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SESSION DETAILS - WORKSHOPS & SYMPOSIA

SESSIONS BY DATE / TIME

Wednesday, November 16 7:00–9:00pm Researchers' Workshop Pre-Conf. Symposium
Thursday, November 17 1:45–3:45pm Workshops 1–3 Symposia 1–4
Friday, November 18 9:30–11:30am Workshops 4–6 Symposia 5–8
1:45–3:45pm Workshops 7–11 Symposia 9–10
3:45–5:45pm Workshops 12–15 Symposia 11–13
Saturday, November 19 2:15–4:15pm Workshops 16–18 Symposia 14–15
4:30–6:30pm Workshops 19–21 Symposium 16

SESSIONS BY PROGRAM TRACK
  W=Workshop       S=Symposium  

  Early Career Extremes
of Life
ICU/Acute Psych Conference Theme A Conference Theme B Women's Issues & Somatoform Disorders Potpourri
Thursday, 1:45–3:45 S3   S4 W1 W2 & W3 S2 S1
Friday, 9:30–11:30 W6   S5 S7 & S8 S6 W5 W4
Friday, 1:45–3:45 W11 W7 & W10 W9 W8   S10 S9
Friday, 3:45–5:45 W13 W14 S12 W12 W15 S11 S13
Saturday, 2:15–4:15 W17 W16 S14 S15 W18    
Saturday, 4:30–6:30 W20 W21 W19 S16      

 

WEDNESDAY, NOVEMBER 16, 2011     7:00–9:00 PM     Pre-Conference Sessions

PRE-CONFERENCE WORKSHOP:
Research and Evidence-based Practice: Developing the Agenda for APM

Facilitators:

Michael C. Sharpe, MD, FAPM, Chair of the APM Research Committee

James R. Rundell, MD, FAPM, Chair of the APM Clinical Practice Committee

Key Participants:

Members of the APM Research Committee

Members of the APM Clinical Practice Committee

Other APM members interested in developing APM's evidence-based clinical research focus

Description:

Growth and development in the field of Psychosomatic Medicine requires a robust research agenda to understand psychopathology in the medically ill patient and to inform evidence-guided treatment interventions. Members of the Research and Clinical Practice committees have developed a special two-hour forum to explore how best to promote research and to disseminate the published evidence, both within and beyond the Academy.  This session is open to all APM members.

  • Hour One will focus on planning efforts for a discrete session or interwoven track with a “researchers focus” for the APM 2012 Annual Meeting. Proposals for development of a stand-alone research meeting will also be presented, reviewed, and critically discussed.
  • Hour Two will provide a collaborative forum for discussion of roles and opportunities for collaboration between the Research and Clinical Practice committees in collating and disseminating the evidence on which we base our practice.

PRE-CONFERENCE SYMPOSIUM:
Hot Topics in Pediatric Psychosomatic Medicine

Moderator: Maryland Pao, MD, FAPM

Presenters:

Elham Mizani, MD
"Attention Deficit Hyperactivity Disorder and Substance Abuse"

Laura Markley, MD
"New Community Drugs of Abuse"

Susan Turkel, MD, FAPM
"Update in Pediatric Delirium"

Khyati Brahmbhatt, MD
"Pharmacologic Treatment of Young Patients with Intellectual Disabilities and Autism"

Abstract:

This special session will offer updates in promising new areas of research in pediatric psychosomatic medicine (PPM) and reviews some common childhood psychiatric disorders such as attention deficit hyperactivity disorder (ADHD) and developmental disorders seen in PM settings (adult and pediatric). Dr. Mizani will review the diagnosis of ADHD and current treatments including stimulants and discuss the relationship between ADHD and substance abuse in adolescence. Not surprisingly, substance abuse is a significant problem for many chronically ill pediatric patients as they go through adolescence as well. Dr. Markley will discuss the identification and management of abuse of over-the-counter natural and designer drugs currently abused by adolescents in the community. She will touch on management of chronically ill adolescents with opiates. An international expert on pediatric delirium, Dr. Turkel will present new research in the identification and management of delirium in infants, children, and adolescents including use of atypical antipsychotic medications. To conclude, Dr. Brahmbhatt will talk about the increasing number of patients with intellectual disabilities and autism seen on psychosomatic medicine services and the challenges of pharmacologic management in these patients when they are medically ill. Diagnostic and treatment issues seen in medically ill children and adolescents remain relevant for adult PM psychiatrists.

THURSDAY, NOVEMBER 17, 2011     1:45–3:45 PM     Workshops 1–3, Symposia 1–4

WORKSHOP 1:
The Medical-Psychiatric Coordinating Physician: An Extended Outpatient Role for Psychosomatic Medicine

Program Track: Conference Theme A

Presenters:

Steven Frankel, MD, University of California Medical Center, San Francisco, San Francisco, California

James Bourgeois MD, FAPM, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada

Abstract:

Background:  Psychosomatic medicine (PSM) is generally practiced as an inpatient consultative specialty, assisting other physicians in the management of co-morbid psychiatric illness in medical/surgical inpatients. In recent years, concurrent with changes in the delivery of medical care from a primarily inpatient to an ambulatory focus, the subspecialty of psychosomatic medicine has expanded its scope to progressively include complex outpatients, many of whom are first encountered by Primary Care Physicians (PCPs).

Objective:  The authors introduce a model for outpatient PSM that broadens the responsibilities of the PSM physician to include development and leadership of a multi-disciplinary outpatient teams, case management, and long term patient treatment. The novel method of care being proposed is especially pertinent for work with "complex" outpatients (de Jonge P, Huyse F, Stiefer F, 2006; Kathol et al., 2007 and 2010). These are patients who present with diagnostic complexity and require the services of multiple physicians and health care providers. We call the physician who assumes this role the Medical-Psychiatric Coordinating Physician (MPCP).

Method:  The authors have examined a range of inpatient and outpatient systems of psychosomatic medicine and systemic medical-psychiatry care delivery for complex patients, and have considered the limitations associated with each. Attempting to progress beyond these strictures, they have introduced the MPCP model. The MPCP model differs from other models of outpatient PSM by advocating: (1) PSM physician centrality in leading multispecialty care teams; (2) the active coordination of medical and surgical workups; (3) ongoing patient care that may include psychotherapy provided by the MPCP; and (4) the provision of a liaison among treatment team members and the patient's extended system of care. This model of care has been used with over forty completed outpatient cases, each followed for at least 18 months. In its evolving forms it has also been practiced for over fifteen years by two seasoned practioners, including one of the authors.

Results:  In addition to suggesting an expanded scope for outpatient psychosomatic medicine, clinical observations support the value of the MPCP model for improving patient outcome and economic containment. Physicians trained in PSM fellowships are ideally suited for working in this specialized role because of their familiarity with the interface of systemic medicine and psychiatry.

Conclusion:  If adopted the proposed new model, the MPCP, will create a distinct expansion in the practice of outpatient PSM to incorporate direct, long term treatment and management of patients. The MPCP role may have the greatest practical utility with complex systemic medical-psychiatric problems, including cases with a high degree of psychiatric co-morbidity and requiring multispecialty care.

WORKSHOP 2:
Consultation-Liaison Psychiatry as Part of the Core Psychiatry Clerkship — What Is the Ideal Educational Model?

Program Track: Conference Theme B

Chair: Marian Fireman, MD, FAPM, Oregon Health and Science University, Portland, OR

Discussant: Lucy Epstein Hutner, MD, Columbia University, New York, NY

Presenters:

Marcus Wellen, MD, University of Arkansas, Little Rock, AK
"Introduction and Review of Survey Data"

Michael Marcangelo, MD, University of Chicago, Chicago, IL
"Perspective of the Inpatient C-L Psychiatrist"

Marian Fireman, MD, FAPM, Oregon Health and Science University, Portland, OR
"Perspective of the Clerkship Director"

Ondria Gleason, MD, University of Oklahoma, Tulsa, OK
"Perspective of the Department Chair"

Lucy Epstein Hutner, MD, Columbia University, New York, NY
"Perspective of the Outpatient C-L Psychiatrist"

Abstract:

The Medical Student Education Subcommittee of the APM Education Committee recently completed a survey of psychiatric educators with regard to the educational value of a consultation-liaison experience as part of the core psychiatry clerkship. The vast majority of the respondents stated that their institution utilized consultation liaison services as part of the core psychiatry clerkship. The educators noted that exposure to a wide range of psychopathology, learning to manage medical presentations of psychiatric illness and working with multidisciplinary teams were major benefits of the rotation. Concerns included less exposure to patients with severe psychopathology, variable caseloads, and too much unstructured time. Importantly, there was general agreement that the students on these services were at least as likely to meet each of the ACGME core competencies in psychiatry as students in other settings.

This workshop will discuss a variety of models of incorporating the consultation-liaison experience into the core psychiatry clerkship including a full time experience and several "part-time" models. Part-time models may be either in discreet blocks of time during the clerkship or a longitudinal experience scheduled throughout the clerkship. Ways to enhance the consultation-liaison experience to address clerkship directors' concerns will be presented including structured didactics and supervision experiences. The utility of incorporating outpatient consultation experiences, when available, will be addressed. The pros and cons of these models will be discussed, drawing on the participants' own experiences and differing roles at five different institutions.

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WORKSHOP 3:
Speed Dating: Checking Out Trends in Health Care

Program Track: Conference Theme B

Presenters:

Mary Helen Davis, MD, Norton Cancer Institute, Louisville, KY
"Maintenance of Certification: Not My Grandfather's Medical License"

Sarah Parsons, DO, Norton Cancer Institute, Louisville, KY
"Electronic Medical Records/Health Information Technology: Who Has That Chart?"

Irwin Muszynski, JD, American Psychiatric Association, Arlington, VA
"Reimbursement Revision: Show Me the Money, the Currency of Healthcare Reform"

Scott A. Irwin, MD, PhD, Institute for Palliative Medicine San Diego Hospice, San Diego, CA
and

Nathan Fairman, MD, MPH, Institute for Palliative Medicine San Diego Hospice, San Diego, CA
"End of Life Care: Quality and Economics: The Right Thing to Do and the Price Is Right"

John Oldham, MD, Menninger Clinic, Baylor College of Medicine, Houston, TX; and 2011 President of the American Psychiatric Association
"Health Care Models: ACOs, HIZs, and the Medical Home: How Not to Become a Homeless Professional"

Abstract:

Our professional lives are on the brink of major transformation with the healthcare world in transition. With the increasing cost of medical education, diminishing workforce, and Medicare becoming a prime driver of the national debt, we are being forced to face and deal with harsh economic realities. This workshop will explore five hot topics. Each presenter will provide a brief update, "state of the horizon" followed by an interactive panel discussion. The goal will be to increase awareness of trends impacting psychiatric practice and to assist providers in preparing for and being able to impact change in their professional lives.

Dr. Davis will provide an overview of trends from the Federation of State Medical Boards (FSMB) and the American Board of Psychiatry and Neurology (ABPN) clarifying what is needed for Maintenance of Certification and considering the transition from renewal of licensure to maintenance of licensure.

