Setting the Stage for ChangeBehavioral Health Regional Training

Chad Morris, PhD

June 20, 2012Santa Rosa, CA

www.bhwellness.org

Research Clinical Care

Education

Evaluation

BHWP

Policy Change

Behavioral Health & Wellness Program (BHWP)

A Wellness Philosophy

Leading a meaningful and fulfilling life through conscious and self-directed behaviors, focused

upon living at one’s fullest potential

A Wellness Philosophy

Wellness is a multifaceted approach made up of eight dimensions.

Emotional Occupational Environmental Physical Financial Social Intellectual Spiritual

This is a Critical Issue

What is killing the majority of us is not infectious disease, but our chronic and

modifiable behaviors

This is a Critical Issue

On average, persons diagnosed with mental

illnesses and addictions have higher rates of

disease and disability, and die up to 25 years earlier

than the general population

TOBACCO USEModifiable Behaviors

Burden of Tobacco 443,000 tobacco-related deaths in the U.S.

each year 6 million tobacco-related deaths worldwide each

year

8.6 million people living with tobacco-related chronic illness

50,000 deaths each year in the U.S. due to second-hand smoke exposure

U.S. Trends in Adult Smoking

19.3% of adults are current

smokers

Males

Females

Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2007 NHIS. Estimates since 1992 include some-day smoking.

BRFSS 2009

Perc

enta

ge o

f Pop

ulati

onCalifornia Smoking Prevalence

Adult Cigarette Use

But …

There were no changes for persons with behavioral health conditions

12

*

Behavioral Causes of Annual Deaths in the United States

Nu

mb

er o

f d

eath

s (t

ho

usa

nd

s)

Sexual Alcohol Motor Guns Drug Obesity/ Smoking Behavior Vehicle Induced Inactivity

* Persons with behavioral health disorders

435

12

*

Cause of Death

Tobacco Use Among Persons with Behavioral Health Conditions

Persons with behavioral health conditions are: Are nicotine dependent at rates 2-3 times

higher; Represent over 44% of the U.S. tobacco

market; Consume over 34% of all cigarettes smoked.

Tobacco Use by DiagnosisSchizophrenia 62-90%

Bipolar disorder 51-70%

Major depression 36-80%

Anxiety disorders 32-60%

Post-traumatic stress disorder 45-60%

Attention deficit/ hyperactivity disorder 38-42%

Alcohol abuse 34-80%

Other drug abuse 49-98%

TOBACCO USEContributing Factors

Dopamine Reward Pathway

Nicotine enters brain

Stimulation of nicotine receptors

Dopamine release

Prefrontal cortex

Nucleus accumbens

Ventral tegmental area

Nicotine Effects

Most symptoms: Appear within the first 1–2 days Peak within the first week Decrease within 2–4 weeks

Receptor Activation Increase arousal Heighten attention Influence stages of sleep Produce states of pleasure Decrease fatigue Decrease anxiety Reduce pain Improve cognitive function

Withdrawal Symptoms Mentally sluggish Inattentive Insomnia Boredom and dysphoria Fatigue Anxiety Increase pain sensitivity Decrease cognitive function

Medications Known or Suspected To Have Their Levels Affected by Smoking and Smoking Cessation

ANTIPSYCHOTICS

Chlorpromazine (Thorazine) Olanzapine (Zyprexa)

Clozapine (Clozaril) Thiothixene (Navane)

Fluphenazine (Permitil) Trifluoperazine (Stelazine)

Haloperidol (Haldol) Ziprasidone (Geodon)

Mesoridazine (Serentil)

ANTIDEPRESSANTS

Amitriptyline (Elavil) Fluvoxamine (Luvox)

Clomimpramine (Anafranil) Imipramine (Tofranil)

Desipramine (Norpramin) Mirtazapine (Remeron)

Doxepin (Sinequan) Nortriptyline (Pamelor)

Duloxetine (Cymbalta) Trazodone (Desyrel)

MOOD STABLIZERS Carbamazepine (Tegretol)

ANXIOLYTICS Alprazolam (Xanax) Lorazepam (Ativan)

Diazepam (Valium) Oxazepam (Serax)

OTHERS

Acetaminophen Riluzole (Rilutek)

Caffeine Ropinirole (Requip)

Heparin Tacrine

Insulin Warfarin

Rasagiline (Azilect)

Tobacco Use Affects Treatment & Recovery from Addiction Addressing tobacco dependence

during treatment for other substances is associated with a 25% increase in long-term abstinence rates from alcohol and other substances.

Smoking cessation has no negative impact on psychiatric symptoms and smoking cessation may even lead to better mental health and overall functioning.

Pic

ture

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Cessation Concurrent with Mental Health Treatment

Smoking Prevalence Among Mental Health Providers30% - 35% of mental health providers smoke as compared to:

Primary Care Physicians 1.7% Emergency Physicians 5.7% Psychiatrists 3.2% Registered Nurses 13.1% Dentists 5.8% Dental Hygienists 5.4% Pharmacists 4.5%

Barriers to Tobacco Interventions –Personal Factors Boredom Self-identity Lack of recovery Expectation of failure Fear of withdrawal symptoms Coping with tension and anxiety Fear of gaining weight

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Tobacco Industry Targeting Tobacco companies sought out individuals

with limited resources to cessation services.

Promoted smoking in treatment settings.

Monitored or directly funded research supporting the idea that individuals with schizophrenia need to smoke to manage symptoms.

Why Community Treatment Settings? Experts in behavioral change

Duration of treatment Therapeutic alliances Co-occurring treatment Integrated and health home models Access to high risk populations Community-based and patient-

directed Complements other prevention and

wellness activity Performance measure

Why Community Treatment Settings?

Services should be integrated at the point of delivery, actively

involve patients as partners in their care, and be coordinated with other

community resources.

-CBHC, 2010

The Limits to Knowledge

© 2012 Behavioral Health and Wellness Program, University of Colorado

Creating Habits

Cue Routine Reward

© 2012 Behavioral Health and Wellness Program, University of Colorado

Autonomy (Separation of Parts)

Coordination (Relation

of Parts)

Integration (Combination of Parts)

Policy + Co-Location ≠ Integration

Integrated Health Care Continuum

Wellness as a Cultural Bridge

Where Does Behavioral Health Fit?

State HIT Plan/ Other Infrastructure

CMSFederal

Legislation

Medicaid

REC

Primary Care

Hospitals

FQHCs

Behavioral

Health?

Employers

Health Plans

ACOsHealth Homes

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Outcomes

F.O.C.U.S. Questions

AIM: What are we trying to accomplish?

MEASURES: How will we know that a change is an improvement?

IDEAS: What changes can we make that will result in an improvement?

PlanDoStud

y

Act

Find a Process to Improve

Organize to Improve the ProcessClarify Knowledge of the Process

Understand Sources of Process Variation

Select the Process Improvement

Rapid Improvement

Contact Information

Chad Morris, PhD

Director, BHWP

303.724.3709Chad.Morris@ucdenver.edu

University of ColoradoSchool of Medicine1784 Racine StreetMail Stop F478Aurora, CO 80045