Northeast Florida Medicine - Fall 2011 - Mental Health Disorders

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Inside this issue of

VOLUME 62, NUMBER 3 Mental Health Disorders Fall 2011 EDITOR IN CHIEF Raed Assar, MD MANAGING EDITOR Leora Legacy ASSOCIATE EDITORS Steven Cuffe, MD Ruple Galani, MD Kathy Harris (Alliance) Sunil Joshi, MD James Joyce, MD Neel Karnani, MD Mobeen Rathore, MD James St. George, MD

Executive Vice President Jay W. Millson DCMS FOUNDATION BOARD OF DIRECTORS Benjamin Moore, MD, President Todd L. Sack, MD, Vice President Kay M. Mitchell, MD, Secretary J. Eugene Glenn, MD, Treasurer Guy I. Benrubi, MD, Immediate Past President Mohamed H. Antar, MD Raed Assar, MD Ashley Booth Norse, MD J. Bracken Burns, DO LT Orlando Cabrera, MC, USN, Resident Malcolm T. Foster, Jr., MD Jeffrey M. Harris, MD Mark L. Hudak, MD Sunil N. Joshi, MD Daniel Kantor, MD Neel G. Karnani, MD Heather Kearney, MD, Resident John W. Kilkenny III, MD Harry M. Koslowski, MD Eli N. Lerner, MD Jeannine Mauney, MD, Resident Jesse P. McRae, MD Jason D. Meier, MD, Resident Nitesh N. Paryani, MD, Resident Nathan P. Newman, MD Mobeen H. Rathore, MD Ronald J. Stephens, MD Jeffrey H. Wachholz, MD David L. Wood, MD Northeast Florida Medicine is published by the DCMS Foundation, Jacksonville, Florida, on behalf of the County Medical Societies of Duval, Clay, Nassau, Putnam, and St. Johns.

Except for official announcements from the County Medical Societies, no material or advertisements published in NEFM are to be seen as representing the policy or views of the DCMS Foundation or its colleague Medical Societies. All advertising is subject to acceptance by the Editor in Chief. Address correspondence and advertising to: 555 Bishopgate Lane, Jacksonville, FL 32204 (904-355-6561), or email: llegacy@dcmsonline.org.

COVER: Noble Last Roll Call by LCDR Ken Meehan PA-C.

www . DCMS online . org

Northeast Florida Medicine

Features

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Mental Health Disorders Important to Recognize and Treat

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Alone in a Crowded Room: The Continuum of Post-Traumatic Stress (CME)

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Steven P. Cuffe, MD, Guest Editor

Tracy S. Hejmanowski, PhD and Steven P. Cuffe, MD

Youth Non-Suicidal Self-Injury: An Overview for Primary Care Physicians Walter R. Gilbert, Jr., MD

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Clinical Considerations in the Treatment of Mentally Ill Homeless Persons Richard C. Christensen, MD, MA

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The Medical Home: Treating Psychiatric Disorders in the Primary Care Setting

Brian Celso, PhD; Kenyatta Lee, MD; Chirag Desai, MD and Eric Stewart, MD

Special Articles

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Philip H. Gilbert Invited Editorial Photographer's Profile DCMS Annual Meeting Jay Millson Elected to AAMSE Post FMA Annual Meeting

Departments

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From the Editor’s Desk From the President’s Desk Residents' Corner Trends in Public Health DCMS History Book Northeast Florida Medicine Vol. 62, No. 3 2011 3

From the Editor’s Desk

Medicine: A Noble Profession in an Ever Challenging World Written in memory and honor of my father, Salah Assar, MD, 1928 – 2011 In thinking about this editorial, I began to remember how I set my sights on medicine as a career and went for it. I made a choice, a life changing one at that, to go through the grueling process of becoming a physician. It turned out to be one of the biggest battles of my life. No matter what level of intelligence I possessed, I still needed an immense amount of discipline, determination, and willingness to put in countless hours of hard work. I had to take it one day at a time. It was the only way to accomplish such an overwhelming task. Failure was not an option.

I have asked colleagues why they went into medicine. I found that following a role model was a relatively common factor in the decision to go into the profession. My role model was, and will always remain my father, Dr. Salah Assar. As a Gastroenterologist, he handled his position in the community with pride and responsibility. He made his work top priority.

My father considered his position an honor. He was enthusiastic, energetic, and caring. His amazing work ethics and commitment to doing his best for his patients left people around him in awe. Helping patients was a joy for him and it showed. As a result, I was proud and wanted to be like him.

Raed Assar, MD, MBA Editor-in-Chief Northeast Florida Medicine

However, the bar seemed to be set too high. Growing up in the shadow of such an intellectual giant left me with large shoes to fill. Any problem I had seemed trivial in comparison to the daily issues he faced as he cared for his patients. I found myself asking, “Is my current question or situation important enough to take my father away from his work?” The answer was frequently “no”. This is something I have to keep in mind with my own family. Am I approachable when they want to come to me for an answer or advice?

We listen to our patients and consider their thanks and praise the highest form of achievement, and we thrive on such appreciation because for us, medicine is not simply a profession—it is a calling.

Sometime during our training or later on when we started practicing, reality set in—the world is not a perfect one. We faced a medley of challenges in our careers and family lives. We spent less time celebrating our accomplishments and started taking them for granted. Solving our patients’ or our own problems became our main focus. We took our work to bed whether in sickness or in health. We started dealing with issues of control and found that disheartening place: the limits of our abilities. At times our world was riddled with frustration and despair.

At these times, I found it necessary to stop and ask: Do I express appreciation to my loved ones for their support? I would be remiss if I didn’t acknowledge how my wife and mother’s enduring love and care keep me going. Can we do what our patients and society expect of us without such care? The answer is “no”. The goal then is to find balance in life and in thought.

So needless to say, before I accepted the appointment as the new Northeast Florida Medicine Editor-in-Chief, I considered how this new responsibility would affect my balance of life and schedule. Additionally, I know my father would be proud to hear I stepped forward into this role.

I would like to thank the DCMS President Dr. Malcolm Foster, Jr. and DCMS Executive Vice President Jay Millson for this opportunity to serve. I will take on this new responsibility with the same pride and dedication that all of us gave to becoming physicians. I promise to be objective, impartial, and above all balanced just like my predecessors.

This is an honor, and I will treat it as such. Please do not hesitate to share your opinions and suggestions. Thank you for your support!

Welcome, Dr. Assar, as the new Northeast Florida Medicine Editor-in-Chief!

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www . DCMS online . org

From the President’s Desk

Preventive Medicine, Health Care Rationing and DCMS Involvement: They Are Related In the past I have written on the topic of promoting preventive medicine to achieve saving precious health care dollars. Each time I approach this subject, I stay away from focusing on rationing. That word and the discussions it triggers are very emotional and explosive. Yet, talking about rationing care is increasingly necessary in these days of soaring medical costs since many still avoid following healthy lifestyles.

Some attainable solutions to high health care costs are reducing unnecessary and redundant tests, not scheduling unnecessary surgeries, shortening hospitalizations and minimizing consultation time; in a word, “rationing” health care.

Yes, health care dollars can also be saved by reducing the cost of drugs and durable medical equipment. But it can be hard to restrict those prices when pharmaceutical and medical equipment companies are for-profit entities always analyzing their bottom lines. As physicians, we have more control over our patients’ repeat admissions to the hospital, often referred to as “bounce backs”.

If there were better patient compliance, another trip to the hospital might not be needed. Home health and rehabilitation are expensive, but not as costly as inpatient care.

Malcolm T. Foster, Jr., MD 2011 DCMS President

The more complicated ethical questions surrounding “rationing” are: At what age should we withhold dialysis? Should coronary bypass surgery be done on someone over 90 years of age? Are any life sustaining therapies just too expensive for the elderly or chronically ill person? Should those over 65 years of age, retired, and considered unproductive by society receive less and less care?

Right now, Medicare pays for these big ticket procedures, but this “Golden Goose” may stop laying those valuable eggs and want hospitals and other health care organizations to be more responsible for poor outcomes, unnecessary readmissions, and certain hospital acquired infections. I am worried that this debate will become so heated that payers will arbitrarily deny care to avoid conflict. But I have to believe all is not lost if we promote good health to our patients, speak in favor of more tort reform, and support quality standards in our profession.

Yet, can physicians influence the decisions that have been and will be made about who gets paid what for which procedures?

Our voices can and will be heard as we advocate loud and clear through organized medicine, subspecialty societies and involved citizen groups.

Physician colleagues, where are you plugged in? Are you a member and active participant of any of these advocacy organizations? If you are reading this article, you are probably a Duval County Medical Society member. I trust you are not just a member so DCMS can be listed on your CV. We need your real involvement which means attending meetings, serving as a committee member, and getting connected with political action projects.

The 2011 DCMS Annual Meeting is scheduled for December 1, 2011 at the Hyatt Regency Jacksonville Riverfront. Why not plan to be there? Clear your schedule for that evening from 5:45-9:00 p.m. and come to view the Exhibit Hall, connect with other physicians, enjoy a good meal, see colleagues receive awards and witness the historic installation of only the third woman DCMS President when Dr. Ashley Booth Norse is sworn in as the 125th President of the Duval County Medical Society. (The first woman president was Dr. Kay Gilmour in 1992 and the second was Dr. Kay Mitchell in 2002.)

Will attending the Annual Meeting solve all the health care cost issues and settle the debate about rationing care? No, but it is a step in the direction of connecting with your physician colleagues and showing support for your professional organization that advocates for you, for medicine and for your patients in the local, state and national arenas. See you December 1!

DCMS Annual Meeting December 1, 2011 Plan to Come!

(See details, p. 38) www . DCMS online . org

Northeast Florida Medicine Vol. 62, No. 3 2011 5

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Northeast Florida Medicine Vol. 62, No. 3 2011 7

Philip H. Gilbert Invited Editorial

Physician Involvement Key in Curbing Health Care Costs Cecil B. Wilson, MD - Immediate Past-President American Medical Association Editor's Note: Philip H. Gilbert served as the Executive Vice President of the Duval County Medical Society (DCMS) from 1984 until his unexpected death in 2004. During those decades, he was an outspoken advocate for the physicians he served and for the needs of their patients. With no fear of retribution, Phil shared his honest informed opinions with his DCMS colleagues and with the community they served. In his honor, the DCMS Board of Directors established the Philip H. Gilbert Invited Editorial to celebrate his spirit for addressing issues that he championed such as advocacy, tort reform, community activism and caring for the underserved.

The “Request for the 2011 Philip H. Gilbert Invited Editorial” invitation was sent in July to local, state, and national leaders (physician or layperson). All editorials received were reviewed by the DCMS Journal and Communications Committee. Two editorials were chosen for publication - one in this issue and the other in the Winter journal.

As physicians, we have an important role to play in caring for our patients. In addition, it is crucial that we are involved in decisions made as our nation addresses rising health care costs. Physicians must persuade Congress to strategically address health care costs while also improving the value of health care instead of implementing across-the-board funding cuts to Medicare and Medicaid that would prove detrimental to patient care and physician practices. Particularly in Florida, where the state is already enacting its own cuts to Medicaid, additional cuts to Medicaid and Medicare would make it harder for patients to get the health care they need.

Our nation’s broken medical liability system weighs heavily on health care costs – every dollar that goes toward medical liability is a dollar that does not go toward patient care. A Harvard study reported that 40% of closed claims lack any evidence of a medical error or patient injury. Closed claim data from the Physician Insurers Association of America shows that nearly two-thirds of claims Cecil B. Wilson, MD against physicians that closed in AMA Immediate 2009 were dropped, withdrawn Past-President or dismissed. The defensive medicine engendered by a dysfunctional medical liability system increases the cost of health care $70 to $126 billion annually according to a 2003 government study. Instituting proven reforms should be included in any plan to address health care costs. The American Medical Association strongly supports medical liability reforms consistent with those working in states around the country because they have proven to be effective.

Florida, like the nation as a whole, is plagued by chronic conditions like heart disease, obesity, diabetes and smokingrelated diseases. In fact, 78 percent of the $2.5 trillion spent annually on health care is for treatment of largely preventable chronic diseases such as these.

To address these cost-drivers, physicians can encourage healthier lifestyles and patients can do their parts to incorporate

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positive changes into their daily routines, improving their health and wellness and reducing the incidence of preventive illness. The AMA is taking an active role in fostering patientphysician partnerships to encourage healthy behaviors. The AMA’s Healthy Life Steps program addresses key patient behaviors like diet, physical activity, tobacco and risky alcohol use, providing information and resources to help physicians and patients work together to promote longer, healthier lives.

Reducing administrative overhead also has the potential to decrease costs while simultaneously improving patient care.

The Centers for Medicare & Medicaid Services annual National Health Expenditures Accounts reports administrative expenditures exceeding $160 billion in 2009. Administrative costs do not contribute to patient care, and standardizing processes and formats across different types of insurance and health care systems can result in significant cost-savings. Administrative simplification has the added benefit of allowing physicians to spend more time with patients and less time burdened by red tape.

Finally, new models for health care delivery that reimburse physicians for services that promote optimal patient care can help ensure that the right patient receives the right care at the right time, reducing costs associated with duplicative tests, hospital readmissions and preventable illnesses. Physicians are uniquely positioned to lead efforts in care coordination and delivery reform, and the AMA is committed to ensuring that physicians lead in developing new models of patient care, including Accountable Care Organizations. These patient-centered, physician-led approaches to new models of health care have the potential to improve patient access to high-quality, cost-effective care.

While there is no single solution to addressing health care costs, it is clear that across-the-board cuts to health care spending are not the answer. Instead, we must strategically tackle the areas that provide an obvious opportunity for improvement.

Our ultimate goal should be to achieve better value for our health care spending by looking at opportunities in all areas of our health care system, including the enactment of medical liability reform, focusing on prevention and wellness, reducing administrative burdens, and improving health care delivery models. The AMA will continue to be a leader in these efforts.

www . DCMS online . org

Residents’ Corner: UF Health Science Center - Jacksonville Editor’s Note: In an effort to connect more Duval County Medical Society members with residents, in each 2011 issue there will be a “Residents’ Corner” with information about a residency program in the area, details about research being done and/or a list of achievements/accomplishments of the program’s residents. This “Residents’ Corner” features University of Florida Health Science Center - Jacksonville.

Overview of Residency Program

Under the direction of Dr. Robert Nuss, Dean of Jacksonville’s Regional Campus, Dr. Constance Haan, Senior Associate Dean for Educational Affairs, and Dr. Frank Genuardi, Associate Dean for Student Affairs, the University of Florida Health Science Center – Jacksonville (UFHSCJ) is growing with 27 Accreditation Council for Graduate Medical Education (ACGME) accredited residency and fellowship programs and one Commission on Dental Accreditation (CODA) accredited residency program.

In partnership with Shands Jacksonville Medical Center, more than 300 residents and fellows train in these programs, making this the third largest postgraduate medical training program in Florida. In addition, an anesthesiology residency program under the direction of Department Chairman Dr. Moeen Panni is getting underway this month.

The UF & Shands Jacksonville medical complex of today began as Duval Hospital and Asylum in 1870, as Florida’s first nonmilitary hospital. After the merger of several hospitals and name changes, in 1999 it became Shands Jacksonville. It is now the home of the University of Florida Proton Therapy Institute and Shands’ nursing staff was granted Magnet® recognition by the American Nurses Credentialing Center for nursing excellence this year. Also this year, the Shands Jacksonville Medical Center was awarded the prestigious Governor’s Sterling Award for Sustained Performance Excellence.

Resident Research

UFHSCJ is dedicated to the advancement of medical knowledge and education through its robust emphasis on research. The Office of Research Affairs sponsored the campus’ annual Research Day on May 12, 2011. Residents and fellows were able to submit research projects in the format of an oral platform presentation or poster presentation. The twelve winners were: Platform Presentation Winners: 1st Place: Ryan Wilson, MD (Internal Medicine), Retrospective validation of pre-hospital electrocardiogram with Zoll E-series monitoring system for field identification of STelevation myocardial infarction patients; 2nd Place: Deborah Williams, MD (Emergency Medicine), Side-stream quantitative end-tidal carbon dioxide measurement as a triage tool in emergency medicine; 3rd Place: Maryam Tabrizi, MD (General Surgery), Inhaled prostacyclin improves oxygenation in severe hypoxemia; 4th Place: Rosalyn Alcalde, MD(Endocrinology), Estrogen-dependent inhibition of hyperglycemia-induced endoplasmic reticulum stress and superoxide generation in endothelial cells; 5th Place: Ehab El-Gabry, MD (Cytopathology), Intraoperative assessment of initial lumpectomy surgical margins significantly reduces subsequent mastectomy rates; and 6th Place: Reginald Griffin, MD (General Surgery) Early protocol-based inferior vena cava filter placement in high-risk trauma patients results in decreased incidence of pulmonary embolism.

Poster Presentation Winners: 1st Place: Sushil Gupta, MD (Pediatrics), Immune biomarker panel monitoring utilizing IDO enzyme activity and CD4 ATP levels: prediction of both extremes of immunosuppression—acute rejection or viral replication events; 2nd Place: Ravi Keshavamurthy, MD (Ophthalmology), Lutein and Zeaxanthin protect retinal pigment epithelium from oxidative stress-mediated cytotoxicity; 3rd Place: Margaret Gladysz, MD (Internal Medicine), Inhibition of Apolipoprotein A-1 gene expression in hepatocytes by TNFa requires the pro-inflammatory transcription factor C-Jun; 4th Place: Nikhil Patel, MD (Pathology), Amniotic fluid lamellar body count using hematology analyzer Sysmex XE-5000: a cost-effective method of assessing fetal lung maturity; 5th Place: Sima Patel, MD (Pediatric Emergency Medicine), The impact of third-hand smoke education in a pediatric emergency department on caregiver smoking policies and quit status: a pilot study; and 6th Place: Gathline Etienne, MD (Neurology), Prevalence of self-reported dysphagia in outpatients with multiple sclerosis.

Also, Dr. Rosalyn Alcalde, an endocrinology Fellow, received two $5,000 Dean’s Grants for her research in July 2010, entitled “Inhibition of endoplasmic reticulum stress in endothelial cells by high-density lipoprotein” and “Acute effects of hookah smoking on hormonal and metabolism parameters: a pilot study.”

