Introduction to Co-located, Collaborative Care

Introduction to PC-MHI Functions: CCC, CM, and How they Work Together Katherine M. Dollar, PhDSara Greenwood, MSWJohanna Klaus, PhDDefinitions**Provided by Dr. Christopher Hunter from literature synthesis for shared definitionsIntegrated Care is an overarching term conceptually defined as:A form of care where behavioral health and primary care providers interact in a systematic manner to meet the behavioral health and health needs of their patients.

Or: Unifies care for physical and mental concerns AHRQ 2008 Butler et al.

PEG: 2,3,5, 6?,7There are multiple definitions of integrated care (see Butler et al., 2008 Table 1 for details). A primary problem with the use of the term Integrated Care is that it is a general overarching term or umbrella concept covering a range of models of health care delivery. The confusion occurs as individuals attempt to narrowly define this umbrella term with the model or components of the model they are describing.

2Introduction to Co-located, Collaborative Care

Katherine M. Dollar, PhDAugust 2011

Based on material previously presented by Andrew Pomerantz, MD and Margaret Dundon, PhD

Co-location/Co-located ServiceA behavioral health provider working in a space that is embedded in (or in close proximity to ) a primary care clinic.

Collaborative Care/Collaboration The interactions between primary care and behavioral health providers for the purpose of developing treatment plans, providing clinical services and coordinating care to meet the physical and behavioral health needs of patients.4Co-located Collaborative CareA state of mind as much as a programA platform for treatment, not a treatmentMany Dimensions

Population-Based BHP ServicesServicesAssessments/Initial contactUsually 30 minutes (2 15 or 20 minute units)

Interventions/Follow-UpsUsually scheduled for 15-20 minute unitFor specific skill training (e.g., progressive muscle relaxation) may want 30-45 minutes

Classes/GroupsCan be used for variety of topics (insomnia, behavioral activation for depression, pain management)Vary from 1-2 hoursMay be co-led

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CCC vs. Traditional MHCo-Located Collaborative MH CareMental Health Specialty CareLocationIn PC ClinicA different floor, bldgPopulationMost are healthyMost have MH DiagnosesInter-Provider CommunicationCollaborative & On-going Consultations via PCPs Method of ChoiceConsult reportsCPRS notesService Delivery StructureBrief appointments (20-30)Limited number of appointments (avg. bet 2 & 3)50 - 90 minute psychotherapy sessions14 week minimumApproachProblem-focusedSolution OrientedPatient CenteredVaries by therapy Diagnosis-focusedTreatment Plan LeaderPCP continues to be leadMHP is leadPrimary FocusSupport the over-all health of the VeteranFocus on functionCure or Ameliorate Mental Health Symptoms7Population-Based Behavioral Health Care: CCCDesigned to have largest effect on population and maximal help to PC patients and providers: A little service for a lot of pts vs. traditional MH

Co-location (embedded)Advanced access (prn tx) and warm handoffs

BHP may see 10-15 pts a day (Visn 2 target: 8-10) with limited follow-up (2-3 visits on average)

Collaboration- develop biopsychosocial treatment plan with PCP and other team members (pharmacist/social worker/dietitian/nurses)

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Staffing an integrated care programPsychiatrist or APN

Behaviorist (Psychologist or LCSW)

Support Staff (some have separate clerks, some use PC clerks)

PACT: Teams and Teamlets 9

SchedulingOpen Access: from no scheduled appointments (WRJ) to limited schedule appointments or alternating scheduled and open

Minimizes wait times

Allows warm hand-offs and increases linkage success

Passes the endorsement of the PCP to the BHP10

Add citation for increased show rates with warm hand-off10Brief Assessment ToolsInterview AssessmentsNot Rorschach or MMPI or., but brief evidence-based screens such asPHQ 9 or PHQ 2GAD 7PCL-MAUDIT CBlessed Orientation Memory ConcentrationOthers?Focus on functioning, and tailored around PCP reason for referralThis 30 min. challenge can be organized around 5 As: AssessAdviseAgreeAssist Arrange11