Dr. Parsons will provide an overview of issues related to meaningful use, confidentiality, and the dynamics of implementation.

Dr. Muszynski's presentation will outline the inevitability of payment reform across the continuum of care, review emerging payment concepts, identify key unanswered questions, and discuss the implications for psychiatric treatment and practice.

The presentation by Dr. Irvin and Dr. Fairman will provide an overview of the economics and policy of healthcare at the end of life, with a particular focus on opportunities for psychiatry in hospice and palliative medicine.

Dr. Oldham will provide an overview and summary of emerging models of care in the public, private, and academic arenas.

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SYMPOSIUM 1:
Innovations in Psychotherapy for Medically Ill Patients

Program Track: Potpourri

Presenters:

James Griffith, MD, George Washington University Medical Center, Washington, DC

Antolin Trinidad, MD, George Washington University Medical Center, Washington, DC

Lorenzo Norris, MD, George Washington University Medical Center, Washington, DC

Louis Joseph, MD, George Washington University Medical Center, Washington, DC

Abstract:

In this symposium, we present innovative psychotherapies that have been tailored for outpatients in cancer and amyotropic lateral sclerosis treatment programs and for medically-ill inpatients who have become demoralized. These include individual brief psychotherapies and couple or family-centered psychotherapies for outpatients, as well as existential bedside psychotherapy for inpatients. For each, we illustrate how cognitive-behavioral, family systems, psychodynamic, and existential psychotherapeutic methods can be tailored creatively to fit the unique needs of a specific medical illness and its treatment context, including (1) clinical problems generated by the natural history of the medical illness and its treatments, rather than an underlying primary psychiatric disorder; (2) patients who do not embrace an identity as psychiatrically ill; (3) existential concerns and resilience against suffering that are primary concerns, rather than symptoms of psychiatric illness.

Time-limited cognitive-behavioral psychotherapy considers the specific type and stage of cancer and assists the patient through the continuum of cancer care, including imminent death. Brief psychotherapeutic strategies are mapped to improve adherence to cancer treatment, avert crises, and help patients attain meaning, purpose, and agency in their lives. Family-centered therapy organizes the family as an effective problem-solving, advocacy, and emotionally-supportive resource for the patient. Couple therapy strengthens secure attachment between couple partners so that emotional expression, communication, quality of relationship, and couple identity are sustained through the stresses and losses of illness, including end of life. Existential bedside psychotherapy aids demoralized patients in recovering hope, purpose, agency, and communion with others as sources of resilience during illness.

We present illustrative cases for each of these therapies and discuss guidelines for tailoring specific psychotherapeutic approaches to fit the natural course, treatment context, and psychosocial stresses of specific illnesses. A psychiatry resident discusses the educational impact from incorporating this psychotherapeutic training into the outpatient year of residency training.

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SYMPOSIUM 2:
Psychopharmacology of the Pregnant and Postpartum Woman

Program Track: Women's Issues & Somatoform Disorders

Presenters:

Ellen Flynn, MD, Alpert Medical School of Brown University, Providence, RI

Carmen Monzon, MD, Alpert Medical School of Brown University, Providence, RI

Teri Pearlstein, MD, Alpert Medical School of Brown University, Providence, RI

Abstract:

This symposium will discuss the frequently changing treatment recommendations and dilemmas for pregnant and postpartum women with mood, anxiety, and psychotic disorders. The presenters have been conducting C-L psychiatry in an obstetric hospital since 2002.

Teri Pearlstein, MD will discuss the diagnosis of depression in the perinatal woman. She will discuss the risks of relapse of mood and anxiety disorders in women who stop psychotropic medications during pregnancy and the risks of untreated mood and anxiety and disorders on birth outcomes. She will review FDA warnings about the use of antidepressants during pregnancy. Practical suggestions for psychotropic medication use in each trimester will be reviewed. Case vignettes will illustrate treatment dilemmas pregnant women currently face.

Carmen Monzon, MD will discuss the treatment options for women with postpartum mood and anxiety disorders. The current literature about the safety of psychotropic medications with breastfeeding will be reviewed. Case vignettes will be utilized to illustrate treatment dilemmas breastfeeding women face. Risks of infanticide will be discussed and case vignettes about neonaticide will be presented.

Ellen Flynn, MD will review the treatment issues that arise with the treatment of bipolar and psychotic women during pregnancy, delivery, and postpartum. The safety of mood stabilizers and antipsychotics with pregnancy and lactation will be discussed. The recent FDA warning about antipsychotic use during pregnancy will be discussed. Case vignettes will be utilized to illustrate representative women with bipolar disorder or postpartum psychosis that are encountered on the C-L service.

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SYMPOSIUM 3:
Teaching Bioethics to Psychosomatic Medicine Psychiatrists (presented by the APM Bioethics SIG)

Program Track: Early Career

Chair: Mary Ann Cohen, MD, FAPM, Mount Sinai School of Medicine, New York, NY

Discussant: Nancy Neveloff Dubler, LLB, Albert Einstein College of Medicine, Bronx, NY

Presenters:

Laura Roberts, MD, FAPM, Stanford University, Stanford, CA
"Defining Bioethical Concepts and Boundaries, Raising Awareness about Bioethics, and Deciding Who Should Do Ethics Consultations"

Linda Ganzini, MD, FAPM, UCLA School of Medicine, Sylmar, CA
"Elopement Risk"

Saba Syed, MD, Portland VA Medical Center, Portland, OR
"Developing an Ethics Consultation Service—from Telephone to Bedside"

Asher Aladjem, MD, FAPM, New York University Medical School, New York, NY
"National Standards for Ethics Consultations—Final Report" (co-author Nancy Neveloff Dubler)

Abstract:

Psychosomatic medicine psychiatrists may be in an ideal position to lead bioethics committees and to teach bioethics, but should they be doing ethics consultations?

Since psychosomatic medicine psychiatrists work with all medical specialties and disciplines and, as their previous name suggested, served as both consultant and liaison to these disparate entities, they are known throughout the institution and are also conversant with not only medicine and its subspecialties, but also skilled in family and group dynamics. However, the clarification of the role of the psychosomatic medicine psychiatrist who does ethics consultations may be important as we begin to define boundaries and establish standards for ethics consultations. In this symposium, we define bioethical concepts, clarify boundaries, and explore just who should be doing ethics consults. Some academic institutions choose pulmonologists, internists, pediatricians, or opthalmologists while others rely on psychiatrists for ethics consultations.

We define the issues involved with elopement risk and describe the structure of a novel hospital program to identify patients at risk for elopement and reduce elopements.

It is rare for us to understand just how ethics consultation services are established. The restructuring of a hospital bioethics committee led to the creation of an ethics consultation service in 2009. Prior to the restructuring, all ethics consults that were requested were handled by telephone. We describe the evolution of this service from telephone to bedside over the course of its first year.

In this symposium we explore strategies for raising awareness about bioethics and present the final report of a program to develop National Standards for Ethics Consultations.

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SYMPOSIUM 4:
Acute Alcohol Withdrawal: A Comprehensive Review of the Literature, Clinical Pitfalls, and a New Symptom-Driven Treatment Approach

Program Track: ICU/Acute Psych

Presenters:

Thomas Beresford, MD, FAPM, University of Colorado Denver, Denver, CO

Julie Taub, MD, University of Colorado Denver, Denver, CO

Andrea DiMartini, MD, FAPM, University of Pittsburgh, Pittsburgh, PA

Abstract:

Recent APM presentations on this difficult clinical entity have promulgated non-standard and potentially regressive treatment approaches for this protean condition. Acute Alcohol Withdrawal (AAW) requires careful diagnosis and appropriate treatment in order to prevent both morbidity and death. This symposium seeks 1) to provide a comprehensive and critical review of the AAW medical literature on a) diagnosis, and b) symptom scale-driven treatment, along with 2) careful differential diagnosis, 3) a new, easy to use clinical symptom scale that links symptom recognition to specific treatment. The symposium aims at 1) informing APM physicians of standard versus non-standard treatment implications for patients, 2) establishing a consensus among C-L physicians that will lead to standard treatment guidelines in the general hospital, and 3) pointing out new areas of research inquiry that can potentially preserve brain and brain-related functions in withdrawing alcohol dependent patients.

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FRIDAY, NOVEMBER 18, 2011     9:30–11:30AM     Workshops 4–6, Symposia 5–8

WORKSHOP 4:
The Use of Opioids in the Management of Chronic Pain: New Guidelines and Approaches

Program Track: Potpourri

Presenters:

Jon Streltzer, MD, University of Hawaii, Honolulu, HI

Carl Sullivan, MD, West Virginia University, Morgantown, WV

Abstract:

Psychiatrists are often asked to consult on the opioid-dependent chronic pain patient. The management of chronic non-cancer pain with opioids has been controversial for many years, increasingly so recently with the dramatic rise in mortality and morbidity from prescription drug abuse. In response, new guidelines have been put forth by pain societies, addiction societies, and various state agencies. These differ in emphasis and approach to management. This workshop will review the various guidelines, the evidence behind them, and provide practical pointers for choosing among them and applying them in practice. The biology and the psychology of prescription opioid dependence will be reviewed. The role of buprenorphine in the management of the opioid-dependent chronic pain patient will be discussed and new outcome data presented.

Dr. Streltzer will critically review the new guidelines. He will review the latest research related to long-term opioid treatment of pain and identify the dilemmas physicians present with. He will present case examples of consultation solutions.

Dr. Sullivan will review techniques of medical management of the opioid-dependent chronic pain patient, including new data on the use of buprenorphine when appropriate.

Both speakers will demonstrate key techniques in history-taking, physical exam, and counseling with the opioid-dependent chronic pain patient.

Brief video interviews with prominent pain physicians and a chronic pain patient will be shown. Audience participation and presentation of problematic cases will be encouraged.

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WORKSHOP 5:
Update in Women's Mental Health for the Psychosomatic Medicine Specialist

Program Track: Women's Issues & Somatoform Disorders

Chair: Lucy Hutner, MD, Columbia University, New York, NY

Moderator: Linda Worley, MD, FAPM, University of Arkansas Medical Center, Little Rock, AR

Presenters:

Madeleine Becker, MD, Thomas Jefferson University Hospital, Philadelphia, PA

Nancy Byatt, DO, MBA, University of Massachusetts, Worcester, MA

Leena Mittal, MD, Brigham & Women's Hospital, Boston, MA

Christina Wichman, DO, Medical College of Wisconsin, Milwaukee, WI

Abstract:

Women's mental health, a specialty of psychiatry which focuses on psychiatric issues across the reproductive life span, is a rapidly expanding field. Psychosomatic medicine specialists are increasingly called upon to evaluate and treat pregnant and postpartum women, in both the acute inpatient and the outpatient setting. Effective treatment of psychiatric disorders in both pregnancy and postpartum can yield improved outcomes for both mother and infant [1]. Yet psychiatrists can be hesitant to treat these disorders, due to questions about any potential impact on fertility, pregnancy, delivery, and/or lactation. This workshop will present an update in women's mental health specifically geared to consultation-liaison psychiatrists. Discussants will first provide an update on the evaluation and management of perinatal depression, which is the most common complication of childbirth [2]. We will then present an update on the management of the obstetric clinical scenarios most often addressed by psychosomatic medicine specialists. We will conclude by presenting an overview of future directions of the field of women's mental health.

