A REPORT OF OUTPATIENT PSYCHIATRIC CARE FOR PERSON WITH DUAL DIAGNOSES MRMI

1
A REPORT OF OUTPATIENT PSYCHIATRIC CARE FOR
PERSON WITH DUAL DIAGNOSES (MR-MI)

• Alya Reeve, MD. Sharon Witemeyer, MD, Carla
  Fedor, RN and Analissa Watkins, LPN
• University of New Mexico Health Sciences Center,
  Albuquerque, N.M.

2
For a Copy of this Power Point Presentation
e-mail

• switemey_at_unm.edu

3
OVERVIEW

• Introductions of presenters
• Continuum of Care Project
• Clinic Model Findings from 3 years
• Demographics
• Diagnoses medications
• Subpopulations autism other
• Hospitalization ER visit rates
• Illustrative Cases
• Conclusions

4
CONTINUUM OF CARE PROJECT

• The mission of the Continuum of Care Project is
  to increase the capacity of New Mexicos health
  care system to provide lifelong quality health
  care for people with developmental disabilities
  and related chronic conditions.

5
WE DO THIS BY

• EDUCATION Medical Students, Graduate Students,
  Residents and Faculty UNM-HSC
• TECHNICAL ASSISTANCE TO PRACTITIONERS STATEWIDE
• TECHNICAL ASSISTANCE TO FAMILIES AND COMMUNITY
  PROGRAMS
• TECHNICAL ASSISTANCE TO CASE MANAGERS

6
Continuum of Care Project Members

• Jennifer Thorne Lehman, Program Manager
• Janice Duran, Program Coordinator
• Javier Aceves, MD, Medical Director
• Jenny Vickers, MD
• Carla Fedor, RN
• Analissa Watkins, LPN
• Rose Hessmiller, Computers
• Garry Hallford, Computers
• Valerie Ford, Mediator
• Alejandro Moralez, LSW
• Alya Reeve, MD
• Sharon Witemeyer, MD

7
CLINIC MODEL

• Continuing care of chronic illness
• Developmental disability
• Psychiatric illness
• Neurologic, medical, behavioral complications
• Nursing Physician collaboration
• Education of practitioners in training

8
AXIS-1 DIAGNOSES

• ADD/ADHD
• DEMENTIA
• PTSD

9
AXIS-1 DIAGNOSES

• ANXIETY DISORDERS
• Anxiety Disorder
• Generalized Anxiety Disorder
• Anxious
• Panic Disorder

10
AXIS-1 DISORDERS

• AUTISM SPECTRUM DISORDERS
• Autism
• Asperger
• Pervasive Developmental Disorder
• Autistic Behaviors
• Autistic Traits

11
AXIS-1 DIAGNOSES

• IED
• Disruptive Behavior
• Explosive Disorder
• Impulse Control Disorder
• Intermittent Explosive Disorder

12
AXIS-1 DIAGNOSES

• MOOD
• Affective Disorder
• Bipolar Disorder
• Depression
• Dysthymic Disorder
• Manic-Depressive Illness
• Mood Disorder
• Psychotic Depression

13
AXIS-1 DIAGNOSES

• SCHIZOPHRENIA
• CPS
• CUS
• Psychosis, Atypical Psychosis
• Psychotic Features
• Schizoaffective Disorder

14
AXIS-1 DIAGNOSES

• OTHER
• Adjustment Disorder
  Personality Disorder
• Borderline Personality Disorder SIB
• Cognitive Disorder
  Tourette Syndrome
• OCB/OCD
• Oppositional Defiant Disorder
• Organic Affective Disorder
• Organic Brain Disorder
• Substance/Alcohol Abuse

15
DEMOGRAPHICS

• AGE RANGE 18-80 YEARS
• GENDER 60 FEMALE
• 91 MALE

16
PREVALENCE OF AXIS-I DIAGNOSES

• Diagnosis FF F MF M
  Total Freq. Total
• ADD/ADHD 3 5 5
  5.5 8 5.3
• Anxiety Disorder 18 30 12 13
  30 20
• Autism Spectrum 7 12 24 26
  31 20.5
• Dementia 3 5
  1 1 4 2.6
  
