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Brief Mental Health Interventions for the Family Physician
Springer Science+Business Media, LLC
Brief Mental Health Interventions for the Family Physician
Michael V. Bloom, Ph.D. Director of Behavioral Science Sioux Falls Family Practice Residency Sioux Falls, South Dakota
David A. Smith, M.D., C.M.D. Professor of Family Medicine College of Medicine Texas A&M University; President Geriatric Consultants of Central Texas Brownwood, Texas
With a Foreword by Macaran A. Baird, M.D., M.S.
, Springer
Michael V. Bloom, Ph.D. Director of Behavioral Science Sioux Falls Family Practice Residency Sioux Falls, SD 57105
With 5 illustrations.
David A. Smith, M.D., C.M.D. Professor of Family Medicine College of Medicine Texas A&M University; President Geriatric Consultants of Central Texas Brownwood, TX 76804
Library of Congress Cataloging-in-Publication Data Bloom, Michael V.
Brief mental health interventions for the family physician Michael V. Bloom, David A. Smith.
p. jcm. Includes bibliographical references and index.
ISBN 978-0-387-95235-2 ISBN 978-1-4613-0153-0 (eBook) DOI 10.1007/978-1-4613-0153-0
1. Brief psychotherapy-Handbooks, manuals, etc. 2. Family medicine-Handbooks, manuals, etc. [DNLM: 1. Psychotherapy, Brief. 2. Family Practice. WM 420.5.P5 B6558h 2001] 1. Smith, David A., M.D., C.M.D. II. Title. RC480.55 .B565 2001 616.89'14-dc21 00-067914
Printed on acid-free paper.
© 2001 Springer Science+Business Media New York Originally published by Springer-Verlag New York, Inc. in 2001 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely byanyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.
Production managed by Terry Kornak; manufacturing supervised by Joe Quatela. Typeset by Impressions Book and Journal Services, Inc., Madison, WI.
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ISBN 978-0-387-95235-2 SPIN 10791734
Foreword
Mike Bloom, Ph.D., has been an excellent teacher of family physicians for many years. He has spent those years honing a model of brief intervention suitable for primary care settings and within the therapeutic grasp of most family physicians. Dave Smith, M.D., a family physician, has been a medical school faculty member for 20 years. He has always had a large private practice as well. Throughout his career he has treated mental health problems with the same initiative as he would a myocardial infarction. His brief intervention skills have served as a model for many medical students.
Underneath the knowledge, skills, and attitudes explained in this book is the authors' understanding, indeed their (our) assumption, that the clinicians using these brief interventions will do so out of compassion and respect for the patients and families they serve. Some of the more challenging problems and associated interventions in this text require stretching the doctor-patient-family relationship. This is done in good faith to arrive at new options for healing and adapting to illness, injury, aging, or starting school. A handbook is not intended to be an exhaustive exploration of each topic held within its cover. It is intended to be a quick review, an outline, a refresher of sensible paths toward the resolution of common clinical problems. These goals are achieved in an easy-to-read style with well focused references for those who want to explore further.
In the first chapter Bloom and Smith review the basic components of brief therapy: reframing, resequencing, restructuring. Next comes a review of four steps of a brief therapy interview: (1) exploring the problem; (2) exploring attempted solutions; (3) exploring visions of improvement or goals of the therapy; and (4) delivering the intervention. The following chapters start with an outline and include a case example or vignette plus a tightly written discussion of brief therapy strategies for each disorder. When appropriate, the indications for consultation or referral are presented along with considerations for pharmacotherapy. Because this book describes brief therapy, the reviews of medications are limited although sufficient to guide the reader away from common pitfalls.
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VI Foreword
Bloom and Smith cover a wide variety of common topics in a concise fashion. After a summary of the brief treatment concept the authors present their perspective on screening in the family physician's office. From there the reader is led through a thumbnail sketch of brief treatment for depression, anxiety, panic disorder, posttraumatic stress disorder, and most childhood and adult mental health disorders. The text covers the full range of common issues and makes it clear in the first chapter that these treatment options are best suited to disorders of recent onset or, when more chronic, before the family is solidly organized in a counterproductive pattern. The authors clarify that as a disorder or symptom becomes more chronic the brief interventions remain worth trying but may not represent the most effective option. The book ends with ideas that smooth the road toward advanced directives and end-of-life decision-making.