Resident Honors The University of Florida School of Medicine – Jacksonville (UFCOMJ) is proud of its residents' accomplishments. Dr. Michelle Stalnaker, an obstetrics and gynecology Resident, received the Outstanding Resident Teacher Award at the Medical Education Banquet on February 22, 2011 in Gainesville, FL. Each summer brings the end of the academic year for UFCOMJ and at a June 22, 2011 ceremony, faculty and staff gave 97 physicians their certificates of completion. The following awards were bestowed: Esenam Lucinda Kjerulff, MD (Obstetrics and Gynecology), the College of Medicine Excellence in Student Education Award; Shawn Tai, MD (Internal Medicine), the Edward Jelks Outstanding Resident Clinician Award; Christopher Y. Hopkins, MD (Surgical and Critical Medicine), the Rosilie O. Saffos Outstanding Resident Teacher Award; Matthew Christopher Lee, MD (Orthopaedic Surgery), the Ann Harwood-Nuss Resident Advocate Award and Alejandro Jesus Garcia, MD (General Surgery), the Louis S. Russo, Jr. Award for Outstanding Professionalism in Medicine.

Residents’ Corner written by: Dr. Jeannine Mauney, a recent graduate from the obstetrics and gynecology residency at the University of Florida College of Medicine – Jacksonville. Dr. Mauney served as UFCOMJ’s resident representative to the DCMS Board of Directors for the 2010 – 2011 academic year. She is a graduate of the Wake Forest School of Medicine and is entering private practice in Jacksonville, FL.

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Northeast Florida Medicine Vol. 62, No. 3 2011 9

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This Issue’s Focus: Mental Health Disorders

Mental Health Disorders Important to Recognize and Treat I am honored to be the Guest Editor for this issue of Northeast Florida Medicine. As the Chair of the Department of Psychiatry at the University of Florida College of Medicine- Jacksonville, it is my pleasure to bring you this issue on mental health disorders. Psychiatric and behavioral disorders are often under-represented topics outside of specialty journals despite the fact that they constitute a highly prevalent group of disorders. It has been estimated that between 15% and 25% of adults currently suffer from a mental disorder1. In fact, the World Health Organization (WHO) has estimated that mental disorders rank third in global disease burden after respiratory and cardiac disorders2. The WHO has also projected that depression will be the second leading cause of disability worldwide by 20201.

So mental and behavioral disorders are widespread, highly prevalent, and cause significant morbidity. A large number of your patients will be affected, and so it is important for you to be aware of psychiatric disorders and to be able to screen patients, provide primary care for mental disorders, and to know when to refer to a specialist. The goal of this issue is to provide you with guidelines to be able to carry out these responsibilities for some selected disorders, in addition to becoming aware of the plight of the seriously mentally ill regarding social and medical needs.

The lead article in this issue, “Alone in a Crowded Room: The Continuum of Post-Traumatic Stress” was written by Tracy Hejmanowski, PhD and me. It explores the impact of combat trauma on service members and veterans. In this article we discuss post-traumatic stress symptoms, the impact a veteran’s response to trauma has on their family members, and evaluation and treatment of veterans of combat. This article is approved for Continuing Medical Education (CME) credit.

Steven P. Cuffe, MD University of Florida College of Medicine - Jacksonville “Youth Non-Suicidal Self-Injury: An Overview for Primary Care Physicians,” was written by Department of Psychiatry Gabriella DePrima, PsyD, and Stephanie Sims, MD. This article examines a highly prevalent

and disturbing set of behaviors ranging from less serious scratching and pinching to serious forms of cutting and burning and discusses the epidemiology, causes, and psychiatric disorders associated with these behaviors in our youth. In addition, the authors provide a template for screening and triage of youth displaying these behaviors.

Richard Christensen, MD, MA, wrote “Clinical Considerations in the Treatment of Mentally Ill Homeless Persons.” In this article he discusses the most common barriers to accessing psychiatric and primary care for homeless persons and explores the devastating effects co-morbid disorders can have in persons struggling to avoid, or escape, homelessness. He concludes by proposing an integrated model of care to better meet the clinical needs of this highly undeserved population.

Finally, “The Medical Home: Treating Psychiatric Disorders in the Primary Care Setting,” explores the concept of the “medical home” and how changing to this model can enhance the treatment of mental disorders in the primary care setting. Brian Celso, PhD; Kenyatta Lee, MD; Chirag Desai, MD and Eric Steward, MD, describe the medical home model at the University of Florida College of Medicine-Jacksonville and the initial collaboration in the treatment of anxiety disorders which was undertaken.

I hope you find this issue interesting and helpful to you in your work with patients.

Resources: 1)Bromet EJ, Susser E. The burden of mental illness. In Psychiatric Epidemiology, E Susser, S Schwartz, A Morabia, EJ Bromet eds. New York: Oxford University Press, 2006, pp. 5-14.

2)Ustun TB. The global burden of mental disorders. Am. J. Public Health. 1999, 89:1315-1318.

Please note Trends in Public Health article, "Mental Health in Duval County" on p. 35. www . DCMS online . org

Northeast Florida Medicine Vol. 62, No. 3 2011 11

'Last Roll Call' Photograph Honors Fallen Marine LCDR Ken Meehan PA-C., Battalion Surgeon 1st LAR, 1stMARDIV, is the photographer for this issue’s cover. He has completed four combat tours in Iraq and Afghanistan and is currently assigned as the Division Officer for the Department of Orthopaedics, Naval Hospital Jacksonville where he works as an Orthopaedic Physician Assistant.

Entitled “Noble Last Roll Call,” the photograph was taken in Rawah, Iraq, July 27, 2007 to honor Hospitalman Daniel S. Noble, 21, of Whittier, Calif., who died July 24, 2007 as a result of enemy action while conducting security operations in the Dilaya Province, Iraq. He was permanently assigned to the 1st Marine Division, Fleet Marine Force Pacific, Camp Pendleton, Calif. Ken said, “Daniel is still missed by everyone who knew him.”

Ken recalls, “HN Noble was in my battalion, but I had assigned him to support another unit that had suffered greater combat losses after we arrived for our tour of duty in Rawah, Iraq. When we got word he was killed in action, we said our good-byes in standard Marine fashion by conducting a last roll call.”

Ken explained, “Back in the day, roll call was conducted every morning to ensure accountability. Traditionally, a member’s name would be called out by the company First Sergeant three times before the person was marked as absent.

So now when a Marine is killed in action, fellow warriors gather together for a symbolic ‘last roll call’ of the fallen and the Battalion roster is read out loud. After the first call of the member’s name, a pair of combat boots is placed before a stack of sandbags. At the second reading of the name, the member’s rifle is fixed with its bayonet plunged into the bags.

And when the name is called for the third and final time, the

member’s helmet is placed atop the rifle, forming a combat cross. At the conclusion of the ceremony, the battalion files past in single file to pay last respects.”

After taking the photo, Ken stylized it so it appeared as a piece of art. Using deep orange and red tones, he was able to “convey the heat of the desert averaging 130-140 degrees by late afternoon and the solitude one can feel even when standing among a few hundred people." Ken added, “In full combat gear, you are sweating so hard that your tears are washed away as quickly as they form.”

Raised near Boston, MA in Medford, Ken became interested in photography when he was 5-years-old. His first camera was “a Brownie complete with disposable flash cubes.” When he was 13-year-old he bought his “first real camera”, a Single Lens Reflex Cannon AE1 that cost him his “life savings” of $350. He still has that camera.

He remembers, “Growing up I wanted to be an artist but never really had a talent with pen or brush. The word ‘photography’ literally means to draw with light, and with my camera I realized that I could paint on a canvas of film. I see my photographs as a myriad of expressions. For me some are eternal stories, others emotions suspended in time and sometimes they are my truth untold.”

Next year Ken will reach the 30-year mark in his Navy career, joining when he was only 17-years-old. For 16 years he was a Hospital Corpsman and then in 1998 received his commission into the Medical Service Corps. Congratulations to Ken for reaching this milestone and a sincere thank you to him and all our military personnel around the world who put themselves in harm’s way protecting the freedoms we enjoy in America.

Reflections

LCDR Ken Meehan in Al Qiam, Iraq, Christmas Day 2004

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The bloody stains of my boots have faded with the sun Yet I remain cloaked in a robe of stolen honor

Raging between Pride & Sorrow my soul is engulfed in flame The ashes of the dead cloud my mind

O' what great pity we reap upon ourselves when dreams and hope fade from the sun Ken Meehan www . DCMS online . org

Alone in a Crowded Room: The Continuum of Post-Traumatic Stress

Background - Benefits that Matter!

The Duval County Medical Society (DCMS) attempts to provide its members with the benefits that consistently meet your professional needs. One example of how this is being accomplished is by providing to DCMS members free Continuing Medical Education (CME) opportunities in the subject areas mandated/and or suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare (SVHC) Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). Helena Karnani, MD, Chair of the CME Committee; Betsy Miller, Director, Medical Staff, Quality Management; and Cindy Williamson, CME Coordinator, from SVHC deserve special recognition for their work on behalf of DCMS. This issue of Northeast Florida Medicine includes an article, “Alone in a Crowded Room: The Continuum of Post-Traumatic Stress” authored by Tracy Hejmanowski, PhD and Steven P. Cuffe, MD.(see pp. 15-19), which has been approved for 1.0 AMA PRA Category 1 credit(s).™ For a full description of CME requirements for Florida physicians (MD/DO), please visit the DCMS website (http:// www.dcmsonline.org/cme_requirements.aspx).

Faculty/Credentials: Tracy S. Hejmanowski, PhD, is a Clinical Psychologist and Program Manager of the Deployment Health Center,

Naval Hospital, Jacksonville. She did her MA and PhD degree work in Clinical Psychology at the University of Connecticut, Storrs.

Steven P. Cuffe, MD, is Professor and Chair, Department of Psychiatry, University of Florida College of Medicine, Jacksonville. He received his medical degree from Bowman Gray School of Medicine of Wake Forest University, interned at Herrick Hospital & Medical Center, Kaiser Permanente Hospital in Oakland, California and did a General Psychiatry Residency at the University of California, as well as a Child Psychiatry Fellowship at UC.

Objectives for CME Journal Article 1. Understand the impact of combat-related trauma on military service members, veterans and their families 2. Recognize the major PTS symptoms in military service members and veterans exposed to the horrors of combat 3. Learn the components of an evaluation of PTS symptoms 4. Understand the major modalities for treatment of PTS disorder, including use of medications and psychotherapeutic techniques

Date of Release: September 2, 2011 Date Credit Expires: September 2, 2013 Estimated time to complete: 1 hr.

Methods of Physician Participation in the Learning Process

1. Read the “Alone in a Crowded Room: The Continuum of Post-Traumatic Stress” article on pages 15-19 2. Complete the Post Test and Evaluation on page 14 3. Fax the Post Test and Evaluation to DCMS (FAX) 904-353-5848 OR members can also go to www.dcmsonline.org & submit test online

CME Credit Eligibility

In order to receive full credit for this activity, a minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted if a passing score is not made on the first attempt. DCMS members and non-members have two years to submit the post test and earn CME credit.

A certificate of credit/completion will be emailed, faxed or USPS mailed within 4-6 weeks of submission. If you have any questions, please contact the DCMS at 355-6561, ext. 103, or llegacy@dcmsonline.org.

Faculty Disclosure Information

Dr. Hejmanowski and Dr. Cuffe report no significant relationships to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee, and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare is accredited by the Florida Medical Association to provide continuing medical education for physicians.The St. Vincent’s Healthcare designates this educational activity for a maximum of 1.0 AMA PRA Category 1 credit(s) .TM Physicians should only claim credit commensurate with the extend of their participation in the activity.

www . DCMS online . org

Northeast Florida Medicine Vol. 62, No. 3 2011 13



Alone in a Crowded Room: The Continuum of Post-Traumatic Stress CME Questions & Answers (Circle Correct Answer) /Free-DCMS Members/$50.00 charge non-members*

(Return by September 2, 2013 by FAX: 904-353-5848, by mail: 555 Bishopgate Lane, Jacksonville, FL 32204 OR online: www.dcmsonline.org) 1. One of the most important transitions for post-deployed service members is: a. Establishing a new routine b. Getting accustomed to work in peacetime c. Developing a coherent self-identity d. Staying in touch with those still deployed

6. Which is the most important to consider when evaluating a combat veteran? a. Veterans will expect to be seen on time b. Veterans usually have no difficulty trusting medical professionals c. Veterans may be guarded & it is critical to establish a connection with them d. Veterans value straightforward communication

2. Some of the most troubling aspects of psychological readjustment 7. Family members of veterans: have to do with: a. Are not typically impacted by war or deployment a. Guilt and regret b. Rarely struggle with depression, isolation or anxiety c. Can experience difficulty with the readjustment period after b. Anger deployment c. Grief d.

Are not an essential part of the veteran's transition back home d. All of the above

3. What is true about PTS and post traumatic growth? (PTG) a. PTS is more common than PTG b. PTG is more common than PTS c. PTS and PTG can co-exist d. PTS and PTG cannot co-exist 4. The three hallmark symptoms of PTSD include: a. Startle, hypervigilance and insomnia b. Re-experiencing, avoidance & numbing, and hyperarousal c. Anger, sadness, remorse d. None of the above 5. When assessing war veterans, it is important to evaluate for: a. Concussive events b. Alcohol use, risk-taking, and aggressive behaviors c. Adequacy of sleep d. All of the above

8. Among the most effective treatment modalities for those with operational stress are: a. Complementary and alternative medicine (CAM) b. Exposure-based therapies c. Both a and b d. Neither a or b 9. Which is the medication of choice to treat most PTS symptoms? a. Risperidone b. Sertraline c. Propranolol d. Alprazolam 10. Which medication has been shown in placebo controlled trials to reduce nightmare and promote sleep? a. Prazosin b. Zolpidem c. Trazodone d. Diphenhydramine

Evaluation questions & CME Credit Information



(Please evaluate this article. Circle one number using this scale: 1= Strongly Agree to 5= Strongly Disagree) The article met the stated objectives: 1 2 3 4 5 The article was appropriate to my practice: 1 2 3 4 5 The topic was current and well presented: 1 2 3 4 5 Comments:______________________________________________________________________________________ ____________________________________________________________________________________________ Name (Print)___________________________________________Email_____________________________________ Address/City/State/Zip_____________________________________________________________________________ Phone__________________________Fax_____________________DCMS Member (circle)

YES

NO

*Non-Member Charge ($50.00) - See payment options below Credit card: Visa

MasterCard

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Account #___________________________________Expiration date:_______________________________________ Signature_______________________________________________________________________________________ 14 Vol. 62, No. 3 2011 Northeast Florida Medicine

www . DCMS online . org

Alone in a Crowded Room: The Continuum of Post-Traumatic Stress Tracy S. Hejmanowski, PhD and Steven P. Cuffe, MD “War is delightful, to those who have no experience of it.”

Desiderius Erasmus, 15th century “Nobody wins in a war; there are only varying degrees of losses.”

Michele Baugh, daughter of KIA Vietnam Veteran, 20th century “No one is really unscathed from war unless you have no compassion for human life.”

COL John Bradley, 21st century

Abstract: Post-traumatic stress disorder (PTSD) is quite

common among military service members and veterans who have served overseas, given their frequent and repeated exposure to the horrors of combat. Responses to such trauma should be viewed on a continuum, with varying degrees of biological and emotional manifestations that can lead to interpersonal consequences. This article explores the impact of war zone trauma on veterans and their families and provides a guide for physicians on the diagnosis and treatment of post-traumatic stress.

Casualties of War

The quotes above, taken from various points in history, reveal the timeless universality of the impact of war upon those who fight and those who care for our nation’s warriors upon their return. War veterans (a term that includes active duty, veterans, guardsmen, and reservists alike) understand the inherent truth in these statements, for they have felt firsthand the intense pride, relief, horror, fear, love, and hatred that encompasses war.

The phenomenon of war trauma has existed for as long as wars have been waged. In his epic poem, “The Odyssey”, Homer portrayed Odysseus, a strong and courageous warrior who became plagued by the trauma of war.1 Similar experiences are felt by veterans of World War I and II, Korea, Vietnam, and the wars in Iraq and Afghanistan. War veterans, regardless of their training, personality, psychological resilience, stoicism, and belief system, return from war changed – for the better, for the worse, or a little of both. Veterans who struggle with war-related stress echo a familiar chorus that war haunts them long after its end.

Of the more than two million service members who have served in the wars in Iraq and Afghanistan and neighboring Address correspondence to: Tracy S. Hejmanowski, PhD, Clinical Psychologist and Program Manager of the Deployment Health Center, Naval Hospital, Jacksonville, 2080 Child Street, Bldg 964, Branch Health Clinic, Jacksonville, FL 32214. Phone: 904-5423500 x8837. FAX: 904-542-0007. Email: Tracy.Hejmanowski. ctr@med.navy.mil. www . DCMS online . org

countries since 2003, over 6,000 service men and women have sacrificed their lives for their country. Nearly 43,000 veterans of Iraq and Afghanistan have been wounded (ranging from shrapnel injuries to amputation to traumatic brain injury).

Well over 100,000 service members have witnessed one or more traumatic events that have caused horrific injuries to or tragic deaths of their comrades in arms. All of them have sacrificed their life as they once knew it.2 And while our nation’s heroes serve in war zones overseas, there are over one million military spouses, two million children, and countless extended family members who have maintained the stability of the family as they witness the toll that war takes on their loved ones.3

The Impact of Trauma

For those military men and women who are fortunate to return home, many carry with them the impact of memories that, in some cases, damage the psyche. Bob Cagle, a Vietnam veteran, once said, “PTSD is not a reasonable diagnosis for something so encompassing that it can and will engulf a person’s life, ruin any chance for intimacy, keep horrid scenes in one’s mind for [decades] or for life in the case of other poor souls. To be angry at the world, jump at the slightest sound or quick movement, and live within one’s own mind because you know that no one would understand or try to help is to live in hell.”1 It is common for veterans to describe living in society as being “alone in a crowded room.” They often feel unable to relate to civilians, including their own families. They feel their ability for true connectedness is lost, except when they are with their comrades, which leads to a sense of loneliness and isolation. From the perspective of veterans’ families, they also can feel ‘alone in a crowded room’ when they experience the emotional distance from their veteran loved one. The ‘crowd’ this time refers to those comrades and souls carried in the veteran’s heart and mind that may command the veteran’s focus.