Peg: slides 12-1611Arrange

Specify plans for follow-up (visits, phone calls, mail reminders)AssistProvide information, teach skills, problem solve barriers to reach goalsAdviseSpecific, personalized, options for tx, how sx can be decreased, functioning, quality of life/health improvedAgreeCollaboratively select goals based on patient interest and motivation to changeAssessRisk Factors, Behaviors, Symptoms, Attitudes, Preferences Personal Action Plan 1. List goals in behavioral terms 2. List strategies to change health behaviors 3. Specify follow-up plan 4. Share plan with practice team5As-Assess, Advise, Agree, Assist, ArrangeDiagram adapted from: Glasgow, R. E & Nutting, P. A. (2004). Diabetes. In Handbook of Primary Care Psychology. Ed., Hass, L. J. (pp. 299-311)12

1212In putting it all together:-You will end up with a specific plan for managing a problem that is clear, shared with whole team

Brief InterventionsMotivational Interviewing

Brief Interventions for SUDs

Problem Solving Therapy

Acceptance and Commitment Therapy

Psychiatric consultations with PCPs

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13CCC Domains of CompetencyDomain 1: Clinical Practice

Domain 2: Practice Management

Domain 3: Consultation

Domain 4: Documentation

Domain 5: Teamwork

Domain 6: Administrative Skills14

DIFFER DRAMATICALLY FROM TRADITIONAL

Clinical PracticePractice ManagementConsultation FOCUS ON RECOMMENDATIONS THAT REDUCE PCP VISITS AND WORKLOAD

14General Practice Management SkillsTeaching PCPs what BHPs can offer

Teaching PCPs how to do effective warm hand-offs

Teaching BHPs how to provide BRIEF, cogent summaries of impression and recommendations to PCP in 3 min. or less

Teaching patients self-management skills

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Tips for Start-UpThis is a new approach to care for many, not a natural shift

PCPs have worked without the support thus far, and often do not know how to use it or understand how it is helpful

BHPs have to promote services and show success from interventions

Shift to seeing PCP as customer

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16Care ManagementJohanna Klaus, PhDHow many are doing care management at your site?How many doing CCC?What do you know about care management (Peg did intro yesterday)?5 Ws not going to talk about the How.1718

Now 52 (as of July 29th) and 43 with fully PCMHI programs.18Care ManagementAlgorithm-based care that includes routine monitoring/assessment of patients focusing onPsychoeducation; encourage self-management skillsBrief treatment including (but not limited to) medicationAdherence to medication, treatment planIn consultation with the supervising clinician, provide relevant information to the PCP to allow collaboration for appropriate care decisions

19Guideline-based treatment supportDesignated Care Manager supporting longitudinal mental health careOften telephone based

Key Components of CM Offer telephonic contact Much appreciated by patientsStepped Care ApproachStrong ties to mental health supervision Initial decisions and prescribing in primary care Assessment basedTracking importantEmphasis on patient self-management supportCare manager facilitates communication

20Interventions: What can be done?Watchful WaitingVeterans preferenceMedication monitoringBrief interventions, eg. for alcohol misuse Brief treatment: eg. problem-solving, behavioral activationRefer to Specialty Mental HealthWhy care management? Supports Veteran-centered care incorporates convenience and preference Better symptom and functional outcomesGreater adherence to treatmentReduced mortalityGreater engagement in care

Most vets prefer to be treated in PC

22Current Evidence BaseDepression very good evidenceAnxiety evidence from a few studiesSubstance UseAlcohol - very good evidence for brief interventionPrescription and non-prescription drugs very few studies yetPost Traumatic Stress Disorder and Chronic Pain little evidence yet; studies in process

Multiple meta-analyses of depression evidence.A few anxiety studies CALM, Roy-ByrneGood evidence for brief interventions for ETOH; Oslin study ongoing; Heather cluster randomized trial in UK. Little evidence for collaborative care for drug abusePTSD studies in processComorbid disorders - Dorrs AHRQ Health Care Innovation; Katons recent study for diabetes & depression 23Large RCTs supporting Care ManagementPROSPECT study: more patients treated for depression, decline in suicidal ideation, faster resolution of depressive symptoms

IMPACT study: faster decline in rates of suicidal ideation, more favorable course of depression in both degree and speed of symptom reduction

Role of the Care ManagerAssessment and triageDecision supportPatient education and activationMonitor adherence to treatment, treatment outcomes, and medication side effectsFollow-up with pts 6-8 times over 6 monthsCollaborate with mental health specialists Support patient self-managementReferral management

Not going to talk about identification of veterans, that is more of a program decision, but should be systematic, may including case finding. Remember PCMHI is population based and is not limited to veterans who have reached the point that they are requesting treatment; often identified by positive screens25Care ManagersNurses and social workers most commonly, but others serve as care managers including psychologistsContent of contacts may differ depending on discipline but includes active follow-up, measurement-based care, medication monitoring (when appropriate) and supporting patient self-management

Care Manager: the GluePrimary Care ClinicianMental Health Supervisor

Care ManagerPatientCare Manager SupervisorTypically psychiatrist, sometimes a psychologist, preferably someone with integrated care clinical experience Regular supervision, i.e. weeklyEncourage PC providers to prescribe; provide recommendations via care management supervisionGet to know PC providers; provide consultationI think one of the most important functions that supervision has is that it really makes you a cohesive program and gives some fidelity or consistency to your program as well.

