: Every 5 years, beginning age 45
• Those at elevated risk could be screened beginning at age 20
CVD Risk Equivalents (10-year risk of CVD ~20%, risk-class high):Diabetes Mellitus
Previous personal history of CVDAbdominal Aortic AneurysmPeripheral Arterial Disease
Carotid Artery Stenosis
Major Risk Factors:
Family history of CVD in 1st deg relative (male < 55, female < 65)Cigarette smokingHypertension, treated or untreated
Age (male > 45, female > 55)
HDL < 40 mg/dL
Risk for CVD
USPSTF 2008
APA/AMP 2014: Primary Care Skills for Psychiatrists 152
Screening: Atypical AntipsychoticsMonitoring Protocol For Patients on Atypical Antipsychotics
Assessment Parameter
Cut-offs Baseline 4 wks 8 wks 12 wks Quarterly Annually
Medical and Family History, Including CVD
n/a x
Weight, BMI (kg/m2)
>7% gain over baseline or >25
kg/m2 x x x x x
Waist Circumference
Men: 40 in., Women: 35 in.
x x
Hemoglobin A1cPre-DM: >5.7%,
DM: >6.5%x x x
Random Plasma Glucose
Pre-DM: > 140 mg/dL, DM: > 200
mg/dLx x x
Blood Pressure >140/90 mmHg x x x
Non-Fasting TC and HDL
Non-HDL: >220mg/dL; or 10-yr
risk > 7.5%x x X
ADA, APA 2004, Vanderlip et al 2014
APA/AMP 2014: Primary Care Skills for Psychiatrists 153
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Bill– Lipid Profile Interpretation• 46 YO white male with:
• Schizophrenia, controlled with Atypical Antipsychotics
• Hypertension, (last 155/94)• Smoker• Non-diabetic
APA/AMP 2014: Primary Care Skills for Psychiatrists 154
Lipid Profile• Total Cholesterol: 260 mg/dL• HDL Cholesterol: 33 mg/dL• Triglycerides*: 258 mg/dL• LDL Direct Measure: 185 mg/dL• LDL Calculated*: 175 mg/dL
*Non-fasting
Non-Fasting Lipid Profile• Total Cholesterol: 260 mg/dL• HDL Cholesterol: 33 mg/dL• Non-HDL: 227 mg/dL• Triglycerides*: 258 mg/dL
Note: Both Total Cholesterol and HDL vary by less than 2% with respect to fasting status (Sidhu 2012).
Calculated LDL is artificially low if non-fasting (slide).
Non-HDL is much more reliable with respect to fasting vs. non-fasting, cut-offs are set 30 pts higher than LDL
Since Non-HDL is greater than 220 mg/dL, that is considered extremely high and alone
warrants high-intensity statin (slide)
Bill – Cardiovascular Risk
APA/AMP 2014: Primary Care Skills for Psychiatrists 155
http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx
What you need to calculate risk:
1. Gender2. Age3. Race (w/nw)4. Smoking Status5. Recent BP and +/-
tmt6. DM status7. Total Cholesterol8. HDL Cholesterol
You do not need LDL values for this
calculation.This uses the newer pooled cohort equations.
Bill – Cardiovascular Risk, 10 Yr.
APA/AMP 2014: Primary Care Skills for Psychiatrists 156
1. Would lowering cholesterol improve his risk?
2. How should it be lowered?
http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx
This uses the newer pooled cohort equations.
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Treatment of Dyslipidemia
• Low saturated fat• No trans fat• < 300 mg chol/day• Fish oil• Tree nuts• Soy• Fiber
• Aerobic exercise• 30 min/day• 120 min/week
• Statins• Statins• Statins
Switching Antipsychotics?
DietExercise
Meds
APA/AMP 2014: Primary Care Skills for Psychiatrists 157
Treatment: Switching?
Weiden 2007, J Clin Psych
Switching may be effective when:1. Weight gain is directly
related to AP2. Long-term therapy with
weight neutral agent can be maintained
Weiden 2003
Newcomer 2008
How clinically relevant is this?What is the role of funding?
How do these compare to FGA’s?
APA/AMP 2014: Primary Care Skills for Psychiatrists 158
Treatment: 4 Types of Statin Candidates
APA/AMP 2014: Primary Care Skills for Psychiatrists 159
ClinicalCharacteristic
TypeofPrevention
ApplicableAgeRange
PreferredStatinIntensity
PotentialActions
ClinicalPresenceofASCVD*
Secondary 21 to75 High ‐‐
SerumLDL>190mg/dLOR
non‐HDL>220mg/dL
Primary 21to75 High
Work‐uppotentialsecondarycauses
TypeIIDiabetes
Primary 40to75Moderate to
High‐‐
10‐yearriskgreaterthan
7.5%Primary 40to75 Moderate
High: ~50% cholesterol reduction Moderate: 30-50% reduction
1
2
3
4
*ASCVD: prior MI, PVD, stable or unstable angina, AAA or ischemic strokeStone 2013, ACC AHA Guidelines
5/10/2016
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High Cholesterol: Secondary Causes
APA/AMP 2014: Primary Care Skills for Psychiatrists 160
Class Details
Disease/Medical/Genetic
Diabetes mellitus
Hypothyroidism
Chronic kidney disease
Nephropathy, proteinuria
Familial (genetic) hyperlipidemia
Pregnancy*
Substance Use Excessive alcohol intake
Medications
Estrogen
HIV Anti-retroviral therapy
Anti-psychotic medications
Steroids, immunosuppressants
DietExtreme obesity
High saturated and trans-fats(Stone et al. 2013; Vodnala, Rubenfire, and Brook 2012)
Treatment: Not all Statins are Equal
Source: www.effectivehealthcare.ahrq.gov Published online: May 16, 2013
Low
Moderate
High
High potency, AM dosing possible
APA/AMP 2014: Primary Care Skills for Psychiatrists 161
Treatment: Statin Details• Monitoring:
• LFT’s should be checked at baseline and 3 mos. if concern about compromised liver exists
• Safe with liver co-morbidities, don’t let transaminases elevate > 3-fold over baseline
• Myalgias are ~10%• If present, hold statin and check CK• Myositis/rhabdomyolysis is rare, CK should be
> 10-fold above baseline• If CK OK, may consider fluvastatin/pravastatin
• Diabetes risk really for those already on the verge
• 0.3/100 cases of DM due to high-potency• 0.1/100 cases of DM due to low-potency
APA/AMP 2014: Primary Care Skills for Psychiatrists 162
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Treatment: Statin Details
• Pregnancy category X• Many psych meds go through CYP450
• Consider pravastatin (generic, dual metabolism)
• Only rosuvastatin (Crestor) and atorvastatin (Lipitor) may be dosed regardless of time
APA/AMP 2014: Primary Care Skills for Psychiatrists 163
Follow-Up1. Recheck lipid profiles periodically (at 3-12 mo.
