- by PAL Psychiatrist, Dr. Stein
The rites of passage that often define childhood — summer camp, prom, tossing a mortarboard into the air at graduation — will look very different this year, if they happen at all. And that can have a profound impact on the mental health of young people. It's not just the loss of fun activities. They're missing out on experiences meant to “conclude one chapter in our life and start the next chapter,” said Dr. Joshua Stein. Read full article here
- by PAL Psychiatrist, Dr. Stein
Parents are taking on new roles as we social distance and schools are closed. This can be joyful but also overwhelming, exhausting and confusing at times. Parents now find themselves acting as parents, chefs, employees, teachers, and more. Adding Therapist to that list might be more than they can handle.
Many families, children and parents are feeling hopeless, helpless and worthless. Children may be more irritable, aggressive, somatic or despondent. Mental Health resources and PrairieCare remain open, essential and readily available. The relaxation of telehealth requirements allows rapid assessments and transitions to treatment from the comfort of your home.
Some beneficial suggestions from the American Academy of Child Adolescent Psychiatry:
Click for full video
- PAL Psychiatrist: Josh Stein, MD
PAL psychiatrist, Dr. Joshua Stein, joined Twin Cities Live this last week with ways to recognize anxiety and how families can manage symptoms during this pandemic.
How to recognize different levels of anxiety for you and your family
How do you know if it’s time to be concerned and seek professional help?
**The recent changes to telehealth allow rapid in home access
How do you stay informed without getting overwhelmed?
What kind of toll can it take on you to “be strong” for your family and how can that be managed?
Is there anything you can do right now to help – unplugging from the news, taking a walk, etc.
If you are a patient or family member or friend in need of immediate assistance:
Our nation is amidst a mental health crisis. For the last decade we have seen an increase in the prevalence of psychiatric conditions, deaths from opioid overdoses, and suicide rates, coupled with a drastic increase in people with mental illness who are homeless or incarcerated. All too often, barriers to accessing care result in individuals and families enduring crisis and experiencing traumatic events that could have been prevented. We are also facing a substantial shortage of psychiatrists as well as access to inpatient beds and specialized psychiatric care. Studies demonstrate a public perception that mental illnesses are linked to dangerousness or violence. Funding strategies are constantly shifting at the federal and state levels, and the insurance reimbursement for psychiatrists is, on average, 21% less than for primary care physicians.
The grim reality is that our current approach to mental health care, shaped in the late 20th century, will not continue be effective today. Effective models for mental health care require radical change and transformation. Bruce Schwartz, MD, president of the American Psychiatric Association, stated recently that, “We have to marshal the entire workforce who cares for people with mental illness. That includes social workers, advanced practice nurses, psychologists, mental health counselors, and peer counselors. It comes down to collaboration and putting aside some of the guild issues about which we all have valid concerns.”
The local angle
Minnesota, on the other hand, has led the way with creative and collaborative new care models. Since the early 2000s, the state has consistently ranked among the top 10 states in health care, education, quality of life, cost of living, social welfare, entertainment—and in mental health. Even before the passage of the Affordable Care Act (ACA) in 2010, nearly 95% of Minnesotans had insurance coverage, and mental health parity was noticeably salient for residents. Today, more Minnesotans than ever have greater access to care, and more children and families are proactively seeking health care through annual check-ups and wellness visits.
Creativity and collaboration have been key factors as Minnesota addresses our mental health crisis in various settings, including hospitals, schools, advocacy groups, and nonprofits. Initiatives to meaningfully manage mental health needs span the continuum of care: resiliency coaching, crisis prevention, trauma response, integrated care, and acute care. This includes service providers and new screening and diagnostic tools.
Prevention and wellness
Examples of Minnesota’s initiatives include Allina Health’s Penny George Institute—the largest integrative health center in a health system in the country—which focuses on holistic health and wellness. The University of Minnesota offers a bachelor’s degree program in Health and Wellbeing Sciences, as well as a graduate degree in Professional Studies of Integrated Behavioral Health. These educational programs, along with the investment into services and infrastructure, help Minnesotans prepare for the future; they are an invitation to change the way we currently react to mental illnesses and crisis, preparing us to prevent and better understand mental health.