In the BHL model, and I believe TIDES as well, we really encourage the PC providers to prescribe. Encourages collaboration versus parallel care. Therefore, in these models, it is important to emphasize that the work for the supervisor may not be reflected in their workload numbers. However, it doesnt need to take a lot of time. At the same time, it is important for the supervisor to know the PC providers and PC leadership they may be working behind the scenes, but it really helps to build trust in your program if they have a face.

28Case Example30

Mr. HowellDuring his PCP visit , Mr. Howell, a 59 year old male with osteoarthritis, diabetes and hypertension told his PCP that in the past few weeks he had not been feeling very well. He tells his doctor, Im sleeping a lot more than usualI dont have to get up for work, but I really dont feel like getting out of bed. I just dont have any energy. He has gained 10 pounds since losing his job and reports his blood sugars are often in the 180-240 range. His PHQ-2 is positive & AUDIT-C score is 1. He does not want to stay to talk someone because he wants to beat the traffic.

How are patients identified?Mr. HowellMr. Howell tells his doctor, Im sleeping a lot more than usualI dont have to get up for work, but I really dont feel like getting out of bed. I just dont have any energy. Since I was laid off a few months ago from my manufacturing job, all I do is sit around the house. My mood is OK, but when I think about money and my financial future, it starts to really bother me. He denies hopelessness, or past or present suicidal ideation. CBC and TSH are normal.

Mrs. PlymouthIm just so tired all of the time. Im exhausted, but I cant sleep. I toss and turn when I go to bed; if I doze off, I wake right back up. Not sleeping just makes me more even more irritablethe littlest things set me off. When asked about her use of alcohol, Mrs. Plymouth says, I have a few drinks. It helps me relax.Further inquiry revealed Mrs. Plymouth feels very stressed out most of the time because Im fighting with my family. She acknowledged having little interest or pleasure in doing things most days and that shes thought that things might be better if I wasnt around.She is not interested in taking medications, but was not resistant to talking with a therapist.

30AssessmentGoals of assessment:Establish Veteran needs and preferences for treatmentIdentify patients appropriate for care management servicesRecognize patients who may benefit from higher-intensity treatment

Provide "on-time, on-target" information to PCPs and collaboratively make appropriate care decisions

Assessment tools & triage options may vary by site

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Mr. HowellContact Mr. Howell next day by the telephonePHQ-9 score is 13He denies past or present suicidal ideation. No history of mental health concerns; medical comorbidities include osteoarthritis, diabetes and hypertensionSince I was laid off a few months ago from my manufacturing job, all I do is sit around the house. My mood is OK, but when I think about money and my financial future, it starts to really bother me; I feel like a failure to my family.Stopped socializing with his friends and family members, notes that he especially misses visiting with his grandchildren.Mr. Howell expresses hesitation in treatment for depressionWhat do we learn from the assessment?Mr. HowellMr. Howell tells his doctor, Im sleeping a lot more than usualI dont have to get up for work, but I really dont feel like getting out of bed. I just dont have any energy. Since I was laid off a few months ago from my manufacturing job, all I do is sit around the house. My mood is OK, but when I think about money and my financial future, it starts to really bother me. He denies hopelessness, or past or present suicidal ideation. CBC and TSH are normal.

Mrs. PlymouthIm just so tired all of the time. Im exhausted, but I cant sleep. I toss and turn when I go to bed; if I doze off, I wake right back up. Not sleeping just makes me more even more irritablethe littlest things set me off. When asked about her use of alcohol, Mrs. Plymouth says, I have a few drinks. It helps me relax.Further inquiry revealed Mrs. Plymouth feels very stressed out most of the time because Im fighting with my family. She acknowledged having little interest or pleasure in doing things most days and that shes thought that things might be better if I wasnt around.She is not interested in taking medications, but was not resistant to talking with a therapist.

