Transcript Document
INTEGRATED TREATMENT OF THE COMPLEX PATIENT
M I C H A E L V . G E N O V E S E , M . D . , J . D .
M E D I C A L D I R E C T O R , S I E R R A T U C S O N
OVERVIEW
• Integrative Holistic Medicine • Co-Occurring/Dual Diagnosis • Professionals As Complicated Patients • Integrative Holistic Modalities
INTEGRATIVE HOLISTIC MEDICINE
• • • • • Reaffirms relationship between practitioner and patient Focuses on the whole person Is informed by evidence Makes use of all appropriate therapeutic approaches and disciplines to optimize health and healing Addresses physical, emotional and spiritual aspects of life
COMPREHENSIVE TREATMENT
• Chemical Dependency Pain • Mood Disorders • Eating Disorders • Trauma • Complex Pain Mood Chemical Dependency
UNIQUE PATIENT NEEDS
Chemical Dependency Eating Disorder Mood Pain Chemical Dependency Trauma
PREVALENCE
• • • Approximately 20% of Americans suffer from diagnosable mental illness each year According to the National Institute of Mental Health major depressive disorder is the leading cause of disability in United States for individuals aged 15 to 44 years 17.5% of adults with psychiatric illness have co occurring chemical dependency = 7.98 million
FINANCIAL BURDEN
• • • • • • • • • • Forbes: Most Expensive Medical Conditions Heart Disease Trauma Cancer
Depression
Chronic Obstructive Pulmonary Disease Hypertension Diabetes Arthritis Back pain
BREAKING (OR PREVENTING) THE CYCLE Poor Health Mood Addiction Anxiety Sleep
Patient
INITIAL EVALUATION
• Establish Rapport & Partnership • History • Lab Work • Initial Treatment Plan
REWARD PATHWAY
NEUROPLASTICITY
EPIGENETICS
PROFESSIONALS AS COMPLEX PATIENTS • Stress • Permissive Cultures • Fear Induced Avoidance • Obstacles to Accurate Diagnosis
PERSONALITY TRAITS ASSOCIATED WITH HIGHER PSYCHIATRIC MORBIDITY • Perfectionism • Indecisiveness • Self-Criticism • Low Flexibility • Highly Disciplined • Idealism • High Degree of Empathy Graske et al. BMJ 2003
IMPAIRED PHYSICIANS
• • • • • • • Compromise patient safety Foster medical errors Poor patient satisfaction Preventable adverse outcomes Undermine individual and team communication and effectiveness Increased the cost of care Prevalence
COMMON PHYSICIAN STRESSORS
• • • • • • • Sitting For Exams Acute Environments (ER, ICU) Juggling Career and Family Overwork/Fatigue English 2 nd Language Physical Illness Authoritarian Hierarchies Intolerant of “Weakness or Failure” • • • • • System Issues (Morale, Funding) Increasing Emphasis on Efficiency Increasing Requirements for Formalized Accountability Increasing Threats of Litigation Financial Difficulties
COMMON PHYSICIAN STRESSORS (CONTINUED) • • • • • Decreased Long-Term Unhurried Relationships with Patients Increasing Emphasis on “Patient Rights” Perceived Decline of Status of Medicine Uncertainty about Career Options Marital Discord
RESIDENCY TRAINING
• “Catastrophic Stress” • “House Officer Syndrome” • • • • • • • Depression (1/3 to1/2) Episodic Cognitive Impairment Sleep Deprivation Chronic Anger Pervasive Cynicism Family Discord Female Residents at Significantly Higher Risk of Suicide (2.5 to 5.7)
“APPARENTLY SUCCESSFUL”
• Co-workers unaware • Other Aspects of Life Secretly Affected
ATTORNEYS AS PATIENTS
DEPRESSION
• •
University of Arizona Study:
General Population 3%-9% • Late Spring of First Year of Law School 32% • Late Spring of Fourth Year of Law School 40%
A PROGRESSIVE PROBLEM
25 20 15 10 5 0 United States Attorneys 2 to 20 years Attorneys over 20 years
40 30 20 10 0 70 60 50 % CHEMICAL DEPENDENCY WITH CO OCCURRING PSYCHIATRIC DISORDER Attorneys Health Professionals Non Professionals Sweeny et al. (2004)
DR. JONES
Cc: “I feel terrible.” HPI: Dr. Jones is a 46-year-old male who presented with complaints of depressed mood, anhedonia, low energy, insomnia, feelings of guilt, decreased appetite and generalized anxiety. Symptoms have been present for “several years” exacerbated over the past six months in the context of marital and occupational stress.
PΨH: No history of psychiatric hospitalizations. Was treated in the past by self with Effexor XR 75 mg QD for anxiety and depression. Was referred by friend to psychiatry three years ago but never followed through. Saw a marital therapist “three or four times about two years ago.” No other psychiatric history reported.
FΨH: Father, who was also a surgeon, may have suffered with, but was never treated for depression. Sister has reported anxiety symptoms and Dr. Jones believes she is engaged in psychotherapy. PMH: Hypercholesterolemia, Chronic Headache, Back Pain Soc. Hx: Dr. Jones has been married for twenty two years and resides with his wife, 20-year-old son and 18-year-old daughter. He is self employed and on staff at a local hospital. He has never missed work due to the symptoms referenced above. She reports social Etoh, denies tobacco, denies illicit drug use.
Current Medications:
Lipitor 20 mg PO QD Ambien CR 12.5 mg PO HS PRN Sleep Percocet 10/325 PRN Headache, Back Pain Previous Medications: Effexor XR as above.
Allergies: NKDA
MSE: Dr. Jones is a 45-year-old neatly dressed male who appears slightly older than his stated age. His speech is normal in rate and tone. He is coherent but easily distracted. His mood is “rotten” and affect is angry. He denies any auditory or visual hallucinations. He denies suicidal or homicidal ideation. His short term memory is intact as is his long term memory. His attention is impaired, insight and judgment are fair.
Assessment/Plan: Dr. Jones is suffering with Major Depressive Disorder, Severe, Recurrent, without psychotic features. He also meets criteria for Generalized Anxiety Disorder. Rule out Opioid Dependence.
We discussed the following treatment options:
BUILDING A BIGGER TOOLBOX
TREATMENT CONSIDERATIONS
• • • • • • • • Diet Supplementation Exercise Pharmacology Psychotherapy Acupuncture Massage Reiki • • • Neuromodulation Equine Therapy Alternative Setting
FOOD AS MEDICINE
• Individualized • Excellent Safety Profile • Treat and Prevent Disease • Empowers the Patient
SUPPLEMENTS
• • • • • • • Vitamin D Vitamin B S-Adenosylmethionine Rhodiola Passion Flower Melatonin/Ashwagandha Kudzu
EXERCISE
PHARMACOLOGY
• Individualized to Every Patient • Education
PSYCHOTHERAPY
ACUPUNCTURE
• Depression • Anxiety • Pain
MASSAGE
REIKI
The root chakra is in relation to the adrenal gland. The navel chakra to the ovaries or testicles. The solar plexus chakra is related to the pancreas. The heart chakra belongs together with the thymus. The throat chakra corresponds to the thyroid gland. The third eye chakra has a connection to the pituitary gland. The crown chakra is usually connected to the pineal gland.
EQUINE THERAPY
NEUROMODULATION
• Neurofeedback • Transcranial Magnetic Stimulation • Electroconvulsive Therapy
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