Many more schools and community-based organizations have started programs that focus on mental well-being, resiliency, and peer support. Seventy percent of mental illnesses have an onset of symptoms before age 14. Programs that can help kids and parents identify these symptoms earlier can help prevent or lessen the potentially devastating impact that untreated mental illnesses can have on the academic and social development of youth. This can be done through screening, conversations with school staff, and breaking down the stigma that often prevents individuals from reaching out for help. Many local charities and non-profit organizations have supported schools in these endeavors through grants and in-kind access to professional mental health resources.
Employers have brought mental health resources, education, and support into the workplace. Studies show that nearly 63% of individuals with a diagnosed mental illness have not disclosed it to their employer. Ryan Companies’ Support without Stigma program allows for open conversation and sharing about mental health issues. Similarly, one large local retailer now hosts monthly educational events and has established a mental health ally program that allows employees to connect with peers who have gone through special training.
The Minnesota chapter of the National Alliance on Mental Illness has helped support funding for countless mental health programs, along with the ongoing development of new programs, such as school-linked mental health. When the state did face cuts and setbacks to mental health programs, NAMI Minnesota’s persistent and staunch advocacy remained intact. And in 2014, Healthpartners launched an award-winning anti-stigma campaign called MakeItOK that is supported by 11 local health systems, mental health providers, and media.
Integrated behavioral health
Many individuals in need of treatment for mental health and substance abuse disorders will never be identified in primary care—and, even if they are identified, will then have to rely on referrals to outside agencies. Less than 50% of these patients follow through on their referrals. In response, many health systems now offer onsite, integrated behavioral health services. This can reduce expenditures, since treating a medical condition can cost upwards of 200% more when an untreated mental health condition also exists.
South Lake Pediatrics, an independently operated and physician-owned medical group, has nourished a culture of listening closely to parents and kids to understand and identify signs of mental illnesses. They have partnered with behavioral health providers to integrate psychotherapy and psychiatry at their sites, allowing for easy referrals, increased communication, and optimized coordination of care. This model delivered a 28% increase in follow-through for initial referrals and a 10% decrease in no-show rates. Clinicians and patients have praised the ease of referrals and resulting quality of care.
Similarly, Ridgeview Medical Center has partnered with PrairieCare Medical Group to establish a jointly managed behavioral health division offering integrated outpatient care and inpatient consultations to their hospital. This partnership will offer expedited access to mental health care to thousands of individuals in the community, through coordination with primary care providers.
Minnesota school systems—long revered as leaders—have often been the “canary in the coal mine,” the first ones to observe and experience changes in youth behavior and engagement. Starting in 2006, the Minnesota Department of Human Services (DHS) supported legislation to help fund school-linked mental health services aimed at reducing barriers to care and to promote early identification and intervention. Newer state-sponsored innovation grants continue to help identify new ideas and creative ways in which school districts can better support students whose academics and futures are jeopardized by unidentified or untreated mental illnesses.
Minnesota has three metro-based Intermediate School Districts with special designations that support integrated services in vocational education, special education, and, increasingly, in the area of mental health. Since summer 2018, five Intermediate School Innovation Grants were awarded with the goal of improving clinical outcomes for students, helping them return to their home school district, reversing the disproportionate impact on students of color, and providing support and training for school staff and parents. Intermediate School District #287 has prioritized funding strategies to have board-certified child and adolescent psychiatrists onsite to integrate care with the families and learning teams. The shortage of these specialists, along with the barriers in accessing care, would otherwise mean that many of these youth in need would likely never receive the care required.
Some schools have even built health clinics on-campus. Brooklyn Center schools offer wellness visits, vaccinations, and mental health counseling. Minnesota Community Care operates clinics in nine St. Paul public high schools, providing mental health case management as well as trauma-focused cognitive behavioral therapy (TF-CBT) therapists. A new grant extension of these programs now includes federal funding to pilot onsite psychiatry.