Intervals) to ensure adherence / therapeutic effects• High Potency 50% Reduction• Moderate Potency 30-50% Reduction• Low Potency 30% Reduction
2. Maintain therapy until >75 years, then consider moderation of dose or discontinuation
3. If intolerant of statin, try lower dose or lower potency
• (OK to start on highest recommended dose – titration not necessary)
4. If general cholesterol goals not met and adherent, consider secondary causes and referral
APA/AMP 2014: Primary Care Skills for Psychiatrists 164
Q: Bill – Statin Candidate?
APA/AMP 2014: Primary Care Skills for Psychiatrists 165
1. Statin Category 4: 10-yr risk >7.5%2. Moderate Intensity Statin OK
• Consider atorvastatin 40 mghttp://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx
Statin Candidacy Classes
Statins by Potency
A:
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What do you do for Bill’s Cholesterol?
• You decide to start Bill on Atorvastatin 40 mg
• Once a day
• In the morning w/ his Aripiprazole
• Moderate-dose statin (vs weaker Pravastatin) for aim of 30% reduction
• Monitor for interactions due to cytochrome P450 inhibition w/ Risperidone (which you are considering titrating down over time)
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• Age >40• SGA therapy?• Smoker?• HTN?• DM?
• Obese?• CVD already?• Significant
family history of CVD?
(Does this person need testing?)
• TC• HDL• TG• ALT• Glucose• HgB A1c if not avail.
Lipid panel
(non‐fasting)
1. TG ≥ 500 mg/dL (confirm
fasting, consider referral)
2. Secondary Cause (Slide 18), if none, screen for FH
3. Unexplained ALT > 3x ULN
If very high…
(evaluate and treat abnormalities)
yes
(4)LDL ≥ 190 mg/dL or
non‐HDLb ≥ 220 mg/dL
(3)Clinical
Atherosclerosis/CVD*
HIGHIntensity
(2)Diabetes 1 or 2
Age 40‐75
(1)No DiabetesAge 40‐75
(estimate 10‐year riska)
10‐yr risk ≥ 7.5% 10‐yr risk ≥ 7.5% Age < 75
ModerateIntensity
No pharmacotherapy
(determine statin intensity)
(re‐check non‐fasting lipid panel in 4‐12 weeks)
Treatment Working?**
1. Monitor Adherence2. Eval. Secondary Causes3. Intensify Therapy4. Modify Diet/Lifestyle
no
eval. secondary cau
ses
no
yes
(Determine Next Interval to Screen or Reassess)Range: 1‐5 years
(categorize into 4 treatment groups)
(diet and lifestyle counselin
g for all)
Questions?
APA/AMP 2014: Primary Care Skills for Psychiatrists 168
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Agenda
• 9-9:50:
• 10-1020 hr:
• 1020-1040hr:
• 1040-1100 hr:
• 1100 to 1200 hr:
• 1200 to 1 PM hr:
• 100 – 120
• 120 - 140 hr:
• 140-200 hr:
• 2-3 PM hr:
• 3-4 PM hr:
APA/AMP 2014: Primary Care Skills for Psychiatrists 169
• Introduction, background
• HTN
• Obesity
• Cholesterol
• Cases on HTN, Obesity, Cholesterol
• Lunch
• Diabetes
• Tobacco
• Preventive Medicine
• DM, Tobacco, Prevention cases
• Collective group discussion
Cases on HTN, Obesity, Cholesterol
• Break into small groups and use the workbook handout.
APA/AMP 2014: Primary Care Skills for Psychiatrists 170
Section
Hypertension
Obesity
Cholesterol
Diabetes
Tobacco Use
Prevention
Presenter
Robert McCarron, DO
Aniyizhai Annamalai, MD
Erik Vanderlip, MD MPH
Martha Ward, MD
Jae Han, MD
Jeff Rado, MD
APA/AMP 2014: Primary Care Skills for Psychiatrists 171
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DIABETES
Edited by:Martha Ward, MDAssistant ProfessorEmory UniversityDepartment of Psychiatry and Behavioral Sciences
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Presented by:Martha Ward, MD
172
Back to the Case
• You decide to do some lab work to check Bill’s sugars• Non fasting glucose 194
• HbA1C 6.1%
• You wonder:• Does Bill have diabetes?
• What can be done to help Bill avoid further medical complications in the future?
APA/AMP 2014: Primary Care Skills for Psychiatrists 173
Screening: Does this sound like any of your patients?
• Screen at baseline, 12 weeks and 12 months on anyone started on atypical antipsychotic.
• Screen every 1 to 3 years IN THOSE AT RISK:• Sustained Blood pressure 135/80
• hypertension or hyperlipidemia
• Risk factors: Gestational diabetes, over 45 years old, BMI >25, family history, sedentary lifestyle, acanthosis nigricans, PCOS, clozapine and olanzapine.
• Risk calculator: http://www.diabetes.org/diabetes-basics/prevention/diabetes-risk-test/
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Diabetes: DiagnosisRandom glucose >200 with symptoms
polyuria, polydipsia, polyphagia, weight loss
OR
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American Diabetes Association. Diabetes Care. 2012;35(Supp 1):S12, table 2.
Non-fasting, simplest
Nonpharmacologic Treatment
• Diet
• Exercise
• treatment of comorbid conditions
• Foot care
• Dilated eye exam
• Smoking cessation
• Immunizations
APA/AMP 2014: Primary Care Skills for Psychiatrists 176
Pharmacologic Treatment
•Metformin is first line • Works well if HbA1c < 9
• Some nausea and diarrhea 1st week
• Start at 500mg bid and titrate slowly to 1000mg bid (Max dose 2550mg daily)
• Contraindications • Pregnancy • Creatinine > 1.4 mg/dL in women, > 1.5 mg/dL in men• During and for 48 hours after major surgery or
radiologic contrast use
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Pharmacologic Treatment
• After metformin (or not tolerated): start sulfonylurea
• Glipizide (glucotrol)• Start 5mg daily (2.5mg in elderly)
• Optimal dosing BID
• Max daily dose 40mg
• Risk of hypoglycemia
• Avoid long-acting formulas
• Caution w hepatic or renal insufficiency but no absolute cutoff
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Goals of Care
• A1c 7-8
• BP less than 140/90
• ACE-I for proteinuria
• Statin
• Aspirin?