Drs. Becker and Byatt will review the current evaluation and management of depression in pregnancy and postpartum (30 minutes).

Drs. Hutner and Wichman will discuss the management of the obstetrical patient in the acute setting (30 minutes).

Dr. Mittal will discuss future directions of the field of women's mental health (30 minutes).

Dr. Worley will moderate and lead the audience discussion (30 minutes).

References:

  1. Wisner KL, Parry BL, and Piontek CM. Postpartum Depression. N Engl J Med 2002; 347:194-199.
  2. O'Hara MW, Swain AM. Rates and risk of postpartum depression: a meta analysis. Int Rev Psychiatry 1996; 8:37-54.

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WORKSHOP 6:
The Business of Psychosomatic Medicine... For Beginners (presented by the APM Early Career Psychiatrists SIG)

Program Track: Early Career

Presenters:

Maunel Pacheco, MD, Tufts Medical Center, Boston, MA

Paul Berkowitz, MD, Scottsdale Health, Scottsdale, AZ

Patrick Aquino, MD, Mount Auburn Hospital, Cambridge, MA

Jason Caplan, MD, St. Joseph's Hospital, Phoenix, AZ

Abstract:

Graduating from a psychosomatic medicine fellowship and July 1st is approaching too fast for you? Are you inheriting or considering starting up a consultation-liaison or emergency psychiatry service?

Either way, this workshop will be helpful to you.

Join the Academy's Early Career Psychiatrist (ECP) SIG for one of its inaugural workshops designed to demystify the business of psychosomatic medicine consultation-liaison services.

We will review various service models including academic medical center, community hospital, and private practice.

Each of our invited speakers will share their direct hands-on experiences and strategies that have assisted them in building and running their services.

Although part of the ECP SIG, the organizers of this workshop welcome all interested individuals from all career phases to join us.

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SYMPOSIUM 5:
Management of Delirium in the Context of Advanced or Life-Threatening Illness

Program Track: ICU/Acute Psych

Presenters:

Scott A. Irwin, MD, PhD, The Insitute for Palliative Medicine at San Diego Hospice, San Diego, CA

Michelle T. Weckmann, MD, MS, University of Iowa Carver College of Medicine, Iowa City, IA

Nathan Fairman, MD, MPH, The Insitute for Palliative Medicine at San Diego Hospice, San Diego, CA

Abstract:

The usual paradigms for delirium diagnosis and management do not hold for patients with advanced or life-threatening illnesses. In such patients, delirium needs to be placed into context within the overall picture of illness, including reasonable medical goals. In addition, the goals of care of the patient and family need to be taken into account. Unfortunately, the symptoms of delirium are often under-recognized, misdiagnosed, and inappropriately treated in patients with life limiting illnesses. However, appropriate approach and interventions can improve outcomes.

Delirium commonly occurs in both hospitalized and community patients, particularly in patients with advanced, life-threatening illnesses. It may occur in up to 80-85% of terminally ill patients, and one-third of palliative care patients may experience terminal delirium. Delirium is associated with significant morbidity and mortality. Behavioral manifestations of delirium, such as agitation, may result in significant patient, family, and caregiver distress, as well as undesired medical interventions or inpatient admissions. Delirium often interferes with the recognition and control of other physical and psychological symptoms, such as pain or depression. Appropriate goal-based interventions are usually successful in reducing these negative outcomes, even at the end-of-life.

The focus of this symposium will be placing delirium into appropriate medical context, accounting for goals of care, and choosing a management strategy based on both of these. A classification of delirium as reversible or irreversible based on context and goals of care will be advocated. Management strategies will be suggested based on delirium subtype, context, reversibility, and goals of care. In addition, we will briefly discuss 1) the definition of delirium and related terminology, 2) data regarding the impact of delirium on patients, caregivers, and healthcare staff, 3) screening and assessment of delirium in the context of advanced, life-threatening illness, 4) common etiologies in patients with advanced illness, and 6) the potential reversibility of delirium in this context.

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SYMPOSIUM 6:
Reducing “Weight Times”: A Collaborative Approach to Managing Obesity

Program Track: Conference Theme B

Presenters:

Sanjeev Sockalingam, University Health Network, Toronto, ON, Canada

Raed Hawa, University Health Network, Toronto, ON, Canada

Stephanie Cassin, Ryerson University & Toronto Western Hospital, Toronto, ON, Canada

Abstract:

With the obesity epidemic reaching epic proportions in North America, weight loss treatments are in increasing demand. Bariatric surgery is a treatment alternative for morbid obesity and its popularity has resulted in over 200,000 surgeries being performed in the United States in 2007.

Currently, Centres of Excellence for bariatric surgery have been established across North America, yet a small proportion of surgical centres offer long-term follow-up or significant post-operative interventions due to patient volumes and clinical demand. The University of Toronto Bariatric Surgery Collaborative is a six-hospital partnership under a provincial mandate for accessible, publicly funded gastric bypass surgery for morbidly obese patients. The collaborative includes the Toronto Western Hospital Bariatric Surgery Centre of Excellence (TWH BSCoE), which performs over 600 surgeries per year and provides 5-year follow-up for patients post-surgery.

This symposium will provide research and programmatic data on this innovative, provincially funded interdisciplinary Psychosocial Bariatric Surgery Program embedded within this Centre of Excellence. Dr. Sockalingam will begin the symposium discussing the program development for this provincial bariatric network, the role of psychiatry in program planning, and an overview of this interdisciplinary psychosocial model for assessment and peri-operative management of patients undergoing bariatric surgery. Dr. Sockalingam will share an approach to determining "readiness" for bariatric surgery within this collaborative model. Dr. Hawa will summarize common neuropsychiatric complications post-bariatric surgery and an approach to managing common sequelae. A case study illustrating neuropsychiatric sequelae secondary to nutritional deficiency will be used to discuss the role for nutritional deficiency screening and protocols post-surgery. Lastly, Dr. Cassin will describe an innovative psychosocial intervention developed to mitigate weight loss failure post-surgery. The intervention consists of a peri-operative telephone cognitive behavioural therapy treatment program for bariatric surgery patients in urban and rural Ontario. Pilot data from this intervention will be presented during this session.

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SYMPOSIUM 7:
Research and Service Innovation: Making It Happen (presented by the APM Research Committee)

Program Track: Conference Theme A

Moderator: Michael Sharpe, MD, FAPM, University of Oxford, Oxford, United Kingdom

Presenters:

Wayne Katon, MD, FAPM, University of Washington, Seattle, WA

Paul Ciechanowski, MD, University of Washington, Seattle, WA

Jurgen Unützer, MD, MPH, University of Washington, Seattle, WA

Abstract:

Dr. Sharpe will outline the challenge of making research relevant to innovative service provision, both by the questions we ask and by the answers we provide. The challenges will be described with reference to trials of treatment for depression in cancer patients, symptoms in neurology patients, and fatigue in chronic fatigue syndrome.

Dr. Katon will describe how his research group applied what they learned in the TEAMcare randomized trial to spend the last year of funding getting ready for dissemination of this model of care including developing a website, nurse training manual, two-day training package, patient educational materials, and an electronic registry. His research group also had to learn to develop contracts to help organizations implement and organize ways to market dissemination efforts.

Dr. Ciechanowski will describe a training institute at the University of Washington that offers skills-based (e.g., motivational interviewing) and program-based (e.g., pearlsprogram.org, teamcarehealth.org) training that is offered regionally and nationally. Our "promise" is to offer "clinic ready" training by using active, adult learning methodologies where the goal is not only retention of data but rapid development of practical skills that can be readily used by front-line clinicians. Program-based trainings are developed during the research cycle of intervention trials to expedite dissemination of evidence-based outcomes.

Dr. Unützer will bring in the perspective of a psychiatrist who works in a new mode, research informed population-focused outpatient consultation psychiatry, and discuss how this differs from typical inpatient C-L or office-based practice. He will present an overview of a state-wide program in which 21 consulting psychiatrists support panels of patients with behavioral health problems cared for in over 100 community health centers in the state of Washington, drawing on experience with over 20,000 patients served in this population-focused model of behavioral health care.

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SYMPOSIUM 8:
Presidential Symposium: Sustaining Self and Service: Challenges to the Community-Based Psychosomaticist (presented by the APM Community-Based PM Physician Practice Issues SIG)

Program Track: Conference Theme A

Presenters:

Fatimah Tahil, MD, MPH, FAPM, Overlook Hospital, Summit, NJ
"Survivor Tips: Reframing Self from Academia to Community Psychosomaticist"

Jason Richter, MD, St. Anthony Hospital, Lakewood, CO
"Making a Living as a Consultation Psychiatrist in Private Practice—Contracts and Payment Models"

Keira Chism, MD, MA, Thomas Jefferson University, Philadelphia, PA
"'Yes, we know the patient.': Challenges and Opportunities of the Readmitted C-L Patient in the Community Hospital Setting—A Case Series"

Linda M. Peterson, MD, FAPM, Ingham Regional Medical Center, Okemos, MI
"Maintaining the Web 'Off-Spring' Spun in Community-Based Consultation and Liaison"

Abstract:

The consultation-liaison psychiatrist in the community-based setting is faced with many challenges. Sustaining a new or pre-established psychiatric consult service must factor in today's ever-changing reimbursement landscape and its impact on the institution's overall vision. Optimization of services with the medical community is as essential as how psychosomaticists survive professionally.

This workshop will provide a framework for solutions to overcome these challenges. In particular, we will address the following: the transition from fellowship to directorship, maintaining relationships with medical colleagues despite difficult patients, establishing oneself in a new medical community and ensuring self solvency. We will focus on skills development and case examples to engage the audience.

Dr. Tahil will present the challenges of transition of practicing consultation-liaison in the academic setting to a community-based one. A blue print to establishing self in this new setting will be presented, and will include discussion of establishing networks while maintaining ties with academia.

Dr. Richter will present and discuss various financial models that are relevant to private consultation work, including fee-for-service, employed/contract and blended models. In addition, he will provide guidelines to successfully negotiate compensation contracts.

Dr. Chism will present on optimizing the management of complex psychiatric issues on the "repeat" patients, and case examples will be used. The mechanism for collaboration with primary care physicians to manage longitudinal psychiatric issues, including nursing home placement for dementia patients, will be elucidated.

Dr. Peterson will present on clinical longevity in C-L in the community-based setting. She will discuss how to sustain and resurrect consultation services despite administrative and institution-wide changes.

Participants will be encouraged to discuss their experiences—challenges and solutions—as community-based psychosomaticists. At the end of the workshop, participants will be able to:

  1. Describe the role and challenges of community-based psychosomaticists.
  2. Identify various financial models of professional compensation.
  3. Formulate strategies to sustain self and service in the community setting.

