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Larry Davidson, Ph.D.Professor of PsychiatryYale University School of Medicineyaleprogramforrecoveryandcommunityhealth1

What makes for good medicine makes for good mentalhealth What makes for evidence-based medicine makes forevidence-based psychiatry What you want from your own health care is what yourpatients want from you Recovery can be a vehicle for reclaiming your field asyour patients reclaim their lives2

“The overall rate of detection of adenomas amongendoscopists who had relatively slow mean withdrawal timeswas nearly four times as great as the rate among endoscopistswho had relatively fast withdrawal times.”(6 - 12 mins.) 4 X (0 - 6 mins.)*Barclay RL, Vicari JJ, Doughty AS, Johanson JF, & Greenlaw RL:Colonoscopic withdrawal times and adenoma detection duringscreening colonoscopy. N Engl J Med, 2006, 355, 24: 2533-2541.3

Doctors whose average consultation length was less than 7minutes were less likely than those doctors who had an averageconsultation length of 9 minutes or more to recognize and dealwith long-term and psychosocial problems. Doctors who had average consultation lengths of 7.3 minuteswere less likely to enable their patients to engage in self-carethan those doctors whose average consultation length was 9.4minutes. Doctors who had longer average consultation lengths prescribedless, were more likely to include lifestyle advice and preventiveactivities, received more information, dealt with more problems,and required fewer follow-up visits.Wilson A & Childs S: The relationship between consultationlength, process and outcomes in general practice: a systematicreview. British Journal of General Practice, 2002, 52, 1012-1020.4

Physicians who had onemore malpractice claims Physicians who did not havemalpractice claims15 minor18.3 min. any*Levinson W; Roter DL; Mullooly JP; Dull VT; & Frankel RM:Physician patient communication: The relationship withmalpractice claims among primary care physicians andsurgeons. JAMA, 1997, 277:553-559.5

Practicing medicine well takes time Rushed practice leads to errors, lack of access toimportant information, inefficient and poor qualitycare, higher rates of recidivism, and more malpracticeclaims Same is probably true for psychiatry6

The term "evidence-based medicine" appearedfirst in the medical literature in 1992 in Guyatt G,Cairns J, Churchill D, et al. [‘Evidence-BasedMedicine Working Group’] "Evidence-basedmedicine. A new approach to teaching the practiceof medicine." JAMA, 1992, 268: 2420-5. The term has been defined as the integration of atleast three main elements: “best research evidencewith clinical expertise and patient values" (Sackett,2000).7

According to Sackett, BMJ, 1996, 312: 71-72: “Evidencebased medicine is not ‘cookbook’ medicine. Because itrequires a bottom up approach that integrates the bestexternal evidence with individual clinical expertiseand patients' choice, it cannot result in slavish,cookbook approaches to individual patient care.”8

At its most basic level, the recovery movementargues that people with serious mental illnesses beoffered evidence-based medicine just like everyoneelse. That, in most instances, they be treated in thesame way that all other individuals are treated. In thiscase, that they have the same freedom to choose, andright to consent to or decline any given interventionthat we might suggest.This is because the recovery movement arguesthat people with serious mental illnesses have been,are, and remain people just like everyone else, with thesame rights and responsibilities as everyone else—even that their crises should be managed like everyoneelse’s.9

Decrease stigma, discrimination, and other barriers toaccess to care Facilitate early identification and ensure timely accessto early intervention Utilize practices that are effective (i.e., that areevidence-based) Eliminate health care disparities based on race,culture, and ethnicity (2001 report)10

We know that only about 1/3 of individuals in need ofpsychiatric treatment for a serious mental illness receivepsychiatric care We know currently that ever fewer people receive effective carein a timely fashion ( 17%) We know that current interventions are limited in their efficacy(e.g., to 70% of population, to positive symptoms, etc.) We know that less than 20%, and as low as 5%, of those beingprescribed medications are receiving the most appropriate andeffective care available (i.e., evidence-based)11

About 80% of people will be rehospitalized within 5 yearsfollowing a first episode Cognitive remediation has small-to-moderate effects onneuropsychological performance, symptom severity, andcognitive functioning Supported employment is received by less than 1% ofpopulation and tends to lead to part-time employment, withjob tenure averaging 6 months, and monthly earningsaveraging only 122/month or 1,464/year ACT significantly increases housing stability and moderatelyimproves symptoms and quality of life, but also is receivedby very few people—as are most ‘evidence-based practices’(less than 5% of population)12

However, we also know that 13

Domains of functioning are only loosely linked There is a broad heterogeneity in outcome 45-65% of people with DSM-IV-TR psychosisexperience significant improvement over time,many recovering fully Unfortunately, people also will lose on the average25 years of life due to co-morbid medicalconditions and poor quality care (i.e., the longerthey live the better their chances at recovery)14

Few people ( 5%) benefit from the?few effective interventions we have,and the effects of these interventionsare only small to moderate. Yet over half will experience partialto full recovery over time, with only15-25% experiencing a deterioratingcondition.How are we to understand this?15