• Eye exam/foot exam
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APA/AMP 2014: Primary Care Skills for Psychiatrists 181
Monitoring
• Every 6 months (2-3 months if changing therapy)• HbA1c
• Yearly• Lipids • Creatinine • LFTS• Electrolytes • Urine microalbumin, Urine Cr, U/A • TSH
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Self-Monitoring of Glucose
• Metformin: No need to monitor
• Sulfonylurea: 1-2 times daily while titrating
• Insulin: QID
• For sulfonylureas and insulin monitor for:• Heavy exercise• Illness
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(e.g. glargine (Lantus), humalog, novalog, NPH, etc…)
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Self-Monitoring of Glucose: Sample Schedule
DateBefore
BreakfastAfter
BreakfastBefore Lunch
After Lunch Before Dinner
After Dinner Before Bed
1/18 X X1/19 X X1/20 X X1/21 X X1/22 X X1/23 X X1/24 X X
APA/AMP 2014: Primary Care Skills for Psychiatrists 184
Case
• You start to wonder: does Bill have diabetes?
• You draw an A1c
• 6.1%
• Random glucose on BMP: 115 mg/dL• His renal function is normal (Cr = 0.9 mg/dL), GFR nl
• You start Bill on metformin 500 mg BID
APA/AMP 2014: Primary Care Skills for Psychiatrists 185
Questions?
APA/AMP 2014: Primary Care Skills for Psychiatrists 186
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Section
Hypertension
Obesity
Cholesterol
Diabetes
Tobacco Use
Prevention
Presenter
Robert McCarron, DO
Aniyizhai Annamalai, MD
Erik Vanderlip, MD MPH
Martha Ward, MD
Jae Han, MD
Jeff Rado, MD
APA/AMP 2014: Primary Care Skills for Psychiatrists 187
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TOBACCO
Edited by:Jaesu (Jae) Han, MDAssociate Clinical ProfessorAssociate Training Director, Family Medicine/Psychiatry Residency ProgramDepartments of Psychiatry and Family/Community MedicineUniversity of California, Davis
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Presented by:Jae Han, MD
Nothing to disclose
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What about Bill’s tobacco use?• Rolls his own q 20-30min while awake
• Approximately 28/day
• Started at age 16, you estimate 60 pack yr hx
• Tried quitting several times
• Went “cold turkey” for 6 months when he was in a state hospital
• He’s not sure what he’d do to pass time if he didn’t smoke
• You wonder:• Can Bill successfully stop smoking?
• Will smoking cessation impact his mental illness, or have an effect on his medications?
• Are cessation medications safe or even effective for Bill?
APA/AMP 2014: Primary Care Skills for Psychiatrists190
TOBACCO DEPENDENCE:A 2-PART PROBLEM and MANAGEMENT
Tobacco Dependence
Physiological Behavioral
Treatment Treatment
Addiction to nicotine
Medications for cessation
Habit of using tobacco
Behavior change program
(APA 2006, US PHS 2008, Fiore 2000)
National guidelines recommend ALL smokers should be screened, advised to quit and offered treatment that
address both aspects of dependence
APA/AMP 2014: Primary Care Skills for Psychiatrists 191
• 234 inpatients with MDD, Bipolar, schizophrenia• Intervention: access to NRT, computer delivered intervention with personally
tailored report and manual, up to 30 minute counseling session, letter to PCP• Primary outcome: 7 day point prevalence abstinence• 18 month f/u
Active Group = 18 month quit rate 20 vs 7.7%OR = 3.15 (CI = 1.22)
Usual Care = greater risk of rehospitalization OR = 1.92 (CI = 1.06)
(Prochaska 2013)
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1. ASSESS readiness on “stages of change”
Precontemplation Action Contemplation Maintenance
Motivational Interviewing
Assist
Behavioral Modification: In-Office• Educate on withdrawal symptoms• Set a quit date• Cognitive- identify / modify reinforcing
thoughts• Behavioral- Modify routine, Identify
triggersOR
Behavioral Modification: Community Know your community resources!
APA/AMP 2014: Primary Care Skills for Psychiatrists 193
ASSIST: Ready to QuitFDA Approved Pharmacotherapy LONG-TERM QUIT RATES
Silagy et al. (2004). Cochrane Database Syst Rev; Hughes et al., (2004). Cochrane Database Syst Rev.; Gonzales et al., (2006). JAMA and Jorenby et al., (2006). JAMA
Per
cen
t q
uit
> 6
mo
nth
s
19.5
14.6
11.5
8.6
16.4
8.8
23.9
11.8
17.1
9.1
20.0
10.2 9.4
22.5
APA/AMP 2014: Primary Care Skills for Psychiatrists 194
TRANSDERMAL NICOTINE PATCH
DISADVANTAGES
• Cannot titrate the dose.
• Allergic reactions to adhesive may occur.
• Taking patch off to sleep may lead to morning nicotine cravings.
ADVANTAGES Consistent nicotine
levels.
Easy to use and conceal.