• IED 7 12
  19 21 26 17
• Mood Disorder 31 52 40
  44 71 47
• PTSD 13 22
  22 24 35 23
• Schizophrenia 9 15 9
  10 18 12
• All Others 12 20 21
  23 33 22
• Total 60
  91 151

17
LEVELS OF MENTAL RETARDATION

• FF
  MF TF T
• Borderline MR 2
  7 9 6.0
• Borderline-Mild MR 2
  0 2 1.3
• Mild MR 20
  23 43 28.5
• Mild-Moderate MR 5
  5 10 6.6
• Moderate MR 11
  23 34 22.5
• Moderate-Severe MR 1
  7 8 5.3
• Severe MR 11
  16 27 17.9
• Severe-Profound MR 2
  1 3 2.0
• Profound MR 6
  9 15 9.9
• Total 60
  91 151 100.0

18
MAJOR MEDICAL CONDITIONS

• DIAGNOSIS PTS PTS
• Obesity 49
  32.5
• Seizures 44
  29.1
• GERD 30
  19.9
• Hypothyroidism 22 14.6
• Hypertension 12
  8.0
• Diabetes 6
  4.0
• Tardive Dyskinesia 6 4.0

19
SYNDROMES

• Trisomy 21/Down 7
• Prader-Willi 3
• Olivo-pontine cerebellar degeneration 1
• Smith-Lemli-Opitz 1
• Trisomy 8 mosaic 1
• Klinefelter 1

• Neurofibromatosis 1
• Congenital Rubella 1
• Histiocytosis X 1
• Fragile X 1
• Tuberous Sclerosis 1
• Fetal Alcohol 1

20
MEDICAL CONDITIONS

• Abuse physical, sexual, childhood
• Acne
• Aerophagia
• Anemia
• Anoxic brain injury
• Aphakia
• Arachnoid cyst
• Arthritis
• Asthma
• Barretts esophagitis

• Bladder diverticulum
• BPH
• Bronchitis
• Bruxism
• Cataracts
• Cerebellar Ataxia
• Cervical dysplasia
• CHD
• Chest pain/CVD
• Chronic allergies

21
MEDICAL CONDITIONS

• Clubfoot
• Colitis
• Congenital Rubella Syndrome
• Constipation
• CP
• CVA
• Decubitus ulcers
• Dermatitis
• Detached retina

• Diabetes insipidus
• Diabetes Mellitus
• Down Syndrome
• Drug allergy
• Drug toxicity
• Duodenal atresia
• DVT
• Dyskinetic movement disorder

22
MEDICAL CONDITIONS

• Edema
• Encephalopathy
• Encopresis/enuresis
• End stage renal disease
• Fetal Alcohol Syndrome
• Fragile X Syndrome
• GERD
• Glaucoma
• Guillian-Barre Syndrome

• Headache general, migraine, sinus
• Hearing loss/impairment
• Hemiplegia/quadriplegia/ paraplegia
• Hemispheric dysfunction
• Hemochromotisis
• Hemorrhoids
• Hepatitis C

23
MEDICAL CONDITIONS

• Hepatosplenomegaly
• Herpes
• Hiatal hernia
• Histiocytosis X
• HTN/HBP
• Hypopituitarism
• Hypotestosteronism
• Incontinence, bowel/bladder
• Increased lipids

• Increased prolactin
• Indwelling urinary catheter
• Intention tremor
• Intracerebral hemorrhage
• Lactose intolerance
• Low BP/hypotension
• Microcephaly
• Multiple sclerosis
• Mycotic nails

24
MEDICAL CONDITIONS

• Neurofibromatosis
• Neuropathy
• Obesity
• Oligopontine cerebellar degeneration.cerebellar
  degeneration
• Optic atrophy
• Osteoporosis
• Ovarian cysts
• Pain Syndrome

• Paralyzed vocal cord
• Pica
• Pituitary tumor
• PMS
• Polyps colon
• Post-menopausal
• Prader Willi Syndrome
• Rectal prolapse
• Recurrent otitis

25
MEDICAL CONDITIONS

• Recurrent pneumonia
• Seizures
• Short stature
• Sleep apnea/disorder
• Slipped disc
• Smith Lemli Opitz Syndrome
• Smoker
• S/P fractured bone
• S/P GI bleed