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FRIDAY, NOVEMBER 18, 2011   1:45–3:45 pm  Workshops 7–11, Symposia 9–10

WORKSHOP 7:
Suicidal and Intoxicated: The Definitive Approach to Assessment and Management in the Medical Setting

Program Track: Extremes of Life

Presenters:

David Gitlin, MD, FAPM, Brigham and Women's Hospital, Boston, MA

Joji Suzuki, md, Brigham and Women's Hospital, Boston, MA

Rebecca Weintraub Brendel, MD, JD, FAPM, Massachusetts General Hospital, Boston, MA

Evan Margetson, Brigham and Women's Hospital, Boston, MA

Abstract:

One of the most common yet challenging clinical situations facing the consultation-liaison psychiatrist is assessing the safety risk of individuals who present with suicidal states in the context of acute intoxication. While such patients may be quite dangerous under the influence of various substances, the persistence of such danger may fluctuate significantly as the intoxicated state resolves. Participants will have the opportunity to review the known data regarding the relationship between substance use and suicide risk, gain knowledge of various management approaches to such patients in the acute medical setting, and consider which patients may remain at high risk. The various medicolegal issues involved with such patients, including risks associated with involuntary commitment or release following a suicidal presentation, will be addressed. Use of an interdisciplinary addictions consultation service will be also be discussed.

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WORKSHOP 8:
Avoiding Mis-Managed Care: The Case for Liaison

Program Track: Conference Theme A

Presenters:

Philip Muskin, MD, FAPM, Columbia University, New York, NY

Juliana Ekong, MD, Amerigroup Community Care, New York, NY

Roger Kathol, MD, FAPM, Cartesian Solutions, Burnsville, MN

Abstract:

Historical tensions between behavioral health clinicians providing direct care (direct care clinicians) and behavioral health clinicians working directly in managed care (managed care clinicians) will have the opportunity to grow with the Affordable Care Act of 2010, i.e., health care reform. More people, significant numbers of whom are believed to have substance use and mental health disorders, are expected to enroll in managed care (Substance Abuse and Mental Health Services Administration, 2011), increasing the probability of interactions between direct care and managed care clinicians. While most managed care clinicians have been, or are, also direct care clinicians, few direct care clinicians have had the opportunity to work within managed care companies and as such may not understand how best to use their interactions with managed care clinicians to further the goals of excellent patient care.

This workshop will use the actual case of a hospitalized patient with dementia, psychosis, and alcohol dependence to highlight the ways in which a liaison between the managed care clinician and the consultation-liaison clinician helped realize the appropriate treatment, treatment setting, and discharge plan for a very ill patient (Dr. Muskin). We will discuss the difficulties inherent in determining the appropriate care setting for patients with dementia and psychosis in general, and how substance abuse further complicates the treatment picture. Dr. Ekong will highlight the structure, processes, and services provided by the behavioral health departments of managed care companies and discuss issues of medical necessity, utilization management, denials and appeals. Dr. Kathol will present how payment is processed by the health plan for the patient, step by step and service by service; describe the mechanics of how payment drives what payers are willing to do in promoting better or worse approaches to care. Finally, there will be a discussion of how the increased interactions between direct care and managed care clinicians should be sought out as opportunities to achieve optimal patient care and maintain the viability to consultation-liaison departments.

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WORKSHOP 9:
Managing High Risk Clinical Scenarios for the Inpatient Consultation Psychiatrist

Program Track: ICU/Acute Psych

Moderator (and "Overview"): James Stinnett, MD, University of Pennsylvania, Philadelphia, PA

Presenters:

Robert Weinrieb, MD, University of Pennsylvania, Philadelphia, PA
"Rapid Decision Tree for Management of Severe Posttransplant Neuropsychiatric Syndromes"

Lisa Rosenthal. MD, University of Pennsylvania, Philadelphia, PA
"Clozapine and the Immunocompromised Patient"

Benoit Dubé, MD, University of Pennsylvania, Philadelphia, PA
"HIV Diagnosis and Suicidality"

Deborah Kim, MD, University of Pennsylvania, Philadelphia, PA
"Using Antipsychotics in the Pregnant or Breastfeeding Patient"

Susan Rushing, MD, University of Pennsylvania, Philadelphia, PA
"My Patient Lacks Capacity, Now What? Assigning Surrogate Decision Makers in the Hospital Setting"

Abstract:

Hospital-based consultation psychiatrists are often faced with complicated, high-risk clinical scenarios in which making accurate, evidence-based assessments and recommendations will protect the patient from harm. These scenarios include complicated biological, legal, and ethical questions the consultation psychiatrist must efficiently work through to knowledgeably advise the consulting medical team. The ability to handle these scenarios supports the psychiatric consultant as useful and adept in the hospital setting. The goal of this workshop is to provide a framework for assessing and treating patients in high risk clinical situations by using several common case-based scenarios. All presenters are experienced members of the Hospital of the University of Pennsylvania's Psychosomatic Service which provides comprehensive inpatient and outpatient services to a large and diverse patient population. Each presentation will review the most recent data relevant to each topic. Case presentations and videos of live patients may be used to stimulate audience discussion.

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WORKSHOP 10:
Models of Providing Psychiatric and Mental Health Services to Palliative Care Patients: What Are the Needs, and Which Way Is the Correct Way: Navigating the Wilderness (presented by the APM Palliative Care SIG)

Program Track: Extremes of Life

Presenters:

Harold W. Goforth, MD, FAPM, Duke University Medical Center, Durham, NC
"Utilizing Combined Medicine/Psychiatry Training as a Model to Provide Mental Health and Psychiatric Care to Palliative Care Patients"

Scott Irwin, MD, The Institute for Palliative Medicine, San Diego, CA
"Mental health and Psychiatric Needs within Palliative Care, and Why a Dedicated Psychiatry Consultation Model Makes Sense"

Jon Levenson, MD, FAPM, New York Presbyterian Hospital-Columbia University AIDS Program, New York, NY
"Other Consultation Models in Palliative Care, and Tailoring Models to Address Specific Needs of Vulnerable Populations"

Abstract:

Increasingly, people are living longer and have multiple issues that cause suffering, interfere with their lives, and lead to an increased burden of disease with significant neuropsychiatric and psychosocial sequelae. The need for mental health providers to work with patients and families living with chronic life-threatening illnesses is expected to grow as the population ages. Experienced mental health providers are needed as consultants to, and members of, interdisciplinary palliative care teams to provide education and engage in research. However, the formal utilization of dedicated mental health providers in palliative care programs is unusual. This symposium seeks to address ways in which these needs may be more seamlessly integrated.

This interactive workshop will begin with Dr. Irwin providing an overview of the illness experience and defining palliative care and the roles for mental health providers. The second half of the symposium will be devoted to exploring different models by which mental health care can be delivered to those patients receiving palliative medicine.

Examples of such models include a) the practice of utilizing a combined internal medicine/psychiatry practitioner; b) a dedicated palliative care consultation-psychosomatic medicine specialist; or c) primarily focusing upon the provision of mental health and psychiatric care by either "de jour" consultation or by models that have been tailored to address specific needs such as those with HIV/AIDS.

Each practice style model will be presented in debate style fashion seeking to generate audience discussion on the benefits and weaknesses of each model and each's potential use among particular populations.

An opportunity for the audience to present questions and share their own experiences of providing mental health and psychiatric care to palliative patients will conclude the session.

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WORKSHOP 11:
Case Formulation in Psychosomatic Medicine and C-L

Program Track: Early Career

Chair: Harold Bronheim, MD, FAPM, Mount Sinai Medical Center, New York, NY

Presenters:

Michael Blumenfield, MD, FAPM, Westchester Medical Center, Valhalla, NY
"Formulation of the Adult"

Audrey Walker, MD, Montefoire Medical Center, Bronx, NY
"Formulation of the Child & Adolescent"

Abstract:

When rounds are conducted on busy medical/surgical units, rapid assessments are made of patients' diagnoses and treatment. Formulation is the overarching phrase that impels the psychiatric consultant to assimilate a vast array of medical, social, and psychological data, to assemble a unique understanding of why a particular individual caught as they are in a web of physical, neurophysiological, and psychological forces feels constrained to react or behave in a particular (often pathological) manner. Formulation as a unique psychiatric skill enjoys a long history of representing the core of what the psychiatric consultant understands of what is disrupting the patient's ability to cope normally.

In this workshop there will be two presentations on the subject of Formulation. The first will relate to Formulation in Adults. The second, which is far less frequently discussed, will be Formulation of the Child & Adolescent by an adolescent psychiatrist.

In both discussions the acute and chronic nature of the medical situation will be reviewed with respect to the kinds of threats faced, the range of coping mechanisms available and the sets of overvalued beliefs and cognitions, and age-specific behaviors that are manifested. Audience participation in the discussion of the formulating process will be encouraged.

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SYMPOSIUM 9:
Innovative Approaches to Clinical Care, Research, and Prevention in AIDS Psychiatry (presented by the APM AIDS Psychiatry SIG)

Program Track: Potpourri

Chair: Mary Ann Cohen, MD, FAPM, Mount Sinai School of Medicine, New York, NY

Discussant: John Grimaldi, MD, Harvard Medical School, Boston, MA

Presenters:

Jordi Blanch, MD, Clinical Institute of Neurociences, Hospital Clinic de Barcelona, Barcelona, Spain
"Clinical Experiences in Caring for Persons with AIDS on Efavirenz"

Kelly Cozza, MD, FAPM, Uniformed Services University, Washington, DC
and

Andrew Angelino, MD, Johns Hopkins University School of Medicine, Baltimore, MD
"Update on Neuropsychiatric Side Effects of Efavirenz—Report from the AP SIG Research Task Force"

Suad Kapetanovic, MD, National Institute of Mental Health, Bethesda, MD
"HIV-Associated CNS Vulnerability in the Antiretroviral Era"

Maria Ferrara, MD, University of Modena & Reggio Emilia, Modena, Italy
and

Silvia Ferrari, MD, University of Modena & Reggio Emilia, Modena, Italy
"The Inclusion of SMI on the HIV Indicator Disease List of the HIV in Europe"

Adriana Carvalhal, MD, McMaster University School of Medicine, Hamilton, ON, Canada
"Supervised Injection Sites and Other Preventive Measures in AIDS Psychiatry"

Abstract:

According to global estimates from the UNAIDS 2009 AIDS Epidemic Update, 33.4 million adults and children are living with HIV, with 2.7 million newly infected annually and 2 million dying of AIDS each year. More than 25 million people have died of AIDS since 1981. As of 2008, the AIDS pandemic had left behind 15 million AIDS orphans throughout the world. Unprotected sexual encounters and sharing of needles and drug paraphernalia are behaviors that account for most new HIV infections.