Fewer adherence issues
APA/AMP 2014: Primary Care Skills for Psychiatrists 195
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Patch Dosage and Schedule
BrandSuggested Dosage
Suggested Plan
Nicoderm CQ or generic
> 10 cig / dStart with 21 mg
6 wks on 21 mg2 wks on 14 mg2 wks on 7 mg
< 10 cig / dStart with 14 mg
6 wks on 14 mg2 wks on 7 mg
Typically begin therapy ON quit day
However…SMI patients (especially Schizophrenia) more likely to smoke > 1 packs per daySo what if I…
(Dickerson 2013)
APA/AMP 2014: Primary Care Skills for Psychiatrists 196
Compared to Standard Patch…
• 25-44 mg (6 studies)• Mixed evidence on long-term quit rate
Increased Dose NRT (Patch)
Increased Dose NRT (Patch)
• (9 studies)• Modest benefit for all forms on short-term quit
rate
Combo NRT (Patch + gum, lozenge, spray, or inhaler)
Combo NRT (Patch + gum, lozenge, spray, or inhaler)
• 6-12 months (4 studies)• Weak evidence on long-term quit rate
Extended NRT (Patch or Gum)Extended NRT (Patch or Gum)
• 2-4 week pre-quit patch (9 studies)• Mixed evidence 6 month quit rate
Pre Quit NRT
(Patch or Gum)
Pre Quit NRT
(Patch or Gum)(Carpenter 2013)
APA/AMP 2014: Primary Care Skills for Psychiatrists 197
FDA Label Change: decreased safety concerns, increased flexibility
Safe to use before quit daySafe to use > 12 weeks
May use during a lapse or relapse and improve outcome
(FDA 2013)
(Zapawa 2011)
APA/AMP 2014: Primary Care Skills for Psychiatrists 198
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BUPROPION SR
DISADVANTAGES
• Avoid if risk for seizures, eating d/o, unmanaged bipolar
• Common side effects:dry mouth, anxiety, insomnia (avoid bedtime dosing)
ADVANTAGES Can be used with NRT
May be beneficial in patients with depression and schizophrenia
Taper not necessary
APA/AMP 2014: Primary Care Skills for Psychiatrists 199
BUPROPION SR: DOSING for SMOKING CESSATION
Begin therapy 1 week PRIOR to quit date
Initial treatment 150 mg po q AM x 3 days, then: 150 mg po qam & qafternoon x 7–12 weeks
If 300 mg is not well tolerated: Reduce dose to 150 mg and reassure that 150
mg dose is still efficacious
(Swan 2003)
APA/AMP 2014: Primary Care Skills for Psychiatrists 200
VARENICLINE: MECHANISM of ACTION
Effects
symptoms of nicotine withdrawal
Blocks DA stimulation associated with smoking
Binds 42 neuronal NIC Ach receptors
Low-level agonist activity
Competitively inhibits binding of nicotine
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VARENICLINE: DOSING
• Begin therapy 1 week PRIOR to quit date
• Take after eating, with full glass of water to reduce nausea.
Treatment Day Dose
Days 1–3 0.5 mg qd
Days 4–7 0.5 mg bid
Day 8 – Week 12 1 mg bid
Can simply write for “Month Starter PAK,” then 2 months of 1 mg bid
APA/AMP 2014: Primary Care Skills for Psychiatrists 202
Varenicline:Warning label in package insert “Serious neuropsychiatric events including, butnot limited to, depression, suicidal ideation, suicide attempt, and completed suicide”•Based on case reports, Led to FDA alert in 2/08
Since then…
•No association in most retrospective studies (Stapleton 2009, Williams et al 2011)
•No association in prospective cohort (Thomas et al 2013) and prospective DB randomized studies (Anthenelli et al 2013) and may actually improve mood (Cinciripini 2013)
•No association in reanalysis of 17 RCT’s and Dept of Defense observational data (Gibbons et al 2013)
APA/AMP 2014: Primary Care Skills for Psychiatrists 203
COMBINATION THERAPIES: EFFECTIVE
• Combination NRT
Long-acting (patch) + Short-acting (gum, inhaler, nasal spray)
• Allows for acute dose titration prn nicotine withdrawal symptoms
• Bupropion SR + Nicotine Patch
• 3 RCT have shown higher abstinence at 6 m
• Varenicline + Nicotine Patch
• PI advises against: risk of increased SE’s
• RCT 2014: combo with higher continuous abstinence at 3 m and 6 m (OR 1.85 p= 0.07 and 1.98 p=0.04) Well tolerated.
(Koegelenberg 2014)
(Fiore 2008)
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COMBINATION Therapies: Effective• Varenicline + Bupropion SR
• RCT showed combo with greater abstinence at 3 and 6 months (OR 1.49 p= 0.03 and 1.52 p=0.03) Combo with less weight gain at 3 months, but more anxiety and depressive symptoms
APA/AMP 2014: Primary Care Skills for Psychiatrists 205
(Ebbert 2014)
Towards and Evidence-Based Algorithm for Stepped Care
Basal Nicotine
Replacement (Patch, 21mg OR 42 mg**)
Wellbutrin SR or XL, Titrated to
goal of minimum 300 mg daily over
a month*
Breakthrough Nicotine
Replacement (Gum,
Lozenge, Inhaler)**
Initial Pharmacotherapy for Tobacco Cessation
3!
Combo
1 Intervention
OR… Chantix…
EMERGING BIOMARKER: Nicotine Metabolite Ratio (NMR)
3-Hydroxycotinine : Cotinine
•2015 RCT: Varenicline vs NRT Patch n=1246
•Normal metabolizers (NMR ≥ 0.31)• Varenicline > NRT Patch at 11 wk, 6 m
•Slow metabolizers (NMR < 0.31)• Varenicline = NRT patch at 11 wk, 6 m
• More side effects to varenicline3-Hydroxycotinine3-Hydroxycotinine
CotinineCotinine
CYP 2A6
NicotineNicotine
CYP 2A6
APA/AMP 2014: Primary Care Skills for Psychiatrists 207
Unanswered questions: • Cost effectiveness: why not just start all with varenicline? • Option for patients concerned about varenicline side effects?• Needs to be replicated (Lerman 2015)
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Medication Coverage
• American Lung Association has state by state tobacco cessation coverage listed
http://lungusa2.org/cessation2/
• Specifically discusses which NRT, pharmacotherapy and counseling options are covered
• Medicaid coverage
• State employee health plan coverage
• Private insurance resources
• What NRT 1-800-QUIT-NOW can dispense
APA/AMP 2014: Primary Care Skills for Psychiatrists 208
Management for specific SMI diagnoses?
Major Depression• NRT, Bupropion, Varenicline: Good evidence of long term
abstinence
Schizophrenia• NRT Insufficient data
• Bupropion Good evidence of long term abstinence
• Varenicline Early evidence for but unclear at 6 m
(Thomas 2013, Gierisch 2012, Hughes 2007)
(Gibbons 2013, Tsoi 2013)
APA/AMP 2014: Primary Care Skills for Psychiatrists 209
Management for specific SMI diagnoses?
