Learning Objectives Upon completion of this presentation, - - PDF document

APNA 30th Annual Conference Session 4015: October 22, 2016 Kverno 1

Responding to the IOM Report on Psychosocial Interventions: Application of the Perspectives of Psychiatry

Karan Kverno, PhD, PMHNP-BC and Tamar Rodney, MSN, PMHNP-BC The speakers have no conflicts of interest to disclose.

Learning Objectives

• Upon completion of this presentation,

participants will be able to:

– Describe key explanatory concepts from each of the four Perspectives of Psychiatry. – Utilize the Perspectives of Psychiatry conceptual framework to match elements of evidence-based psychotherapeutic interventions to the needs of individual patients. – Take part in the recommendations of the IOM (2015) report on psychosocial interventions for mental and substance use disorders.

The Need for an Elements Approach to Evidence-based Psychosocial Interventions

• Psychopharmacology alone is often insufficient for

complete recovery.

• Psychosocial interventions are effective, yet there

has been a decline in their use.

• Evidence based, psychosocial interventions are

made up of multiple elements.

• We don’t know what elements are effective at

improving specific symptoms, functioning or well- being.

• (Delaney & Handrup, 2011; Institute of Medicine, 2015; Janicak, Marder &

Pavuluri, 2011)

APNA 30th Annual Conference Session 4015: October 22, 2016 Kverno 2

Psychosocial Intervention Concepts

• Elements: activities, techniques or strategies

– Non-specific elements – Specific elements

• How change is affected:

– Mechanisms: Biological, behavioral, cognitive, emotional, interpersonal – Moderators: Person-specific factors such as sex, race, class

• Outcomes:

– Symptoms, functioning and well-being

(IOM, 2015)

IOM Framework for Developing Standards for Psychosocial Interventions

Strengthen the evidence‐base Strengthen the evidence‐base Conduct systematic reviews to inform clinical guidelines Develop quality measures Identify elements of interventions Implement interventions and improve outcomes (IOM, 2015) Engage Consumers

Application

• The application of effective

interventions involves assembling combinations of elements that, based

• n evidence, are targeted to particular

disorders and other patient

• characteristics. (IOM, 2015, p. 10)
• Case formulation is key in matching

elements to patient characteristics.

APNA 30th Annual Conference Session 4015: October 22, 2016 Kverno 3

Case Formulation and Treatment Implications

DSM- 5 Approach

• Considers whether

symptoms fit into a recognizable disorder or syndrome - or not. Perspectives of Psychiatry

• Considers the presentation

from each of four perspectives.

(APA, 2013; Chisolm & Lyketsos, 2012; McHugh & Slavney, 1998) Bird Life: A Guide to Study of Our Common Birds (1897).

HIDE

• Diseases—what a patient . . . Has
• Dimensions—what a patient . . . Is
• Behaviors—what a patient . . . Does
• Stories—what a patient . . . Encountered

(McHugh & Slavney, 1998)

Disease Perspective

Example: Schizophrenia Treatment: Medication

(McHugh & Slavney, 1998)

APNA 30th Annual Conference Session 4015: October 22, 2016 Kverno 4

Dimensional Perspective

Example: Wild Boy of Aveyron (circa 1798) Treatment: Guidance

(McHugh & Slavney, 1998)

Behavior Perspective

• Example: Anorexia
• Treatment: Interruption

(McHugh & Slavney, 1998)

Life Story Perspective

Example: Bandura’s Bobo Doll Experiment (1961) Treatment: Rescripting

(Bandura, Ross & Ross, 1961; McHugh & Slavney, 1998)

APNA 30th Annual Conference Session 4015: October 22, 2016 Kverno 5

Examples of Disorders and Syndromes Across the Perspectives

Diseases Behaviors Dimensions Life Stories Delirium Alcohol dependency Subnormal IQ Demoralization Dementia Drug dependency Personality disorders Grief Schizophrenia Paraphilias Excessive emotional responses (“neurosis”) Adjustment disorder Bipolar disorder Anorexia / bulimia PTSD Panic disorder Sleep disorders False memory syndrome (McHugh & Slavney, 1998)