In areas of the world where there is access to competent HIV medical care and antiretroviral medication, AIDS has become more like other severe and complex medical illness. However, as with other such illnesses, the treatments are often accompanied by severe and devastating side effects. There is conflicting evidence about the neuropsychiatric side effects of antiretroviral therapy with efavirenz. The APM AIDS Psychiatry SIG Research Task Force reports the results of a study that was inspired by a member’s question about the side effects of efavirenz. The task force developed and implemented a current practice consensus survey to assess what experienced AIDS psychiatrists have observed in their patients.

A definitive correlation between antiretroviral therapy and preventing HIV-associated neurocognitive disorders and other CNS involvement is yet to be established. New research findings relevant to CNS exposure to HIV in utero, in childhood, and in adulthood will be reported.

While AIDS is similar to other severe and complex medical illnesses, it differs in its public health implications. We provide an update on preventive approaches to HIV transmission. Substance use disorders in HIV-infected individuals are associated with risk behaviors and affect both adherence to ARV treatment as well as immunologic and virologic responses to the treatment. The Canadian approach to harm reduction will be described in the settings of safe injecting facilities, “seek and treat” programs, and other community-based interventions. The European approach to prevention includes adding SMI to the HIV indicator disease list.

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SYMPOSIUM 10:
Could There Be a Unifying Explanation for Medically Unexplained Symptoms?

Program Track: Women's Issues and Somatoform Disorders

Presenters:

Cynthia Stonnington, MD, Mayo Clinic, Scottsdale, AZ

J. Michael Bostwick, MD, FAPM, Mayo Clinic, Rochester, MN

A.D. (Bud) Craig, PhD, Barrow Neurological Institute, Phoenix, AZ

Shirlene Sampson, MD, MS, Mayo Clinic, Rochester, MN

Abstract:

Functional somatic syndromes (FSS) and medically unexplained symptoms are variously diagnosed and treated, depending on the patient's phenotypic presentation and clinical practice of the particular specialist, e.g., fibromyalgia in rheumatology, medically unexplained vomiting/abdominal pain and irritable bowel syndrome in gastroenterology, functional movement disorders, behavioral spells, and functional paralysis in neurology. As an update to a previously very well-attended APM symposium ("Confronting the Elephant in the Room: Identifying Emotional Processing Deficits in Functional Somatic Syndromes and Somatoform Disorders," November 2009), the panel will present recent findings that suggest a paradigm shift in the way we conceptualize these patients.

Dr. Stonnington will present the results from a recent study that explored and compared measures of emotional processing and theory of mind in 30 patients with FSS, 29 conversion disorder patients, and 30 medically ill controls, all with the same level of physical symptoms. The results from this outpatient population in Arizona, which show differences in somatoform patients from the medical controls in certain theory of mind tasks involving emotional content, replicated and extended findings from a previous study of inpatients with somatoform disorder and healthy controls in Germany.

Dr. Bostwick will discuss delusions of parasitosis as an outcome of the attempt to make sense of physical sensations that have no logical or immediate explanation.

Dr. Craig will present neuroanatomical evidence for the progression of integrative representations of affective feelings from the body, with particular attention to the organization of the mid-insula and anterior-insula and its brain pathways.

Dr. Sampson, drawing from both her own and others' work, will present a neuropsychiatric hypothesis of centrally augmented and maintained physical symptoms (CAMPS), which may provide a unifying neuropsychiatric explanation for patients with medically unexplained symptoms across multiple medical specialties.

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FRIDAY, NOVEMBER 18, 2011   3:45–5:45 pm  Workshops 12–15, Symposia 11–13

WORKSHOP 12:
Screening Tools in Outpatient Psychosomatic Medicine Clinics: The Good, the Bad, and the Ugly

Program Track: Conference Theme A

Presenters & Panel:

George Tesar, MD, Cleveland Clinic, Cleveland, OH

Leo Pozuelo, MD, FAPM, Cleveland Clinic, Cleveland, OH

Kathy Coffman, MD, FAPM, Cleveland Clinic, Cleveland, OH

Elias Khawam, MD, Cleveland Clinic, Cleveland, OH

Mayur Pandya, DO, Cleveland Clinic, Cleveland, OH

Abstract:

Psychosomatic medicine, as other disciplines, is increasingly being challenged to demonstrate "value added" to patient care as well as measure outcomes. The use of screening tools and measurement instruments in outpatient subspecialty psychosomatic medicine clinics poses unique opportunities and challenges.

In this interactive workshop, we will first review the current indications and rationale of screening tools such as the PHQ-9, GAD-7, and the European Quality of Life (EQ5D). We will then share cross-sectional data across the outpatient psychosomatic medicine populations of transplant, multiple sclerosis, movement disorders, preventive cardiology, arrhythmia cardiology, and epilepsy patients. This will be followed by a more focused look at the experience of a busy C-L psychiatrist in the implementation of these tools. Finally, we will discuss the nuances, pitfalls, and lessons learned with these distinct outpatient psychosomatic medicine populations. A panel audience discussion will close out the workshop.

The ultimate goal of the workshop is to empower the community C-L psychaitrist to implement and/or perfect screening tools and measurements in their respective outpatient PM clinics.

Agenda:

  1. Instruments and Implementation (Dr. Tesar)
    1. Patient and clinician rated scales
    2. Rationale and goals of screening
    3. Knowledge Program© experience at the Cleveland Clinic
  2. Outpatient PM clinic data (Dr. Pozuelo)
    1. Implementation of the PHQ-9, GAD-7, and EQ5D
    2. Cross-sectional and follow-up data across six outpatient subspecialty PM clinics
  3. Experience in a busy outpatient subspecialty PM clinic (Dr. Coffman)
    1. From pen and paper, to electronic tablets
    2. Patient acceptance and compliance issues
    3. Use in the clinical encounter
  4. Nuances, pitfalls, lessons learned with distinct patient populations (Drs. Khawam and Pandya)
    1. Individual psychiatric characteristics of each population
    2. Other patient specific scales and recommendations
    3. Clinical applicability to the community-based C-L psychiatrist
  5. Audience Panel Discussion (All)

Data Sample of New Visits with Median Scores of PHQ-9*, GAD-7**, EQ5D***

Outpatient PM Clinic # of patients PHQ-9 GAD-7 EQ5D
Transplant 180 9 6 0.71
Multiple Sclerosis 19 13 8 0.60
Movement Disorder 180 9   0.60
Cardiology Arrhythmia 19 10 9 0.57
Cardiology Preventive 85 10 9 0.71
Epilepsy 271 7 5 0.80
* Statistical Difference seen in Cardiology Preventive more depressed than Epilepsy
** Statistical Difference seen in Cardiology Preventive more anxious than Epilepsy
    Cardiology Preventive more anxious than Transplant
*** Statistical Difference seen in Epilepsy higher quality of life compared to Transplant

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WORKSHOP 13:
Preparation for the "Real World": A Transition to Practice Workshop

Program Track: Early Career

Presenters:

Christina Wichman, MD, Medical College of Wisconsin, Milwaukee, WI

Amy Christianson, MD, Cedars Sinai Medical Center, Los Angeles, CA

Lucy Hutner, MD, Columbia University, New York, NY

Sandra Rackley, MD, Children's National Medical Center, Washington, DC

Sanjeev Sockalingham, MD, University of Toronto, Toronto, ON, Canada

Thomas Heinrich, MD, FAPM, Medical College of Wisconsin, Milwaukee, WI

Maryland Pao, MD, FAPM, National Institute of Mental Health, Bethesda, MD

James Rundell, MD, FAPM, Mayo Clinic, Rochester, MN

Theodore Stern, MD, FAPM, Massachusetts General Hospital, Boston, MA

Abstract:

The transition to practice is a time of great turmoil for many residents and fellows. Many trainees express an interest in having guidance around pragmatic considerations of this transition. However, many existing "transition to practice" curricula or workshops may not adequately answer practical questions for individuals hoping to pursue careers in psychosomatic medicine. In this workshop, we will explore practical issues such as networking and mentoring, CV preparation, career options, how to locate a job, and interviewing and negotiation skills.

The first 20-30 minutes, led by Dr. Wichman, will be spent in large group didactics/discussion and will provide an overview on all of these areas, as well as giving resources as to where to find more information on these topics. Participants will then be given the opportunity to choose between three small groups for more focused discussion:

  1. CV Preparation and Interviewing Skills (led by Drs. Heinrich, Pao, and Sockalingham)
  2. Negotiation and Contracts (led by Drs. Christianson, Hutner and Rundell)
  3. How to Find Your First Job... and Your Next One (led by Drs. Rackley, Stern, and Wichman)

An early career panellist, as well as mid-to-late career panellist, will co-lead each small group discussion in order to provide depth and a wide range of experience to each discussion, as well as provide ample opportunity for networking. After 30 minutes of small group discussion, participants will rotate to a secondary group of their choosing for an additional 30 minutes, in order to give further exposure to these topics.

During the last 15-20 minutes of the workshop, the small groups will reconvene. Time will be dedicated to questions that arose in small group discussion, as well as providing resources on transition-to-practice topics for our participants.

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WORKSHOP 14:
“What am I gonna do now?”: The Management of Suicidal Ideation in the Terminally Ill and Disenfranchised Patient

Program Track: Extremes of Life

Presenters:

Emily Gastelum, MD, Columbia University, New York, NY

Linda Ganzini, MD, FAPM, Portland VA Medical Center, Portland, OR

Rebecca Brendel, MD, JD, FAPM, Harvard University, Boston, MA

Philip Muskin, MD, FAPM, Columbia University, New York, NY

Abstract:

Psychiatrists are often called to assess safety in medically ill patients who express suicidal ideation upon being diagnosed with a terminal illness. This wish to die may be shared in many contexts. Patients may be in the midst of a severe depression which is independent of their medical diagnosis or which is a complication of another medical illness. Patients may express the wish, possibly with a plan, to die as a means of exerting control in the face of uncertainty about when and what circumstances will surround their death (e.g., fear of being in pain at the end of their lives). Patients may never have consciously considered the meaning death holds for them, and experience diagnosis of a terminal illness as an overwhelming, infuriating or frightening narcissistic injury. Other patients may already be so overwhelmed with social stressors (e.g., poverty, lack of adequate medical insurance, immigration issues, social isolation) that they experience a terminal diagnosis as truly too much to bear.

The approach to the patient who wishes to prematurely end his or her life after receiving a terminal diagnosis requires careful understanding of the biological, psychological, and social factors which are contributing to the patient’s suicidal ideation. The biopsychosocial model provides a framework for psychiatric consultants to assess such patients and target interventions.

Dr. Gastelum will present a case of a patient for whom a psychiatric consultation was requested. The patient had an ultimately terminal, but in the short term treatable, medical illness and upon learning his diagnosis expressed suicidal ideation with a highly lethal plan to shoot himself. In assessing this patient, it was clear that a complex array of biological, psychological, and social stressors were at work, presenting the consultant with the difficult task of how to address these issues in the context of an impending discharge. During the course of the consultation the task of the consultant altered, which will be discussed.