All veterans who return from war experience some degree of change to their beliefs, priorities, philosophy, perspective, and/or personality – essentially their sense of identity is altered. Whereas post-traumatic symptoms have been shown to result in biochemical and neurological changes and impairments in cognitive functioning, the impact of war also has a more intangible consequence that has been referred to as an existential or soul injury.1 This injury, although often at the crux of combat stress, has not been delineated in the formal diagnostic nomenclature to date.

The most important task for veterans in their journey back from war may be the development of a coherent and well-integrated self-identity.1 War’s impact on one’s sense of Northeast Florida Medicine Vol. 62, No. 3 2011 15

meaning, purpose, direction, and self-esteem compromises the ideal of the self. This injury may manifest in complicated grief, fueled by the moral ambiguities and imperatives of war, including killing, violence against noncombatants (especially children), and violations of the rules of engagement. It is the veterans’ defensive mechanisms of dissociation and somatization that result from repeated trauma which compromise the attainment of this coherent self.1 Some trauma transforms into complicated grief, survivor’s guilt, regret, or shame. The rumination about the what-if ’s and if-only’s sometimes exist as a perpetual presence in veterans’ consciousness as they try to undo the events and actions in which they participated or in which they witnessed humanity’s darkness. Veterans’ war-time exposure can cause them to be anxious and somatic in the presence of emotionally-charged triggers and lead them to be sentimental and sensitive to situations involving injustice and dishonor.

For our nation’s warriors, their psychological wounds impact not only their quality of life, but that of their family. Many family members are often ill-prepared for and unaware of the repercussions of their loved one’s exposure to the hellish conditions that may have cost others their lives and their veteran’s sense of safety and peacefulness. Whereas the dissociative symptoms, sleep disturbance, and sexual problems mostly impact intimate relationships, veterans’ anger and emotional distancing has a profound impact on their children.4,5

Post-Traumatic Growth Not all sequelae from war have a negative valence, however.

Although much of the focus of literature on the impact of war has been biased toward understanding post-traumatic stress, some of the cognitive and emotional shifts that result from difficult experiences can provide inner strength — ­ what has been called post-traumatic growth.6 Some traumatic events provide a renewed focus and purpose in life that guide veterans along a meaningful path. This can take the form of maximized empathy, optimism, a more neutral perspective, clearer purpose, and motivation to give to others. Many clinicians and researchers agree that an individual can experience both post-traumatic stress and post-traumatic growth out of the same events.6

The Continuum of Post-Traumatic Stress PTSD was first recognized as a psychiatric diagnosis in the Diagnostic and Statistical Manual (DSM) in 1980, classified as a stress and anxiety disorder. The hallmark symptom clusters of PTSD include: 1) re-experiencing of the traumatic event in the form of intrusive images, nightmares, dissociative events such as flashbacks, and physical signs of distress (not unlike those manifested during a panic episode), 2) hyperarousal in the form of insomnia, hypervigilance, irritability, edginess and restlessness, and 3) emotional numbing and avoidance of potential triggers that might lead to recall of past traumatic events that could potentiate muscle memory responses or emotional reactivity.7 16 Vol. 62, No. 3 2011 Northeast Florida Medicine

The nature of the wars in Iraq and Afghanistan forces an unnatural recalibration of security and sanity. In places where innocent civilians are used as human shields, children are used as bait for an attack, and ordinary moments can turn extraordinarily devastating in seconds, veterans’ fundamental belief systems become altered. Upon reintegration, veterans may assess and assume the presence of non-discriminating threats in even the most benign circumstances. It is difficult to convince a veteran to dial back their level of vigilance and situational awareness, for they have known the randomness of violence, they have fought to keep their comrades alive, and they will do whatever it takes to avoid ever being caught unaware. It is the proverbial sheepdog who will always set the perimeter around the flock of sheep, even when the wolves are not visibly present.8 The most prevalent complaints among returning war veterans include somatic, emotional, cognitive, behavioral, interpersonal, and psychosocial components. Somatic concerns include primary and middle insomnia, fatigue, headaches, tinnitus, impotence, restlessness, and chronic pain. Emotional and psychological complaints may involve nightmares, racing thoughts (particularly at bedtime), generalized and social anxiety, anger and irritability, impulsive hostility, emotional numbing, hypervigilance, complicated bereavement, and despair.

Cognitive problems include poor sustained and divided attention (in part due to continual scanning of the environment), poor concentration, impaired memory, rumination, and distorted thinking (e.g. jumping to conclusions, dichotomous decision-making).9 Common, yet underreported behavioral problems include abuse of alcohol, illicit drugs, and prescription medication and risk-taking behaviors (e.g., reckless driving, starting fights). Interpersonal concerns include feeling misunderstood, being intolerant of others, distrust, isolation, and withdrawal. Psychosocial concerns may involve spiritual crisis, domestic violence, child abuse, and general family dysfunction.

The most likely concerns of veterans who present to physicians include anger, sleep problems, and erectile dysfunction – all of which can be complicated by substance abuse. All of these clinical presentations can be influenced by the individual’s characterological constitution, cultural sensitivities, or pre-existing life trauma that can serve as an additional vulnerability.

Veterans often report their sensitivity to triggers, which include those that stimulate each of the basic sensory modalities (e.g., sudden or loud sounds, noxious or unusual smells, high temperatures, foreign foods, or uneven terrain).

However, triggers that also produce anxiety, panic, fear, anger, and overall sympathetic nervous system arousal include less concrete stimuli, such as situations deemed unpredictable (i.e., crowds), with minimal controllability (i.e., a room without an easy exit), or foreboding of potential danger (i.e., traffic or building complexes). www . DCMS online . org

Triggers can snap a veteran back into the muscle memory of the combat condition, ready to fight, aggress, and escalate – none of which are appropriate in the civilian milieu. And for some, the combat condition gets stuck in the “on” position, such that they cannot easily turn off their defensive or aggressive posture. For some, this heightened state of arousal serves as an artifact of war, such that the adrenaline rush of battle becomes addictive and leads some veterans to seek behaviors or environments that maintain that high.

The Threshold for PTSD

Although a war veteran may experience many of these earlier mentioned hallmark symptoms of post-traumatic stress, the threshold for rendering a diagnosis of PTSD depends on the degree of functional, psychological and emotional impairment that it causes. Without clinically significant impairment in the social and/or occupational functioning of the individual, the diagnosis may be more indicative of an Adjustment Disorder, Anxiety Disorder, Depressive Disorder, or Complicated Bereavement. Many veterans operate as “functionally stressed” in their life, much like a workaholic functions at the office.

It is common for PTSD to be diagnosed by physicians who do not specialize in behavioral health. In some cases, a patient who reports one or two symptoms of post-traumatic stress, such as nightmares and insomnia, may quickly be diagnosed with PTSD. In other cases, the diagnosis of PTSD may be overlooked as part of the diagnostic differential, when neurocognitive complaints are prominent, suggestive of traumatic brain injury. Likewise, neurovegetative symptoms (e.g., depressed mood, sleep problems) that are more disruptive to the individual’s daily functioning may overshadow classic PTSD symptoms.

It is not uncommon for PTSD to be diagnosed by providers who do not specialize in behavioral health. In some cases, a patient who reports one or two symptoms of post-traumatic stress, such as nightmares and insomnia, may prematurely or erroneously be diagnosed with PTSD. In other cases, the diagnosis of PSTD may be overlooked as part of the diagnostic differential, when neurocognitive complaints are prominent, suggestive of traumatic brain injury. Likewise, neurovegetative symptoms (e.g., depressed mood, sleep problems) that are more disruptive to the individual’s daily functioning may overshadow classic PTSD symptoms.

As the nuances of military operational stress disorders are complex and the implications for diagnosis are broad with regard to disability compensation and treatment management, it is advisable for physicians to screen for impairment caused by symptoms of operational stress, while deferring formal diagnosis to behavioral health specialists who have experience working with military personnel.

Biomechanical Injury

In addition to the psychological trauma incurred in war, the most common cause of physical injury from fighting in Iraq and Afghanistan is “biomechanical trauma” to the brain caused by explosions and blast waves.10 Traumatic brain injury www . DCMS online . org

(TBI) symptoms fall into three categories: cognitive (e.g., memory, poor attention, limited concentration), emotional/ behavioral (e.g., irritability, depression, anxiety, dyscontrol, isolation), and somatic (e.g., insomnia, headache, tinnitus, dizziness). Patients who have experienced mild TBI are at increased risk for psychiatric disorders (e.g., PTSD, depression, anxiety, substance abuse, suicide) as compared to the general population.10 An adequate history of the mechanism of injury may not be possible, due to the often chaotic nature of TBI events in a war zone and the tendency of service members to overlook or be amnestic for non-evacuating concussive events. However, it is crucial when assessing a veteran to consider the severity and type of the injury (as well as prior history of brain injuries) and to what extent symptoms consistent with traumatic brain injury overlap with PTSD to provide a more holistic diagnostic picture. The overlap of symptoms for PTSD and TBI include depression, anxiety, irritability/anger, trouble concentrating, fatigue, hyperarousal, and avoidance.10

Safety

Across all modern wars, inclusive of those in Iraq and Afghanistan, more veterans of war have taken their lives through suicide than have been killed on the battlefield. For the Army and Marine Corps in particular, the military suicide rate has surpassed that of the general population since 2007.11 The military has responded with more aggressive efforts to assess and prevent suicidal behavior.

Many causal models of suicide include the predictive variables of depression, relationship strain, financial and occupational loss, and degree of life impairment.12, 13 Clinically speaking, it is the presence of overwhelming negative thoughts and a sense of hopelessness over the future that potentiates suicidal behavior.

Another safety concern to address among veterans is the potential for harm to others, including family members and community members. A small proportion of veterans dealing with impulse dyscontrol and irritability may unconsciously or consciously seek opportunities to enact their aggression against others. A study by Riggs, Byrne, Weathers, and Litz (1998) found that 63% of veterans seeking help for PTSD had been aggressive to their partners in the last year.14 With regard to concerns for both suicidal and violent potential, it is important for physicians to assess the authenticity of a veteran’s supportive network (including fellow veterans), their access to lethal means of self-harm, their history of impulsivity and substance use, the sufficiency of their sleep, their medication regimen, and their outlook on the near and distant future. During this assessment of risk, the physician has an opportunity to directly connect the veteran with various support and community service organizations and utilize case management services at the Vet Center, VA, and community veteran service organizations.

Northeast Florida Medicine Vol. 62, No. 3 2011 17

Treatment Modalities

The modalities of treatments for PTSD vary widely.

Empirically-validated treatment protocols exist for exposurebased treatments (e.g., Prolonged Exposure Therapy and Stress Inoculation Training), and cognitive therapies (e.g., Cognitive Behavioral Therapy and Cognitive Processing Therapy). An additional empirically-validated treatment protocol, albeit one that is relatively more controversial, is Eye Movement Desensitization and Reprocessing.15 These validated treatment methods tend to be structured and modularized, which has received some criticism from those who propose a more humanistic and emotionally validating approach. Group and family therapies are known to be very beneficial to both veterans and family members alike, by assisting with the transition back into their personal and public lives, through taking a systems approach to care.

Complementary and Alternative Medicine (CAM) therapies have also been shown to be effective as adjunctive elements to comprehensive PTSD treatment. These include art therapy, acupuncture and acupressure, massage, yoga, meditation, and animal-assisted therapies (e.g., equine therapy, service dog placement).16 Pharmacotherapy is helpful for some veterans to treat symptoms of PTSD (nightmares, avoidance or hyperarousal symptoms), depression, and/or anxiety.17 This is usually done in combination with psychotherapeutic interventions. Antidepressants such as serotonin and serotonin/norepinephrine reuptake inhibitors (sertraline, paroxetine, fluoxetine, citalopram, venlafaxine, duloxetine) are usually the first choice for treating veterans since they can target symptoms of PTSD, depression and anxiety.17 Sertraline (dosed up to 200 mg) and fluoxetine (dosed 20-80 mg) have the best research base and are FDA approved for the treatment of PTSD. Side effects of these medications include an initial risk of increased irritability, thus the veterans should be monitored more closely at the beginning of treatment. In addition, gastrointestinal and sexual side effects are common and should be discussed with the patient.

Many other medications have been used to treat PTSD symptoms with varying degrees of success. Interestingly, while widely prescribed for patients with PTSD, benzodiazepines have not been shown to be very helpful. They have shown little to no improvement in core symptoms of PTSD, and only minimal improvement of anxiety symptoms.18, 19, 20 There are few controlled trials of other medications to treat PTSD symptoms. There have been a few small trials of anticonvulsants in the treatment of PTSD. Studies of valproate, carbamazepine, tiagabine and topiramate have shown mixed results, which is disappointing since they follow relatively positive results from some open trials.21 Positive trials showed only modest at best, and many studies were totally negative.

No agent showed consistent positive results precluding any recommendation to use them.

Low-dose risperidone and olanzapine have been shown in small controlled trials to decrease irritability and psychotic 18 Vol. 62, No. 3 2011 Northeast Florida Medicine

symptoms in patients with PTSD.17 However, the risk of metabolic side effects (weight gain, increased blood pressure and lipids, increased risk of diabetes) should limit the use of atypical antipsychotics to those patients with serious irritability or aggression.

Nightmares and other major sleep problems plague many patients with PTSD. Encouraging results have been found using the α1 antagonist prazosin. In a large double-blind, placebo-controlled study Raskind et al. titrated up to as high as 15 mg and found significant improvements in suppression of nightmares, sleep quality and global improvement.22 The dose should be started low (1 mg at bedtime), and slowly titrated up to either symptom resolution or side effects preventing further increase. It is important to warn the patient about possible orthostatic hypotension and the risk of falling if arising too quickly. Evidence for pharmacological management of patients with PTSD thus points to a management plan that starts with SSRI/SNRI medication and augments with low-dose antipsychotic medications for serious agitation and irritability and/or prazosin for nightmares and sleep disturbances.

The Need for Genuine Connection

Despite the significant change in availability of counseling for Iraq and Afghanistan veterans and families and improvements in the culture of stigma around behavioral health care, many veterans remain reluctant to seek psychological treatment and are more likely to present to family physicians, emergency rooms, and outpatient clinics. Hence it is vital to establish meaningful relationships with veteran patients. Physicians need to keep in mind that war veterans may downplay the degree of their impairment for various reasons: 1) some military members’ occupations create a stoic expectation that they will engage in activities prone to psychological trauma (from infantry combat to impromptu mortuary affairs to battlefield medical aid), 2) their training is designed to prepare them for dangerous or threatening situations, 3) military and deployment culture and indoctrination breeds stoicism and a machismo response, 4) veterans may fear and deny their diagnosis or use avoidance behavior to avoid discussing their war experiences, and 5) veterans may fear a negative impact on their career options, although this fear is unfounded.

Medics and corpsmen, for example, are exposed to some of the most graphic and horrifyingly intense injuries and deaths on the battlefield. Because they are relied upon for medical support, as well as psychological, spiritual, and emotional guidance, they believe in the need to “heal thyself ” and are consequently less likely to seek assistance with the burden they carry.

Establishing rapport with those who have experienced traumatic events can be tenuous, but it is essential. Since veterans are trained as sensors to quickly size up people and situations, physicians may observe constricted affect or guarded behavior and assume a personality disorder or a defensive character structure. If the veteran does not feel a physician is genuinely www . DCMS online . org

invested in their well-being, the veteran will not share what has been impacting their mind and body, let alone their heart and soul. Although the veterans may prefer to focus exclusively on symptoms, to the exclusion of the history behind them, this precludes veterans sharing important details that can illuminate the psychological etiology of somatic complaints, such as sleep disturbance, headaches, erectile dysfunction, low energy or fatigue, and general malaise.

When conducting an assessment with veterans, it is important to address their connectedness with others (particularly family), risk-taking behavior, home safety (e.g., weapons, drinking), sense of honor and dedication as a veteran, sense of being appreciated, degree of family knowledge about their diagnoses, amount of stress related to parenting, impulse control (i.e., road rage), memory problems, and sleep hygiene. Also important to assess is how the veteran’s family is functioning and how this may be impacting the veteran.

Despite the behavioral and psychological concerns that can trouble war veterans, it is also important to recognize their strengths, some of which have resulted from post-war traumatic growth. Veterans tend to be situationally aware and protective, reliable, committed, direct, respectful, and appreciative.

They often have tremendous inner strength and resilience and persevere through adverse situations. Their tenacity serves as a buffer against conditions that impact their quality of life.

It is essential that physicians caring for veterans conduct regular and direct follow-up monitoring of symptoms and co-morbid health concerns.15 Forewarning of potential unpleasant side effects from psychopharmacological treatment (especially sexual side effects) can go a long way in developing trust. A multidisciplinary treatment approach is ideal, with the primary physician coordinating care and referring to specialists as needed. Non-traditional modalities of therapy (e.g., veterans’ support groups, bibliotherapy, creative arts therapy) should also be considered as part of the treatment regimen. It is highly recommended that non-behavioral health physicians establish a good working relationship with a military and trauma-trained therapist if working with this most deserving veteran population.

References

1.

Tick, E. War and the Soul: Healing Our Nation’s Veterans From Post Traumatic Stress Disorder. Wheaton, Illinois. Theosophical Publishing House, 2005.

2.

Department of Defense, http://www.defense.gov/news/ casualty.pdf Accessed: June 16, 2011.

3.

VHA Office of Public Health and Environmental Hazards, US Department of Veterans Affairs. Analysis of VA health care utilization among US Global War on Terrorism (GWOT) Veterans: Operation Enduring Freedom, Operation Iraqi Freedom.

Washington, DC. January 2009.

4.

Nelson Goff, BS, Crow JR, Reisbig, AMJ, & Hamilton, S. The impact of individual trauma symptoms of deployed soldiers on relationships satisfaction. J Fam Psych. 2007; 21:344-353.

5.

Sayers, SL, Farrow, VA, Ross, J, & Oslin, DW. Family problems among recently returned military veterans referred for a mental health evaluation. J Clin Psychiatry. 2009; 70: 163-70.

www . DCMS online . org

6.

Tedeschi, RG and Calhoun, LG. Trauma and Transformation: Growing in the aftermath of suffering. Thousand Oaks, CA: Sage. 1995.