• Spinal cord injury
• SPO appendectomy, bowel obstruction, cardiac
  surgery, commissurotomy, gallbladder removal,
  hysterectomy, orchiectomy,resection thoracic
  ependymoma, thyroidectomy (cancer,) tubal
  ligation
• Strabismus

26
MEDICAL CONDITIONS

• Sweating disorder
• Tardive dyskinesia
• TBI MVA, GSW
• Thyroid disease
• Transfusions
• Trisomy 8
• Tuberous sclerosis
• UTI
• Vertigo

• Vision impairment
• Weight loss

27
NUMBER OF MEDICATIONS PER INDIVIDUAL

• Number of Medications
  Number of Individuals
• 0 8
• 1 10
• 2 22
• 3 20
• 4 24
• 5 27
• 6 16
• 7 11
• 8 7
• 9 2
• 10 2
• 12 1
• 13
  1

28
NO MEDICATIONS FOR MEDICAL CONDITIONS

• AGE RANGE MALE FEMALE
• 18-30 Years 14 2
• 31-40 Years 9 3
• 41-50 Years 2 4
• Over 50 Years 0 1
• Age Not Known 2

29
NO MEDICATIONS FOR MEDICAL CONDITIONS

• Axis-1 Diagnosis Number of Patients
• ADD/ADHD 4
• Anxiety Disorder 5
• Autism Spectrum 11
• IED
  7
• Mood
  8
• PTSD
  7
• Schizophrenia 8
• Other
  4

30
NO MEDICATIONS FOR MEDICAL CONDITIONS

• Level of MR Number of Patients
• Borderline to Mild 18
• Mild-Moderate to Moderate 14
• Moderate-Severe 3
• Severe-Profound 2
• Total 37
  

31
ANTIDEPRESSANT MEDICATIONS

• Amitriptyline, Elavil
• Celexa
• Doxepin, Sinequan
• Effexor
• Imipramine, Tofranil
• Luvox
• Paxil

• Prozac
• Serzone
• Wellbutrin
• Zoloft
• Anafranil, Clompiramine
• Trazodone

32
MEDICATIONS FOR ANXIETY

• Buspar
• Lorazepam, Ativan
• Serax, Oxazepam
• Valium

33
ANTIPSYCHOTIC MEDICATIONS

• Clozaril
• Haldol
• Loxitane
• Mellaril
• Navane
• Perphenazine, Trilafon
• Prolixin
• Stelazine
• Thorazine

• Risperidol
• Seroquel
• Zyprexa, Olanzapine

34
MEDICATIONS FOR IED, ADD/ADHD. AND MOOD STABLIZER

• IED
• Atarax
• Clonidine
• Propanolol
• ADD/ADHD
• Dexedrine
• Ritalin
• MOOD STABLIZER
• Lithium

35
ANTICONVULSANT THERAPY

• Tegretol
• Dilantin
• Felbamate
• Klonopin
• Lamictal

• Neurontin
• Phenobarbital
• Primidone
• Depakote/Depakene
• VNS

36
Other Classes of Medications

• Anti-Parkinson
• Artane
• Cogentin
• Parlodel
• NSAIDS
• Anaprox
• ASA
• Ibuprofen
• Novasen
• Tylenol

• Cardiac
• Cardura Metoprolol
• Clonidine Plendil Nitroglycerin Tenex
• Coumadin Verapamil
• Cozaar Zestril
• Diltiazem
• HCTZ
• Inderal
• Lipitor

37
Other Classes of Medications

• GI
• Accolate Reglan
• Antacids Tagamet
• Asacol Zantac
• Bowel Aids
• Compazine
• Prilosec
• Prevacid
• Cisapride

• Pulmonary/Allergy
• Allegra, Claritin
• Benadryl
• CPAP
• Flonase
• Inhalers
• O2
• Singular
• Vancenase
• Zyrtec

38
Other Classes of Medications

• Hormones/Anti-Diabetic
• Clemastine
• DDAVP
• Glipizide, Glucotrol
• Glyburide
• HRT
• Insulin
• Thyroid Replacement

• Lupron
• Nelova
• Ogen
• Prednisone
• Testosterone
• Triphasil

39
Other Classes of Medications

• Vitamins/Minerals/Herbs
• Calcium
• DMG
• Iron
• Melatonin
• MVI
• Phos-lo, Nephrox-Vite