The case will be discussed from three perspectives:

  1. Assessment and utilization of resources/systems for elderly, ill, disenfranchised patients—Dr. Ganzini
  2. Social factors which overwhelm our patients and our system of care and how to begin an intervention in the hospital and make a bridge to a stable enough outpatient situation— Dr. Brendel
  3. Psychodynamic issues potentially at work in such a patient and how to intervene briefly in the hospital and make a bridge to an outpatient psychiatrist/therapist—Dr. Muskin

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WORKSHOP 15:
Novel Telepsychiatry Applications in Psychosomatic Medicine (presented by the APM Telepsychiatry SIG)

Program Track: Conference Theme B

Presenters:

Terry Rabinowitz, MD, FAPM, Fletcher Allen Health Care/University of Vermont, Burlington, VT

Nanette Concotelli, MD, University of New Mexico, Albuquerque, NM

M. Cornelia Cremens, MD, FAPM, Massachusetts General Hospital/Harvard Medical School, Boston, MA

Carol Larroque, MD, University of New Mexico, Albuquerque, NM

Megan Olden, MD, Weill Cornell Medical College, New York, NY

Donald Rosenstein, MD, FAPM, University of North Carolina at Chapel Hill, Chapel Hill, NC

Kathy Sanders, MD, FAPM, Massachusetts General Hospital/Harvard Medical School, Boston, MA

Abstract:

The types and numbers of telemedicine applications have increased steadily since this modality was first introduced in the 1960s. Telepsychiatry is commonly used to provide care to patients who cannot visit with providers face-to-face due to long distances and/or inability to travel. However, its use by C-L psychiatrists has been more limited.

Last year, the first workshop about telepsychiatry in psychosomatic medicine was presented at the APM annual meeting. Its intention was to describe some telepsychiatry approaches and to allow attendees to use state-of-the art telemedicine equipment under the expert guidance of telemedicine technicians. The workshop was well-attended and well-received. Thus, our goal this year is to follow up on that workshop with one that will describe several novel telepsychiatry applications by real users of this technology and to allow attendees to ask questions about its use as well as to generate ideas for further innovative applications.

This workshop, presented on behalf of the APM Telepsychiatry SIG, will include 5-7 short (approx. 15 minute) presentations about some novel telepsychiatry (TP) applications relevant to C-L psychiatry/psychosomatic medicine including the use of videoconference to: 1) deliver psychiatric care to nursing home residents, 2) provide consultation and treatment to veterans and others with PTSD, 3) provide "group therapy" to adolescents with cystic fibrosis who, because of the risk of cross contamination, cannot be in the same room with each other, 4) provide supervision of psychiatry residents and fellows at multiple distant sites, 5) provide psycho-oncology consultations and to train cancer support group leaders from a distance, and 6) provide psychiatric services to elders at their homes. Where possible, these oral presentations will be enhanced with video clips of relevant TP encounters. There will also be time allotted for questions and audience participation.

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SYMPOSIUM 11:
Understanding and Treating Multiple Somatic Symptoms in Non-Psychiatric Settings

Program Track: Women's Issues and Somatoform Disorders

Presenters:

Kurt Kroenke, MD, Regenstrief Institute, Indianapolis, IN

Francis Creed, MD, University of Manchester, Manchester, United Kingdom

Michael Sharpe, MD, FAPM, University of Edinburgh, Edinburgh, United Kingdom

Wayne Katon, MD, FAPM, University of Washington School of Medicine, Seattle, WA

Abstract:

This symposium addresses the problem of numerous somatic symptoms in patients attending cancer, neurology units, and primary care. It aims to highlight the importance of detecting and treating these symptoms in populations, which have little or no contact with psychiatrists. We shall explore the impact these symptoms have on outcome and illustrate the potential gain of treating psychological disorders on medical symptom burden in non-psychiatric settings.

Dr. Kroenke will report on the prevalence and impact of somatic symptoms in a prospective study of patients with cancer experiencing pain and/or depression. Cross-sectional and longitudinal analyses revealed a high burden of somatic symptoms regardless of type or stage of cancer and persistence of symptoms over 12 months in many patients. Somatic symptoms were not only strongly associated with depression and anxiety but also an independent predictor of functional impairment and disability days after controlling for psychiatric comorbidity. The management implications of somatic symptoms in cancer patients will be discussed.

Dr. Creed will present a prospective cohort study in a population-based sample registered with two UK general practices (n=1443). Twenty-one per cent of participants scored over 25 on the Somatic Symptom Inventory (SSI) at baseline; 14% did so at both baseline and follow-up. A persistent high SSI was predicted by reported childhood psychological abuse, recent illness/death of a close relative, <12 years of education, co-exisiting medical illness, anxiety and depression. In multivariate analysis, which adjusted for confounders (n=741), baseline SSI predicted health status (SF12 Physical component score and EUROQOL) 12 months later.

Dr. Sharpe will present data on the characteristics, outcome, and determinants of one year outcome in 1,114 patients with medically unexplained symptoms attending neurology clinics. At outcome very few patients had developed neurological disease. Subjective outcome was available on 716 patients. Poor outcome was reported by 482 (67%). Independent baseline predictors were patients' beliefs [expectation of non-recovery (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.40-2.96), non-attribution of symptoms to psychological factors (OR 2.22, 95% CI 1.51-3.26)] and the receipt of illness-related financial benefits (OR 2.30, 95% CI 1.37-3.86). Together, these factors predicted 13% of the variance in patient rated outcome.

Dr. Katon will illustrate ways psychological factors can affect somatic symptom perception in patients with chronic medical illness, describe the bidirectional effects of pain and depression, and present studies that show that enhancing depression outcomes of patients with chronic medical illness can decrease the medical symptom burden that these patients experience.

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SYMPOSIUM 12:
Management of Alcohol Abuse, Withdrawal, and Dependence: A Practical Guide for Psychosomatic Medicine Specialists

Program Track: ICU/Acute Psych

Presenters:

Jose Maldonado, MD, FAPM, Stanford University, Stanford, CA

Joji Suzuki, MD, Harvard Medical School, Boston, MA

Abstract:

Alcohol use disorder (AUD) is the most serious substance abuse problem in the United States and worldwide. Alcoholism has been reported in 20% to 50% of hospitalized medical patients. Most of the alcohol dependent patients admitted to the general medical wards will develop alcohol withdrawal symptoms, significant enough to require pharmacological intervention regardless of the cause for admission. Alcohol abuse and withdrawal are associated with an increased risk for medical comorbidities (e.g., infections; cardiopulmonary insufficiency; cardiac arrhythmia; bleeding disorders; need for mechanical ventilation) and longer, more complicated hospital and ICU stays making it particularly important for psychosomatic medicine specialists to be adept in the recognition and management of alcohol dependence and withdrawal states.

Alcohol renders its depressant central effects through its agonistic effect on GABAA receptors primarily in the cerebral cortex, medial septal neurons, and hippocampal neurons. But it is through its disinhibition of GABA-mediated dopaminergic-projections to the ventral tegmental area, leading to increases in extracellular dopamine in the nucleus accumbens, that it mediates the initially pleasurable effects of alcohol and thus the impulse to drink more.

The development of alcohol tolerance is a neuroadaptive process directed at reducing the acute effects of alcohol and thereby providing homeostasis via an adaptive suppression of GABA activity, mediated by internalization and down regulation of GABAA-BZ receptor complexes; increased synaptic glutamate release; and overactivity of noradrenergic neurons in the CNS and the peripheral nervous system. The symptoms of alcohol withdrawal syndromes (AWS) are then associated with abnormalities in the levels of NE (i.e., symptoms of autonomic hyperactivity, DA (i.e., agitation & psychosis), and GLU (i.e., seizures). Certainly the use of benzodiazepines and other GABAergic agents (e.g., barbiturates, propofol) can lead to suppression of excess activity of all these neurotransmitters and associated receptors, but at a high cost: significant neurological (e.g., ataxia), medical (e.g., respiratory depression), and cognitive (e.g., amnesia, delirium) impairment; as well as possible development of iatrogenic benzodiazepine dependence.

This symposium will review the neurobiology of alcohol dependence and neurochemical mechanisms of withdrawal and address the state of the art regarding the use of benzodiazepine and explore the potential of non-benzodiazepine agents (i.e., anticonvulsants, antipsychotics, and alpha-2 agonists) in the management and treatment of AWS. We will examine the available evidence for their effectiveness and compare these results to what benzodiazepines can do; highlighting advantages and pitfalls in treatment. We will also discuss the pharmacological and non-pharmacological treatment of alcohol dependence and methods to manage cravings and prevent recidivism. The currently available treatment options for alcohol dependence will be summarized and reviewed, covering acamprosate, naltrexone, and disulfiram. The evidence on treatment integration with non-pharmacologic interventions will also be reviewed, with a particular focus on cognitive-behavioral therapies and motivational interviewing.

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SYMPOSIUM 13:
At the Cutting Edge: Transplant, Technology, and Organ Replacement Therapy

Program Track: Potpourri

Presenters:

Sheila Jowsey, MD, FAPM, Mayo Clinic, Rochester, MN
"Hand Transplantation"

Kathy Coffman, MD, FAPM, Cleveland Clinic, Cleveland OH
"Face Transplantation"

Michael Marcangelo, MD, University of Chicago, Chicago, IL
"Replacement Therapies"

Mary Amanda Dew, PhD, University of Pittsburgh, Pittsburgh, PA
"Kidney Exchange Programs"

Abstract:

Hand Transplantation (Dr. Jowsey): Hand transplantation is increasingly viewed as an acceptable option for improving functional outcomes and quality of life for both unilateral and bilateral amputees with several U.S. centers starting hand transplant programs in 2011. The role of psychiatry in assessing and treating this population of patients will be discussed including a discussion of alternatives to transplantation, weighing the risks of life-long immunosuppressive therapy for physically healthy patients and a review of psychiatric sequelae from the world experience in hand transplantation The assessment of amputees' experience with bioelectric prostheses prior to transplantation will be reviewed and a proposed multicenter standardized evaluation protocol will be discussed.

Face Transplantation (Dr. Coffman): Face transplantation has been performed now at two centers in the US and several centers in Europe providing a fundamental change in the management of patients with devastating facial injuries and deformities. Face transplant incorporates new strategies for reconstructing the face while raising many challenging questions about recipient identity, donor identification and risk-benefit considerations. Initial outcomes have been notable for improved function and social reintegration. This presentation will provide an overview of the Cleveland Clinic experience and address the evaluation and ongoing assessment of the face transplant recipient.

Replacement Therapies (Dr. Marcangelo): Heart and liver replacement therapies continue to present the potential for life saving strategies for patients unable to proceed with transplantation or to provide a bridge to transplantation. The risks and benefits of these strategies are continuing to evolve while the waitlist for organs continues to lengthen. The decision to proceed with transplantation following successful placement of a left ventricular assist device LVAD[MAD1] raises questions about potential risks from transplantation in patients no longer experiencing end organ symptoms. The capacity for very ill patients to understand these complex medical options and the post-implantation psychiatric sequelae will be reviewed.