7.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, D.C. American Psychiatric Association. June 2000.

8.

Grossman, D. & Christensen, L. “On Sheep, Wolves, and Sheepdogs” In Warriors: On Living with Courage, Discipline and Honor, L. Christensen (Ed), Boulder, CO, Paladin Press, 2004.

9.

Hamblen, JL, Schnurr, PP, Rosenberg, A, & Eftekhari, A. “Overview of PTSD Treatments.” Washington, DC, National Center for Post-traumatic Stress Disorder, U.S. Department of Veterans Affairs. July 2010.

10. Stein, MB & McAllister, TW. Exploring the Convergence of Post-traumatic Stress Disorder and Mild Traumatic Brain Injury. Amer J Psychiatry, 2009; 166:768-776.

11. “Suicide Rivals the Battlefield on Toll on US Military.”Centers for Disease Control and Prevention. U.S. Military Branches (2001-2009) Accessed on July 15, 2011, http://www.npr.org/ templates/story/story.php? storyId=127860466.

12. Kaplan, A. Can a Suicide Scale Predict the Unpredictable?

Psychiatric Times, May 23, 2011.

13. Panagioti, M, Gooding, PA, Dunn, G, & Tarrier, N. Pathways to suicidal behavior in post-traumatic stress disorder. J Traum Stress, 2011; 24(2):137-145.

14. Riggs, DS, Byrne, CA, Weathers, FW, & Litz, BT. The quality of the intimate relationships of male Vietnam veterans: Problems associated with post-traumatic stress disorder. J Traum Stress, 1998; 11: 87-101.

15. Hamblen, JL. Treatment of PTSD. Washington, DC. National Center for Post-traumatic Stress Disorder, U.S. Department of Veterans Affairs. January 2010.

16. VA/DoD Clinical Practice Guidelines for the Management of Post-traumatic Stress: Guideline Summary. October 2010; Module I-2: 40-41, 44-45.

17. Davidson, JRT, Connor, KM, & Zhang, W. Treatment of Anxiety Disorders. The American Psychiatric Publishing Textbook of Psychopharmacology, Fourth Edition. Schatzberg, AF and Nemeroff, CB (Eds.) American Psychiatric Publishing, Inc., Arlington, VA. 2009.

18. Braun P, Greenberg D, Dasberg H, et al. Core symptoms of post-traumatic stress disorder unimproved by alprazolam treatment. J Clin Psychiatry 1990; 51:236–238.

19. Cates ME, Bishop MH, Davis LL, et al. Clonazepam for treatment of sleep disturbances associated with combat-related post-traumatic stress disorder. Ann Pharmacother 2004; 38:1395–1399.

20. Gelpin E, Bonne O, Peri T, et al. Treatment of recent trauma survivors with benzodiazepines: A prospective study. J Clin Psychiatry; 1996; 57:390–394.

21. Benedek DM, Friedman MJ, Zatzick D, Ursano RJ. Guideline Watch: Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Post-traumatic Stress Disorder. Arlington, VA, American Psychiatric Association, March 2009.

22. Raskind MA, Peskind ER, Hoff DJ, et al. A parallel group placebo controlled study of prazosin for trauma nightmares and sleep disturbance in combat veterans with post-traumatic stress disorder. Biol Psychiatry 2007; 61:928–934.

Northeast Florida Medicine Vol. 62, No. 3 2011 19

Youth Non-Suicidal Self-Injury: An Overview for Primary Care Physicians Gabriela DePrima, PsyD and Stephanie Sims, MD Abstract Non-suicidal self-injury (NSSI) is both a problematic be-

havior and a coping technique utilized by many adolescents. Primary care physicians must become aware of the epidemiology, comorbidities, and risk factors for this behavior in order to properly screen patients for this problem. This article will describe NSSI and provide guidelines for assessment in primary care and information about pharmacological and psychotherapeutic treatment options. A list of resources is included at the end of the article for providers and patients to obtain further information about NSSI.

Introduction

Due to its high prevalence of patients who deliberately injure themselves, clinicians of different specialties should be aware of the various aspects of this behavior. Many terms are used to describe this phenomenon, including self-mutilative behaviors, deliberate self-harm, self-injurious behaviors, non-suicidal self-harm, non-suicidal self-damaging acts, self-mutilation, parasuicide, self-wounding, suicide gestures and non-suicidal self-injury (NSSI). The difficulty that clinicians and researchers have encountered in labeling this behavior highlights the baffling nature of its occurrence. We will use the term NSSI to describe this behavior. This article is intended to serve as an introduction to NSSI to help the general practitioner identify, assess, and refer these individuals for more specialized care.

Epidemiology

Primary care physicians and particularly pediatricians may be the first to detect signs of self-injury. An understanding of the typical characteristics of individuals who self-injure is an essential component to adequate detection, screening, and referral for further treatment.

Age – Overall, there is a greater risk of self-injury in adolescents and young adults. Studies show the usual age of onset of self-injurious behaviors between 13 and 24 years of age.1-3 Prevalence – The rate of self-injury in the community has been difficult to measure and reports in studies are highly variable. The rate of self-injury among psychiatric and clinical populations is estimated at 40% to 61% of adolescents in psychiatric inpatient settings and 20% within adult psychiatric patients.3,4 Studies that have examined community adolescent samples have estimated NSSI ranges from 5.1% to 21%.5-7 There is a 4% prevalence rate within the general adult population.3,5 Address Correspondence to: Gabriela DePrima, Psy.D., Clinical Lecturer, UF College of Medicine-Jacksonville, Department of Psychiatry, 580 W. 8th Street, 6th Floor, Tower 2, Suite 6005, Jacksonville, FL 32209. Email: Gabriela.DePrima@jax.ufl.edu.

20 Vol. 62, No. 3 2011 Northeast Florida Medicine

Form of Self-Injury – Among adolescent self-injurers, the most common form is skin cutting (14%-65%) with self-hitting as the second most common (32.8%).6,7 Other forms of self-injury include pinching, biting, scratching, and burning. Many adolescents engage in multiple forms of NSSI with one study citing more girls (28%) than boys (13%) engaging in multiple forms of self-harm.8 Gender – In community studies there appears to be similar overall rates in men and women.9,10 Among adolescents receiving psychiatric treatment, there is a clear gender disparity with adolescent girls more likely to self-mutilate than boys.6 However, there is no clear pattern among the general adolescent population with results varying from no gender differences to greater self-injury among adolescent girls.6,8 Ethnicity – Several studies have identified greater rates of self-injury in Caucasians than other ethnic groups.6,11,12 Frequency – There were no consistent findings across studies regarding frequency of NSSI among youth. Frequency estimates varied from daily to only once among non-clinical adolescents and many reported no longer engaging in this form of behavior.6 Overall, it appears that for many adolescents and young adults, NSSI may be time-limited.

Clinical Correlates

It is important for primary care providers to be aware of potential comorbidities among patients who engage in NSSI. Although many individuals automatically equate NSSI with Borderline Personality Disorder, NSSI is only one symptom that encompasses this condition according to the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSM-IV, TR). Individuals who engage in NSSI are a diagnostically heterogeneous population and may present with various forms of psychiatric dysfunction ranging from mood to anxiety disorders.

Depression/Anxiety – Individual who engage in NSSI have been found to experience more intense and negative emotions and score higher on measures of depression, anxiety, and negative temperament.6,13,14 Some have suggested that anxiety may be more strongly related to NSSI than depression due to the emotional arousal or pressure present in anxiety that may precipitate self-injury.14 Adolescents who have self-injured report more depressive and anxious symptoms as compared to those who do not self-mutilate.6 Specific prevalence estimates of the presence of Axis I diagnoses within outpatient adolescents who deliberately self-injure is limited. A study of inpatient adolescent populations yielded a prevalence rate of 41.6 % for Major Depressive Disorder, 23.6% for Post-Traumatic Stress Disorder, and 15.7% for Generalized Anxiety Disorder.3 www . DCMS online . org

Suicide – Self-injury and suicide are two distinct behaviors as they are clearly differentiated by intent, method, and psychological sequelae. Early studies have identified individuals who self-injure to be at a greater risk for suicide attempts and to have a higher probability of committing suicide after many years of NSSI.15 However, recent studies have yielded mixed results. Some studies indicated that people who engage in NSSI do not have a greater risk for suicide and instead NSSI represents a maladaptive coping behavior. These studies cite evidence that many individuals who self-injure have never attempted suicide or experienced suicidal thoughts.3,16 Other studies concur with earlier research.8,16 These studies indicate that 50% of individuals in community samples versus 70% of inpatient psychiatric samples who partake in NSSI report at least one suicide attempt.3,6 An additional study concluded that adolescents who engaged in NSSI were six times more likely to attempt suicide than those who did not report NSSI.17 Ultimately, it will be important for practitioners to assess for suicidal ideation among those suspected of NSSI.

most commonly cited reasons for self-injury in adolescents.4,9 More specifically, this refers to the reduction of intense and negative feelings. Commonly cited motives include, “I wanted to get my mind off of my problems,” “to stop bad feelings,” and “to manage stress.” The act of self-injury is often followed by a feeling of calm.

Borderline Personality Disorder – It is often believed that since self-injury is a symptom of Borderline Personality Disorder (BPD), all individuals who self-injure must meet criteria for this disorder. In fact, individuals who engage in NSSI are considered a diagnostically diverse group and may present with a variety of psychiatric conditions.3,9 There are studies which show that individuals who engage in NSSI have more symptoms of BPD than individuals who do not engage in this behavior.3,13 Approximately 70 to 75% of individuals with BPD exhibit self-injury.18

Resisting Suicidal Impulses – Self-injury is used as an alternative to suicide and to manage suicidal urges. Inconsistencies exist among studies regarding the link between NSSI, suicidal ideation, and suicide attempts.

Eating Disorders – Self-injury has been found to be more common among individuals with eating disorders such as bulimia and anorexia. A recent study that focused on a college student population found a positive correlation between eating disorder symptoms and self-injury.19 It is speculated that binging and purging may be preceded by negative emotions that are similar to those that also precede self-injury. However, some studies have not confirmed this link.20 Childhood Abuse – There has only been a modest relationship between childhood sexual abuse and NSSI, suggesting that although child abuse may be an important factor for some who self-injure, there are many individuals who have experienced abuse who do not engage in NSSI.21 Substance Use – Individuals who have substance abuse disorders have been found to be more likely to self-injure than non-substance abusers.22

Purpose of Self Injury

NSSI is clearly differentiated from suicidal behavior as the intent of NSSI is not to cause death. It may be difficult to understand the underlying reasons for individuals who engage in NSSI; however this is an important aspect of directing treatment and it should be adequately explored. The many functions of NSSI that have been identified through research include the following: Affect Regulation – Among the identified functions of NSSI, this has been recognized by several studies as one of the www . DCMS online . org

Self-Punishment – Self-directed anger is the second most common function of self-injury.9 Interpersonal Influence – This function of self-injury describes the social reinforcement that can be obtained from this behavior. Examples include: gaining attention from peers, caregivers, romantic partners, and authority figures. Individuals may self-injure to elicit help, affection, and acceptance, and/or to avoid being abandoned or rejected. These motives may be unconscious or conscious.

Anti-Dissociation – This emphasizes the desire that some self-injurers have to stop dissociative experiences (e.g., depersonalization, de-realization) and feel “real” or “alive”.

Sensation Seeking – Self-injury is used as a way of generating excitement, exhilaration, or to experience a “high”.

The release of endogenous opiates has been speculated to be triggered from repeated NSSI that may elicit feelings of pleasurable physical sensation and pain analgesia.9 Oftentimes individuals will also verbalize wanting to feel “something”, even if it is pain.

Assessment

Professional community groups such as the American Academy of Pediatrics and the American Medical Association support early identification and screening for mental illness within primary care settings.23, 24 Mental health checkups are recommended annually during well visits and should include an assessment of NSSI. Integral components of successful mental health screening within primary care settings include 1) Brief and efficient screening for possible mental health concerns (including NSSI), 2) Risk assessment of NSSI and suicidal ideation, and 3) Referrals for follow-up mental health services or immediate emergency medical or mental health services if needed.25 General Considerations – When interviewing patients who self-injure, it is important to maintain an attitude of “respectful curiosity” that will minimize discomfort for them and facilitate their disclosure of the extent and underlying function of their self-injury.26 Providers should avoid labeling the patient’s self-injury as “wrong” as this will likely serve to close off further communication with the patient and decrease their chances of seeking out treatment.18 Mental Health Screening – Mental health screening measures that have been used within pediatric primary care settings include the Pediatric Symptoms Checklist (PSC), Pediatric Symptom Checklist-Youth Report (Y-PSC), and Patient Health Questionnaire-9 for Adolescents (PHQ-9).

These measures can be obtained via the Columbia University Northeast Florida Medicine Vol. 62, No. 3 2011 21

Teen Screen Program at www.teenscreen.org, www.brightfutures.org, and www.phqscreeners.com.

• PSC & Y-PSC - The PSC is a 35-item psychosocial screen to detect cognitive, emotional, and behavioral problems to facilitate referrals for appropriate intervention services. The PSC can be completed by parents and the Y-PSC can be completed by adolescents ages 11 and up. Positive scores indicate the need for further evaluation by a medical or mental health professional.

• PHQ-9 for Adolescents - The PHQ-9 is a self-report depression screening that is completed by adolescents 11 to 18 years old. It consists of 9 questions with total scores ranging from 0 to 27. Scores of 5, 10, 15, and 20 correspond to cutoff scores for mild, moderate, moderately severe, and severe depression respectively.

Item 9 queries specifically for suicidal ideation and self-harm.

NSSI Screening – Although these measures provide valuable tools for brief screening of psychiatric concerns, they do not specifically assess for NSSI. To screen for the presence of NSSI, the following questions are suggested: • Have you deliberately harmed or injured yourself? How? • Were you thinking of killing yourself?

A positive endorsement of NSSI will warrant a closer assessment and risk assessment that will be discussed later.

NSSI and Risk Assessment – To date there are no official guidelines in the assessment of NSSI within a primary care setting. However, a recent article published in the Journal of the American Board of Family Medicine offers an indispensable guide in evaluating NSSI and conducting a risk assessment.18 This guide is modified and replicated in Table 1 (p.23) and uses the mnemonic device “STOPS FIRE” that represents each key assessment point. This tool is useful for provider to remember key areas to assess in a patient presenting with NSSI. Some of the domains assessed include suicidal ideation, type of self-injury, function of NSSI, and intensity of urges. This guide also establishes high-risk behavioral thresholds for each area assessed that would necessitate a referral for immediate follow-up behavioral health services.

Referral Recommendations – The level of risk of self-harm largely determines the type of referral that will be necessary.

In general, patients who present as an imminent risk of suicide or who require immediate medical services due to the extent of their NSSI (i.e. injury that requires sutures) will be referred to emergency services (i.e. 911 or nearest emergency room) and upon stabilization, an urgent appointment will be made with a mental health provider. Patients who present with moderate and low risk of self-harm should be referred for outpatient behavioral health services that may include counseling and medication management.

Treatment

Psychopharmacology – Treatment of NSSI is complicated and ideally involves both psychopharmacology as well as psychotherapeutic and behavioral interventions. Currently, there is no U.S. Food and Drug Administration (FDA) 22 Vol. 62, No. 3 2011 Northeast Florida Medicine

approved psychopharmacological treatment for non-suicidal self-injurious behavior. There are also few if any studies evaluating the effectiveness of pharmacological options in treating adolescents or children with NSSI. There are studies in adults evaluating the use of medications from multiple categories. These drugs are as follows: • SSRIs. Given the frequent comorbidity of depression and NSSI and the association of decreased serotonin levels and impulsivity, the use of selective-serotonin reuptake inhibiting antidepressant medications for treatment of NSSI is theoretically sound. Studies have shown that the use of selective-serotonin reuptake inhibitors such as fluoxetine reduces the frequency of self-mutilation.27, 28 • Atypical Antipsychotics. In one case study, risperidone was found to lead to remission of self-mutilation in a patient with borderline personality disorder.29 A placebo-controlled trial of treatment with aripiprazole (Abilify™) of patients with borderline personality disorder did not show a reduction in self-injury.30 • Lithium. Lithium has been found to reduce deliberate self-harm and to reduce deaths by suicide in patients with mood disorders.31 • Anticonvulsants. There have been a few studies showing a reduction in self-mutilation with topiramate.32 Carbamazepine reduced behavioral dyscontrol (which included cutting behaviors).33 • Opiate Antagonists. There have been multiple recent studies evaluating the effectiveness of the opiate antagonist naltrexone. Theories have been developed that deliberate self-harm is an addictive-type of behavior involving the endogenous opioid system. Studies have shown a reduction and even cessation of deliberate self-harm as well as a reduction in self-injurious thoughts when patients are treated with naltrexone.34, 35 • Alpha Agonists. Clonidine reduced self-injurious urges in patients with borderline personality disorder.36 • Glutamate-Modulating Agents. A case study has shown evidence that glutamate-modulating agents such as riluzole & N-acetylcysteine (NAC)decrease cutting behaviors in patients with borderline personality disorder.37 General Guidelines – General guidelines for the pharmacological treatment of NSSI in adolescents are somewhat difficult to make due to the limitation in randomized, controlled trials. Treatment of comorbid and underlying psychiatric conditions such as depression and anxiety is very important. Concerns about an increase in suicidal thinking in adolescents using antidepressants and other psychotropic medications should be thoroughly discussed with the patient and his or her family. Close monitoring of patients started on psychotropic medications is indicated. The protective effect of antidepressant treatment has been shown to outweigh the potential risk of increased suicidal ideation.38 Recommendations have suggested using SSRI antidepressants as the first-line treatment for self-harm with low-dose www . DCMS online . org

Table 1 STOPS FIRE Assessment Guide 18 (Modified from the Original)

Area of Assessment

Potential Questions

( *Use of cutting as example)

High-Risk Indicators

Suicidal Ideation

“Do you ever thing about killing yourself when you cut?”

Thoughts of suicide are intense and occur before or after episode of self-injury

Types

“In what ways do you self-injure?”

Multiple Types (≥ 3 Methods)

Onset/Duration

“When did you first begin to cut?”

“How long have you been cutting?

Early childhood onset; Duration ≥ 6 months

Place/Location

“What parts of your body have you cut?