Case Example: Personalizing Treatment

• Life Story
• Demoralization
• Behavioral
• Risky alcohol

use

• Dimensional
• Unstable

extroversion

• Disease
• Bipolar

Medicate Medicate Guide Guide Rescript Rescript Interrupt Interrupt

Case Example: Evidence-based Psychosocial Elements

Behavior: Risky alcohol use Dimensional: Unstable extroversion Life Story: Demoralization Nonspecific (Examples) ‐ Therapeutic alliance ‐ Engagement ‐ Health literacy ‐ Therapeutic alliance ‐ Engagement ‐ Health literacy ‐ Therapeutic alliance ‐ Engagement ‐ Health literacy Specific (Examples) ‐Brief intervention (SBIRT) ‐Problem solving for conflict resolution ‐ Use of thought records to identify and reframe distorted cognitions Psychosocial elements (IOM, 2015)

APNA 30th Annual Conference Session 4015: October 22, 2016 Kverno 6

LEADERSHIP

Do not wait to ‘be invited to have a seat at the table,’ find ways to be an active participant and take full advantage of the opportunities to establish psychiatric mental health nursing’s expertise in psychosocial interventions.

(Susie Adams, PhD, PMHNP/CNS-BC, FAANP, 2015, p. 347)

Take Part in Building an Elements Based Framework

• Consider the nonspecific and specific

interventions that you provide for patient-specific problems.

• Do a systematic review of the literature to

strengthen the evidence base.

• Conduct clinical studies to identify and validate

elements of psychosocial interventions. Use quality measures to track effectiveness.

• Participate in developing an elements framework,

with a common language, whereby strategies and techniques can be applied across target problems, disorders, or contexts.

Future: Implications for Teaching and Practice

• An elements framework will:

– advance training in and implementation

• f evidence-based psychosocial

interventions. – provide guidance as to what models of training are most effective – determine how the acquisition of core competencies should be assessed.

(IOM, 2015)

APNA 30th Annual Conference Session 4015: October 22, 2016 Kverno 7

Conclusions

• The IOM committee recommends that psychosocial

interventions be elevated to a position of equal regard as physical health care.

• Nurses have an important role in identifying key

elements and examining the evidence to build a framework to improve the outcomes of psychosocial interventions.

• The Perspectives of Psychiatry provide an approach

for matching elements of evidence-based psychosocial interventions to the needs of individual patients.

Participant Discussion

Nonspecific Specific Generalist APRN

• What is your system of case formulation?
• How do you determine the appropriate elements of

psychosocial care?

• How can we work together to contribute to an

elements based framework to improve the

• utcomes of psychosocial interventions?
• How will this framework inform nursing practice?

References

• Adams, S. (2015). The IOM report on psychosocial interventions for mental and substance use disorders. Opportunities for

psychiatric-mental health nurses. Journal of the American Psychiatric Nurses Association, 21(5), 343-347. doi: 10.1177/1078390315606107

• American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA:
• Author. ISBN: 978-0-89042-555-8
• Bandura, A., Ross, D., & Ross, S. A. (1961). Transmission of aggression through imitation of aggressive models. Journal of

Abnormal and Social Psychology, 63, 575-582.

• Chisolm, M. S., & Lyketsos, C. G. (2012). Systematic psychiatric evaluation. A step-by-step guide to applying the Perspectives
• f Psychiatry. Baltimore: The Johns Hopkins University Press. ISBN: 978-1-4214-0702-9
• Delaney, K. R., & Handrup, C. T. (2011). Psychiatric mental health nursing's psychotherapy role: Are we letting it slip away?

Archives of Psychiaric Nursing, 25(4), 303-305. Doi:10.1016/j.apnu.2011.04.005

• Institute of Medicine. (2015). Psychosocial interventions for mental and substance use disorders: A framework for

establishing evidence-based standards. Retrieved from http://iom.nationalacademies.org/Reports/2015/Psychosocial- Interventions-Mental-Substance-Abuse-Disorders.aspx

• Janicak, P. G., Marder, S. R., Pavuluri, M. N. (2011). Principles and practice of psychopharmacotherapy (5th ed.). Riverwoods,

IL: Wolters Kluwer Health. ISBN 978-1-60547-565-3

• McHugh, P. R., & Slavney, P. R. (1998). The perspectives of psychiatry (2nd ed.). Baltimore, MD: The Johns Hopkins University
• Press. ISBN: 0-8018-6046-6
• Substance Abuse and Mental Health Services Administration , & U.S. Department of Health and Human Services (SAMHSA-

HRSA). (n.d.). SBIRT: Screening, brief intervention, and referral to treatment. Available online: http://www.integration.samhsa.gov/clinical-practice/sbirt