32Decision SupportTreatment algorithms are a set of decision rules aimed at reducing variability in treatment and maximizing patients ability to achieve full remission.

The data gathered during the initial assessment help the care manager decide upon a treatment plan to suggest to the PCP.

Although care managers play a critical part in depression treatment, they do not make treatment decisions or prescribe medications. The patients PCP will make final decisions about prescribing medicines; the care managers input on diagnosis, co-morbidities and other treatment factors will help guide the providers choices.

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The role of the care manager, as has been emphasized throughout this manual, is to assess, monitor, recommend and refer. The PCP and patient make final treatment decisions using evidencebased recommendations resulting from care manager assessments.

33Whos appropriate for care management?Likely CandidatesMajor DepressionOther depressionGAD, PanicAdjustment disorderNew antidepressantPatients who request txPTSD?Pain?Alcohol dependence?

Likely UnsuitableSevere cognitive impairmentPrimary psychotic or bipolar disorderBenzo addictionNeeds hospitalization Somewhat depends Speaks to importance of an initial assessmentCare Management ServicesStepped care: a range of services available; patent is triaged to appropriate level of care based on patient preference and need

Watchful WaitingPatient Education & ActivationDepression & anxiety care managementBrief Alcohol InterventionFollow-up & MonitoringReferral Management

35Watchful waiting: series of calls to monitor symptomsReferral Mgt: Coordinating care with appropriate referrals

The key component of the DACM intervention is the introduction of a care manager into the primary care setting who will collaborate with the PCP, promote clinical management that adheres to treatment guidelines, and monitor and encourage patient acceptance and adherence to treatment recommendations through support, education, and motivational engagement.

The care manager is able to discuss needed information with patients, such as symptoms, goals, treatment preferences and potential barriers, as well as changes in clinical status, treatment adherence and presence of side effects. Furthermore, the care manager is able to use this information to prompt PCPs with timely recommendations about appropriate care for their patients.

follow-up of patients to assess whether they are getting better and whether and when referrals are indicated if they are not improving, or need specialty care for co-morbidities.

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Mr. Howell

What treatment plan recommendations would you make? Mr. Howell tells his doctor, Im sleeping a lot more than usualI dont have to get up for work, but I really dont feel like getting out of bed. I just dont have any energy. Since I was laid off a few months ago from my manufacturing job, all I do is sit around the house. My mood is OK, but when I think about money and my financial future, it starts to really bother me. He denies hopelessness, or past or present suicidal ideation. CBC and TSH are normal.

Mrs. PlymouthIm just so tired all of the time. Im exhausted, but I cant sleep. I toss and turn when I go to bed; if I doze off, I wake right back up. Not sleeping just makes me more even more irritablethe littlest things set me off. When asked about her use of alcohol, Mrs. Plymouth says, I have a few drinks. It helps me relax.Further inquiry revealed Mrs. Plymouth feels very stressed out most of the time because Im fighting with my family. She acknowledged having little interest or pleasure in doing things most days and that shes thought that things might be better if I wasnt around.She is not interested in taking medications, but was not resistant to talking with a therapist.

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Mr. Howell

After 5 weeks of monitoring and behavioral activation over the phone, Mr. Howells PHQ remains above 10. He is agreeable to trying an antidepressant.

Mr. Howell tells his doctor, Im sleeping a lot more than usualI dont have to get up for work, but I really dont feel like getting out of bed. I just dont have any energy. Since I was laid off a few months ago from my manufacturing job, all I do is sit around the house. My mood is OK, but when I think about money and my financial future, it starts to really bother me. He denies hopelessness, or past or present suicidal ideation. CBC and TSH are normal.

Mrs. PlymouthIm just so tired all of the time. Im exhausted, but I cant sleep. I toss and turn when I go to bed; if I doze off, I wake right back up. Not sleeping just makes me more even more irritablethe littlest things set me off. When asked about her use of alcohol, Mrs. Plymouth says, I have a few drinks. It helps me relax.Further inquiry revealed Mrs. Plymouth feels very stressed out most of the time because Im fighting with my family. She acknowledged having little interest or pleasure in doing things most days and that shes thought that things might be better if I wasnt around.She is not interested in taking medications, but was not resistant to talking with a therapist.