Genitals, Breasts, or Face

Severity of Damage

“How deep do you cut?”

“Have you ever had to go to hospital after you cut?”

“Have your cuts ever needed stitches?”

Hospitalization or suturing the required; Reopening of wounds

Functions

“What do you get out of cutting?”

“How do you usually feel before after you cut?”

Any relationship to suicide (e.g., reduces suicidal impulses)

Intensity of self-injury urges

“How strongly would you rate your urge to cut usually from 0 to 100?”

70 or higher

Repetition

“Roughly, how many times have you cut since you started?”

11-50 (Moderate Risk); ≥ 50 (High Risk)

Episodic frequency

“How often do you cut in a typical day/week?"

atypical antipsychotic medications as a second-line intervention.39 Third-line treatment could involve lithium or an anticonvulsant mood-stabilizer. In cases of self-mutilation that do not respond to the aforementioned treatments, naltrexone or clonidine may be added. Omega-3 fatty acids have been shown to lower impulsive aggression in patients with borderline personality disorder and may be an additional pharmacologic intervention.40 Interestingly, there is evidence that benzodiazepines, specifically alprazolam, can worsen behavioral uncontrollability, thereby increasing self-injurious behaviors.41

Psychological Treatments

There are a limited number of randomized clinical studies examining the efficacy of different psychotherapies in the treatment of self-injury. However, there are several evidencebased therapies that have been used for the treatment of selfinjury, including cognitive behavioral therapy and dialectical behavior therapy. www . DCMS online . org

Multiple times per week; ≥ 5 wounds per episode

Cognitive-Behavioral Therapy (CBT) – Cognitivebehavioral therapy has been widely discussed as a viable treatment option for the reduction of self-injury.16 Components of this approach include the use of an assessment to evaluate the function of self-injury, skills-training (problem-solving, assertive communication), application of behavioral interventions (manipulating reinforcers, exposure, activity scheduling) and cognitive restructuring. Studies using manual assistedcognitive behavioral therapy (MACT) have yielded reductions in self-injury and increased periods of time between episodes of self-injury. These changes have been observed over 12 months after treatment.42 Dialectical Behavior Therapy (DBT) – DBT is also a welldocumented treatment for suicidal and parasuicidal behavior and incorporates similar techniques to CBT. It has proven efficacy in the treatment of borderline personality disorder and in the reduction of suicidal behavior. There has also been a documented benefit in the reduction of NSSI.43 Research Northeast Florida Medicine Vol. 62, No. 3 2011 23

is ongoing in determining whether DBT is superior to other modes of therapy in the reduction of NSSI. The goal of DBT when working with individuals with self-injurious behaviors is to identify the antecedents and consequences of NSSI to understand the function of the behavior and identify pathways for change. Once the function of self-injury has been identified, there is an attempt to identify alternative and incompatible behaviors. Learning to accept negative affective states without trying to change these feelings or circumstances is a focus of treatment. Main components of DBT include 1) Decreasing life threatening behaviors, 2) Decreasing therapy-interfering behaviors, 3) Decreasing quality of life-interfering behaviors, and 4) Increasing behavioral skills.

The main skills taught include mindfulness, emotional regulation, interpersonal effectiveness, distress tolerance, and “walking the middle path skills”. Mindfulness skills emphasize the importance of focusing on thoughts, actions, and experiences in the present without judgment and can help reduce stress and easier to cope with daily problems. Distress tolerance strategies are used for coping with distressing emotions, situations, and crises. They can be used to detract from urges for self-harm and encourage use of incompatible behaviors.

Emotional regulation skills promote increased understanding of emotions and the ability to manage them. Attention is paid to increasing positive emotions and reducing negative emotions. Relationship skills or interpersonal effectiveness skills teaches patients to meet their goals in relationships with other people. Lastly, “walking the middle path skills” is used exclusively with adolescents and involves teaching family–based skills that include validation, behavioral skills, and specific problems between parents and teens. This form of treatment is delivered in a combination of group and individual therapy modalities.

Conclusions

Primary care providers will require an understanding of typical characteristics of individuals who engage in NSSI and the components of a successful NSSI assessment within a primary care setting. This assessment will include: • Mental health screening via use of brief mental health screening instruments including NSSI with follow-up questioning • Follow-up NSSI assessment (if NSSI endorsed) and Risk Assessment • Referral for adequate follow-up mental health services based on level of risk and severity of NSSI. • Low to Moderate Risk = Referral for outpatient behavioral health services • High Risk = Referral for urgent psychiatric evaluation and counseling • High Risk with imminent risk for self-injury and medical attention needed = 911 or Emergency Room with urgent follow-up appointment upon medical clearance 24 Vol. 62, No. 3 2011 Northeast Florida Medicine

Effective psychotherapeutic services along with pharmacological interventions are available for patients who self-injure.

Pharmacological treatment is likely to include consideration of SSRI therapy if clinically indicated and potential referral to a psychiatrist. A behavioral health provider is able to provide effective psychotherapies that may involve CBT or DBT. The availability of DBT outpatient treatment is often limited by the intensive nature of treatment and scarcity of mental health providers trained in this treatment modality.

Resources

Websites: S.A.F.E. Alternatives (Self-Abuse Finally Ends): www.selfinjury.com and To Write Love on Her Arms: www. twloha.com.

Organizations: American Family Physician Website: www. aafp.org/afp, American Academy of Psychiatry: www.aap. org, Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults: www.crpsib.com, and Mental Health America: www.nmha.org.

Hotlines: National Suicide Prevention Lifeline: 1-800-273TALK (8255) and Hope Line: 1-800-SUICIDE (784-2433)

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13. Andover MS, Pepper CM, Ryabchenko KA, Orrico EG, Gibb BE. Self-mutilation and symptoms of depression, anxiety, and borderline personality disorder. Suicide and Life-Threatening Behaviors. 2005; 35: 581-591.

14. Klonsky ED, Oltmanns TF, Turkheimer E. Deliberate selfharm in a nonclinical population: Prevalence and psychological correlates. American Journal of Psychiatry. 2003. 160:1501-1508.

15. Morgan H. Death wishes? The understanding and management of deliberate self-harm. New York: John Wiley & Sons, 1979.

16. Muehlenkamp JJ, Guitierrez PM. Risk for suicide attempts among adolescents who engage in non-suicidal self-injury.

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17. Whitlock J, Knox KL. The relationship between self-injurious behaviors and suicide in a young adult population. Archives of Pediatric and Adolescent Medicine. 2007; 161 (7):634-640.

18. Kerr PL, Muehlenkamp JL, Turner JM. Nonsuicidal selfinjury: A review of current research for family medicine and primary care physicians. Journal of the American Board of Family Medicine. 2010; 23:240-259.

19. Whitlock J, Ekenrode J, Silverman D. Self-injurious behaviors in a college population. Pediatrics. 2006; 117:1939-1948.

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Northeast Florida Medicine Vol. 62, No. 3 2011 25

Clinical Considerations in the Treatment of Mentally Ill Homeless Persons Richard C. Christensen, MD, MA Abstract: Individuals suffering the devastating effects of persistent

mental illnesses and substance use disorders constitute a profoundly vulnerable segment of the homeless population. It is well documented that untreated mental illness and chemical addictions can be both a cause of homelessness and a life-shortening consequence of a life on the streets. This paper will discuss the most common barriers to accessing psychiatric and primary care for homeless persons and explore the devastating effects comorbid disorders (e.g., serious mental illness, substance use disorders, and general medical conditions) can produce in persons struggling to avoid or escape homelessness. It will conclude by proposing an integrated model of care to better meet the clinical needs of this highly underserved population.

Introduction

Individuals with persistent mental illnesses and substance use disorders constitute a large number of the homeless population in this country. Although methodological limitations may constrain attempts to count precisely the number of people who are homeless and also contending with mental illness, addictions or both, several investigations provide reliable estimates. In the United States there are an estimated 643,000 persons who are homeless on any given night and over one million citizens who experienced homelessness at some point during the 2008 year.1 In Duval County there are an estimated 3,500 individuals who are homeless at any given time and well over 2,500 who are literally living on the street due to lack of emergency shelter beds.2 The causes of homelessness are myriad and complex. Many are socially systemic and range from high unemployment, a low minimum wage standard, a dearth of low income housing options, and the lack of universal access to health care.

In addition, there are personal factors that can create a loss of stable housing and shelter such as domestic violence, recent incarceration as well as extended medical or psychiatric hospitalizations.3 Without doubt, the presence of untreated mental illness and addictions can be both a cause and consequence of homelessness. The most recent study conducted by the U.S. Conference of Mayors, for instance, estimated that 26% of the homeless population in this country suffers from a serious mental illness such as schizophrenia, bipolar disorder, major depression or posttraumatic stress disorder. 4 Other data gathered from several studies over the years support a range between 22 and 33%.5-6 Further, the Substance Abuse and Address Correspondence to: Richard C. Christensen, MD, MA, Professor and Chief, Division of Public Psychiatry, University of Florida College of Medicine-Gainesville. Director of Behavioral Health Services, Sulzbacher Center, Jacksonville, Florida.

Email:rchris@ufl.edu.

26 Vol. 62, No. 3 2011 Northeast Florida Medicine

Mental Health Services Administration has estimated that approximately 38% of the homeless population is dependent upon alcohol and 26% actively abuse other drugs.7 In Duval County, the 2009 point-in-time census showed that nearly 46% of the homeless population surveyed acknowledged their lives had been impacted by the effects of mental illness and nearly 58% reported a substance use disorder.2

Case Example

A typical example of a mentally ill homeless person needing treatment is Kevin, a 32-year-old male with a history of schizophrenia, alcohol dependence and noninsulin dependent diabetes. His family allowed him to live with them until 6 years ago when they decided they could no longer tolerate his substance use and non-adherence to his psychiatric and primary care treatment. Since that time, he has been living on the street and occasionally in local shelters. On numerous occasions he has been involuntarily committed to the local crisis stabilization unit due to psychotic exacerbations and bizarre public behavior. He has also been frequently arrested for trespassing, disorderly conduct and alcohol-related charges.

During his periods of inpatient treatment and incarceration, he is treated with psychotropic medication and is provided primary care, but upon his release he has no established clinical follow-up since he lacks public or private health insurance.

Although he is unable to work for any extended period of time because of his persistent mental illness, he has not been able to negotiate the disability application process due to his cognitive disorganization, ongoing substance use issues and lack of stable housing.

Obstacles to Treatment for Homeless Persons

Barriers to health care for homeless persons include a wide list of potential obstacles.8 Although some are common to the general population, those described here represent formidable obstacles for homeless persons who are mentally ill and/or addicted. Indeed, accessing health care, particularly behavioral health services (e.g., psychiatric care, counseling, and addiction services) can be nearly an impossible task for most homeless persons due to the following road blocks: Lack of public or private insurance – The most recent estimate of individuals in this country who lack some form of health care insurance increased from 46.3 million in 2008 to 50.7 million in 2009.9 The Medicaid system is the most important insurer for persons living in poverty with serious mental illness and will likely grow under health reform.10 Not surprisingly, however, it has been estimated that nearly 70% of the homeless population lack any form of health insurance, including Medicaid.11 Moreover, “coverage” does not always translate into “access,” particularly with regard www . DCMS online . org

to federal/state-supported Medicaid plans. Many private psychiatrists and health care organizations, particularly in Duval County, do not accept Medicaid patients due to the low reimbursement schedule and what are perceived to be onerous documentation requirements. Hence, even for those homeless persons who may qualify to receive this form of public insurance, their ability to locate and readily access a provider is highly limited.

Lack of money – This barrier seems so obvious it requires little explanation. However, a homeless person’s lack of disposable income hinders seeing a private practitioner, the purchasing of prescriptions (even generics) and medical supplies, procuring identification required at clinics, covering the minimal co-pays required at many safety net medical/ dental organizations, or obtaining bus fare to access a “free” clinic or emergency department. Those homeless persons who lack insurance and the financial means to pay out-of-pocket expenses are unable to access the vast majority of health care systems or purchase the medications prescribed through emergency services.

Lack of transportation – Most homeless persons do not own personal vehicles and frequently cannot readily obtain the money needed to pay for a cab or the city bus. Moreover, navigating a complex public bus system, frequently requiring multiple transfers, can be an overwhelming task for persons who struggle with mental illness. Yet many have mobility problems due to multiple medical illnesses and cannot easily walk a mile or two to a safety net clinic, emergency department or public crisis unit. Because of their social marginalization, mentally ill homeless persons (particularly those with co-occurring disorders), can no longer rely upon relatives or friends who might assist them with a ride to a very limited number of free clinics or safety net organizations. In other words, services that might be “available” to homeless persons are not always easily “accessible” due to barriers related to securing and effectively utilizing transportation.

Lack of personal identification – Most health care organizations and clinics, even those that are designed to be safety net options for homeless persons, require proof of identification. Since the terrorist event of September 11, 2001, requirements for obtaining necessary documentation to verify a homeless person’s identity have become increasingly complex and difficult.11 Oftentimes in order to obtain a state-issued photo ID, a birth certificate and mailing address are required, items a homeless person usually does not have.

In particular, the process of locating, tracking and obtaining one’s birth certificate and the costs associated with the requests are frequently beyond the abilities of homeless individuals who struggle with mental illness, cognitive challenges or the effects of ongoing substance use.

Inability to access entitlements – The process involved in the application for Social Security benefits (SSI/SSDI), as well as public health insurance, requires a diligent and oftentimes painstaking process of proving disability. Criteria are strictly defined under the guidelines provided by the Social Security www . DCMS online . org

Administration (SSA). In all cases, what is minimally required is a clear and coherent set of medical records documenting disability that have followed the patient over time. Moreover, an applicant must tenaciously follow-up with required telephone interviews as well as mandated physical/psychological examinations required by the SSA. In general, applications for these benefits can go through several rounds of appeal and review, extending the process to several years.12 For most homeless persons who live chaotic, day-to-day lives, particularly those who struggle with cognitive, mood or psychotic disorders, the process is an administrative gauntlet that cannot be run without the assistance of a dedicated advocate, outreach worker or case manager. 13

Psychiatric Outreach and Engagement

Case Example continued – The psychiatric street outreach team affiliated with the local homeless center has been contacted by a member of a local church. Kevin is reported to be lying in the church doorway, partially clothed and smelling of urine, claiming he is the “pastor and prophet for all who come unto me.” Upon approach, Kevin is very guarded and initially will not make eye contact or speak to the outreach workers. However, he recognizes the team leader as someone who has provided a shelter bed for him in the past. He agrees to return to the shelter with the outreach team, but is only willing to stay “for just a couple of days since I need to watch over my church.” He admits he has been drinking for several days and has not been taking any medications for his diabetes or schizophrenia.

Working with homeless mentally ill persons, who may also be suffering from the consequences of addiction as well as untreated medical illness, requires a significant adaptation to traditional medical practice.14 The very way in which most mentally ill homeless persons enter into psychiatric treatment differs from the traditional process that might involve a referral from a primary care provider, insurance company, or an employer. It should be remembered that many homeless individuals are socially disaffiliated individuals who are estranged not only from a web of familial or intimate relationships, but medical and behavioral health service systems as well. Those with severe mental illness have often experienced previous treatment in public-funded settings (e.g., crisis units, jails, busy emergency departments, prisons) that are not always remembered as being welcoming or recovery-oriented environments.15 Hence, the very first step to fostering care is establishing rapport and relationship with persons who are oftentimes highly suspicious of mental health providers. This is most commonly accomplished through community-based outreach initiatives that seek to foster relationship and trust with the identified homeless person, whether they are living on the street, in an abandoned house or in a shelter. 16 One example of this approach in Duval County can be seen at the Sulzbacher Center, a large multidisciplinary service center for homeless persons located in urban Jacksonville. Two medical/psychiatric street outreach teams scour the downtown and beaches areas on a daily basis looking for persons who are unsheltered and in need of services. Each of the two Homeless Northeast Florida Medicine Vol. 62, No. 3 2011 27

Outreach Project Expansion (HOPE)Teams consist of two case managers as well as a primary care nurse practitioner and psychiatrist. The initial approach is to meet the client where he or she is, literally and figuratively, in order to establish rapport and build a relationship. For most homeless persons who suffer from mental illness, their initial personal goals will likely consist of meeting basic human needs rather than pursuing psychiatric or medical care.17 Before any discussion of treatment begins, the engagement process must first address issues of shelter, food, clothing, and safety. This will often involve entry into a safe living environment (e.g., Sulzbacher Center shelter) where survival needs can be initially addressed. Once the engagement process has reached the point of introducing mental health and/or primary care services, which may take weeks or months, attempts will be made to move the person to a greater level of insight regarding his/her mental illness, addiction or both. Employing techniques of harm reduction and motivational interviewing, the shelter-based team, headed by the psychiatrist, will help the person begin to identify the barriers that are preventing him/her from reaching their life goals. As the individual recognizes the need for treatment and change, he/she is then offered a more intensive level of treatment involving active participation in their personal recovery plan.

Homelessness and Co-Morbid Conditions

Case Example continued – Because Kevin had been drinking heavily prior to entering the shelter, he agreed to the medical team’s recommendation that he enter the local detox unit where he was medically monitored and treated for alcohol withdrawal. While there his oral hypoglycemic was re-initiated. However, he refused all antipsychotic medications.

After four days he returned to the shelter where he was willing to stay “for a few more days.” Over a two week period he met several times, briefly, with the shelter-based psychiatrist and discussed his goal of getting his own apartment and eventually obtaining his driver’s license. During this time he was willing to be seen in the shelter’s primary care clinic for his diabetes, but was hesitant to start antipsychotic medication or begin substance abuse treatment. Finally, after 6 weeks he agreed to take a “low dose” of an antipsychotic medication and to see the psychiatrist on a regular biweekly basis.

It is well established that even in the general population persons with the most severe mental illnesses have the highest rates of co-occurring substance related disorders.18 According to a national epidemiological survey, for instance, substance use disorders are co-morbid in approximately 20% of persons with depression and 15 percent with anxiety disorders.19 Moreover, people treated for schizophrenia and bipolar disorder are 12 and 20 times more likely to be treated for alcohol abuse, and 35 to 42 times more likely to be dependent upon illicit drugs, respectively. 20, 21 However, one recent study revealed that greater than 50% of adults known to have co-morbid mental illness and a substance use disorder did not receive treatment for either condition during the previous year.22 The obvious consequences of delayed or lapsed treatment includes 28 Vol. 62, No. 3 2011 Northeast Florida Medicine

more severe symptoms, frequent relapses, multiple crises hospitalizations, and loss of employment and employability.