This brief text is ideal for keeping handy on the office bookshelf or your desk. Readers can enjoy it by reading it carefully from start to finish, or they can jump into a favorite topic and seek new options for common patient problems. These interventions can help our patients, and they can be done respectfully. Moreover, family physicians and other primary care providers are capable of the interactions skillfully outlined herein.
Macaran A. Baird, M.D., M.S. Senior Associate Consultant Department of Family Medicine Mayo Clinic and Mayo Foundation; Professor of Family Medicine Mayo Medical School Rochester, Minnesota
Preface
The official definition of family practice from the American Academy of Family Practice is that it is a medical specialty that provides continuing and comprehensive health care for the individual and family. It is the specialty in breadth that integrates the biologic, clinical, and behavioral sciences. The scope of family practice encompasses all ages, both genders, each organ system, and every disease entity.
The definition implies that family physicians must be expert in diagnosing and treating the common diseases and disorders of humankind. However, there is no assurance that because a malady is common, it is simple.
The definition also promises that family physicians will provide care through an integrated biopsychosocial model and will treat diseases and promote health in the context of the family. Nowhere in medicine is this a more useful construct than when providing prevention for and treatment of social and mental health problems. These problems are a major part of the activity of the prototypical family practice, and family practitioners deliver a significant portion of this care in the United States (Leon et aI., 1995).
Although our activities in this arena overlap with those of social services, psychology, and psychiatry, there are a number of reasons family physicians should be expert and active in the provision of social and mental health care. A family physician, who already has rapport with an individual or family, may be more accessible than other providers and, right or wrong, comes with less stigmatization. The family practitioner can be available for those mental health and social problems that are not serious enough to motivate the patient or family to seek out a specialist. Indeed, minor social and psychiatric problems are so common that were they to present to the formal mental health system that system would be swamped. Yet it is often valuable to "nip things in the bud."
In the process of seeing one's patient's, the family practitioner has the opportunity to be part of their lives, and to recognize changes and identify problems early, before they become entrenched and less apt to be remedied. The family practitioner may even recognize high-risk situations for social or mental health problems and be proactive, instituting preventive measures.
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The family practitioner may recognize the potential for parenting problems or a child's grief after a divorce, and so intervene. After the death of a child, the family practitioner may counsel a married couple on the feelings they may naturally have toward each other that might threaten their marriage. At the time of an elder's placement into long-term care the family practitioner may manage his or her medications to prevent polypharmacy and create a milieu and activities care plan to promote a positive adjustment. The family practitioner might even catalyze community mental health activities as a form of good citizenship, interacting with schools to identify children involved in risk-taking behavior or those isolated from their families and peers (the common thread in most recent school violence incidents). Finally, a subtle but extremely important reason for family practitioners to be involved in the prevention and care of social and mental health problems is that the dichotomy of mind and body that pervades our Western culture and infuses the culture of medicine is false.
Psychiatry is becoming rapidly transformed into neuroendocrinology, with the recognition of the genetic, anatomic, hormonal, and neurochemical bases for many mental illnesses. The interrelationship of "mental illness" and "physical illness" is becoming so strong as to blur the boundaries. For example, myocardial infarction occurs more often in those chronically depressed, and death among those who develop depression after myocardial infarction is significantly higher than among those who do not. Polymorphonuclear leukocytes in grief-stricken surviving spouses of long marriages show impaired chemotaxis in vitro. Children are at greater risk of accidental injury for a period of time after relocation of the family home. The evidence that mind and body are one and that the dichotomy of physical and social or mental illness is an antiquated construct are myriad. The family practitioner with a firm foundation in the biopsychosocial model is well positioned to discard old thinking and move into an enlightened future.
Unfortunately, there remain many barriers to fulfilling the potential for family practitioners to deliver care in the social/mental health arena. Some of us still are nihilistic, believing that the social problems of our society are so large as to be unapproachable or that they have no impact. Others, for one reason or another, have not accepted the responsibility of this aspect of family practice. Medical school undergraduate curricula and to a varying degree family practice residency training often fail to emphasize these aspects of health and disease in proportion to their true significance.
