Council Co-chair Karen Rosene-Montella, MD opened this year’s Conference by describing the common themes that have come to define the Women’s Health Council of RI. Specifically, collaboration among members of many disciplines, practical application of new ideas, and the present push to bridge physical and behavioral health.
Information on this website showcases the Council’s areas of focus to date: Women’s Health in terms of obesity and exercise, Intimate Partner Violence, Smoking Cessation, Pregnancy as a health stress test, and a new focus on Bridging Physical and Behavioral Health in the area where women are at high risk: depression and suicide.
“In all these areas,” Dr. Rosene said “We need to continually address new program, policy and payment models.”
Lt. Gov. Elizabeth Roberts, MBA, greeted attendees by saying “Women’s health is a big determinant of family health.” She noted that people at this conference are changing the healthcare landscape. And policy makers are increasingly aware that they now have the opportunity to redefine health reform to get the healthier outcomes we all want.
Linda Carpenter, MD spoke in detail about the interface between depression and physical illness. 1 in 10 Americans have or had or will have Major Depressive Disorder. Patients typically focus on physical health with their primary care provider and don’t mention emotional or mental health. In 69% of patients, only physical symptoms were reported but all went on to meet criteria for depression. In describing how to recognize depression, the physician starts with 2 simple questions to determine if there has been a change in sense of well-being and a change in functioning. Dr. Carpenter’s slides showed the longer list of symptoms, including loss of hedonic drive and hopelessness leading to suicide. While there are multiple factors contributing to depression, early childhood stress including mother’s stress while infant is in utero, puts the patient at greater risk and makes recovery more difficult.
Teri Pearlstein, MD reviewed current treatment protocols for depression and suicide prevention. She stressed that primary care providers who screen for depression need to know where to refer patients for further evaluation and treatment. Screening is most beneficial when staff-assisted care and follow-up systems are in place. Evidence-based treatments for depression include psychotherapy, medication and alternative treatments, Efforts are ongoing to establish integrated care, ideally coordinated by care managers at regular PCP visits. The easy accessibility and follow-up of care is necessary because depressed patients face many barriers to receiving treatment. There is a 50% chance of another episode after first remission and anti-depressants work only 50-60% the first time.
Dr. Pearlstein also described the progressive phases of suicide, which begin with the idea, then thoughts, followed by plans. Successive suicide plans and attempts grow in intention and lethality until patient is successful or there is an intervention. She noted that suicidality may be a risk with anyone first starting anti-depressants and should be monitored.
Beatriz Perez, MPH, discussed suicide as a public health issue. In her role with the RI Department of Health, she described statewide violence and injury prevention programs she administers for the CDC and SAMSHA. She noted that RI women are below the national average for suicides, but suicide in men is showing a steeper increase than the national rate. Ms. Perez rarely sees an individual with just one risk factor and cautioned that any screening should consider multiple factors. Her programs make an effort to get to children at risk before depression sets in. And she teaches parents in at risk neighborhoods how to suicide-proof their homes by removing weapons and making medications unavailable.
Michaei Fine, MD, Director of the RI Department of Health,introduced the keynote speaker Regina Benjamin.
US Surgeon General Regina M. Benjamin, MD, MBA began her talk by observing that community events such as our council are important: they allow one person to stand up and make a difference whether in practice or policy.
Dr. Benjamin’s purpose as America’s Doctor is to stop illness and disease before it starts by using an integrative and holistic approach. She learned early in her career that practicing medicine was not about medicine alone, so she became involved in every organization that might help her patients receive better health services.
Today as Surgeon General her focus is on prevention and eradicating preventable causes of illness and disease.
In addition to the new American Affordable Healthcare Act, her policy agenda includes
Dr. Benjamin’s solutions focus on providing the best information available to live a healthy life. She has created the National Prevention, Health Promotion and Public Health Council, and released a National Prevention Strategy(www.healthcare.gov/prevention/nphpphc/strategy/report.pdf).
Her approach combines state of art medicine with an integrative and holistic approach for:
This approach she believes can reduce the five leading causes of illness and death.
“We need your help,” Dr. Benjamin said as she introduced a new campaign to help change how everyone looks at health. In her program, health is translated as joyful, active living and includes activities that bring joy.