Bipolar Disorder• NRT, Bupropion: Insufficient data
• Varenicline• Case reports of mania, 2 retrospective studies of smokers with mental
illness (some with bipolar) showed safety
• First adequately powered study (n=60) showed varenicline vs placebo: 48.4% vs 10.3% at end of treatment (3 months) and 19.4% vs 6.9% at 6 months.
APA/AMP 2014: Primary Care Skills for Psychiatrists 210
(Stapleton 2008, McClure 2010, George 2012)
(Chengappa 2014)
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Pharmacotherapy SummaryNRT (Patch) Bupropion SR Varenicline
Initiation On quit date 1-2 w before quit date 1 w before quit date
Dosing < 10 cigs/d: 14 mg x 6 w, 7 mg x 2 w> 10 cigs/d:21 mg x 6 w, 14 mg x 2 w, 7 mg x 2 w
150 mg qam x 3 d, then 150 mg qam and qafternoon (8 hours later)
0.5 mg qd x 3 d, then bid x 4 d, then 1 mg bid
Duration 12 w 12 w 12 w
Precautions Local Reaction Eating disorderSeizure disorderUnmanaged bipolar
Monitor for adversemood and behavior changes
RCT Data specifically for:
NRT Bupropion SR Varenicline
Depression (history of) ++ ++ ++
Schizophrenia ? ++ +
Bipolar ? ? +
? Insufficient data + limited data ++ RCT data support use NRT Nicotine Replacement Therapy
APA/AMP 2014: Primary Care Skills for Psychiatrists 211
Electronic Cigarettes “Vaping”
• Controversial!!• Helps quitting smoking vs “gateway” to smoking
• Harm reduction vs yet unknown risks
• Not cheap
• WHO 7/14 calls for ban in work, restaurants
and public places
• FDA proposing rules: pending…
• First RCT with e cigarettes vs NRT patch: similar but low efficacy (Bullen 2013)
APA/AMP 2014: Primary Care Skills for Psychiatrists 212
Psychiatrists Should Take the Lead in Tobacco Cessation in Public Mental Health Settings
APA/AMP 2014: Primary Care Skills for Psychiatrists 213
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Back to the case
• Bill is smoking approximately 28 roll-your-own cigarettes a day
• You ask him about smoking cessation, and he reports that he’d like to give it a try again, and is ready to quit in the next month
• You set a quit date of June 17th and you both agree to • Start Bill on varenicline 1 week prior to the quit date
• Discuss potential barriers to cessation and triggers to relapse
• “Rescue” Bill if he hasn’t reduced his smoking by half (14 cigarettes) on his quit date by prescribing NRT
• You consider both long-acting NRT and breakthrough
• You consider adding bupropion to his varenicline and NRT if he is still motivated but having difficulty
APA/AMP 2014: Primary Care Skills for Psychiatrists 214
Any Questions…?
APA/AMP 2014: Primary Care Skills for Psychiatrists 215
Section
Hypertension
Obesity
Cholesterol
Diabetes
Tobacco Use
Prevention
Presenter
Robert McCarron, DO
Aniyizhai Annamalai, MD
Erik Vanderlip, MD MPH
Martha Ward, MD
Jae Han, MD
Jeff Rado, MD
APA/AMP 2014: Primary Care Skills for Psychiatrists 216
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PREVENTION
Edited by:Jeffrey Rado, MDAssistant Professor Departments of Internal Medicine and Psychiatry Rush University
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Presented by:Jeff Rado, MD
Nothing to disclose
APA/AMP 2014: Primary Care Skills for Psychiatrists 218
Education Objectives
1. Understand different types of prevention
2. Become familiar with current disease screening and prevention guidelines:• Cancer
• Infectious Diseases
• Vaccines
• Cardiovascular and Endocrine Disorders
3. Utilize office-based or web-based tools that aid with adherence to evidence-based screening guidelines.
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Why prevention?
APA/AMP 2015: Primary Care Skills for Psychiatrists
Types of Prevention
• Primary Prevention: Prevent disease in individual with no symptoms or diagnosed disease (e.g. sunscreen, vaccines).
• Secondary Prevention: Goal is to find and diagnose disease early (before symptoms are evident) so that treatment can be initiated as early as possible (mammography, PAP smears).
• Tertiary Prevention: Disease is diagnosed and patient exhibits symptoms; goal is to prevent complications or progression of disease.
APA/AMP 2015: Primary Care Skills for Psychiatrists
What makes a good screening test?
• Disease:• Common condition with significant morbidity and mortality (important public health problem).
• Effective treatment available.
• Screening tool:• Available at a reasonable cost.
• Safe and tolerable to patient.
• Capable of identifying the disease and shown to lead to improved outcomes.
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Where do recommendations come from?• U.S. Preventive Services Task Force (USPSTF)• American Academy of Family Practice (AAFP)• American College of Physicians (ACP)• American Academy of Pediatrics (AAP)• American College of Obstetrics and Gyn (ACOG)• American Psychiatric Association (APA)• American Academy of Child and Adolescent Psych• American Medical Association (AMA)• Centers for Disease Control (CDC)• Insurance Companies (CMS, Commercial etc.)• Special Societies ( American Cancer Society, American
Heart Association)
APA/AMP 2015: Primary Care Skills for Psychiatrists
U.S. Preventive Services Task Force Grading Recommendations• A There is high certainty that the net benefit is substantial. Offer this service.
• B There is Moderate certainty that the net benefit is moderate to substantial. Offer this Service.
• C “It depends” May be a benefit depending on the individual patient and there symptoms, presentation.
• D No benefit and possible harm. Discourage using this service.
• I Statement: We don’t know.• Also quality statement: Good, Fair and Poor
APA/AMP 2015: Primary Care Skills for Psychiatrists
jr7
Breast Cancer• Mammography:
• Age 40-49: Individualized discussion of risk/benefits
• Age 50-74: Every two years
• Age 75+: benefit of screening uncertain.
• ONLY 70% of eligible women receive mammograms—most common reason women give is that their doctor never told them to get one.
Self Breast Exam: no benefit
Unknown if beneficial:• Breast MRI
• Clinical Breast Exam
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Slide 224
jr7 I'm assuming that the presentation will highlight primarily the USPSTF recs. May help to mention why we chose to highlight these (a slide of the USPSTF background and how the recs come to be? so others viewing this later will be able to ID where the recs are coming from and why we chose these?) I will talk about whyUSPSTF is used primarily but did not think it needed an entire additional slide devloted toit. hope that is okay. jrado, 1/30/2014
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Cervical Cancer
• PAP Cytology• Up to age 21: do not screen
• Age 21-65: every 3 years (usually with reflexive HPV testing).