Managed care, third-party insurance, and even the government have not provided parity for remuneration of services for social and mental health care compared to services clearly defined as somatic care and far less than for procedural medicine. This may be out of fear of opening Pandora's box and becoming fiscally responsible for all sorts of "touchy-feely" services or never-ending "couch therapy" that almost anyone with a little stress or a little situational sadness might want and for which they might qualify.
Preface ix
Campbell et al. (2000), however, reported that primary care physicians who diagnosed mental health problems in a managed care environment significantly more often than their colleagues were about 9% more economical providers for the organization. This validates the authors' beliefs that much unnecessary medical and social expense is incurred because of nonrecognition and non treatment of these problems. We suspect that unnecessary laboratory and radiographic testing and symptomatic therapy for somatic complaints associated with anxiety, depressive disorders, dependence, or loneliness-instead of identification and appropriate treatment -may head the list of wasteful, expensive consequences of our current situation.
The increasing pressures of time for the family practitioner are an especially powerful barrier to the provision of excellent social and mental health services in primary care. Managed care and low remuneration per unit of cognitive service tendered by Medicare and Medicaid are potent disincentives for the family practitioner to spend the time perceived to be required for the job.
Finally, perhaps the largest obstacle for family physicians addressing mental health problems is that most of the literature describing treatment is written by mental health specialists. Although this information can be valuable (and in fact informed us significantly for this book), it is often a poor fit for the family practice setting. These treatment protocols must often be altered significantly before they accommodate the family practice content.
In these regards, our book may be of some relief. We offer interventions for prevention, identification, and treatment of social and mental health problems in efficient, provider/time-sensitive increments designed to fit the typical practice patterns of our readers. We are aware of the trepidation we each experience when we catch a glimpse of a potential problem of this sort near the end of a is-minute office visit for episodic health care while a full waiting room buzzes in discontent. We have experienced the temptation to "let this sleepy dog lie" out of fear that we will be committed to service time we do not have.
Every evaluation and treatment protocol offered in this book has been used repeatedly in academic and nonacademic family practice settings. Furthermore, the protocols have all been taught and learned by family practice residents. We have constantly adjusted and improved them based on feedback received from patients, residents, and former residents now in practice, as well as based on our own experience.
We have made every effort to design the book to be an easy, efficient handbook. Although the chapters can be read consecutively, it is not required and might not be the most effective way to absorb the material. We do recommend reading Chapters 1 and 2 first, as they lay down the basic concepts for the brief therapy interventions used throughout the book. It is then most useful to read the appropriate chapter in response to a patient who presents with just such a problem. The chapters are designed to be read
x Preface
in 5 to 10 minutes. Once a chapter has been read, the outline preceding the text in each chapter can be used as a memory aid and guide. Residents have used some of these outlines in the patient's room to guide the interview.
Readers are invited to send comments to the following e-mail address: [email protected]
References
Campbell TL, Franks P, Fiscella K, McDaniel SH, Zwangziger J (2000) Do physicians who diagnose more mental health disorders generate lower health care costs? J Fam Pract 49:305-310.
Leon A, Olfson M, Broadhead WE (1995) Prevalence of mental disorders in primary care. Arch Fam Med 4:857-861.
Michael V. Bloom, Ph.D. David A. Smith, M.D., C.M.D.
Acknowledgments
Along with profound technologic changes in medicine, perhaps the most significant other change during the last 75 years is that good medicine now requires teamwork. This book is no exception. In fact the genesis of this book did not come from the authors but from a family practice resident. While seeing a patient in the clinic for insomnia, the resident consulted one of the authors. Within 5 to 10 minutes they had gone over the patient's problem and came up with a treatment plan that the resident proceeded to present to the patient. As the resident was leaving the faculty member's office he casually remarked that the faculty member might write down some of his treatment protocols so the residents could have quick access to them. Whereas the resident might have seen this as a causal remark, the faculty member took the suggestion seriously, and hence the writing of this book. As chapters were produced they were made available to residents, who then gave feedback that provided important guidance for subsequent revisions of the chapters.