Kicking off on December 2, 2011 is a radio campaign called the “Surgeon General’s Dance Break,” a 60-second music broadcast urging people to stop what they’re doing, stand up and dance for 60 seconds every day.
Her closing words of advice: “Take care of yourself first. Relax, enjoy, and dance!”
Moderated by Rebekah Gardner MD and facilitated by Lisa Shea, PhD
This wide-ranging discussion touched on the following topics:
CLOSURE Mary Reich Cooper, MD, JD
Dr. Cooper described RI as a “magical state,” because of people’s willingness to collaborate across disciplines on new solutions to improve women’s healthcare. “But,” as she thanked the participants, “we still have a lot of work to do!”
FOLLOW-UP The next Critical Workshop Training, Practical Applications: Bridging Physical and Behavioral Health, is scheduled for March 6, 2012. Presenters will offer more in-depth training for providers in how to implement the “chain of care” so patients receive more integrated and holistic treatment.
US Surgeon General Regina M. Benjamin, MD, MBA
Regina Benjamin wants to change the way we think about health in this country.
As the US Surgeon General, Dr. Benjamin is on a mission to improve preventive care and reduce the five leading causes of preventable death. Part of her efforts include a new campaign to redefine health as a “Journey to Joy.”
When she spoke at our Second Annual Quality Conference on November 10, 2011, Dr. Benjamin gave an overview of her perspectives on the current challenges in healthcare. In order to change our thinking, she said, we need to take a much more integrative and holistic approach. She invited us to help with the implementation of her new campaign by encouraging patients to find their own levels of fun and healthy activities, foods and friendships…and to bring more joy into their lives as well as our own.
As Lt. Gov. Elizabeth Roberts said at the start of our 2011 Conference, “Healthcare today is like a deck of cards tossed up in the air. We have the opportunity to put the deck together in a new way, especially by building a better bridge between physical and mental health.”
While it may be difficult to get a handle on the overlap between physical health problems and emotional/mental health disabilities, what is known is that depression (the most prevalent mental health disorder) is a medical problem that portends much worse outcomes for other health problems. Depression isn’t just in the head; it affects nearly every internal organ system adversely. Women are twice as likely as men to suffer from depression.
Suicide is the 10th leading cause of death in the US and is recognized as a public health issue in RI even though the rate of suicide for women is below the national average. However, suicide rates for men are on the rise. The white population is most affected, although this population is least likely to live in poverty.
Depression has multiple causes. Some causes we have control over; others we do not. Preventable causes include: smoking, sedentary lifestyle, obesity, system inflammation and failure to report. But abundantly and strongly associated with depression is early childhood stress (abuse, neglect and poverty). Large-scale studies link this early life stress to many other preventable diseases.
Many risk factors for suicide are treatable but 80% of completed suicides went untreated. The number one cause of suicide is relationship separation or conflict. A program sponsored by the RI Youth Suicide Prevention Project focuses on core RI cities where more than 15% of children are living in poverty. Parents are taught how to suicide-proof their homes by such things as removing weapons and medication availability.
Recent studies show that some people are born with genes that protect them from depression and suicide no matter what their present or early-childhood stressors. Others have genes that indicate they are at greater risk.
Adverse social environments may impact physical and behavioral disease through epigenetic effects on genes that regulate physiological systems involved in stress and inflammation.
What blocks the bridge? Lack of access to universal healthcare. Access to good education. Decent housing. Stigma attached to mental health problems and suicide. Sensationalizing suicide by media.
Both the fact and the perception of “maternal warmth” is a mitigating factor in all aspects of physical and behavioral health. We have the ability to improve preventive care by providing people with better resources to take care of themselves, their children and each other.
Because early childhood stress is implicated in both physical and behavioral health, Freud’s question, “Tell me about your childhood” turns out to be a relevant question with any disease.
Regardless of economic status, housing or education, we can improve resilience by intervening at an early age. We may not be able to reduce poverty but we can lessen its effects on both physical and emotional health.
A physical health provider writing an anti-depressant prescription and seeing the patient six months or a year later is not enough. Institute a “chain of care” for depression and other behavioral health risks. Primary care providers who screen for depression need to know where to refer patients for further evaluation and treatment. Screening is most beneficial when staff-assisted care and follow-up systems are in place. Screening tools from this website and other sources provide the first link on the chain.