37SupervisionCare manager presents case to MH supervisor who recommends starting on a medication (Celexa 10mg, increase to 20mg after 1 week if tolerated).Care manager follow-ups with PCP regarding recommendationCare manager follows-up with Veteran and schedules contact for 1 week post medication start

38Watchful waiting: series of calls to monitor symptomsReferral Mgt: Coordinating care with appropriate referrals

The key component of the DACM intervention is the introduction of a care manager into the primary care setting who will collaborate with the PCP, promote clinical management that adheres to treatment guidelines, and monitor and encourage patient acceptance and adherence to treatment recommendations through support, education, and motivational engagement.

The care manager is able to discuss needed information with patients, such as symptoms, goals, treatment preferences and potential barriers, as well as changes in clinical status, treatment adherence and presence of side effects. Furthermore, the care manager is able to use this information to prompt PCPs with timely recommendations about appropriate care for their patients.

follow-up of patients to assess whether they are getting better and whether and when referrals are indicated if they are not improving, or need specialty care for co-morbidities.

38Example of Acute Phase of Treatment for Depressive Disorders BaselineWeek 1 (if med)Week 3Week 6Week 9Week 12PHQ-9XXXXXXMed Side Effect and AdherenceXXXXXXAlcohol useXXXGAD-7Asneeded

39Again structured; guideline driven careGoal -actively manage to achieve adequate treatment response or referral to specialty care

Care Manager: the GluePrimary Care ClinicianMental Health Supervisor

Care ManagerPatient41

Mr. Howell

After 3 months, Mr. Howells PHQ9 =3 and he reports feeling much better. Is now planning activities and interacting more with his family. Next steps?Initial Score on 8/2/2011Most recent score on 11/10/2011Change in ScorePHQ-9 score: 0-27134-9

Mr. Howell tells his doctor, Im sleeping a lot more than usualI dont have to get up for work, but I really dont feel like getting out of bed. I just dont have any energy. Since I was laid off a few months ago from my manufacturing job, all I do is sit around the house. My mood is OK, but when I think about money and my financial future, it starts to really bother me. He denies hopelessness, or past or present suicidal ideation. CBC and TSH are normal.

Mrs. PlymouthIm just so tired all of the time. Im exhausted, but I cant sleep. I toss and turn when I go to bed; if I doze off, I wake right back up. Not sleeping just makes me more even more irritablethe littlest things set me off. When asked about her use of alcohol, Mrs. Plymouth says, I have a few drinks. It helps me relax.Further inquiry revealed Mrs. Plymouth feels very stressed out most of the time because Im fighting with my family. She acknowledged having little interest or pleasure in doing things most days and that shes thought that things might be better if I wasnt around.She is not interested in taking medications, but was not resistant to talking with a therapist.

41Maintenance and relapse preventionFollow-up 1 time/month for next 2 monthsProvide education on relapse preventionPer supervision, provide PCP recommendation on medication discontinuation

42Watchful waiting: series of calls to monitor symptomsReferral Mgt: Coordinating care with appropriate referrals

The key component of the DACM intervention is the introduction of a care manager into the primary care setting who will collaborate with the PCP, promote clinical management that adheres to treatment guidelines, and monitor and encourage patient acceptance and adherence to treatment recommendations through support, education, and motivational engagement.

The care manager is able to discuss needed information with patients, such as symptoms, goals, treatment preferences and potential barriers, as well as changes in clinical status, treatment adherence and presence of side effects. Furthermore, the care manager is able to use this information to prompt PCPs with timely recommendations about appropriate care for their patients.

follow-up of patients to assess whether they are getting better and whether and when referrals are indicated if they are not improving, or need specialty care for co-morbidities.

42Review ArticlesBower, P., et al. (2006). British Journal of Psychiatry, 189, 484 493.Gilbody, S., et al. (2006). Arch Intern Med, 166(21), 2314-21.Williams, J.W., et al. (2007). General Hospital Psychiatry, 29(2), 91-116.Roy-Byrne, et al. (2010) JAMA,303(19):1921-1928

In case you have heard of these Care Management Models in PC-MHITranslating Initiatives for Depression into Effective Solutions (TIDES)Evidence-based collaborative care model supporting depression management in the primary care settingHas promoted improvements in treatment adherence for Veterans with depression in several VISNs

Behavioral Health Laboratory (BHL)Evidence based clinical service supporting mental health and substance abuse management in the primary care settingAssociated with a significant increase in screening and identification of patients needing MH/SA services (Oslin, et. al. 2005)

Other evidence based strategies approved by the Office of Mental Health Services (ex. IMPACT)44Both TIDES & BHL were developed by VA clinicians and researchersBoth telephone based

McArthur FoundationIMPACT

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Introduction to Blending ProgramsSara Greenwood, MSWPC-MHI Education & Training Coordinator

With acknowledgement to Mr. Lawrence Daily, LMSW, Network 16 Integrated Care Coordinator for his contribution to content development.