Not surprisingly, co-occurring disorders are directly related to the loss of stable housing and, consequently, homelessness.

Once on the streets, the risk of prolonged, chronic homelessness increases due to the impact of the dual disorders. In fact, one study of chronically homeless persons (i.e., those individuals who had been on the streets for one year or longer or at least 4 times in the past 3 years) found that the presence of a co-occurring disorder was the expectation, rather than exception, among this difficult-to-engage population.23 In other words, those persons who suffer from a serious mental illness like schizophrenia or bipolar disorder, as well as a substance use disorder (SUD), are at greater risk of winding up on the streets and experiencing great difficulty finding a way out of homelessness.

Co-occurring disorders among homeless persons involve more, however, than just mental illness and SUDs. Multiple studies have shown that homelessness and mental illness increase the risk of medical illness.24-26 It is well established that even in the general population, persons with schizophrenia or bipolar disorder have a life expectancy on average 25 years less than those who do not have a serious mental illness. 27 However, the risk for premature death among the population of homeless persons who suffer from mental illness is extreme.

A 10-year longitudinal study of mentally ill homeless persons and premature death conducted in urban Australia found that the average age at time of death was 51 years.28 Untreated chronic medical conditions, particularly cardiovascular and respiratory illnesses, were the leading causes of death in this particularly vulnerable cohort. Not surprisingly, mentally ill homeless persons seek medical care far less often than their age and illness matched domiciled counterparts largely due to the social and personal obstacles identified earlier.29

Active Treatment and Recovery

Case Example Continued – While at the shelter Kevin participated in Life Skills training, a diabetes education class, and was actively engaged in both his primary care and psychiatric treatment. On many occasions he stated he could trust his doctors and believed they were there to help him. He no longer made references to being the pastor of a local church and his self-care was greatly improved. He met with his case manager on a regular basis who initiated the Social Security disability process and helped identify housing options. She explained the housing program that might accept him had a “No Substance Use” policy.

Mentally ill persons who are homeless and fighting to overcome the formidable obstacles they face because of their multiple medical and addiction issues, need so much more than any one health care provider can provide. Those individuals who struggle with the challenges related to homelessness, mental illness, addiction and poor physical health require a clinical approach that is simultaneously multidisciplinary and integrated. A best practices medical model designed to meet the needs of this hard-to-engage population will invariably www . DCMS online . org

involve mental health, addiction, primary care and case management services that are co-located and integrated.30, 31 An example of this clinical approach and practice can be seen at the Sulzbacher Center in Jacksonville.

The Sulzbacher Center provides emergency shelter, case management services, and housing programs for over 350 men, women and children at any given time. In addition, the Sulzbacher Center has developed an integrated model of medical care that employs the use of psychiatric/medical outreach teams, medical case managers and co-located behavioral health and primary care clinics in the attempt to meet the needs of homeless persons who contend with the “tri-morbidity” of mental illness, addictions and life-threatening medical disorders. The goal is to create an integrated, psychiatricmedical “home” that is accessible, physician-directed, recoveryoriented, multidisciplinary and continuous for persons who are both literally and systemically “homeless.”

During an average month, over 400 individuals are treated in the behavioral health clinic for mental illness and substance use disorders, and greater than 600 persons receive primary care treatment. Most of these persons receive all their psychiatric, primary care, substance abuse and case management services in this one medical “home,” provided by a consistent cadre of coordinated providers with whom they have formed a continuous, consistent therapeutic relationship. The use of electronic medical records allow the multiple providers the capacity to communicate and coordinate their treatment recommendations.

Conclusion

Case Example result – Because a major goal for Kevin was to obtain his own apartment, he agreed to enter into a program that was specifically designed to meet the needs of chronically homeless persons who struggled with mental illness and chemical dependence. After 3 months in the program, he moved into his own apartment and is actively participating in his recovery program on an outpatient basis. He recently received SSI and volunteers as a peer support person at a local drop-in center for persons who have persistent mental illnesses. He maintains close contact with his case manager at the homeless center and sees his treating physicians in the clinic on a regular basis. His family, once again, is a part of his life.

Most physicians in Duval County do not work exclusively with homeless persons and do not have ready access to supports provided by an integrated model of care. However, there will be many times, whether in the emergency department, on the inpatient service, in an outpatient clinic, or while volunteering one’s medical services, that the patient receiving care is identified as being homeless. As noted, the clinical approach to persons who are homeless and mentally ill requires adaptations and special considerations in order to foster recovery and rehabilitation.32 Recalling the central issues of access, engagement, comorbidity and service planning, the following clinical strategies are the best when providing care to persons who are homeless, mentally ill and struggling with substance use disorders: www . DCMS online . org

1) Engage Patiently – Because so many homeless mentally ill persons view the health care system with suspicion and apprehension, meaningful engagement is frequently complex and protracted. Empathy and persuasion may be the most important therapeutic elements of the initial engagement process that may span weeks or months before the individual establishes trust.

2) Assess Needs Broadly – Paying attention to the basic needs of safety, food, clothing and emergency shelter, in addition to the medical symptoms, is essential during the initial evaluation and follow-up. Understandably, the homeless person may place a much higher priority on food and shelter than on mental health, addiction or primary care services.

3) Shape Interventions Pragmatically – Treatment interventions need to be shaped according to the realities of the person’s living situation. The chaotic conditions of a shelter or the street will affect adherence to the most basic treatment interventions. Providing samples of medications (rather than written prescriptions), simplifying dosing regimens to once-a-day, and developing safe storage strategies for medications to prevent theft and exposure are measures that will improve adherence.

4)Retain Arduously – Nonadherence to treatment regimens, lost or stolen medications, failure to show for appointments, sporadic follow through with other service agencies, and an inability to remain consistently abstinent from substances of abuse should be expected occurrences.

Setting limits and establishing consequences should be designed to retain the homeless person in treatment rather than justifying termination.

5) Include Housing Always – Treating a homeless person with multiple medical and psychiatric issues will be difficult unless the person has stable shelter. Treatment plans for a patient who is homeless will always be incomplete unless there is also an actionable strategy to obtain emergency, transitional or permanent housing.32

References

1.

The 2009 Homeless Assessment Report to Congress. Available at http://www.hudhre.info/documents/5thHomelessAssessm entReport.pdf . Accessed April 24, 2011.

2.

2009 Report of Duval, Clay and Nassau Counties Homeless Population. Available at http://www.unf.edu/coas/cci/cms/ CCI/Reports/Homeless/2009 %20Homeless%20Report.pdf.

Accessed April 14, 2011.

3.

National Coalition for the Homeless.Why are People Homeless?, 2010. National Coalition for the Homeless, 2201 P St. NW, Washington, DC 20036. Available at http://www. nationalhomeless.org. Accessed April 24, 2011.

4.

The United States Conference of Mayors. Hunger and homelessness in America’s cities, a 25 city survey.

Washington, DC. Conference of Mayors, 2008 Dec. Available at: http://usmayors.org/pressrelaeases/documents/ hungerhomelessnessreport_121208.pdf. Accessed April 21, 2011.

5.

Susser, E., Struening EL, Conover S: Psychiatric homeless men: lifetime psychosis, substance use and current distress in Northeast Florida Medicine Vol. 62, No. 3 2011 29

new arrivals at New York City shelters. Arch Gen psychiatry.

1989 Sep; 46:845-50.

use disorder. US Department of Health and Human Services, Rockville, MD. 2004.

6.

Breakey WR, Fischer PJ, Kramer M, et al.: Health and health problems of homeless men and women in Baltimore. JAMA. 1989 Sep; 262(10):1352-7.

23. Lam JA, Rosenheck R. Street outreach for homeless persons with serious mental illness: Is it effective? Med Care. 1999 37(9):894-907.

7.

Substance Abuse and Mental Health Services Administration.

2003. Homelessness-Provision of mental health and substance abuse services. Available at: Accessed April 21, 2011.

8.

Kushel MB, Vittinghoff E, Haas JS.: Factors associated with the health care utilization of homeless persons. JAMA. 2001 285(2):200-06.

24. Hibbs JR, Benner L, Klugman L, et al.: Mortality in a cohort of homeless adults in Philadelphia. 1994. N Engl J Med, 331(5):304-09.

9.

U.S. Census Bureau. n.d.; www.census.gov/. Accessed April 10, 2011.

10. Donohue J, Garfield R, Lave J.: Health reform and the scope of benefits for mental health and substance use disorder services.

Psychiatric Services 2010 61(11):1081=1086 11. Health Care for the Homeless Clinicians’ Network, National Health Care for the Homeless Council. (2010).

Working to Eliminate Barriers to Care for Homeless People.

Available at: www.nhchc.org/Network/HealingHands/2010/ June2010HealingHands.pdf. Accessed April 28, 2011.

12. Leo RJ, Del Regno P: Social Security claims of psychiatric disability: elements of case adjudication and the role of primary care physicians. Prim Care Companion J Clin Psychiatry. 2001 3:255-262.

13. Perret YM, Dennis D., Lassiter M: Improving Social Security disability programs for adults experiencing long-term homelessness. (2009) Washington, DC: National Academy of Social Insurance. Available at: www.nasi.org/research/2009/ improving-social-security-disability-programs-adults Accessed April 21, 2011.

14. McQuistion HL, Finnerty M, Hirschowitz J, et.al: Challenges for psychiatry in serving homeless people with psychiatric disorders. Psychiatric Serv. 2003 54:669-676.

15. Kryda AD, Compton MT.: Mistrust of outreach workers and lack of confidence in available services among individuals who are chronically homeless. Community Mental Health Journal.

2009 45 (2):144-50.

16. Christensen RC: Psychiatric street outreach to homeless people: Fostering relationship, reconnection and recovery. J of Health Care for the Poor and Underserved. 2009 20:1036-1040.

25. Hwang SW, Orav EJ, O’Connell JJ, et al.: Causes of death in homeless adults in Boston. Ann Intern Medicine 1997.

126(8)625-28.

26. Barrow SM, Herman DB, Cordova P, et al.: Mortality among homeless shelter residents in New York City. Am J Pub Health 1999. 89(4):529-34.

27. Parks J, Svendsen D, Singer P., et al.: Morbidity and mortality in people with serious mental illness. 2006. Alexandria: National Association of State Mental Health Program Directors (NASMHPD). Report available from www.nasmhpd.org/ publicationsmisc.cfm Accessed April 21, 2011.

28. Babridge NC, Buhrich N, Butler T.: Mortality among homeless people with schizophrenia in Sydney, Australia: A 10-year follow-up. Acta Psychiatr Scand. 2001 103(2):105-10.

29. Desai MM, Rosenheck RA, Kasprow WJ: Determinants of receipt of ambulatory medical care in a national sample of mentally ill homeless veterans. Med Care. 2003 41:275-287.

30. Health Care for the Homeless Clinicians’ Network, National Health Care for the Homeless Council. (2006) Integrating primary and behavioral health care for homeless people.

Available at: www.nhchc.org/Network/HealingHands/2010/ June2010HealingHands.pdf. Accessed April 21, 2011.

31. Christensen RC, Garces LK: Caring for homeless persons: A call for transdisciplinary collaboration. Journal of Health Care for the Poor and Underserved. 2005 16(2):181-82.

32. Christensen RC: Homeless, not hopeless: 4 strategies for successful interventions. Current Psychiatry. 2005. 4(6):94.

Special Congratulations

17. Osterberg LG, Barr DA.: Planning services for the homeless in the San Francisco Peninsula. J of Health Care for the Poor and Underserved. 2007 18:749-756.

18. Drake RE, Mueser KT, Brunette MF.: Management of persons with co-occurring severe mental illness and substance use disorders: program implications. World Psychiatry. 2007 6(3):131-36.

19. Grant BF, Stinson FS, Dawson DA, et al.: Prevalence and cooccurrence of substance use disorders and independent mood and anxiety disorders. Results from the national epidemiological survey on alcohol and related conditions. Arch Gen Psychiatry.

2004 Vol 61(8):807-816.

20. Carney CP, Jones L, Woolson RF: Medical co-morbidity in women and men with schizophrenia: a population based controlled study. J of Gen Internal Med. 2006 21(11):1133-37.

21. Carney CP, Jones L: Medical co-morbidity in women and men with bipolar disorders: A population based controlled study.

Psychosomatic Medicine. 2006 68(5):684-91.

22. Office of Applied Studies, SAMHSA. The NSDUH Report: Adults with co-occurring serious mental illness and a substance

30 Vol. 62, No. 3 2011 Northeast Florida Medicine

Dr. Ashley Booth Norse and her husband, Ronald, became parents of a baby boy, Hudson, born August 1. Dr. Booth Norse is the DCMS President-Elect. She will become the third woman DCMS President at the December 1 DCMS Annual Meeting.

Congratulations to this new family. www . DCMS online . org

The Medical Home: Treating Psychiatric Disorders in the Primary Care Setting Brian Celso, PhD; Kenyatta Lee, MD; Chirag Desai, MD; and Eric Stewart, MD Abstract: The rising cost of medical care has been a topic of much

debate in healthcare and public policy circles. Projects across the country for handling the high cost of health care has lead to the formation of the Patient-Centered Medical Home. Terms such as “healing landscapes” and “medical neighborhoods” have been used to describe the concept of the medical home. The Jacksonville Urban Disparities Institute is a part of The Community Affairs Department Shands Jacksonville that was established in 1989 to address the unmet medical needs of the community surrounding Shands Hospital. To decrease disparities in mental health care across ethnic and economic lines, the University of Florida Departments of Community Health and Family Practice have partnered with the Department of Psychiatry to treat mental and behavioral disorders. This paper describes the first intervention of this partnership: treatment of anxiety disorders.

Patient-Centered Medical Home

One approach to the problem of maintaining access to care while keeping cost contained is the concept of the Patient-Centered Medical Home (PCMH). The principles and standards that define a “medical home” are based on the core values of primary care (easy access to first-contact care, comprehensive care, coordination of care, personal relationship over time).1 The medical home adopts a whole person orientation with a treatment team led by a personal physician who takes responsibility for coordinating care among providers for the entire life of the patient. An emphasis of the medical home is on enhanced access to care by integrating all elements of the healthcare system and community and Health Information Technology to optimize both care coordination and provider payment.2 There have been several medical home programs started across the country. Rather than a “cookie cutter” approach, each program was uniquely designed to address the specific challenges of the state. For example, North Carolina targeted lowering emergency room use for Medicaid recipients with asthma.3 Pennsylvania implemented a chronic disease management model with the intent of reducing costs for chronic care by improving control to avoid emergency room visits and hospital admissions.4 States that have focused on transitioning an integrated healthcare system to the PCMH model found that change does not always come easy. The National Demonstration Project — a comprehensive evaluation of the PCMH programs started in 2006 — concluded that transforming primary care delivery required a significant Address Correspondence to: Brian Celso, PhD., Assistant Professor, Department of Psychiatry, University of Florida College of MedicineJacksonville, 580 W. 8th St., Tower 2, Suite 6005, Jacksonville, FL 32209. Email: Brian.Celso@jax.ufl.edu. www . DCMS online . org

effort on the part of providers.5 There was also a strong need for resources and support external to the practices to make a PCMH succeed.

The Jacksonville Urban Disparity Institute (JUDI) is a community-based health initiative that oversees ten clinics operated by the University of Florida serving a predominantly minority population in the urban core of Jacksonville. Disparities in access to care and health outcomes are epidemic in the disadvantaged areas of the city served by the JUDI clinics. Multi-disciplinary teams staff the clinics, which include physicians, nurse case managers, midlevel providers, clinical pharmacist, social worker and clinical psychologist. On July 1, 2010, six of the JUDI clinics became the first Academic Medical Center affiliated ambulatory practices in Florida to receive National Committee on Quality Assurance recognition as a Patient-Centered Medical Home. Consistent with the PCMH philosophy, JUDI provides self-management and care-management support of disease conditions with high prevalence and major causes of morbidity and mortality to urban core residents such as such as sickle cell disease, diabetes, HIV/AIDS, diabetes, hypertension and behavioral health conditions like anxiety and depression.

Anxiety Disorders and Treatment

Anxiety disorders are a group of psychiatric conditions that involve excessive anxiety and worry. According to data collected by the National Institute of Mental Health (NIMH), approximately 40 million American adults ages 18 and older, or about 18.1% of people in this age group have an anxiety disorder in a given year.6 The range of anxiety disorders described in the DSM-IV TR include: Panic Disorder, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, Phobias and Generalized Anxiety Disorder.

Symptoms include exaggerated worry, discomfort, and irritability that appear to have no cause or are more intense than the situation warrants. Physical signs typically reported are restlessness, trouble falling or staying asleep, headaches, trembling, muscle tension, and sweating. 7 A person may be diagnosed with more than one anxiety disorder. For example, someone with posttraumatic stress who experiences panic attacks. These disorders also frequently co-occur with substance abuse or depressive disorders.

Along with serotonin reuptake inhibitors, one of the primary treatments for anxiety disorders is the use of benzodiazepines.8 The pharmacology of benzodiazepines play a large role in their efficacy as an anxiolytic. Benzodiazepines work by potentiating the neurotransmission mediated by GABA, the main inhibitory neurotransmitter in the Central Nervous Northeast Florida Medicine Vol. 62, No. 3 2011 31

System, making neurons more difficult to excite. The first benzodiazepine, chlordiazepoxide (Librium) was launched in the United Kingdom in 1960, followed by diazepam (Valium) in 1963. Alprazolam was introduced in the early 1980s. A Washington Post article reported that 85 million prescriptions were filled for the top 20 benzodiazepines in 2008, an increase of 10 million over 2004, according to IMS Health, a healthcare information company based in Norwalk, Connecticut.9 The same article notes that “worldwide revenue for Xanax™ alone rose to $350 million last year, up nearly 50 percent from 2003, according to pharmaceutical company Pfizer’s financial reports.”9 The majority of prescriptions for anxiolytics are written by primary care physicians while psychiatrists write less than 20% of the prescriptions.10 Patients who present to their primary care physician with physical complaints often also report symptoms of anxiety such as feelings of apprehension, fear or excessive worry. The source of this uneasiness is not always known or recognized, which can add to the distress being felt and lead to poorer treatment outcomes.11 Benzodiazepines for treatment of anxiety disorders are generally meant for short term use.