Statewide psychiatric consultation
In 2010, the Minnesota Legislature directed DHS to make psychiatric consultation available statewide to primary care providers. The goal was to create rapid access to psychiatrists for consultation on cases, triage, and referral, and to provide ongoing education to primary care providers. Nearly half of the states in the nation have some form of a psychiatric consultation service, ranging from telephonic consults to brick-and-mortar clinics based in academic medical centers. Minnesota’s Psychiatric Assistance Line (PAL) has provided thousands of consultations to primary care providers across the state, and has trained hundreds of pediatricians and nurse practitioners. PAL can be accessed weekdays via a toll-free number or online. This service is supported by DHS, PrairieCare Medical Group, and the Minnesota Community Mental Health Foundation. In addition to the core clinical team members at PAL, clinicians at Pregnancy & Postpartum Support Minnesota are available for mothers who have specific needs requiring their expertise.
Most of the consultations are with youth, who otherwise would endure delays in getting specialized treatment and suffer from the adverse developmental impact that mental illnesses can have during childhood. A six-month follow-up study confirmed PAL’s efficacy and the overall positive experience of the providers, individuals, and families that utilized it. The psychiatric consultation service was recently honored by the American Psychiatric Association (APA) and the Association of Medicine and Psychiatry (AMP). Several other states and outstate health systems continue to express interest in partnering with PAL.
In addition to psychiatric consultation and education, an online tool called the Fast-Tracker was developed to link people to mental health and substance use disorder services and resources with real time availability. This online tool, which is free to the public, uses sophisticated search tools and algorithms to help identify niche services for individuals seeking care.
Future considerations and improvements
While creativity and collaboration have made Minnesota a leader, there are still critical needs that require attention. It has been said that our mental health system is not broken, because it has yet to be built. The aforementioned innovations have helped many patients, but are just a part of the necessary transformation, which still needs to grow and adapt to future needs.
While the ACA and mental health parity have moved us forward in some ways, concerning trends in the behavior of many health insurance companies suggest that adequate coverage for services is still in our distant future. High-deductible plans have become more popular, and large employers have elected to carve out mental and chemical health coverage to lower premiums, perpetuating both barriers in accessing care and the stigma surrounding mental illnesses. Many individuals and families are simply finding themselves under-insured.
Communication between health providers continues to lag, especially with regard to mental health. While electronic health records allow for the possibly of a seamless community, expensive integrations between systems often prohibit this from happening, and release of information and consent laws create confusion around what information is released. Some patients may bounce between several providers, and the refusal to disclose past mental health information can be common and detrimental to care.
Minnesota is indeed a leader in mental health care, as we have continued to demonstrate through our creativity and collaboration. However, we have a long journey ahead of us, and we must have the perseverance and gumption required to move our local communities and the rest of the nation forward.
Todd Archbold, LSW, MBA, is a licensed social worker and the chief executive officer at PrairieCare.
Written by Joshua Stein, MD
A common difficulty in the outpatient office is determining the steps needed to ensure the safety of a patient once they identify that they are suicidal. There are two known methods to ensure safety; mental health treatment at the appropriate level of care and means reduction. The need to determine level of care will be examined in a future post. The significant importance of the removal of means to suicide, or Means Reduction, is the focus of this article.
A common myth is that a suicidal person, who has identified a source for completion, will substitute an alternative method if his/her original method is taken away. This belief in almost all settings represents a fallacy. The lethal means, whether overdose, a firearm, a one car crash etc, will not be substituted for another.
Given the opportunity, the removal of chosen lethal means, especially firearms, will greatly reduce the How people attempt: leading to time to determine the Why, and introduce treatment.
Per NAMI, there are numerous examples from history where the removal of a lethal means has decreased the death rate. In 1960, lethal oven gas ingestion was the leading cause suicides in the UK. By 1970, the country had substituted non-poisonous gas, resulting in a one third decrease in the suicide rate. The entirety of the drop stemmed from the change in gas, and non-gas related suicides had only increased slightly. The entirety of the change stemmed from means reduction to lethal gas.
The Israeli Defense Force (IDF) struggled significantly with suicides off base on vacations and weekends. In 2006 soldiers were no longer allowed to carry firearms off base for breaks. The suicide rate dropped approximately 40 % with no change in the rate of suicides during the week. The entirety of the change appeared to be related to the means reduction to firearms off base.