• Age 30-65: every 3 years or every 5 years with high-risk HPV testing
• Over age 65: do not screen
• Do not screen high-risk HPV before age 30.
APA/AMP 2015: Primary Care Skills for Psychiatrists
jr8
Colon Cancer
• No screening recommended prior to age 50 for average risk persons.
• Age 50-75:• Fecal-Occult Blood Testing (FOBT) yearly
• Flexible Sigmoidoscopy every 3-5 years
• Colonoscopy every 10 years
• Age 75+: no screening • There may be considerations that support colorectal
cancer screening in an individual patient between age 75 and 85.
APA/AMP 2015: Primary Care Skills for Psychiatrists
Lung Cancer
• Low dose CT scan of Chest for individuals age 55-80 with a 30 pack-year history who currently smoke or quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.(new December 2013—Grade B recommendation)• Ex: “Bob” is 57 years old. He started smoking at age 16, 1 packs per day.
For last 15 years he reduced his use to 1/2 pack per day. • 1 ppd X 26 years = 26 pack-years PLUS
• ½ ppd X 15=7.5 pack-years
• Total=33.5 pack-years.
APA/AMP 2015: Primary Care Skills for Psychiatrists
jr9
Slide 226
jr8 can we add the specifier that the HPV testing here is the testing for the more invasive types w pap smear? people may be confused by the last bullet
DONE. I was going to explain the reasoning for this as well.jrado, 1/30/2014
Slide 228
jr9 This one is particularly relevant to the CMHC population.
Would it be helpful for a quick side-bar example of how to calculate the pack-years so the members canget a sense of who would be screened for this? Also - I imagine there are questions about coverage and how to order - I haven't yet ordered this. Have you? The ACA should cover all USPSTF preventive services - would it be helpful to add some on that? just thoughts...
I have NOT ordered this yet so actually not sure it is even covered yet. I added a pack year example.jrado, 1/30/2014
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Other Cancers
• No benefit from screening:• Pancreatic
• Ovarian
• Testicular
• Prostate
•Unknown benefit from screening:• Bladder
• Skin
• Oral
APA/AMP 2015: Primary Care Skills for Psychiatrists
Cardiovascular Disease
• Hypertension: every 2 years in adults.
• Hyperlipidemia: every 5 years in men age 35 or older and women age 45 and older.
• Abdominal Aortic Aneurysm (AAA): single screening ultrasound in MEN age 65-75 who have ever smoked.
• Tobacco: ask at every encounter.
• Screening for peripheral artery disease or carotid artery disease not recommended.
APA/AMP 2015: Primary Care Skills for Psychiatrists11
Endocrine Disorders
•Diabetes: screen every three years only if Blood pressure is >135/80 (Grade B).
•Thyroid Disorders: not recommended due to unclear benefit.
•Osteoporosis: DEXA scan in women >65 years older with out known fractures or secondary causes of osteoporosis (Grade B).
APA/AMP 2015: Primary Care Skills for Psychiatrists
jr10
Slide 230
11 Would organizing this slide into a quick table be helpful? Erik Vanderlip, 1/27/2014
Slide 231
jr10 can we add how often (once, once yearly, etc.?) I can't remember myselfNo consensus guidelines (no evidence) on how frequently to screen plus it depends on so many factors (dexa results, bisphosphonates, what other RF's do they have, etc.) I think this is too complicated to add.jrado, 1/30/2014
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Infectious Diseases
• HIV: all individuals age 15-65 should be screened.
• Hepatitis C: All adults born between 1945 and 1965 should receive one time testing.• More regular screening may be indicated for HIV and Hepatitis C if
risk factors are present.
• Chlamydia and Gonorrhea: screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors).
APA/AMP 2015: Primary Care Skills for Psychiatrists
jr11
Vaccines
• Influenza: Yearly for everyone age 6 months and up.• Pneumococcal polysaccharide 23: One dose after
age 65 and one or two doses prior to age 65 for individuals with chronic medical illnesses (including smokers, asthmatics).
• Pneumococcal 13 valent conjugate (Prevnar): One dose <65 with chronic medical illness or one dose >65.
• Zoster (Shingles): single dose at age 60 or older.• Tetanus/Diptheria (Td): every 10 years. One dose booster should be TDAP.
• Hepatitis B: Recommended if risk factors present.• HPV: three doses before age 26 in females and before age 21 in males.
APA/AMP 2015: Primary Care Skills for Psychiatrists
jr12
Disease Recommended Screening or Vaccine
Breast CA 50-74: MGM q 2 years
Cervical CA 21-65: q 3 years 30-65 q 3 yrs or q 5 with high risk HPV test.
Colon CA 50-75: c-scope q10 yrs OR FOBT q1yr OR flex sig q 3-5 yrs.
Lung CA 55-80 30 pack-yrs: low dose CT chest
AAA Male smokers 65-75 : abdominal US
HIV 15-65: once ---------------------------------------------------------------------------------
Hepatitis C Birth years 1945-65: once----------------------
Osteoporosis
>65: dexascan
Diabetes Q3 yrs if BP>135/80-------------------------------------------------------------------------
Influenza Yearly---------------------------------------------------------------------------------------
Pneumovax Once <65 if chronicillness
Once >65.
Prevnar-13 Once<65 if chronic illness or once >65
Tet/dipth Q 10 yearsAPA/AMP 2015: Primary Care Skills for Psychiatrists
Slide 232
jr11 bullets 1 and 2 - this is the general population recommendation but I think that we could also consider saying something along the lines of yearly sreening is justified if risk factors persist
I added a sentence. Did not specify yearly only because there is no consensus on how frequently to screen. There may be cases where you screen every 6 months.jrado, 1/30/2014
Slide 233
jr12 Let's add that this includes smokers and asthmatics, which is at least 1/2 of patients that we see
DONEjrado, 1/30/2014
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APA/AMP 2015: Primary Care Skills for Psychiatrists
Resources: http://healthfinder.gov/myhealthfinder/
APA/AMP 2015: Primary Care Skills for Psychiatrists
Resources: http://epss.ahrq.gov/ePSS/search.jsp
APA/AMP 2015: Primary Care Skills for Psychiatrists
Also available on mobile devices.