Long term use often results in limited efficacy and increased abuse potential. Antidepressants such as serotonin reuptake inhibitors are preferred for long term management. Longer term use of benzodiazepines is commonly associated with altered use patterns (from night time to daytime use), excessive sedation, cognitive impairment, increased risk of accidents and adverse sleep effects. Benzodiazepines also have an additive effect with alcohol and other CNS depressants, increasing the risk of fatal overdose when prescribed to persons with a co-occurring alcohol or sedative use disorder.12 The benzodiazepines were first believed to be absent of dependence-inducing properties. Subsequent research has shown that tolerance, withdrawal and dependence are all liabilities with benzodiazepine use. The euphoric effects and abuse potentials of alprazolam, diazepam and lorazepam were shown to be similar with diazepam rated the highest.13 When the benzodiazepines were discontinued, symptoms of the original disorder often recurred in a pattern about equal to that experienced before treatment. Withdrawal symptoms during discontinuation for both short half-life and long halflife benzodiazepines suggest that patients experience similar difficulties.14 Alprazolam withdrawal, however may be more severe and may occur after shorter-term use than with other benzodiazepines.14 Feelings of jitteriness, palpitations, clamminess, sweating, nausea and confusion have all been reported.

The recurrence of anxiety symptoms in intensity greater than that experienced prior to drug treatment is termed rebound.15 A secondary form of rebound after benzodiazepine discontinuation is rebound insomnia when a person’s previous sleep disturbance returns. Rebound usually develops within hours to days of benzodiazepine discontinuation, depending on the particular benzodiazepine. Although reported symptoms may seem similar to withdrawal, rebound is distinguished from withdrawal in that rebound is a relapse of the underlying anxiety disorder for which the drug was originally taken.

32 Vol. 62, No. 3 2011 Northeast Florida Medicine

Rebound of panic attacks occurred in almost one third of patients treated with alprazolam.16 For patients with panic disorder taking short and intermediate acting benzodiazepines that experienced rebound anxiety, clonazepam was found to be a useful alternative to alprazolam.16 Interestingly, rebound was not experienced by those individuals treated by placebo.

Purpose of JUDI

A major consideration in the development of JUDI was to assure that not just medical needs were met but also the mental and behavioral health of patients were adequately addressed.

A particular concern was those patients with long-term use of a benzodiazepine at risk of physiologic and psychologic dependence on the drug. Thus, a decision was made by the JUDI PCMH treatment team to identify patients prescribed the high-potency, short-acting agent alprazolam because of its strong potential for dependence and abuse. The team needed to be prepared for patients who may be reluctant to discontinue the drug due to over-reliance on the agent and expect varying degrees of drug-seeking behavior. Because benzodiazepines often are used with other types of medications, including other drugs with abuse potential that can interact synergistically, the team was reminded to be vigilant about recognizing signs of withdrawal and rebound anxiety.

A protocol driven treatment approach for anxiety was developed in close collaboration with Psychiatry and the PCMH team. It was implemented with two main goals.

The first goal was to wean those patients currently prescribed alprazolam. The second goal was to improve the quality of anxiety care by insuring that the primary care providers were using evidenced based guidelines in the management of patients. To address the risk of rebound anxiety and withdrawal symptoms, the longer-acting benzodiazepine clonazepam and the antidepressant sertraline were started. The expectation was that once sertraline was at a therapeutic level the use of clonazepam would be reevaluated and weaned. Only those patients who failed treatment would be referred to psychiatry in accordance with the PCMH philosophy of increasing the appropriateness of specialty services referrals. The protocol followed by the primary care physicians is shown in Figure 1. A query of the JUDI clinics registry identified over 3000 patients diagnosed with an anxiety disorder. A letter was sent to the patients informing them that alprazolam was no longer to be prescribed at the JUDI and an alternative treatment would be offered.

The preliminary results at JUDI showed a reduction in the utilization of alprazolam in the target population by 86%.

While most studies of PCMH have shown improved patient and provider satisfaction, patients may initially become more dissatisfied with the care they receive.17 It was anticipated that a backlash of complaints would quickly be forthcoming.

Our experience found that initially patients were resistant to change. Sixty-one patients chose to leave the PCMH rather than change from alprazolam. (Figure 1, p.33) However, some patients, including their family members, communicated that they appreciated the education about alprazolam and its www . DCMS online . org

Figure 1 Medical Home Anxiety Treatment Protocol PSWQ Screening ≥ 65

Currently Prescribed Benzodiazepine?

No

Yes Prescribed Alprazolam?

Monitor

No

Yes Age 70 or greater?

Consider PRN use and start Sertraline 50 mg daily and titrate to effect. Reassess in 6 months to consider continued need for benzodiazepine.

No

Yes

Start Sertraline 50 mg daily, increase by 50 mg in 7 days.

Start Clonazepam at half the last Alprazolam dose.

Start Sertraline 25 mg daily, increase by 25 mg in 7 days.

Start Clonazepam at half the last Alprazolam dose.

Monitor for side effects. 10% reduction of last Alprazolam dose every 3 days until discontinued.

Tolerating Sertraline

No

Yes

Switch to Citalopram 20 mg daily.

Consider 50 mg increase at week 4 if necessary.

Continue to monitor

Positive response in 6 weeks?

No

Yes

Consider 50 mg increase of Sertraline or 20 mg increase of Citalopram at week 6.

Reassess in 6 months to consider need for Clonazepam.

Continue to monitor

Positive response in 8 weeks?

No

Yes

Consider 50 mg increase of Sertraline to maximum dose of 200 mg. For age 70 or greater 150 mg maximum dose.

Or increase of Citalopram to maximum dose of 60 mg at week 8.

Reassess in 6 months to consider need for Clonazepam.

Positive response?

No Refer for Psychiatry Screening

Yes

Reassess in 6 months to consider need for Clonazepam.

www . DCMS online . org

Northeast Florida Medicine Vol. 62, No. 3 2011 33

potential adverse side effects and that we “cared enough about them as a practice to initiate this program, free of charge.”

Providers commented on the benefits of having a close working relationship with psychiatry. Many have indicated that the protocol provides an important decision support tool when managing complex patients. Thus, the authors believe building an infrastructure of effective communication and trust seems instrumental to maintain motivation among patients and staff alike.

6.

Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry, 2005 Jun;62(6):617-27.

7.

Longo LP, Johnson B. Addiction: Part I. Benzodiazepines-Side effects, abuse risk and alternatives. Am Fam Physician 2000;61:2121-2128.

8.

Burrows GD, Norman TR, Judd FK, Marriott PF. Shortacting versus long-acting benzodiazepines: Discontinuation effects in panic disorders. J Psychiat Res 1990;24(Suppl.

2): 65-72.

9.

Balestra K. “Anti-Anxiety Drugs Raise New Fears” The Washington Post-Washington, D.C. Jun 30, 2009.

Conclusion

An aspiration of the PCMH was to encourage innovative methods toward a more integrated and coordinated delivery of healthcare.18 The implementation of a PCMH has shown to improve the value and efficiency of care through better prevention and care of chronic illness.19 The successful transition to a PCMH requires staff to maintain their motivation while effectively managing the stress from constant change.20 Reform to the healthcare system through a PCMH may lead to additional benefits such as improvement in the way mental health services are provided as they have often been treated as separate and distinct from medical care.21 This project shows how the medical home can be used to improve management of anxiety disorders in the primary care setting. It also underscores the risk associated with starting a high potency, short-acting benzodiazepine, including high abuse and dependence potential along with resistance to discontinuation. The next collaboration that will be undertaken at JUDI is to evaluate the extended release formulation of the antipsychotic SEROQUEL used for sleep and determine if there is an equally effective alternative medication with fewer side effects to treat insomnia.

1.

2.

References

Green LA, Graham R, Bagley B, Kilo CM, Spann SJ, Bogdewic SP. Task Force 1 Writing Group. Report of the Task Force on Patient Experience, Core Values, Reintegration, and the New Model of Family Medicine. Ann Fam Med. 2004;2(Suppl 1):S33–S50.

Medicaid Medical Home Task Force Report Recommendations for Designing and Implementing a Medical Home Pilot Project for Florida Medicaid at http:// ahca.myflorida.com/Medicaid/deputy_secretary/recent_ presentations/medical_home_tf/medicaid_medical_ home task_force_report_020110.pdf. Accessed February 7, 2011.

3.

Steiner BD, Denham AC, Ashkin E, Newton WP, Wroth T, Dobson LA Jr. Community Care of North Carolina: improving care through community health networks. Ann Fam Med. 2008;6(4):361-367.

4.

Medical home payment structure offered: report issued in preparation of CMS demonstration project. Dis Manag Advis 2008;14:1-6.

5.

Crabtree BF, Nutting PA, Miller WL, Stange KC, Stewart EE, Jaén CR. Summary of the National Demonstration Project and recommendations for the patient-centered medical home. Ann Fam Med.2010;8(Suppl 1):s80-s90.

34 Vol. 62, No. 3 2011 Northeast Florida Medicine

10. Schatzberg AF, Cole JO, DeBattista C. Manual of Clinical Psychopharmacology, Seventh Ed. Arlington, VA: American Psychiatric Publishing; 2010.

11. Campbell-Sills L, Grisham JR, Brown TA. “Anxiety disorders in primary care.” In Behavioral Integrative Care: Treatments that work in the primary care setting. O’Donohue WT, Byrd MR, Cummings NA, Henderson DA (Eds).

New York: Brunner-Routledge; 2005.

12. Ashton H. Toxicity and adverse consequences of benzodiazepine use. Psychiatr Ann 1995;25:158-65.

13. Orzack MH, Friedman L, Dessain E, Bird M, Beake B, McEachern J, Cole JO. Comparative study of the abuse liability of alprazolam, lorazepam, diazepam, methaqualone, and placebo. Int J Addict 1988 May;23(5):449-67.

14. Juergens S. Alprazolam and diazepam: Addiction potential.

J Subst Abuse Treat 1991;8:43-51.

15. Greenblatt DJ, Miller LG, Shader RI. Benzodiazepine discontinuation syndromes. J Psychiat Res 1990;24(Suppl.

2):73-79.

16. Herman JB, Brotman AW, Rosenbaum JF. Rebound anxiety in panic disorder patients treated with shorteracting benzodiazepines. J Clin Psychiatry 1987 Oct;48 Suppl:22-28.

17. Jaén CR, Ferrer RL, Miller WL, et al. Patient outcomes at 26 months in the patient-centered medical home National Demonstration Project. Ann Fam Med. 2010;8(Suppl 1):s57-s67.

18. Epperly, T. The patient-centered medical home in the USA. J Eval Clin Pract 2011;17:373-375.

19. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of Transformed Primary Care.

Am J Manag Care 2010;16:607-614.

20. Nutting PA, Crabtree BF, Miller WL, Stewart EE, Stange KC, Jaén CR. Journey to the patient-centered medical home: a qualitative analysis of the experiences of practices in the National Demonstration Project. Ann Fam Med. 2010;8(Suppl 1):s45-s56.

21. Parks J, Svendsen D, Singer P, Foti ME. (Editors). Morbidity and Mortality in People with Serious Mental Illness.

Thirteenth in a Series of Technical Reports. National Association of State Mental Health Program Directors Medical Directors Council. 2006. At http://www.nasmhpd. org/publicationsmeddir.cfm. Accessed Feb 3, 2011. www . DCMS online . org

Trends in Public Health

Mental Health in Duval County Niketa Walawalkar, MD, MPH; Thomas Bryant III, MSW; Jeffrey Goldhagen, MD, MPH and Robert Harmon, MD Mental health is as important as physical health to the overall well being of individuals and communities. Mental and behavioral disorders are more common than we might imagine. A 2001 report published by the World Health Organization (WHO) states that more than 25% of people are affected by these conditions at some time during their lives, and one in four families is likely to have at least one member with a behavioral or mental disorder. Further increases in these disorders are expected due to the aging population and worsening social and economic problems. This growing burden will not only amount to huge medical costs and disabilities, but also cause economic loss. According to the Kaiser Foundation, more than 33% of U.S. adults and about 29% of adults in Florida reported poor mental health in 2007. A U.S. Department of Health and Human Services 1999 report states that 55,000 of 275,000 children in Duval County, under 18 years of age, are living with a behavioral disorder. Less than 50% of these children with mental health problems in Duval County receive treatment. Despite the demonstrated need for mental and behavioral health services, Florida ranks 48th in per capita mental health spending.

In 2008, 4,756 youth with Serious Emotional Disturbance (SED) in Duval County received mental health services.The Duval County Health Department (DCHD) estimated that approximately 50% of foster care children are at risk of or diagnosed with SED.1 SED includes all diagnosable mental, behavioral, or emotional disorders and is listed as one of thirteen disabilities outlined in the Individuals with Disabilities Education Act. SED includes, but is not limited to, learning difficulties, unhappiness or depressed mood, hyperactivity, aggression or self-injurious behavior and suicidal tendencies.

According to the 2009 Youth Risk Behavioral Survey, more than 27% of high school students in Duval County felt sad or hopeless almost every day for two or more weeks, which made them unable to perform daily activities. More than 14% of high school students seriously considered attempting suicide and 10% attempted suicide one or more times during the 12 months before the survey. In 2009, there were 16 suicide deaths per 100,000 persons in Duval County. This was almost two points higher than the 2009 death rate for Florida and approximately six points higher than the Healthy People 2020 target, 10.2. This was more than a 33% increase in the 2007 suicidal death rate, 12.1.

In 2009, 752 of 7,229 hospital visits per 100,000 persons in Duval County were due to mental health disorders.2 Males comprised slightly more than half the visits. Duval County had 5,724 emergency room (ER) visits, 53% were females.2 www . DCMS online . org

Most of the hospital visits were by individuals 45-54 years old, while most ER visits were among the 25-35 year olds.

Whites in Duval County had more than double the ER and hospital visits compared to blacks. Among the six health zones, Health Zone 2 (Arlington) had the highest number of ER and hospital visits for mental and behavioral disorders with Health Zone 1 (Urban Core) being a close second.

Substance Abuse and Mental Health Services Administration (SAMHSA) lists twenty-one locations in Jacksonville that provide mental health services, of which five centers provide inpatient and outpatient services and ten centers provide only outpatient care. The state and counties work together to provide mental health services across northeast Florida. The DCHD provides mental health services through all DCHD clinics. Services include individual, couples and family counseling, parent education, psychiatric evaluation and medication management for adults, children (6 years and older) and families. DCHD clinics refer patients diagnosed with mental illness to River Region Clinical Services and Renaissance Behavioral Health System for further treatment. The Duval County Public Schools has the Exceptional Education & Student Services program for children with SED to enhance the quality of instructional services, educational opportunities and support for students, their families and schools.

Mental health care in Duval County is fragmented, with limited access to care and inefficient communication.

Preventive care is inconsistent and lacks case management.

Given these challenges, it is important to integrate services and develop an efficient and seamless system of care. The Northeast Florida Children’s Community Mental Health Coalition, with a SAMHSA grant, started a system of care initiative for children with SED called Kids ‘N Care in January 2011. Initiative members work in collaboration with the community, schools and families of children to develop and implement effective mental health services and establish a system of care to recognize and respond to SED among children in northeast Florida.

Mental health impacts all aspects of our community. It is important that health care professionals, teachers, health educators, social workers and the community recognize and support individuals with mental and behavioral disorders.

Together we can help all residents of northeast Florida live mentally healthier lives.

Resources: 1. Duval County Health Department, 2008 2. Agency for Health Care Administration (ACHA), 2009 Northeast Florida Medicine Vol. 62, No. 3 2011 35

Annual LBA Physician Client Update

Tuesday, October 11, 2011 6:00 p.m. – 8:00 p.m.

The River Club of Jacksonville

Admission - $49 per person; Complimentary for LBA Clients.

Updates on key issues being faced by healthcare professionals and practices today, to include:

Internal Controls

How Protected is Your Practice from Employee Theft?

SPEAKERS

2nd

Richard Brock

Jim White

Delena Howard

Carrie Jones

Compliance Audits

What are Auditors Looking for?

Financial Planning and Wealth Management

“Very informative

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Year End Tax Planning

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Are You Covering Your Bases?

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To register, please call LBA at 904.396.4015 or visit LBAnews.com

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I look forward to the next presentation.”

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www . DCMS online . org

Join us, with Honorary Chairpersons, J. Wayne and Delores Barr Weaver, to recognize our new Strategic Development Council and pay tribute to this year’s We Care Caring Award recipients:   

Baptist Health Brooks Health System Mayo Clinic

  

Memorial Hospital St. Vincent’s HealthCare Shands Jacksonville

2nd Annual Caring Awards Thursday, November 10th ● 5:30pm EverBank Field Terrace Suite

SAVE the DATE!

The mission of We Care Jacksonville is to improve healthcare access by developing and coordinating a community-wide network of medical volunteers and donated healthcare services to care compassionately for the uninsured and underserved.

904-253-2205 wecarejacksonville.org

Department of Health, Bureau of Vital Statistics Physicians’ Online Tutorial for Completing Cause of Death on the Florida Death Record

The Department of Health Bureau of Vital Statistics, in cooperation with the Florida Medical Association and the Florida Association of Medical Examiners, has an online tutorial for physicians. This complimentary tutorial, which is worth one CME credit, takes about one hour to complete and can be accessed at: http://floridavitalstatisticsonline.com.

The tutorial is constructed for physicians, providing an overview of the death registration process in Florida and how to go about properly completing the medical information on the death record. It provides sample case histories; an explanation of the physician’s, the medical examiner’s, and the funeral director’s responsibilities in getting death records filed; how mortality data is used and why the death record is so important to families. =====

Electronic Death Registration System Launched in Florida

Vital Statistics has moved to electronic filing of Florida Death records. This means the record is filed online, via a secure Internet site, using the Electronic Death Registration System (EDRS). The user has direct access to the state database for entry of death record information. EDRS increases accuracy and timeliness while improving statistics for state and national surveillance systems.

Funeral directors are online users and complete the demographic/personal information on the decedent. The EDRS record is then sent electronically to the physician for certifying the medical information.

The certifying physician can be an online user and complete the medical certification electronically, using EDRS; OR can be an offline user and complete the medical certification via Fax Attestation. The fax is system generated and looks much like the medical portion of the paper death record.