Numerous studies demonstrate that the acute action phase towards suicide is commonly brief. By removing the means to attempt, people often reach a plateau of safety when support can be introduced. The most common method of suicide attempt is by intentional overdose. The most likely lethal attempt is by firearm. Practical steps are outlined below:
At times, resistance to removing the means may occur from a friend/family member. A common desire to increase the difficulty of the attempt often is a practical point to reach agreement. As these are common objects in the home and firearms carry significant value, there is a time at which reintroduction should occur. Similar to the safety assessment in the medical office that led to removal of means, a safety assessment can take place to approve returning these objects to the home.
In conclusion, removal of the means works in significantly improving safety. If a patient is deemed appropriate to return home, whether from a hospitalization or an outpatient appointment, steps towards means reduction need to take place. Finally, when a patient identifies a means, action should be taken, the fallacy to believe an alternative means will be substituted is incorrect.
Minnesota's Psychiatric Assistance Line (PAL) was honored by the American Psychiatric Association with the 2019 Community Gold Award🥇. Our state continues to be a leader in health care through creativity and collaboration. This transformative service is a partnership between Minnesota Department of Human Services, PrairieCare Medical Group, and the Minnesota Community Mental Heath Foundation.
Read the article here: https://www.prnewswire.com/news-releases/minnesotas-psychiatric-assistance-line-receives-the-2019-community-gold-award-from-the-american-psychiatric-association-300928897.html
Psychiatric assessments for children continue to have both extensive wait times and geographic disparities. In the state of Minnesota the only county according to the American Academy of Child Adolescent Psychiatry (AACAP) to have an adequate child psychiatrist to patient ratio is Olmstead, due to presence of the Mayo Clinic. Given these issues, the burden to initiate care often falls on the pediatrician or family practitioner regardless of the complexity of the situation. The goal of PAL is to provide support for these providers with immediate phone consultations at the moment they are needed.
The most common but also most difficult diagnostic patient is the irritable young child. The differential is extensive and includes learning disorders, social concerns, adverse childhood events, mental illness and medical considerations including absence seizures. A common question from primary care is, "can medications be used for treatment even if the differential outside of mental health cannot be exhausted?"
There is no simple approach, however the outline below is beneficial:
After clarification of the details above, there is often treatment modalities that are non-pharmacologic that are primary. This is includes recommendation for an IEP, an occupational therapy eval, in home skills, family/individual therapy, tutors, glasses, social skills groups etc. These are primary, but medication initiation, especially those that palliate severe agitation symptoms can be an effective adjunct treatment.
The goal is often to decrease agitation to the point that the above non-pharmacologic options can be started effectively rather than lead to further escalations. Hydroxyzine, clonidine and guanfacine often demonstrate benefit in the short term setting while the above treatments are initiated.
In addition to psychiatric consult services with PAL, there is also a triage therapist available to assist with non-medical questions, referrals and concerns. They are available to help find services throughout the state of MN.
You can contact PAL by calling 855-431-6468, email@example.com, or scheduling online!
As a practitioner in a partial hospital and inpatient setting the most common reason for adverse reaction to stimulants is incorrect diagnosis. In these support rich settings the ability to gain psychological testing helps to clarify the differential for hyperactivity and/or inattention. Often, learning disabilities (i.e. reading disorder, math disorder, and auditory processing disorder), anxiety or sensory concerns were missed. This is a common dilemma and a point of profound difficulty for the outpatient prescriber who doesn't have the assistance of formal testing in clinic. Despite these limitations, remembering that impairment must occur in two settings (most commonly home and school) to meet diagnostic criteria, is a helpful tool. Commonly, the absence of symptoms at home or school helps to clarify a need to deepen the differential. Additionally keep in mind that obstructive sleep apnea commonly can masquerade as ADHD. Questions about sleep are necessary as part of the initial workup.
Once the diagnosis of ADHD is made stimulants remain the most effective treatment for ADHD in children. Stimulant use remains the primary step in treatment, and non-stimulants are deferred in common cases until both classes of stimulants are failed. The vast majority of children will respond to either the methylphenidate class or amphetamine class. It is appropriate to build comfort with one or two medications in each class to support treatment. As a provider it is appropriate to choose either class first. If the initial class is failed then switching to the other class is warranted prior to a non-stimulant trial.