As Dr. Michael Fine, Director of the RI Department of Health, said at the start of our March 6, 2012 workshop: “We need to eliminate deaths from prescription drug overdoses.” RI has the third highest opioid pain-killer use in the country. And prescription drug overdose is now the leading cause of unintentional death in the state.
“Many, many people are involved with many, many prescription drugs, all prescribed by RI physicians and pharmacists.” These drugs are killing people. Dr. Fine’s goal is to work with the healthcare community to minimize misuse and still provide access to effective chronic pain management.
In describing the patterns of substance abuse in women, Panelist Catherine Friedman, MD, described it as an “exploding epidemic.” Opioids were available to women in tonic form 100 years ago and sold as “Mother’s Little Helper.” Women still tend to use prescription drugs as a coping mechanism. Teenagers get the drugs from their parent’s medicine cabinet. Pregnant girls have the highest rate of use, and the rate of depression is higher in opioid users. Also, the patterns are telescoping: users are more likely to progress from experiment to abuse and dependence in a shorter period of time; 3 years for women vs. 6 years for men.
RI has initiated a prescription drug monitoring task force, with the goal of creating a database to track all prescription medications prescribed and used, so that they can identify misusers earlier and intervene before they become addicted.
RI Medicaid has 175,000 members, nearly one-fifth of the population. Women with chronic pain use twice the number of services as men, at double the monthly cost. (Medicaid: Men $1200 average; women $2400).
Methadone has a much longer half-life than originally thought. It should be used with caution, especially when other opioids are prescribed.
Allison Croke, MHA, introduced the “Communities of Care” program begun 2 years ago by RI Medicaid. This targeted intervention provides short-term case management, using an interdisciplinary team, for people who have used the ER 4 or more times in a 12-month period where chronic pain has been the significant driver.
The integrated treatment plan includes a pain management program, a team of supporters including a peer navigator, and self-responsibility combined with complementary care. Holistic nurses who are trained in outreach meet with the patient to develop their treatment plan. In addition to medication, the program supports the patient’s well-being with both physical and behavioral healthcare, chiropractic treatments, acupuncture and massage.
Michael Maher, MD acknowledged that managing patients with chronic non-malignant pain is very difficult, and that “we are under-educated” about the drugs we are using. Originally there were no standards for how to manage patients on pain medication. Today standards include RI Department of Health Guidelines which require a physician and patient relationship, patient history and a physical exam.
Dr. Maher added strong suggestions for improved care that include determining the functional impact of the patient’s pain, and screening for substance use disorders. Other recommendations include:
Providers should recognize that treating pain is not just about bringing down the pain number; it is about improving the patient’s functionality. Can they go out and take care of themselves in a better way? Do they meet functional improvement goals? Rather than just handing out the next month’s prescription, ask if this medication is helping. Because these are dangerous medications, “If they are not helping the patient, get them off it.”
The World Health Organization predicts that by 2020 the leading disability in women worldwide will be depression. Women are at higher risk for both depression and suicide. At present, twice as many women as men (17%) will have a major depressive disorder in their lifetime. They have more severe symptoms, including self-criticism, guilt, worthlessness, anxiety, low energy and interpersonal sensitivity. (Carpenter)
Suicide is an escape behavior; a way to get out of seemingly unmanageable problems, including the pain of anxiety, guilt, hopelessness, loss of status, job and money, and/or relationship separation or conflict. Both disorders reflect the additional risk factors for women: intimate partner violence, eating disorders and hormonal changes. (Jordan)
Patients with multiple physical and behavioral health problems often are treated by providers, who “don’t talk to each other and make the patient way worse,” according to Jane Hayward, CEO and President of the Community Health Center Association. When chronic pain, substance abuse and chronic mental health issues are combined in one patient, the costs of treatment are 7 times higher than with just one situation. People with chronic mental illness are likely to die 25 years sooner than the average.
In many practices, including Community Health Centers, legal precedents and payor policies lag behind new integrated care solutions, and can inhibit effective patient treatment. This is a compelling issue now because of the epidemic issues around depression and prescription drug misuse, increase in illicit drug misuse and the unmet need for affordable, accessible mental health professionals.