• Selenium
• St. Johns Wort
• Vit B6
• Vit B12
• Vit C
• Vit E

40
Other Classes of Medications

• Antibiotics/Antiviral
• Acyclovir
• Cephalexin
• Minocin
• Paradex
• TCN

• Miscellaneous
• Acne Aids Topicals
• Baclofen Bontril SR
• Bethanechol
• Cinobar
• Ditropan
• Eye Drops
• Fosamax
• Methotrexate

41
Autism Spectrum

• 151 patients were seen in DD Clinic
• 31 (20.5) patients had a diagnosis within the
  autism spectrum
• Males 24
• Females 7
• Age Range 19-51 years

42
Autism Spectrum

• Level of Mental Retardation
• Borderline 5
• Mild 4
• Moderate 5
• Moderate-Severe 2
• Severe 10
• Severe-Profound 1
• Profound 4

43
Autism Spectrum

• Axis III Diagnoses
• Gastrointestinal Problems 9
• GERD 6
• Other 5 (2 also have GERD)
• Seizures 9
• Obesity 9
• Allergies/Sinus 7
• Endocrine Problems 3
• Hypothyroidism 2
• Diabetes 1

44
Autism Spectrum

• Number of Medications/Patient
• 0 2 5 6
• 1 4 6 2
• 2 4 7 2
• 3 3 8 1
• 4 7

45
AUTISM SPECTRUM Psychotropic Medications Used

• Clonidine 9 Serax 2
• Zyprexa 5 Atarax 2
• Prozac 5 Inderal 2
• Trazodone 3 Ritalin 2
• Ativan 3 Elavil 1
• Mellaril 3 Paxil 1
• Risperidone 3 Buspar 1
• Luvox 2 Thorazine 1
• Zoloft 2
• Anafranil 2

46
Autism Spectrum

• Associated Axis I Diagnoses
• OCD/OCB 8
• Depression 2
• Anxiety Disorder/GAD 8
• PTSD 2
• ADD/ADHD 2
• Impulse Control Disorder 2
• Organic Brain Syndrome 2
• SIB 1

47
Autism spectrum - Anticonvulsant Medications Used

• Neurontin 8
• Tegretol 7
• Klonopin 6
• Depakote 5
• Lamictal 2
• Dilantin 2
• Phenobarbital 1

48
ADD/ADHD Psychoactive and Anticonvulsant
Medications Used

• Ritalin 3 Clonidine 1
• Prozac 2 Risperidol 1
• Zoloft 2 Zyprexa 1
• Mellaril 2
• Imipramine 1 Tegretol 2
• Paxil 1 VPA 1
• Wellbutrin 1 Klonopin 1
• Buspar 1
• Ativan 1

49
ANXIETY Psychotropic and Anticonvulsant
Medications Used

• Zoloft 7 Risperdal 2
• Trazodone 6 Inderal 2
• Zyprexa 6 Prozac 2
• Ativan 6 Serax 1
• Buspar 4 Catapres1
• Effexor 3 Anafranil 1
• Imipramine 3
• Paxil 3
• Prolixin 2
• Ritalin 2

• Depakote 9
• Tegretol 7
• Neurontin 2
• Klonopin 2
• Other ACM 2

50
IED Psychotropic and Anticonvulsant Medications
Used

• Zoloft 8 Effexor 1 Tegretol 10
• Clonidine 6 Paxil 1 VPA 7
• Ativan 4 Prozac 1 Neurontin 4
• Risperidol 4 Trazodone 1 Klonopin 1
• Zyprexa 4 Buspar 1 Other ACM3
• Inderal 3 Loxitane 1
• Haldol 3 Navane 1
• Mellaril 2 Ritalin 1
• Anafranil 2

51
MOOD Psychotropic Medications Used

• Zoloft 17 Elavil 2
  Luvox 1
• Prozac 10 Buspar 2
  Wellbutrin 1
• Risperdal 9 Clonidine 2 Serax
  1
• Trazodone 8 Navane 2 Haldol
  1
• Zyprexa 8 Prolixin 2
  Loxitane 1
• Ativan 5 Ritalin 2
  Mellaril 1
• Paxil 5 Celexa 1 Stelazine
  1
• Effexor 4 Doxepin 1
  Thorazine 1
• Inderal 4 Imipramine 1