5/10/2016
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After reviewing the guidelines…• You decide to screen Bill for HIV, syphilis, hepatitis B and
C, and tuberculosis with a skin test
• You administer a flu shot, TDaP and Hepatitis A and B
• He has no family history of cancers so he is not due for screening until age 50 • At 50, recommend colon cancer screening and discuss prostate
cancer screening
• At age 55, you would consider the low dose CT scan of chest to screen for lung cancer (given < 15 yrs since smoking cessation)
APA/AMP 2015: Primary Care Skills for Psychiatrists
Any Questions…?
THANK YOU!!!!
APA/AMP 2015: Primary Care Skills for Psychiatrists
Section
Obesity
Hypertension
Cholesterol
Diabetes
Tobacco Use
Prevention
Presenter
Aniyizhai Annamalai, MD
Robert McCarron, DO
Erik Vanderlip, MD MPH
Martha Ward, MD
Jae Han, MD
Jeff Rado, MD
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Primary Care Skills for Psychiatrists
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Agenda
• 9-9:50:
• 10-1020 hr:
• 1020-1040hr:
• 1040-1100 hr:
• 1100 to 1200 hr:
• 1200 to 1 PM hr:
• 100 – 120
• 120 - 140 hr:
• 140-200 hr:
• 2-3 PM hr:
• 3-4 PM hr:
APA/AMP 2014: Primary Care Skills for Psychiatrists 241
• Introduction, background
• HTN
• Obesity
• Cholesterol
• Cases on HTN, Obesity, Cholesterol
• Lunch
• Diabetes
• Tobacco
• Preventive Medicine
• DM, Tobacco, Prevention cases
• Collective group discussion
DM, Tobacco, Prevention cases
• Break into small groups, get out handbook of cases.
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Collective Discussion, Roles and Boundaries
APA/AMP 2014: Primary Care Skills for Psychiatrists 243
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Lastly: Survey!
APA/AMP 2014: Primary Care Skills for Psychiatrists 244
Same Number!!!
Primary Care Skills for Psychiatrists
APA/AMP 2014: Primary Care Skills for Psychiatrists 245
a collaboration of:
APA Workgroup on Integrated CareLori Raney, MD (chair)Medical Director, Axis Health Systems Dolores, Colorado
Aniyizhai Annamalai, MDInternal Medicine/Psychiatry
Jae Han, MDFamily Medicine/Psychiatry
Robert McCarron, DO Internal Medicine/Psychiatry
Jeffrey Rado, MD Internal Medicine/Psychiatry
Erik Vanderlip, MD MPHFamily Medicine/Psychiatry
Martha Ward, MD Internal Medicine/Psychiatry
Faculty
PRIMARY CARE SKILLS FOR PSYCHIATRISTSAmerican Psychiatric Association Annual Meeting
Atlanta, Georgia
May, 2016
5/10/2016
1
PREVENTION
Edited by:Jeffrey Rado, MDAssistant Professor Departments of Internal Medicine and Psychiatry Rush University
APA/AMP 2015: Primary Care Skills for Psychiatrists
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Presented by:Jeff Rado, MD
Nothing to disclose
APA/AMP 2014: Primary Care Skills for Psychiatrists 2
Education Objectives
1. Understand different types of prevention
2. Become familiar with current disease screening and prevention guidelines:• Cancer
• Infectious Diseases
• Vaccines
• Cardiovascular and Endocrine Disorders
3. Utilize office-based or web-based tools that aid with adherence to evidence-based screening guidelines.
APA/AMP 2015: Primary Care Skills for Psychiatrists
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Why prevention?
APA/AMP 2015: Primary Care Skills for Psychiatrists
Types of Prevention
• Primary Prevention: Prevent disease in individual with no symptoms or diagnosed disease (e.g. sunscreen, vaccines).
• Secondary Prevention: Goal is to find and diagnose disease early (before symptoms are evident) so that treatment can be initiated as early as possible (mammography, PAP smears).
• Tertiary Prevention: Disease is diagnosed and patient exhibits symptoms; goal is to prevent complications or progression of disease.
APA/AMP 2015: Primary Care Skills for Psychiatrists
What makes a good screening test?
• Disease:• Common condition with significant morbidity and mortality (important public health problem).
• Effective treatment available.
• Screening tool:• Available at a reasonable cost.
• Safe and tolerable to patient.
• Capable of identifying the disease and shown to lead to improved outcomes.
APA/AMP 2015: Primary Care Skills for Psychiatrists
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Where do recommendations come from?• U.S. Preventive Services Task Force (USPSTF)• American Academy of Family Practice (AAFP)• American College of Physicians (ACP)• American Academy of Pediatrics (AAP)• American College of Obstetrics and Gyn (ACOG)• American Psychiatric Association (APA)• American Academy of Child and Adolescent Psych• American Medical Association (AMA)• Centers for Disease Control (CDC)• Insurance Companies (CMS, Commercial etc.)• Special Societies ( American Cancer Society, American
Heart Association)
APA/AMP 2015: Primary Care Skills for Psychiatrists
U.S. Preventive Services Task Force Grading Recommendations• A There is high certainty that the net benefit is substantial. Offer this service.
• B There is Moderate certainty that the net benefit is moderate to substantial. Offer this Service.
• C “It depends” May be a benefit depending on the individual patient and there symptoms, presentation.
• D No benefit and possible harm. Discourage using this service.
• I Statement: We don’t know.• Also quality statement: Good, Fair and Poor
APA/AMP 2015: Primary Care Skills for Psychiatrists
jr7
Breast Cancer• Mammography:
• Age 40-49: Individualized discussion of risk/benefits
• Age 50-74: Every two years
• Age 75+: benefit of screening uncertain.
• ONLY 70% of eligible women receive mammograms—most common reason women give is that their doctor never told them to get one.
Self Breast Exam: no benefit
Unknown if beneficial:• Breast MRI
• Clinical Breast Exam
APA/AMP 2015: Primary Care Skills for Psychiatrists
Slide 8
jr7 I'm assuming that the presentation will highlight primarily the USPSTF recs. May help to mention why we chose to highlight these (a slide of the USPSTF background and how the recs come to be? so others viewing this later will be able to ID where the recs are coming from and why we chose these?) I will talk about whyUSPSTF is used primarily but did not think it needed an entire additional slide devloted toit. hope that is okay. jrado, 1/30/2014
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Cervical Cancer
• PAP Cytology• Up to age 21: do not screen
• Age 21-65: every 3 years (usually with reflexive HPV testing).