Commonly, a provider will start with a short acting stimulant such as Ritalin SA or Adderrall to test tolerance. Once tolerated, a long acting stimulant is preferred to avoid need for additional dosing. If trials in one class (i.e. methylphenidate) are not tolerated it is appropriate to switch to the alternate class (i.e amphetamine). There is significant individual details in finding dose and toleration. Stimulants have weight based indications but overall appear to be more individual based. It is appropriate to move to higher doses if tolerated to achieve symptomatic relief. Regular input from school is often needed as well.
Keep in mind cost and delivery methods when choosing medications. For example, Concerta (a long acting methylphenidate stimulant) is a pill that must be swallowed, while its analog Quillichew/Quillivent can be chewed or drank in liquid form. In small children delivery is often a concern. Vyvanse, a long acting amphetamine based stimulant, has the option of opening the tab and dissolving in liquid. Additionally it is a pro-drug, requiring digestion to promote action, decreasing the risk of diversion. For these reasons many providers prefer it to Adderall XR when it is affordable.
Some youth will require a second dose of a stimulant despite being on a long acting formulation. Short acting doses of Ritalin, Focalin, Metadate, Dexedrine or Adderall should be considered. This is where the regular check-ins become important. There is an art to prescribing these meds which includes determining how to cover a child for the duration needed with medication, while decreasing side effect risk. Over time, dosing needs and patterns will change. Clinic visits three times per year at the least are needed.
Stimulant breaks are appropriate and often needed due to appetite suppression. At times, this can be on weekends, school breaks or summer break. For the hyperactive child this may not be a tolerable option for the family. Appetite suppression is often an issue for younger children as eating is related to hunger, while in teenagers it has gained social value similar to adults. If suppression is severe with a long acting stimulant consider returning to a short acting dosed after breakfast and lunch to support appetite.
There are numerous other considerations with stimulant use. Further blogs will provide additional information. I hope you find this initial dosing guide beneficial.
An excellent resource for the diagnosis, treatment and use of stimulants in children is the American Academy of Pediatrics Clinical Practice Guideline. It can be found here https://pediatrics.aappublications.org/content/108/4/1033
The use of second generation antipsychotics in the pediatric population is commonplace on inpatient psychiatric units and outpatient psychiatric clinics. Should this class of medications be in the primary care provider’s “toolbox” of medications for their patients with behavioral and/or mood symptoms when the first and second-line medications fail?
There are currently seven second generation, or atypical, antipsychotics approved for use in children and adolescents. These include risperidone (irritability associated with autism, schizophrenia, bipolar disorder), aripiprazole (irritability associated with autism, schizophrenia, bipolar disorder), quetiapine (schizophrenia and bipolar disorder), olanzapine (schizophrenia and bipolar disorder), lurasidone (schizophrenia and bipolar disorder), paliperidone (schizophrenia), and asenapine (bipolar disorder).
The child or adolescent with schizophrenia or bipolar disorder is typically having medications managed by a psychiatric provider. However, children with autism spectrum disorder and major depressive disorder are often managed by primary care.
You may notice that augmentation of a SSRI medication with a second generation antipsychotic such as aripiprazole for major depression is not an FDA-approved use for adolescents. This use is only FDA approved for adults, so this would be off-label use, but also a reasonable strategy for augmenting treatment of depression in adolescent patients in the primary care clinic. I have found this to be helpful in adolescents who have partial benefit from SSRI or SNRI medication, but with residual symptoms of depression, especially irritability. A typical starting dose of aripiprazole for antidepressant augmentation is 1mg, which can be titrated to 2-5mg.
Both aripiprazole and risperidone can be quite helpful for managing behaviors and irritability in children with ASD. Aripiprazole can be started at 1mg daily, and titrated up to 5-10mg daily depending on tolerability. 1-2 mg is often a beneficial dose. Risperidone is started at 0.25mg daily, and titrated in increments of 0.25mg to max of 3mg total daily dose. Oftentimes 0.25mg BID is a beneficial dose.