Questions? 904-359-6900, ext. 9020 • Quality Assurance • Bureau of Vital Statistics P.O. Box 210 • Jacksonville, Florida 32231-0042 www . DCMS online . org

Northeast Florida Medicine Vol. 62, No. 3 2011 37

38 Vol. 62, No. 3 2011 Northeast Florida Medicine

www . DCMS online . org

AAMSE Elects Jay Millson to 2011-2012 Leadership Post Jay W. Millson, MBA, Executive Vice President of the Duval County Medical Society (DCMS) in Jacksonville, FL, is the new President of the American Association of Medical Society Executives (AAMSE). Millson was installed at AAMSE’s 30th Annual Conference July 20-23, 2001 in Boston, MA. He will continue as DCMS EVP during his term as AAMSE President.

being kicked, shoved and drowned as we try and navigate our way to solid ground.” Jay then encouraged his colleagues “to work together” and said, “Doing the swim, working with other swimmers and drafting off each other provides a huge advantage…likewise, leveraging our collective and combined resources in organized medicine will be the only way we can survive and not drown in a sea of uncertainty.”

Ja y j o i n e d t h e AAMSE Board of Directors in 2006 after chairing the New Medical Executives Institute in 2001 and has served on multiple committees during his fifteen-year membership in the Association.

AAMSE’s mission is to advance the profession of medicine by enhancing and recognizing the talent and work of medical society execuJay W. Millson, MBA - DCMS EVP and tives.

Its membership AAMSE President comprises more than 800 executives from around the nation and represents over 360 medical societies. AAMSE focuses on the highest priority issues facing physicians, their patients, and their medical societies, and works to develop progressive, collaborative solutions.

As for the bike portion of a triathlon, it is the longest and requires the athlete to “remain strong, steady and committed.”

Jay challenged AAMSE that after 66 years in existence, the Association needs to stay its course, “ride out the long road ahead” and “not reinventing the wheel but working through the evolution medical societies encounter daily in order to remain relevant.”

Robert W. Seligson, Executive Vice President, CEO of the North Carolina Medical Society in Raleigh, NC and the one who hired Jay when both were on staff at the Florida Medical Association (FMA), introduced him at the Board Installation Lunch on July 23. A congratulatory video prepared by the DCMS staff was shown and a special plaque from the DCMS Board of Directors was presented. It read in part, “Recognition by your fellow executives of your longstanding leadership, passion and vision for our medical profession is an honor. Your knowledge and hard work on behalf of all levels of organized medicine have prepared you for this role and we applaud AAMSE for allowing you this opportunity.

We look forward to participating in this journey with you.”

In his speech to those gathered at the installation lunch, Jay compared how AAMSE assists its members to the way an athlete prepares for a triathlon’s swim, bike and run. Jay took each basic event and connected it to medical executives’ professional activities.

He explained “the swim” is difficult, rough, and “somewhat terrifying” as you get kicked, punched, and poked while trying to keep from drowning. He related this to the pandemonium of health reform and how “Often times I feel like my medical society and the physicians we represent are www . DCMS online . org

Finally, the run is “the most painful element of the triathlon because you typically start to cramp up, get dehydrated and feel like walking.” Jay had a mentor who advised him to smile as he ran because it both psycs out the competition while making you feel better. He thanked the mentors who have influenced him in his professional career and personal life and explained, “Mentors provide the road for us to run on during the race.” He concluded, “I am grateful for this opportunity to lead AAMSE…Your support of me and the Association will be the only way to achieve success [in the current Health Reform environment]…smiling along the way."

An Orange Park, Florida native, Jay was hired as the Executive Vice President/CEO of the Duval County Medical Society (DCMS) in October 2004. He oversees, through administrative agreement, the management of four contiguous county medical societies in Northeast Florida (400+ physicians in Clay, Nassau, St. Johns, and Putnam) in addition to coordinating all advocacy and administrative functions for the 2,000 DCMS members. Jay has spent his 18-year professional career in medical society management working first for the FMA in Tallahassee, FL (1993-1995) in the area of medical economics and then the Jacksonville-based American Association of Clinical Endocrinologists (1995-2004), seven of those years as Deputy CEO. A long-standing advocate for physicians and patients, Jay serves on multiple local boards that help promote access to healthcare and healthy living including: Mayor’s Council for Fitness & Wellbeing, YMCA, Healthy Start Coalition, We Care, Northeast Florida Medical-Legal Partnership and more.

Jay received both his undergraduate degree in healthcare management and masters of business administration from Appalachian State University, where he also lettered in football as a place kicker from 1989-1992. He enjoys racing in triathlons with Ironman Florida (2002) and Wisconsin (2004) being his most significant accomplishments. However, his favorite hobby is spending time with his wife Whitney and three daughters: Abby (13), Grace (11) and Emma (8).

Northeast Florida Medicine Vol. 62, No. 3 2011 39

DCMS Membership Applications These physicians’ applications for membership in the Duval County Medical Society are now being processed.

Any information or opinions you may have concerning the eligibility of the applicants listed here may be directed to Ashley Booth Norse, MD, DCMS Membership Committee Chair (904-244-4106 or Barbara Braddock, Membership Director (904-355-6561 x107).

Bestoun Ahmed, MD General Surgery/Surgical Oncology UF Surgery Medical Degree: Mosul University College of Medicine Residency: University of Florida College of Medicine-Jacksonville Fellowship: University of Pittsburgh Medical Center Nominated by: UFJP Rosalyn R. Alcalde, MD Endocrinology Endocrinology Group, Baptist Primary Care, Inc. Medical Degree: Ross University School of Medicine Residency/Fellowship: University of Florida College of MedicineJacksonville Nominated by: Emad Naem, MD; Kent Wehmeier, MD; Mae SheikhAli, MD Neil Alviedo, MD Pediatrics/Neonatology UF Neonatology Medical Degree: University of Philippines Residency: Children’s Hospital of Michigan & William Beaumont Hospital Fellowship: UFHSC/Jacksonville Nominated by: UFJP Cynthia Anderson, MD Radiation Oncology Florida Radiation Oncology Group Medical Degree: Emory University School of Medicine Residency: Emory University School of Medicine Nominated by: Allison Grow, MD; Dwelvin Simmons, MD; Sonja Schoeppel, MD Maria B. Antigua, MD Neonatology

Flagler Hospital/Shands Jacksonville Newborn Nursery Medical Degree: Cebu Institute of Medicine Residency: Dell Children’s Medical Center of Central Texas Fellowship: Jackson Memorial Hospital Nominated by: UFJP Faheem W. Guirgis, MD Emergency Medicine UF Emergency Medicine Medical Degree: Rosalind Franklin University of Medicine & Science Residency: Albert Einstein College of Medicine Nominated by: UFJP Richard J. Hernandez, MD Family Medicine Family Medicine/Peds Center at Plantation Oaks Medical Degree: Albany Medical College Internship: Evanston Northwestern Healthcare Residency: US Naval Hospital Nominated by: UFJP Christopher Hopkins, MD Emergency Medicine UF Emergency Medicine Medical Degree: University of Florida College of Medicine Residency/Fellowship: University of Florida College of Medicine/Jacksonville Nominated by: UFJP Igor Ianov, MD Anesthesiology UF Anesthesiology Medical Degree: Faculty of Medicine of Patrice Lumumba Residency: University of Arkansas Nominated by: UFJP Valerie Jacobson, MD Pediatrics Baptist Pediatrics Medical Degree: University of South Florida College of Medicine Residency: University of North

40 Vol. 62, No. 3 2011 Northeast Florida Medicine

Carolina at Chapel Hill Nominated by: R. Matt Paton, MD; Kenneth Horn, MD; Erica Tarbox, MD Lisa M. Jones, MD Pulmonary Medicine UF Critical Care Medical Degree: University of Cincinnati College of Medicine Residency: University of Cincinnati College of Medicine Fellowship: Naval Medical Center Nominated by: UFJP Sartaj M. Kadiwala, DO Pediatrics Shands Jacksonville Newborn Nursery Medical Degree: Touro University Residency: University of Florida College of Medicine Jacksonville Nominated by: UFJP Brandon E. Kuebler, MD Pediatric Cardiology UF Pediatric Cardiology Center Medical Degree: West Virginia University School of Medicine Residency/Fellowship: Virginia Commonwealth University Nominated by: UFJP George G. Le-Bert, DO Cardiology/Nuclear Cardiology Southern Heart Group, PA Medical Degree: Nova Southeastern University College of Osteopathic Medicine Residency/Fellowship: Mount Sinai Medical Center Nominated by: Paul Dillahunt, MD; Salvatore Diloreto, MD; Girish Shroff, MD Rajiv Luthra, MD Ophthalmology UF Ophthalmology Medical Degree: Christian Medical College Panjab University Internship/Residency: Henry Ford Hospital Fellowship: Louisiana State University Eye Center & Johns Hopkins Hospital Nominated by: UFJP

www . DCMS online . org

Emad Naem, MD Endocrinology UF Endocrinology & Diabetes Medical Degree: Damascus University Internship: Hahnemann University School of Medicine Residency: St. Joseph Hospital Fellowship: UFHSC/Jacksonville Nominated by: UFJP Kenneth Obiaja, MD Family Medicine Family Medicine Center at Lem Turner Medical Degree: Institute of Medical Sciences of Havana Residency: Jackson Memorial Hospital Nominated by: UFJP Omeni Osian, MD Cardiothoracic Surgery UF Cardiothoracic Surgery Medical Degree: University of Virginia Medical School Residency/Fellowship: University of Florida Shands Hospital Nominated by: UFJP

Craig B. Sussman, MD Neonatology UF Neonatology Medical Degree: St. George’s University Medical School Residency/Fellowship: University of Florida – Shands Hospital Nominated by: UFJP

RESIDENTS/FELLOWS – MAYO CLINIC

Faisal Usman, MD Critical Care Medicine UF Pulmonary Medical Degree: King Edward Medical College Punjab Residency: Queens Hospital Center Fellowship: University of Florida Jacksonville Nominated by: UFJP

Diagnostic Radiology Maria DeBenedetti, MD Ryan Goff, MD Santo Maimone, MD Ashishkumar Parikh, MD Nitesh Paryani, MD

Velyn Lisa Wu, MD Family Medicine/Primary Care Sports Medicine Family Care Partners Medical Degree: University of South Florida College of Medicine Residency/Fellowship: Halifax Health Nominated by: Ashley Booth Norse, MD

Cross Sectional Imaging Candice Bolan, MD Dermatology Fridolin Hoesly, MD Katherine J. Willard, MD

Endocrinology Aashish Shah, MD Musculoskeletal Imaging Robert Kennedy, IV, MD Kevin McLean, MD Neurosurgery Ribal S. Darwish, MD Orthopedic Surgery Ken Kaminski, MD

Kalina M. Sanders, MD Neurology The Neuroscience Institute @ Shands Medical Degree: University of Texas Health Science Center Internship/Residency: University of Florida Health Science Center Nominated by: UFJP James S. Scolapio, MD Gastroenterology UF Gastroenterology Center @ Emerson Medical Degree: Marshall University School of Medicine Residency/Fellowship: Mayo Graduate School of Medicine Nominated by: UFJP Swati Sharma, MD Family Medicine St. Johns Bluff Primary Care Center Medical Degree: Baroda Medical College Residency: Baroda Medical College & Howard University Hospital Nominated by: UFJP

www . DCMS online . org

Northeast Florida Medicine Vol. 62, No. 3 2011 41

NE Florida Leaders Selected for Key FMA Posts

During the Florida Medical Association (FMA) 2011 Annual Meeting, July 28-30 at Disney's Contemporary Resort in Orlando, FL, Dr. Miguel A. Machado (above, left) was inaugurated as FMA President. Dr. Machado, a member of the St. Johns County Medical Society, is a neurosurgeon in private practice in St. Augustine, FL. Also elected at the meeting were DCMS members: (above, L to R) Dr. W. Alan Harmon, as FMA Treasurer and AMA Delegate; Dr. Nathan Newman as AMA Delegate; and Dr. Daniel Kantor as AMA Alternate Delegate to the Young Physicians' Section. Congratulations to these physicians from Northeast Florida!

Referral?

Phone Number?

Address or Directions?

Use the DCMSonline Physician Directory on your Smartphone!

You can easily search for a DCMS member’s practice information and get a map and directions to their office.

Check it out

www.db.dcmsonline.org/directory or use your SmartPhone QR reader!

Stay Connected!

42 Vol. 62, No. 3 2011 Northeast Florida Medicine

ď °

www.dcmsonline.org www . DCMS online . org

Photo of surgery in a combat hospital in Al Taqaddum, Iraq, 2006, showing CDR Mark Gould and the surgical team removing IED fragments from a wounded Marine. Dr. Gould is an Orthopedic Surgeon and is currently Director of Surgical Services at Naval Hospital, Jacksonville. Photo taken by LCDR Ken Meehan.

“Duval County Medical Society has long played a critical role in bringing together leaders in medicine to focus on national and regional issues and the collective challenges health care providers face daily in their efforts to provide quality health care to patients throughout the region. As one of the Navy's largest medical treatment facilities with clinics in five locations across two states, and as a member of the Northeast Florida Quality Collaborative, we understand the value of this type of collaboration and see first-hand the mutually beneficial partnership between DCMS and its members."

(Commanding Officer Captain Lynn Welling, Naval Hospital, Jacksonville)

Read more about the link between the U.S. Navy and DCMS in the DCMS History Book to be published in 2012.

Plan to purchase your copy! www . DCMS online . org

Northeast Florida Medicine Vol. 62, No. 3 2011 43

Special thanks to the DCMS physicians and other healthcare professionals who volunteered their time and expertise to perform JSMP Student Athletic Screenings August 6 & August 13 at Nemours Children's Clinic & Wolfson Children's Hospital.

A total of 1,058 students were screened and 700+ physicians, healthcare professionals and other volunteers assisted with the screenings.

The Jacksonville Sports Medicine Program (JSMP) is a volunteer based organization that is dedicated to the improvement and maintenance ofSpecial the physical mental well-being ofand studentthanksand to the DCMS physicians other athletes in northeast Florida. healthcare professionals who volunteered their time and expertise perform JSMP Athletic Why not get to involved next year inStudent this worthwhile Screenings August 6 & August 13 at Nemours project? Go to www.jsmp.us for more information.

Children's Clinic & Wolfson Children's Hospital.

A total of 1,058 students were screened and 700+ physicians, healthcare professionals and other volunteers assisted with the screenings.

The Jacksonville Sports Medicine Program (JSMP) is a volunteer based organization that is dedicated to the improvement and maintenance of the physical and mental well-being of studentathletes in northeast Florida.

Why not get involved next year in this worthwhile project? Go to www.jsmp.us for more information.

(L to R) Rena Smith with Nemours and Dr. Ronald Mars

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Dr. Bruce McIntosh and another volunteer screen a young athlete.

44 Vol. 62, No. 3 2011 Northeast Florida Medicine

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Significant discounts available for eligible DCMS members.

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A financial advisor dedicated to the medical industry can help you navigate changes in your practice’s finances.

The business of medicine, much like your practice itself, is forever evolving. And with new financial opportunities and ongoing concerns — like protecting against fraud, managing risk and anticipating the impact of insurance and reimbursements on cash flow — you need the guidance of an advisor who uniquely understands your industry. At SunTrust, advisors with our Private Wealth Management Medical Specialty Group work solely with physicians and their practices to deliver solutions designed for the medical community. To schedule an appointment with an advisor, call 904.632.2854 or visit suntrust.com/medicine to learn more.

Treasury and Payment Solutions

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Deposit products and services are offered through SunTrust Bank, Member FDIC.

Securities and Insurance Products and Services: Are not FDIC or any other Government Agency Insured • Are not Bank Guaranteed • May Lose Value SunTrust Private Wealth Management Medical Specialty Group is a marketing name used by SunTrust Banks, Inc., and the following affiliates: Banking and trust products and services are provided by SunTrust Bank. Securities, insurance (including annuities and certain life insurance products) and other investment products and services are offered by SunTrust Investment Services, Inc., an SEC-registered investment adviser and broker/dealer and a member of FINRA and SIPC. Other insurance products and services are offered

by SunTrust Insurance Services, Inc., a licensed insurance agency. ©2011 SunTrust Banks, Inc. SunTrust and Live Solid. Bank Solid. are federally registered service marks of SunTrust Banks, Inc.

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Northeast Florida Medicine Vol. 62, No. 3 2011 45

Introducing the

St Johns Vein Center

Dr. James St. George is proud to join the Jacksonville community, bringing more than 20 years experience in treating vascular disorders. The recent opening of the St Johns Vein Center provides you with a new option for patients suffering from lower extremity venous disease including: • Chronic venous insufficiency • Chronic distal skin changes including abnormal increased pigmentation, eczema, ulceration • Leg, ankle and foot swelling

• • • •

Leg pain, cramps, discomfort Restless legs Varicose veins Spider veins

Your patients no longer have to drive downtown for specialist vein care. Our state-of-the-art facility is conveniently located just off the Baymeadows road exit on 9A. We provide the following treatment options: • Radiofrequency ablation • Laser ablation • Ultrasound-guided chemical ablation

• Foam sclerotherapy • Liquid sclerotherapy • Ambulatory phlebectomy

We are a participating provider for Medicare, Tricare and most Commercial payers.

Please visit www.stjohnsvein.com for more information or call (904) 402-VEIN (8346) to learn more about the care we can provide for your patients.

James St. George, M.D. is a vascular specialist and a diplomat with the American Board of Radiology with a Certificate in Interventional Radiology. He completed his fellowship training at Harvard Medical School’s 9191 RG Skinner Parkway

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Suite 303

w w w. stjo h n sve in . com •

46 Vol. 62, No. 3 2011 Northeast Florida Medicine

Brigham and Women’s Hospital and served for 12 years as faculty at Harvard Medical School, Dartmouth Medical School and Drexal School of Medicine. He also held the position of Head of Special Procedures at Hahnemann Hospital in Philadelphia. Dr. St. George takes the time to know each patient and creates customized treatment programs to obtain the best possible results.

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Jacksonville, FL 32256

(904) 402-VEIN (8346) www . DCMS online . org

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Northeast Florida Medicine Vol. 62, No. 3 2011 47