52
MOOD Anticonvulsant Medications Used

• Depakote 16
• Tegretol 12
• Neurontin 3
• Other ACM 12
• Lamictal 6
• Dilantin 3
• Phenobarbital 2
• Felbamate 1

53
PTSD Psychotropic Medications Used

• Zoloft 9
• Zyprexa 9
• Risperdal 8
• Clonidine 5
• Trazodone 3
• Ativan 3
• Inderal 3
• Paxil 2
• Prozac 2
• Wellbutrin 2

• Mellaril 2
• Thorazine 2
• Celexa, Imipramine, Luvox, Serzone, Buspar,
  Haldol, Loxitane, Trilafon, Prolixin, Stelazine
  1 each

54
PTSD Anticonvulsant Medications Used

• Tegretol 10
• Depakote 5
• Neurontin 3
• Other ACM
• Klonopin 1
• Dilantin 1
• Lamictal 1

55
SCHIZOPHRENIA Psychotropic Medications Used

• Zoloft 11
• Zyprexa 10
• Trazodone 5
• Prozac 4
• Risperdal 4
• Clonidine 3
• Inderal 3
• Haldol 3
• Mellaril 3
• Prolixin 3

• Paxil 2
• Ativan 2
• Serax 2
• Thorazine 2
• Effexor, Anafranil, Buspar, Valium, Clozaril,
  Loxitane, Navane, Stelazine, Dexedrine 1 each

56
SCHIZOPHRENIA Anticonvulsant Medications Used

• Tegretol 6
• Depakote 6
• Neurontin 3
• Other ACM 2
• Klonopin 1
• Lamictal 1

57
PSYCHIATRIC HOSPITALIZATION DAYS
58
PSYCHIATRIC EMERGENCY SERVICE UTILIZATION
59
IMPACT OF CLINIC MODEL

• Reduced frequency of PES utilization
• Improved coordination between primary care and
  psychiatric services
• Increased awareness of drug-drug interactions
• Decreased numbers of medications

60
CASE A

• 49 C W institutional care ages 8-49
• Prior dxs Schizophrenia, Schizoaffective,
  persistent delusions, Seizure d/o.
• New dxs Hypothyroidism PTSD
  resolved Borderline Personality Disorder
  Generalized Anxiety Disorder Attention
  Deficit Disorder Hypertension Asthma
  Post-menopausal

61
CASE B

• 29 C M s/p GSW to head age 19
• Aversive shock at previous institution
• Haldol, Cogentin, Depakote, Valium
• Dx was Schizophrenia unsubstantiated
• EPS, stiffness, masked facies H reduced gt
  increased interest and communication 4-6 months
  later sexual interests returned, Risp started for
  disorganized thinking and agitation
• Paranoia re-emerged as well as sexual actions,
  increased agitation
• Behavioral dyscontrol tipping wheelchair,
  biting, screaming.State Hospital

62
CASE C first slide

• 39 H M, fraternal twin
• Depressed, SI, wishing to join his deceased
  father, to join God
• Lived with mother yard work bicycled
• Haldol IM gt cogwheel rigidity O-B TD masked
  facies
• Initiated antidepressant gt hypomania

63
CASE C second slide

• Self-discontinued medication gt severe suicidal
  depression, paranoia, somatic delusions
• SSRI gt akathisia
• Tricyclic gt severe constipation
• Benzodiazepine gt reduction of anxiety
• Treatment guardian not a family member

64
CONCLUSIONS

• IMPROVED COMMUNICATION WITHIN MEDICAL/PSYCHIATRIC
  TEAM
• DECREASED HOSPITALIZATIONS
• IMPROVED QUALITY OF LIFE
• INCREASED ACCESS TO COMMUNITY OPPORTUNITIES

65
CONCLUSIONS

• NO SERIOUS ADVERSE EVENTS
• VERY FEW MISSED APPOINTMENTS

66
FUTURE DIRECTIONS

• WHAT ARE LONG TERM OUTCOMES FOR PERSONS WITH
  MR-MI?
• COMPARISON OF THESE PATIENTS WITH GENERAL
  PSYCHIATRIC POPULATION WITH SAME DISORDERS
• HOW DO CURRENT MEDICATIONS COMPARE WITH PRIOR
  TREATMENTS?
• AT TIME OF ENTRANCE TO CLINIC
• AT TIME OF INSTITUTIONALIZATION