• Age 30-65: every 3 years or every 5 years with high-risk HPV testing
• Over age 65: do not screen
• Do not screen high-risk HPV before age 30.
APA/AMP 2015: Primary Care Skills for Psychiatrists
jr8
Colon Cancer
• No screening recommended prior to age 50 for average risk persons.
• Age 50-75:• Fecal-Occult Blood Testing (FOBT) yearly
• Flexible Sigmoidoscopy every 3-5 years
• Colonoscopy every 10 years
• Age 75+: no screening • There may be considerations that support colorectal
cancer screening in an individual patient between age 75 and 85.
APA/AMP 2015: Primary Care Skills for Psychiatrists
Lung Cancer
• Low dose CT scan of Chest for individuals age 55-80 with a 30 pack-year history who currently smoke or quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.(new December 2013—Grade B recommendation)• Ex: “Bob” is 57 years old. He started smoking at age 16, 1 packs per day.
For last 15 years he reduced his use to 1/2 pack per day. • 1 ppd X 26 years = 26 pack-years PLUS
• ½ ppd X 15=7.5 pack-years
• Total=33.5 pack-years.
APA/AMP 2015: Primary Care Skills for Psychiatrists
jr9
Slide 10
jr8 can we add the specifier that the HPV testing here is the testing for the more invasive types w pap smear? people may be confused by the last bullet
DONE. I was going to explain the reasoning for this as well.jrado, 1/30/2014
Slide 12
jr9 This one is particularly relevant to the CMHC population.
Would it be helpful for a quick side-bar example of how to calculate the pack-years so the members canget a sense of who would be screened for this? Also - I imagine there are questions about coverage and how to order - I haven't yet ordered this. Have you? The ACA should cover all USPSTF preventive services - would it be helpful to add some on that? just thoughts...
I have NOT ordered this yet so actually not sure it is even covered yet. I added a pack year example.jrado, 1/30/2014
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Other Cancers
• No benefit from screening:• Pancreatic
• Ovarian
• Testicular
• Prostate
•Unknown benefit from screening:• Bladder
• Skin
• Oral
APA/AMP 2015: Primary Care Skills for Psychiatrists
Cardiovascular Disease
• Hypertension: every 2 years in adults.
• Hyperlipidemia: every 5 years in men age 35 or older and women age 45 and older.
• Abdominal Aortic Aneurysm (AAA): single screening ultrasound in MEN age 65-75 who have ever smoked.
• Tobacco: ask at every encounter.
• Screening for peripheral artery disease or carotid artery disease not recommended.
APA/AMP 2015: Primary Care Skills for Psychiatrists2
Endocrine Disorders
•Diabetes: screen every three years only if Blood pressure is >135/80 (Grade B).
•Thyroid Disorders: not recommended due to unclear benefit.
•Osteoporosis: DEXA scan in women >65 years older with out known fractures or secondary causes of osteoporosis (Grade B).
APA/AMP 2015: Primary Care Skills for Psychiatrists
jr10
Slide 14
2 Would organizing this slide into a quick table be helpful? Erik Vanderlip, 1/27/2014
Slide 15
jr10 can we add how often (once, once yearly, etc.?) I can't remember myselfNo consensus guidelines (no evidence) on how frequently to screen plus it depends on so many factors (dexa results, bisphosphonates, what other RF's do they have, etc.) I think this is too complicated to add.jrado, 1/30/2014
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Infectious Diseases
• HIV: all individuals age 15-65 should be screened.
• Hepatitis C: All adults born between 1945 and 1965 should receive one time testing.• More regular screening may be indicated for HIV and Hepatitis C if
risk factors are present.
• Chlamydia and Gonorrhea: screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors).
APA/AMP 2015: Primary Care Skills for Psychiatrists
jr11
Vaccines
• Influenza: Yearly for everyone age 6 months and up.• Pneumococcal polysaccharide 23: One dose after
age 65 and one or two doses prior to age 65 for individuals with chronic medical illnesses (including smokers, asthmatics).
• Pneumococcal 13 valent conjugate (Prevnar): One dose <65 with chronic medical illness or one dose >65.
• Zoster (Shingles): single dose at age 60 or older.• Tetanus/Diptheria (Td): every 10 years. One dose booster should be TDAP.
• Hepatitis B: Recommended if risk factors present.• HPV: three doses before age 26 in females and before age 21 in males.
APA/AMP 2015: Primary Care Skills for Psychiatrists
jr12
Disease Recommended Screening or Vaccine
Breast CA 50-74: MGM q 2 years
Cervical CA 21-65: q 3 years 30-65 q 3 yrs or q 5 with high risk HPV test.
Colon CA 50-75: c-scope q10 yrs OR FOBT q1yr OR flex sig q 3-5 yrs.
Lung CA 55-80 30 pack-yrs: low dose CT chest
AAA Male smokers 65-75 : abdominal US
HIV 15-65: once ---------------------------------------------------------------------------------
Hepatitis C Birth years 1945-65: once----------------------
Osteoporosis
>65: dexascan
Diabetes Q3 yrs if BP>135/80-------------------------------------------------------------------------
Influenza Yearly---------------------------------------------------------------------------------------
Pneumovax Once <65 if chronicillness
Once >65.
Prevnar-13 Once<65 if chronic illness or once >65
Tet/dipth Q 10 yearsAPA/AMP 2015: Primary Care Skills for Psychiatrists
Slide 16
jr11 bullets 1 and 2 - this is the general population recommendation but I think that we could also consider saying something along the lines of yearly sreening is justified if risk factors persist
I added a sentence. Did not specify yearly only because there is no consensus on how frequently to screen. There may be cases where you screen every 6 months.jrado, 1/30/2014
Slide 17
jr12 Let's add that this includes smokers and asthmatics, which is at least 1/2 of patients that we see
DONEjrado, 1/30/2014
5/10/2016
7
APA/AMP 2015: Primary Care Skills for Psychiatrists
Resources: http://healthfinder.gov/myhealthfinder/
APA/AMP 2015: Primary Care Skills for Psychiatrists
Resources: http://epss.ahrq.gov/ePSS/search.jsp
APA/AMP 2015: Primary Care Skills for Psychiatrists
Also available on mobile devices.