Kidney Exchange Programs (Dr. Dew): The increasing organ shortage has resulted in waiting times for deceased donor transplantation of many years. Until recently, transplant candidates with willing but unmatched prospective donors were unable to be transplanted. Computer algorithms have enabled matching of unrelated potential donors to generate donor exchanges for otherwise unmatched recipients. Donor exchanges initiated by nondirected donors have resulted in multiple unrelated donor-recipient pairs proceeding with transplantation, resulting in more available deceased donor organs for other recipients as exchange pair recipients move off the list. The logistical and practical challenges of matching the pairs in the exchange will be reviewed, and the psychological and ethical issues for the nondirected donor and other unrelated donors will be discussed.

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SATURDAY, NOVEMBER 19, 2011   2:15–4:15 pm   Workshops 16–18, Symposia 14–15

WORKSHOP 16:
"Evaluate for Capacity": Identifying and Addressing Underlying Ethical Dilemmas in the Capacity Assessment Request

Program Track: Extremes of Life

Presenters:

Laura Dunn, MD, University of California, San Francisco, San Francisco, CA

Jewel Shim, MD, University of California, San Francisco, San Francisco, CA

Kristen Brooks, MD, University of California, San Francisco, San Francisco, CA

Laura Roberts, MD, FAPM, Stanford University, Stanford, CA

Scott Kim, MD, PhD, University of Michigan, Ann Arbor, MI

Abstract:

Consultations are frequently requested for capacity assessment. However, further inquiry into the basis for such requests often uncovers underlying difficult medical and ethical dilemmas. Often, the requesting service has not identified these issues and may need the PM psychiatrist’s help in developing an approach to handling these. Therefore, to address these issues, this workshop will pose the following questions:

  1. What is the ideal role for PM psychiatrists in requests for capacity assessments?
  2. How can we best help our medical colleagues identify the core underlying issues and unstated needs (e.g., physician or nurse distress) that may drive capacity assessment requests?
  3. What are best practices for teaching capacity assessments to medical colleagues and PM trainees?

These questions and related issues will be illustrated using three actual consultations that highlight the challenges involved in providing care to patients whose capacity to make medical decisions may be compromised.

Case 1:  A 40-year-old woman with an intellectual disability refused a medically indicated corneal transplant for an eye abrasion and infection—risking loss of the eye, severe infection, or even death. The patient’s mother and treating team believe that one reason for the patient’s refusal might relate to her desire for a glass eye (a possible alternative) for its novelty. Consultation request: “Evaluate for capacity.”

Case 2:  An elderly male with multiple medical comorbidities and global treatment non-adherence presents repeatedly to the ED with complaints of chest pain, but then refuses work-up or admission. Consultation request: “Assess for capacity” and “conserve this patient.”

Case 3:  An ICU patient, who suffers from an idiopathic and extremely debilitating skin condition, screams at every dressing change, causing significant distress for nurses. Consultation request: “Assess for capacity.”

A panel of PM psychiatrists and ethics experts will facilitate this interactive exploration of ethical conflicts that arise in considering cases involving both treatment refusal and treatment acceptance. We will discuss the role of the PM psychiatrist in assisting clinicians resolve these dilemmas, as well as consider the issue of who can and should assess capacity. The relationship of capacity standards to risk level and the nature of the decision under consideration will be addressed. We will discuss, and solicit from workshop participants, clinical pearls for helping clinicians (both psychiatrists and non-psychiatrists) with the challenges of caring for patients with impaired capacity. Finally, we will synthesize these elements into a “best practices” model for effective teaching of thoughtful and comprehensive capacity evaluation to PM trainees and non-psychiatric colleagues.

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WORKSHOP 17:
Writing and Publishing 101

Program Track: Early Career

Presenters:

Lewis Cohen, MD, FAPM, Baystate Medical Center, Springfield, MA

Maryland Pao, MD, FAPM, NIH/NIMH, Bethesda, MD

James Levenson, MD, FAPM, Virginia Commonwealth University School of Medicine, Richmond, VA

Abstract:


"I get a fine warm feeling when I'm doing well, but that pleasure is pretty much negated by the pain of getting started each day. Let's face it, writing is hell."

— William Styron
 

"A writer is someone for whom writing is more difficult than it is for other people."

— Thomas Mann
 

"The secret to being a writer is that you have to write. It's not enough to think about writing or to study literature or plan a future life as an author. You really have to lock yourself away, alone, and get to work."

— Augusten Burroughs


This workshop is designed for both beginning and more senior attendees to the Academy who have a desire to write and publish. While much of the focus will be on preparing papers, chapters, and books for an academic audience, it is also intended to convey lessons for those who aspire to write for the general public.

Dr. Levenson is a prolific author and the newly appointed North American editor of the Journal of Psychosomatic Research. He has also edited the American Psychiatric Publishing Textbook of Psychosomatic Medicine and Essentials of Psychosomatic Medicine among other textbooks. Dr. Levenson will describe from an editor's perspective how authors can submit articles that cry out to be published, or alternatively, the common flaws and errors that contribute to rejections.

In addition to being an author or coauthor of more than 60 medical publications, Dr. Pao has mentored numerous residents and fellows as they attempted to prepare manuscripts for publication or poster presentations. She will describe what she has learned about organizing and compiling research findings and other valuable tips for novice authors.

Dr. Cohen is a recipient of a Guggenheim Fellowship that facilitated publication of his first non-fiction book for the general public. He will describe the process of preparing a formal proposal, securing the services of a literary agent, and working with a lay publishing company.

Especially for those individuals who are attending their first meeting of the Academy, this session will provide a rare opportunity to have a candid conversation with three experienced Fellows. The workshop will be shaped by the questions and interests of the audience, but topics will likely include: determination of authorship order, resolution of conflicts, selection of a journal, and how to acquire a lay publisher. Given William Styron's quotation above, the workshop will also attempt to answer why we are driven to write!

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WORKSHOP 18:
Creating a Vision for Psychiatric Services in Patient-Centered Medical (Healthcare) Homes

Program Track: Conference Theme B

Presenters:

Roger Kathol, MD, FAPM, University of Minnesota, Minnepolis MN

Lori Raney, MD, Axis Health Systems, Durango, CO

David Katzelnick, MD, Mayo Clinics School of Medicine, Rochester MN

Jurgen Unützer, MD, MPH, University of Washington, Seattle WA

Abstract:

The thrust of this workshop will be to help the audience create a vision for the type of things that psychiatrists should be thinking about when they decide to participate in care in patient-centered medical (healthcare) homes (PCMHs).

  • How should they suggest that their talents and those of other mental health (MH) team members be used to support MH and chemical dependence (CD) services in PCMHs, e.g., roles, responsibilities, leadership?
  • Which patients should they target for care, e.g., illness-focused, complexity-focused, referrals only?
  • Who should be a part of their mental health/chemical dependence teams, e.g., nurses, social workers, psychologists, CD counselors, care managers?
  • How would MH teams add value to primary care (PC) physicians and their patients, e.g., less hassle, improved outcomes, lower cost?
  • How should they be paid, e.g., medical benefits, behavioral benefits, salaried, RVU-based?
  • How do their services coordinate/interact with other PCMH services?
  • Do they provide primary support for “health behavior” improvement, e.g., adherence, diet, medications, exercise, in addition to MH and CD treatment?

Presentations and Discussion: After Dr. Kathol provides background about general components of behavioral health and its relationship to PCMHs and PCMHs’ role in the development of accountable care organizations (ACOs), Drs. Raney, Katzelnick, and Unützer will the summarize thoughts about psychiatric participation in PCMHs from the perception of a rural community psychiatrist (Raney—Durango, CO), a psychiatrist charged with integrating psychiatric care in PCMHs at an established private health system (Katzelnick—Mayo), and a psychiatrist with extensive knowledge about personnel training and delivery of depression services in primary care settings (Unützer—University or Washington).

Each speaker will provide their personal/organizational vision of psychiatrists’ role in PCMHs during 15-minute presentations. These will be followed by discussion/dialogue among workshop participants about important next steps for consultation psychiatrists as they position themselves to participate in healthcare as ACOs and PCMHs become a central part of the new healthcare practice environment.

Objectives: At the completion of the workshop, participants should understand:

  1. Contributions that psychiatrists can make to PCMHs and ACOs and how they should be included in their formulation
  2. Core components of and targeted patients for value-added psychiatric “team” services that should be considered for inclusion in PCMHs
  3. Organizational and fiscal barriers preventing psychiatric involvement in PCMHs
  4. Steps for consultation psychiatrists to take in fostering psychiatric involvement in PCMHs

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SYMPOSIUM 14:
ICU Psychiatry: Approaches to Critical Care at Academic and Community-Based Hospitals

Program Track: ICU/Acute Psych

Presenters:

Jose Maldonado, MD, FAPM, Stanford University Medical Center, Stanford, CA
"Diagnostic Challenges Posed by Critical Illness: Delirium, Pain, Depression, and Anxiety/Acute Stress Disorder"

Robert Stern, MD, Emerson Hospital, Concord, MA
"Psychiatric Care in Critical Care Units of Community Hospitals"

Shamim Nejad, MD, Massachusetts General Hospital, Boston, MA
"Psychopharmacological Approaches to Critically Ill Patients"

Theodore Stern, MD, FAPM, Massachusetts General Hospital, Boston, MA
"Nonpharmacological Approaches to ICU Patients, Their Families, and Clinical Staff"

Dimitry Davydow, MD, University of Washington, Seattle, WA
"Outcomes and Quality of Life Following an ICU Stay"

Abstract:

With more than 500,000 critically ill individuals in intensive care units (ICUs) across the country, thoughtful approaches to care are required. Given recent advances in critical care, more and more patients are surviving their ICU experience after sustaining severe physiological stress; however, concerns about long-term neuropsychiatric effects of this exposure have arisen. Guidelines for timely and effective evaluation, diagnosis, and treatment will be discussed, and collaborative strategies to improve care will be reviewed.

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SYMPOSIUM 15:
Management of Depression in Heart Disease in Different Cardiac Care Settings: The Changing Role of a Psychosomatic Psychiatrist

Program Track: Conference Theme A

Chair & Moderator: Hochang Benjamin Lee, MD, FAPM, Johns Hopkins University School of Medicine, Baltimore, MD

Discussant: Peter Shapiro, MD, FAPM, Columbia University, New York, NY

Presenters:

Jeff Huffman, MD, FAPM, Massachusetts General Hospital, Boston, MA
"Impact of Depression Care Management Program for Hospitalized Cardiac Patients: Role of the PM Psychiatrist in the Inpatient Setting"

Leopoldo Pozuelo, MD, FAPM, Cleveland Clinic, Cleveland, OH
"Development and Management Cardiovascular Behavioral Medicine Clinic at a Tertiary Hospital: Role of the PM Psychiatrist in the Specialty Outpatient Setting"

Hochang Benjamin Lee, MD, FAPM, Johns Hopkins University School of Medicine, Baltimore, MD
"Screening and Detecting for Depression in Patients Undergoing Percutaneous Coronary Interventions: Role of the PM Psychiatrist in the Cardiac Catheterization Laboratory"

Bruce Rollman, MD, MPH, University of Pittsburgh School of Medicine, Pittsburgh, PA
"Telephone-delivered Collaborative Care for Heart Failure: New Directions"

Abstract:

This symposium is a follow-up to last year's successful symposium titled, "From Mechanisms to Treatment in Depression in Cardiovascular Disease (CVD): From Bench to Bedside." This time each speaker will focus on the delivery of psychiatric care for depression in CVD in different practice settings (inpatient, outpatient, primary care, and cardiac catheterization laboratories) by reviewing the pertinent literature and/or presenting the latest findings from their own studies. Despite burgeoning recent literature on psychiatric aspects of CVD, the role of the PM psychiatrist has gradually diminished in the depression-CVD field. By highlighting the role of the PM psychiatrist in each setting, this symposium aims to examine and re-establish the PM psychiatrist's role in management of depression in different cardiac settings.