45Specialty Mental Health CarePrimary Health CarePCMHIorCare ManagementCo-located Integrated CareWhat many integrated care programs look like now46Blended programs combine functions of CCC & CM

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Now 52 (as of July 29th) and 43 with fully PCMHI programs.4748

Quickly divide into groups of 4-6 & discuss the following questions [dont forget to assign a note-taker!]:What are the functions of colocated collaborative care?What are the functions of care management?What functions are similar?How are the functions complementary? What unique contributions do each provide?

Small Group Pop Quiz!Break up into small gropus10 minutes@ 3-5 minutesif you havent gotten past functionsWhat might a blended program look like? 48PCMHISpecialty Mental Health CarePrimary Health CareCare ManagementCo-located Integrated CareBLENDEDA Well-functioning Blended ProgramCare managers & co-located collaborative care staff work as a team to provide services to Primary Care Providers and act as a liaison with specialty mental health care services.4950

Mr. HowellDuring his PCP visit , Mr. Howell, a 59 year old male with osteoarthritis, diabetes and hypertension told his PCP that in the past few weeks he had not been feeling very well. He tells his doctor, Im sleeping a lot more than usualI dont have to get up for work, but I really dont feel like getting out of bed. I just dont have any energy. He has gained 10 pounds since losing his job and reports his blood sugars are often in the 180-240 range. His PHQ-2 is positive & AUDIT-C score is 1.

When the PCP expresses concern about his lack of energy and weight gain, Mr. Howell shrugs it off; Egh, what else is there to do? Thats life, docMr. HowellMr. Howell tells his doctor, Im sleeping a lot more than usualI dont have to get up for work, but I really dont feel like getting out of bed. I just dont have any energy. Since I was laid off a few months ago from my manufacturing job, all I do is sit around the house. My mood is OK, but when I think about money and my financial future, it starts to really bother me. He denies hopelessness, or past or present suicidal ideation. CBC and TSH are normal.

Mrs. PlymouthIm just so tired all of the time. Im exhausted, but I cant sleep. I toss and turn when I go to bed; if I doze off, I wake right back up. Not sleeping just makes me more even more irritablethe littlest things set me off. When asked about her use of alcohol, Mrs. Plymouth says, I have a few drinks. It helps me relax.Further inquiry revealed Mrs. Plymouth feels very stressed out most of the time because Im fighting with my family. She acknowledged having little interest or pleasure in doing things most days and that shes thought that things might be better if I wasnt around.She is not interested in taking medications, but was not resistant to talking with a therapist.

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Mr. HowellDuring his PCP visit , Mr. Howell, a 59 year old male with osteoarthritis, diabetes and hypertension told his PCP that in the past few weeks he had not been feeling very well. He tells his doctor, Im sleeping a lot more than usualI dont have to get up for work, but I really dont feel like getting out of bed. I just dont have any energy. He has gained 10 pounds since losing his job and reports his blood sugars are often in the 180-240 range. His PHQ-2 is positive & AUDIT-C score is 1.

Toward the end of the appointment, Mr. Howell tears up. I just sit around the house all day. Not being able to play with my grandkids my wife is working extra shifts to pay the bills, I just cant handle it all.

Mr. HowellMr. Howell tells his doctor, Im sleeping a lot more than usualI dont have to get up for work, but I really dont feel like getting out of bed. I just dont have any energy. Since I was laid off a few months ago from my manufacturing job, all I do is sit around the house. My mood is OK, but when I think about money and my financial future, it starts to really bother me. He denies hopelessness, or past or present suicidal ideation. CBC and TSH are normal.

Mrs. PlymouthIm just so tired all of the time. Im exhausted, but I cant sleep. I toss and turn when I go to bed; if I doze off, I wake right back up. Not sleeping just makes me more even more irritablethe littlest things set me off. When asked about her use of alcohol, Mrs. Plymouth says, I have a few drinks. It helps me relax.Further inquiry revealed Mrs. Plymouth feels very stressed out most of the time because Im fighting with my family. She acknowledged having little interest or pleasure in doing things most days and that shes thought that things might be better if I wasnt around.She is not interested in taking medications, but was not resistant to talking with a therapist.

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