Also of note: no one system of care is right for every setting. Effective systems of integrated care must be culturally specific. “If you’ve seen one health center, you’ve seen one health center.” (Hayward)
Depression is linked to multiple factors: aging, genes, hormone changes, exposure to toxins, infectious pathogens, injury and inflammation. Early childhood stress is a powerful contributor, including low socioeconomic class. Evidence of abuse and neglect is visible in brain tissue; abuse and neglect leaves a biological scar, which indicates risk of chronic inflammatory illnesses, depression and suicide.
Conditions linked to depression include diabetes, obesity, smoking, alcohol and a sedentary lifestyle. These co-existing conditions should be treated together. (Carpenter)
Bullying often precedes sexual violence and suicidal ideation. Students who are bullied at school are at higher risk of suicide. Men are exposed to more physical violence; women to more sexual abuse. (Perez)
Suicide is like having a glass already filled to the brim; just one more drop of agitation from panic, anger, helplessness—and in that moment the scale is tipped towards self-harm. It is the ultimate expression of hopelessness: “There is no answer for me and I’m giving up.” (Jordan)
Improved care from the Community Health perspective means increasing better outcomes and decreasing costs. Many patients require a level of complex care no one person can provide. Some basic principles for integrated care include
Rapid Access RI demonstrates one approach—an urgent care center designed to divert people from expensive and excessive ER use. The Providence Center is seeing good outcomes in their intersection of primary care and behavioral health care. The challenge remains: continue to look for ways to integrate disciplines and overcome legal and policy barriers, because “We forget that we need to focus on systems of care, not systems of silos.” (Hayward)
When the potential for depression or suicide appears, learn as much as possible about the patient’s history of trauma and functional impairment. Initial screening questions are listed on the Pocket Cards created for this workshop: Screening for Depression which includes the patient self-screening form (PHQ-9), and the series of suicide risk assessment questions known by the mnemonic IS PATH WARM? The SAFE-T card details Risk Factors, Protective Factors, Suicide Inquiry and recommended Interventions.
Other questions recommended at the workshop include:
Consider how to move from silos of care to integrated systems of care, where the approaches of PCP’s and therapists come together to create:
o Improved physical health, including nutrition (i.e. vitamin D for depression) and exercise to change sedentary lifestyle.
o Behavioral health care including sessions to raise hope and self-esteem, internalize qualities of maternal warmth and assume more self-responsibility.
o Social health including support groups for depression and suicide survivors, peer navigators and an on-going care team.
o Complementary activities including massage, chiropractic treatments, acupuncture for pain and improved energy, and light therapy to relieve depression.
Karen Rosene Montella, MD: Opening the Second Annual Conference with a review of the new ideas and new tools created in the past year, Dr. Rosene-Montella identifies the necessity for bridging physical and behavioral health for women.
Linda Carpenter, MD: Slides detail the complex interface between physical and behavioral health as well as the impact of environmental concerns and early-childhood experiences.
Teri Pearlstein, MD: This series of in-depth slides reviews treatment options for depression, as well as providers’ responsibility to follow up and why.
04-Beatriz-Perez-MPH: An overview of local and national government efforts to reduce the incidence of depression and suicide, especially in the younger, at-risk population.
2011 Women’s Behavioral Health Report Card: Reports RI’s incidences of mental illness are 25% – 33% higher than the national average. Opportunities include more research into contributing factors as well as links between behavior and illness.
2011 Women’s Physical Health Report Card: Indicates that women need a social and physical environment that supports healthy eating and active living, combined with increased access to timely, comprehensive, quality health services.
Screening for Depression Physical and Behavioral Health: Details why clinicians should screen for depression, groups at greater risk for experiencing depression, and the patient self-assessment PHQ-9 clinicians can use to further understand a patient’s experience with mental health and wellness.
Screening for Suicide: Includes the most common list of questions used to determine patient’s risk of suicide. In mnemonic form, this list is known as “IS PATH WARM?”
Bridging Physical and Behavioral Health: Shows how depression affects both physical and behavioral health; includes an infographic illustrating the multiple external risk factors that are correlated to adverse health behaviors and outcomes.
Safe-T Suicide Assessment Five Step Evaluation and Triage: Provided by the National Suicide Prevention Lifeline, this card details risk factors, protective factors, suicidality patterns, and possible interventions.