Dr. Huffman will present the findings from his recent study which examined the impact of a depression care management program for hospitalized cardiac patients at MGH and discuss the traditional role of general hospital consultation-liaison psychiatrist.

Dr. Pozuleo will discuss the development and evolution of the Cardiovascular Behavioral Medicine Clinic at Cleveland Clinic and the pitfalls and triumphs of working with CVD patients, cardiologists, and cardiac surgeons as a PM psychiatrist in a specialty clinic.

Dr. Lee will discuss the potential role of a PM psychiatrist in screening, detecting, and treating depression in CVD patients who are undergoing cardiac catheterization.

Dr. Rollman will discuss his ongoing research work related to telephone-delivered collaborative care for patients with cardiovascular disease. His presentation will emphasize his team's most recent work with heart failure patients that builds on their prior research on post-CABG depression, and provide his perspective on the role of psychiatry for managing these medically complex patients in primary care.

Finally, Dr. Shapiro will discuss the potential implications of the above presentations and project the future roles of PM psychiatrists in psychiatric care of CVD patients in the rapidly changing health care system.

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SATURDAY, NOVEMBER 19, 2011   4:30–6:30 pm   Workshops 19–21, Symposium 16

WORKSHOP 19:
Training Physicians to Improve Communication and Reduce Disruptive Behaviors

Program Track: ICU/Acute Psych

Presenters:

Philip Bialer, MD, FAPM, Memorial Sloan-Kettering Cancer Center, New York, NY

Steve Epstein, MD, FAPM, Georgetown University Hospital and School of Medicine, Washington, DC

Linda Worley, MD, FAPM, University of Arkansas Medical Sciences, Little Rock, AK

Abstract:

Psychosomatic medicine psychiatrists are particularly qualified to train physicians to improve communication skills and reduce disruptive behaviors. This workshop will consist of presentations on three successful programs, including: how the programs were initiated; program delivery strategies; funding sources; the role of a PM psychiatrist; and data on outcomes. Faculty will present on their experiences in the following programs and the workshop will conclude with audience participation in role-playing exercises.

COMSKIL Program of the Memorial Sloan-Kettering Cancer Center (Dr. Bialer)

The Comskil (Communication Skills) Program, which was developed by the Department of Psychiatry at MSKCC, addresses challenging communication situations in the cancer setting. The core teaching modules include Shared Decision Making about Treatment Options, Discussing Prognosis, End of Life Discussion, Responding to Patient Anger and Unanticipated Adverse Events. PowerPoint presentations of each module include background material and specific communication strategies and skills that are modeled by senior faculty in videos embedded in the presentation. Experiential role play using prepared scenarios and simulated patients follows. The role play is co-facilitated by one of over 40 trained specialty-specific clinicians and a Psychiatry faculty member. Video recording of the role play is used to enhance the feedback. Approximately 90-100 Oncology fellows are trained each year in addition to biannual faculty trainings.

Georgetown University Hospital Physician Patient Communication Program (Dr. Epstein)

This program offers small group interactive training in communication skills for attendings and residents. Six core faculty, led by a PM psychiatrist, have provided training for over 500 physicians. Training consists of a didactic presentation followed by role-playing of challenging communication scenarios, e.g., difficult patient encounters, breaking bad news. The program has recently expanded to include individualized coaching for physicians with more problematic communication behaviors.

Vanderbilt Center for Professional Health Course for Distressed Physicians (Dr. Worley)

The Vanderbilt Distressed Physicians’ course is offered quarterly for six participant physicians whose disruptive behavior has become problematic. Many attend under duress to meet an external hospital or medical board requirement to maintain practice privileges. In the initial three days, faculty help the physicians tie together elements including learning ones’ own triggers, the flooding response, gaining control skills, communication skills, and empathy exercises role playing the situations that got them into trouble followed by practice doing the interaction differently. The physicians return three additional times throughout the subsequent six months to reinforce gains made in improving both their emotional intelligence and their interpersonal skills. Pre- and post-course 280-degree evaluations are conducted to increase self awareness and to measure behavioral change. Over 100 physicians have participated in this course since 2004 and have been referred from throughout the country.

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WORKSHOP 20:
Doing Research; Tips, Tricks, and Inspirational Stories from the Coal Face (presented by the APM Research Committee)

Program Track: Early Career

Moderator: Michael Sharpe, MD, FAPM, University of Oxford, Oxford, United Kingdom

Presenters:

Jennifer Knight, MD, Medical College of Wisconsin, Milwaukee, WI

Dimitry Davydow, MD, University of Seattle, Seattle, WA

Sherwood Brown, MD, University of Texas Southwestern Medical Center, Dallas, TX

Teresa Rummans, MD, FAPM, Mayo Clinic, Rochester, MN

Abstract:

This workshop will use brief autobiographical presentations from researchers at various career stages followed by a question and answer session. The aim is to stimulate and inform the participants about the inspirations for, and challenges of, building research into the psychosomatic specialist's career. There will be an emphasis on practical lessons and useful tips. Topics will include how to identify a mentor, the choice of research topic, writing research protocols, obtaining funding, getting the research done and published and overall career planning.

Dr. Sharpe will outline basic requirements for successful research.

Dr. Knight, a 2009-2010 Webb Fellow who has recently secured a research-based faculty position, will talk about her experiences of getting onto the first rung of the academic career ladder.

Dr. Davydow was recently awarded a KL2 Career Development Award. He will describe how he achieved this.

Dr. Brown, an established researcher and associate professor studying interventions to reverse the effects of prescription corticosteroids on the brain and on the treatment of depressed asthma patients, will describe how he has developed a biologic research program in psychosomatics.

Dr. Rummans, an established researcher and full professor, will discuss the challenges of getting the right expertise for the research you want to do.

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WORKSHOP 21:
Assessment and Management of Suicidality in a Medical Setting

Program Track: Extremes of Life

Chair: Maryland Pao, MD, FAPM, NIMH, Bethesda, MD

Presenters:

Lisa Horowitz, PhD, NIMH, Bethesda, MD

Donald Rosenstein, MD, FAPM, University of North Carolina at Chapel Hill, Chapel Hill, NC

Abstract:

Purpose:  Medical patients are a vulnerable population at higher risk for suicidal thoughts and behaviors; yet very few studies have focused on assessing suicide in the medically ill. While hospital-based suicides are rare, they are the second most commonly reported sentinel event to the Joint Commission (JC), with 25% involving patients admitted to non-behavioral health units. Moreover, the majority of those who have committed suicide visited a medical professional within three months of their death, making under-detection a significant public health threat. Nevertheless, recognizing suicidality in medically ill patients remains a challenge for all clinicians. In 2010, the JC recommended suicide screening for all medical patients. The purpose of this workshop is: 1) to discuss the epidemiology and assessment of suicidal thoughts and behaviors in a medical setting; 2) to discuss the C-L clinician's role in the new JC recommendations; and 3) to discuss clinical and institutional management when a suicide occurs.

Methods:  Literature review and case presentations involving suicidal thoughts and behaviors in a medical setting will be discussed. Suicide assessment strategies and tools will be presented. A framework for the diagnostic and management challenges posed by medical patients who may be suicidal will be discussed. Clinical scenarios will be described to illustrate various diagnostic and therapeutic approaches to assessing patients for suicide risk at critical periods. Specific institutional responses to a hospital-based suicide including immediate and long-range tasks will be discussed.

Results:  Estimates of suicide risk in medically ill populations remain imprecise; studies show that screening for depression alone may not be adequate for identifying patients at risk for suicidal thoughts and behaviors, especially with oncology patients. Growing numbers of cancer programs are implementing systematic screening for suicidal ideation and have generated prevalence estimates. Consensus is lacking with respect to when, how, and by whom patients with cancer should be screened for suicide risk. Studies utilizing data from cancer registries demonstrate clearly that cancer patients are at increased risk for suicidal ideation, attempts, and completions compared to the general population. Unfortunately, accurate data on suicide phenomenology at the end of life are lacking and the clinical management of end-stage cancer patients remains, to a large extent, a clinical art.

Conclusions:  Presentation of empirical data and clinical cases will demonstrate that medical patients are at increased risk for suicide. Suicide screening instruments designed for the medical setting are critical. Moreover, education in the detection and management of suicide risk at the end of life is an important, but rarely taught skill for clinicians. The JC implementing national patient safety goals that include mental health issues is an opportune time for psychosomatic medicine clinicians to help their non-psychiatric clinician counterparts to improve mental health care for medical patients.

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SYMPOSIUM 16:
Collaborative Management of Chronic Diseases: Challenges and Solutions

Program Track: Conference Theme A

Moderators: Stephanie A. Moore, MD and Theodore A. Stern, MD, FAPM, Massachusetts General Hospital, Boston, MA

Presenters:

Jeff Huffman, MD, FAPM, Massachusetts General Hospital, Boston, MA
"Recognition and Treatment of Depression in Patients with Coronary Artery Disease and Myocardial Infarction"

Stephanie Moore, MD, Massachusetts General Hospital, Boston, MA
"Collaborative Management of Congestive Heart Failure"

Oliver Freudenreich, MD, FAPM, Massachusetts General Hospital, Boston, MA
"Antipsychotics, Metabolic Syndrome, and Psychosis: Management Strategies"

Wayne Katon, MD, FAPM, University of Washington Medical School, Seattle, WA
"Multicollaborative Care of Depression, Diabetes, and Coronary Artery Disease: Results of a Randomized Trial"

Abstract:

Chronic diseases are prevalent and problematic. They account for a preponderance of lost days at work, disability, and recurrent hospital stays among those with serious medical illness. When complicated by comorbid psychiatric conditions, treatment adherence declines and outcomes suffer. This symposium will provide an overview of the scope and impact of chronic diseases, and discuss collaborative management strategies that can improve care.

Objectives:

  • To educate attendees about the challenges faced by patients and clinicians surrounding the management of chronic diseases
  • To illustrate how co-morbid medical and psychiatric conditions jeopardize health care
  • To learn how collaborative management can improve outcomes for those with chronic diseases

Reference:
McGregor M, Lin EH, Katon WJ. TEAMcare: An integrated multicondition collaborative care program for chronic illnesses and depression. J Ambul Care Manage. 2011 Apr-Jun; 34(2):152-162.

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