The most common side effect from these two medications is weight gain. Also there is the risk of dyslipidemia and development of type 2 diabetes. Fasting lipids and glucose should be obtained at baseline, and again after three months of treatment, and every year thereafter. Weight should be checked at each appointment. Some psychiatrists obtain a baseline prolactin level prior to initiation of risperidone, though not necessarily the community standard of practice. The risk of gynocomastia should be discussed with the patient and guardian prior to initiation.
Extrapyramidal side effects are a risk with second generation antipsychotics. There continues to be a risk of tardive dyskinesia, though is relatively rare when compared with first generation antipsychotics. Second generation antipsychotics also carry the risk of dystonic reaction, akathisia, and rarely neuroleptic malignant syndrome.
EKG is not routinely obtained when starting aripiprazole or risperidone. This can be considered in a patient with a history of arrhythmia, or if used in combination with other potentially QT-prolonging medications (guanfacine/clonidine or stimulant medication, high dose (30-40mg) citalopram).
Another consideration with risperidone and aripiprazole specifically is their drug-drug interaction with fluoxetine (and paroxetine, though this is not routinely used in children). These SSRI medications inhibit the metabolism of both risperidone and aripiprazole, so lower starting doses are advised. Children with known deficiency of cytochrome 2D6 metabolism should start on lower doses as well.
Identifying Patients At-Risk for Bipolar disorder and Screening for Mixed Depression in Primary Care
Over 1/3 of unipolar depression patients are eventually re-diagnosed with bipolar disorder. The primary care clinic is often the first line of medical treatment of mood disorders such as depression, as well as anxiety disorders. The first line medication intervention for major depression and anxiety disorders for both children and adults are SSRIs. However, as we all know, these medications, along with SNRIs and TCAs, are known to have the risk of “activation” in some individuals. Though this phenomenon is not sufficient to diagnose bipolar I or II, it is an important “red flag” for ongoing risk of conversion. However, there are other more subtle clues in a person’s personal and family history that can be predictive of future conversion to bipolar disorder. This brief article will address these clues, and Depression with Mixed Features (DMX).
Family history of bipolar disorder (type I or II) is the single most important predictive factor of future bipolar diagnosis, and should be asked when seeing a patient initially for depression treatment. Lifetime risk of bipolar diagnosis is 5-10% in a first degree relative, and 40-70% in monozygotic twins. Other clues include early age of onset of first depressive episode, rapid onset of depressive episodes, postpartum depression, greater severity of depressive episodes and number of hospitalizations, increased number of depressive episodes, poor response to antidepressants, antidepressant induced hypomania or mania, depression with psychotic features, and mixed features. The underlined portion indicates (in my opinion) important factors to consider in a primary care setting, and should influence your decision to adjust treatment or refer to psychiatry.
Depression with mixed features, according to DSM-V criteria, indicates full criteria met for a major depressive episode, with at least three manic/hypomanic symptoms present concurrently nearly every day during the episode. Symptoms include elevated/expansive mood, inflated self-esteem or grandiosity, more talkative, flight of ideas or racing thoughts, increase in energy or goal directed activity, increased risky activities, and decreased need for sleep (not insomnia).
Due to overlap of irritability, distractibility, and psychomotor agitation (non-euphoric (hypo)manic symptoms) with other disorders (anxiety/ADHD/borderline personality), these symptoms are excluded from the DSM diagnostic criteria for depression with mixed features. Some argue that these are in fact the defining features of DMX, and several research criteria include these. DMX is a “significant risk factor for the development of bipolar I or bipolar II” according to the DSM-V. Patients with DMX are less likely to respond to treatment as usual, perhaps because their eventual diagnosis will not be unipolar depression.
According to Balazs et al, presence of mixed features increases risk of suicidality by 4x in both unipolar and bipolar depression. This may underlie the connection between antidepressant use and suicidality.
The message I feel you should incorporate into your primary care practice are simply asking the questions consistently for patients you are seeing for depression “Any manic or hypomanic symptoms?” and “Any family history of bipolar disorder?” Some psychiatrists argue that a person with the slightest hint of hypomania or family history of bipolar disorder should not be treated with antidepressant as a monotherapy. This outlook may be somewhat drastic in a complicated patient population with comorbid trauma history, substance use, and emerging personality characteristics. At the least, any person on antidepressant therapy should be monitored for emergence of hypomania.