May need to rethink relationship of care torecovery May need to rethink role of practitioner May need to shift focus from what we can’tchange to what we can16

Recovery is not possible for my patients. Talking about“recovery” with them just builds up false hopes and iscruel. There is nothing new about recovery. We alreadypractice in a recovery-oriented way. It’s just a newname for old values.17

Let’s get concrete.Recovery-oriented care isdifferent.18

In his frequent efforts to promote the transformation agenda in Connecticut,Commissioner of Mental Health and Addiction Services, Tom Kirk, Ph.D., tells the storyof a 27 year-old man named Steve who he met during a visit to a supported housingprogram. When he asked the staff how Steve was doing in his recovery, CommissionerKirk reports that they responded favorably about how well Steve was doing in theprogram, following the rules, taking his medication as prescribed, and having hissymptoms relatively under control.When asked if this was the kind of life they hoped for this young man for the foreseeablefuture, the staff seemed puzzled, confident that they were doing their best. His condition,after all, was stable and he had not been admitted to the hospital for several years.Commissioner Kirk, however, was not satisfied. He asked the staff to go one step furtherand consider whether or not this would be the kind of life that would make them contentwere they in Steve’s place.Once it was phrased this way, the staff began to think that more could be done for, andmore could be expected from, this clever college graduate who was engaging, loved carsand racing, and had aspirations of becoming a mechanic. But how could they help himwith that? They had little idea as to what they could do beyond treating his schizophreniaand encouraging him to participate in program activities as a way of luring him awayfrom his television set. Becoming a mechanic seemed a long way off, if it was to be19possible at all.

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People with mental illnesses may want the same thingsout of life as other people do. People are not their diagnoses, are not subsumedentirely by the illness, and continue to exist alongside ofthe illness. Mental health care has addressed illness and itssymptoms more so than the person and his or hereveryday life.21

President’s New Freedom Commission on Mental Health:Current mental health system “simply manages symptomsand accepts long-term disability” (DHHS, 2003, p. 1). “I don’t know how to find my way in the world” – Participantin “A Day in the Life” Study (Davidson, Shaw, Welborn, etal., 2010) “I had to learn how to be human again. I had to relearn howto be a dweller.” -- formerly homeless man in “A Day in theLife” “To be able to participate in person-centered care, first youhave to believe that you have the right to be a person” -- EdKnight22

The same things that help other people adapt to and livesatisfying lives in the face of other chronic illnesses ordisabilities These include:– Social support (being accepted and valued as a worthwhileand contributing person vs. patient)– Sense of personal agency and self-efficacy– Internal locus of control– Accurate and accessible information on self-care23

But to have access to these resources, people first mayhave to regain a sense of themselves as worthwhile andeffective human beings who are more than their illnesses Both because of the nature of the illness and because ofthe treatment they have received This becomes the first focus of care24

“ And then something odd happens. My awareness instantly growsfuzzy. Or wobbly. I think I am dissolving. I feel—my mind feels—like asand castle with all the sand sliding away in the receding surf Thisexperience is much harder, and weirder, to describe than extreme fear orterror Explaining what I’ve come to call ‘disorganization’ is a differentchallenge altogether. Consciousness gradually loses its coherence. One’scenter gives way. The center cannot hold. The ‘me’ becomes a haze, and thesolid center from which one experiences reality breaks up like a bad radiosignal. There is no longer a sturdy vantage point from which to look out,take things in, assess what’s happening. No core holds things together,providing the lens through which to see the world, to make judgments andcomprehend risk. Random moments of time follow one another. Sights,sounds, thoughts, and feelings don’t go together. No organizing principletakes successive moments in time and puts them together in a coherentway from which sense can be made. And it’s all taking place in slowmotion.” -- Elyn Saks, 200725

Cognitive intrusionsand disruptionsLife before illnessDecline in functioningDemoralization& despairIncreasingwithdrawal& isolationNeo-Kraepelinianmodels of illnessWays of makingsense ofintrusions &disruptionsHopeDiminished sense ofagency & increasedvulnerabilityDelusions & otheridiosyncratic ways ofmaking senseExperiences of failure,stigma & rejection26

If I can’t direct my own attention If I no longer experience my actions as stemming fromme If I can’t hold thoughts together or remember fromone minute to the next If even my thoughts seem to come from someone orsomewhere else 27

If other people act as if I am not here If other people do things to me without mypermission or consent If other people make decisions for me and aboutme without asking me If other people tell me that I’ll never get better If other people act as if I have nothing to offer If other people no longer treat me as a person 28

If other people act as if I am not here If other people do things to me without mypermission or consent If other people make decisions for me and aboutme without asking me If other people tell me that I’ll never get better If other people act as if I have nothing to offer If other people no longer treat me as a person 29

the Tinkerbell issue30

Stigma, discrimination& messages of otoContributingContributingcitizen & visible(but invisible)role modelcitizenHope, determination &encouraging support31