A number of physicians, both family physicians and psychiatrists, also read chapters of the book and provided valuable critiques. They include, in alphabetical order, Berne Bahnson, M.D., Michael Glenn, M.D., David Keith, M.D., Richard McClaflin, M.D., Fredric Thanel, M.D., Barbara Yawn, M.D., and Dr. Wesley Nord, who read and critiqued nearly all the chapters.
Esther Gumpert, consulting editor for Springer-Verlag, provided not only editorial support but also overall guidance for the book for more than a year of its development. Terry Kornak, Supervising Production Editor, and her staff did an outstanding job of guiding the book through its production phase. Jane Nyhhaug prepared the manuscripts and provided editorial feedback from start to finish.
Renowned psychologist Erik Erikson in his book Childhood and Society (1963) said: "The fashionable insistence on dramatizing the dependence of children on adults often blinds us to the dependence of the older generation on the younger one. Mature man needs to be needed, and maturity needs guidance as well as encouragement from what has been produced and must
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xu Acknowledgments
be taken care of. Generativity, then, is primarily the concern in establishing and guiding the next generation." It has been our calling and privilege to participate in the education of the next generation of doctors. This book is primarily the product of the exchange between patient, doctor in training, and faculty. We hope this interaction has enriched the lives of our patients and the clinical performance of our medical students and family practice residents. We know it has contributed greatly to the development of the two authors as people and doctors. We therefore dedicate this book to our medical students and resident physicians.
Reference
Erikson E (1963) Childhood and Society, 2nd ed., New York: Norton.
Michael V. Bloom, Ph.D. David A. Smith, M.D., C.M.D.
Contents
Foreword ....................................................................................... v Macaran A. Baird
Preface ......................................................................................... vii
Acknowledgments ... '" ... ... ... .... ..... ... ... ... ... .... ..... ... ... ............... ...... xi
CHAPTER I
Approach to Brief Treatment in Family Practice ........................... 1
CHAPTER 2
Brief Approach to Mental Health Screening ................................ 18
CHAPTER 3 Depression ................................................................................. , 26
CHAPTER 4 Anxiety ....................................................................................... 37
CHAPTER 5 Panic Disorder ............................................................................ 45
CHAPTER 6 Posttraumatic Stress Disorder ...................................................... 53
CHAPTER 7 Somatoform Disorder ................................................................. 61
CHAPTER 8 Overutilizers ................................................................................ 67
CHAPTER 9 Chronic Pain (Nonmalignant) ..................................................... 74
X1l1
XIV Contents
CHAPTER 10
Nonadherence ............................................................................. 85
CHAPTER II
Insomnia ....... ... ...................................... ............................. ........ 94
CHAPTER 12
Substance Abuse.......................................................................... 99
CHAPTER 13
Habit Problems ......................................................................... 109
CHAPTER 14
Relaxation Exercise Training .................................................... 117
CHAPTER 15
Crisis Intervention for the Suicidal Adult .................................. 122
CHAPTER 16
Crisis Intervention for the Suicidal Adolescent.......................... 131
CHAPTER 17
Behavioral and School Problems of the Child and Adolescent ... 138
CHAPTER 18
Attention Deficit-Hyperactivity Disorder ................................... 151
CHAPTER 19
School Phobia/Separation Anxiety ............................................ 161
CHAPTER 20
Eating Disorders ....................................................................... 168
CHAPTER 21
Adolescent Substance Abuse ..................................................... 182
CHAPTER 22
Marital Problems ...................................................................... 191
CHAPTER 23
Sexual Problems ........................................................................ 200
CHAPTER 24
Domestic Abuse.. ......................... ...... ...... ...... ......... .................. 214
Contents xv
CHAPTER 25
Problems Associated with Chronic Illness in Adults .................. 240
CHAPTER 26
Problems Associated with Chronic Illness in Children............... 248
CHAPTER 27
Problems in the Nursing Home ................................................. 260
CHAPTER 28
Death: Dying and Grief............................................................. 267
CHAPTER 29
Resolving Problems of Advanced Directives and End-of-Life Decision-Making ....................................................................... 277
Index ......................................................................................... 283
