Skyland Trail's "Benefits of Laughter" Transcript Part 2

The following is the second part in a series of posts containing transcripts of a presentation given by Skyland Trail's medical director, Ray Kotwicki, MD.

The criteria for a major depressive episode (if you have more than one episode in your lifetime you have major depressive disorder) fits this pneumonic that we call SIGECAPS, so here are the criteria for major depression: You have to feel sad, the I is for interest – you have to have decreased interest in things you used to enjoy, the G is for guilt, people who are depressed often feel guilty or worthless, decreased energy, problems concentrating, change in appetite, P is for psychomotor changes – it means that either your body doesn’t want to move or it can’t sit still, either way. Then the final S is for sleep problems. Either for increased sleep, which we call hyper-somnia or decreased, sleep which we call insomnia. If you have most of these, at least 5 out of the 8 most of the day, every day for two weeks in a row, you meet the criteria for having a major depressive episode. If you have more than one of those periods in your lifetime you have major depressive disorder. We call it the kindling effect. So kindling is small wood that you use to build a fire. Every next episode of depression that you have makes it more likely that you will have another one. So people who have had their first episode of depression have roughly between 35 and 40% chance of having a second episode at some point in their life. By the time you get up to having 4 or 5 episodes of depression it is almost a certainty that you will have a 6th or a 7th because it is harder to treat as more of them occur. So let me finish with the mood disorder and I’ll go back to Schizophrenia.

When you think about bipolar disorder, we often call that manic depression in the general media. It’s this – having the depressive episode, and then at least one point in your life you have a manic episode, which is sort of like the opposite of depression, and the pneumonic for a manic episode is DIGFAST. So, people who are manic are distractible, irritable, grandiose, they have flight of ideas, their thoughts go so fast that their mouth can’t keep up with it, increased goal-directed activities, which is the A, so they have multiple projects going on at the same time and can’t finish any of them. They are sleepless, they don’t sleep but they don’t feel tired the next day, and they had thoughtless behaviors. The most common thoughtless behaviors in this order of likelihood are having increased sexual activity that you regret with multiple partners, spending money you don’t have causing bankruptcy or financial ruin in your family and having impulsive travel. So people who get on a plane and fly to Paris for the day without having booked a hotel, without knowing what they are going to do when they get there or they want to go because they want to watch the sunrise – that would be considered a thoughtless behavior in a potentially manic episode. Again, if you have the majority of these things for a certain period of time, that would be criteria for a manic episode. And again, if they have ever had one manic episode in their life, even if every other episode in their life has been depression, they have bipolar disorder. So together we call depression and mania mood disorders. That is different than thought disorders of which schizophrenia is the most common. So schizophrenia is an illness that is really misunderstood. And you see a lot of wrong portrayals of what schizophrenia is in the movies. A great example of positive symptoms of schizophrenia is in the movie A Beautiful Mind with Russell Crowe. So John Nash, the character who had schizophrenia that was played by Russell Crowe, was actually a Nobel Laureate in Physics – a very smart man so he didn’t have any cognitive problems. He was so intensely focused on his work that everything else around him didn’t matter. He heard voices that other people couldn’t hear – we call those audio hallucinations. He believed that he was working for the government and he was getting special messages out of magazines. He would cut out these words and paste them up. He had a fixed false idea that we call a delusion. So together, delusions and hallucinations are the positive symptoms of schizophrenia. They are the “movie” symptoms – the symptoms people like to watch and can be scary. When you look at outcome data, positive symptoms actually are not the best indicator of whether or not somebody can get better if they have schizophrenia. It’s the negative symptoms. So positive symptoms are the things that somebody with schizophrenia experiences that we wish was not there. The negative symptoms are things somebody with schizophrenia is missing. So negative symptoms include a-motivtion, - the desire to get out of bed and do something every day, alosia – being able to organize thinking and speech so that they can communicate with others, affective flattening – not showing any emotion on your face when you are inter-relating with others, asocial – not caring whether they have social relationships with others, lack of attention to hygiene and how somebody is portraying themselves physically. Those are the things that make it harder to have relationships. They are the better predictor of whether or not somebody can get better, and we call those negative symptoms. So, in programs that specialize in treating the positive symptoms and getting rid of the scary movie symptoms, but they neglect the negative symptoms – it is not actually helping somebody with schizophrenia recover from their illness. It is stabilizing somebody perhaps, but it is not using the maximum benefit of evidence-based medicine to help somebody live a productive life.

My definition of mental health is that when people have a very diverse set of ways to get through things in life that they can use at the appropriate time – so they have a battery or arsenal of unique things that will help somebody be okay – requiring them to pick one of those things to use at the right time – to me is what mental health is. Let me give you an example. I make a joke out of everything and that works 50 % of the time just to laugh something off. But if I make a joke out of going to a funeral when I’m sad rather than sort of experiencing that sadness, being there for the family, participating in what’s going on, that’s probably a mistake. And that might produce a disability for me and problems with my relationship with that group of people in the long run. This would suggest to me that it wasn’t the best strategy I could have used. You can kind of think about that in the more serious mental illnesses as well. People who have had traumas, who dissociate, they say I’m not going to experience what is going on in body right now because that is what I need to do in order to survive. That’s very functional if you are in the middle of being raped – you are not going to get killed, but if you use that strategy in other situations where you are not at imminent risk for trauma or abuse, that is not helpful. So we can kind of take that same situation and that analogy of what to use when for all the mental illnesses.

Let’s take a look at who comes to Skyland Trail and I’ll try to match the program that we offer with our patient’s needs. So between the years 2007, 2008, 2009, we’ve had a real spike in the number of people between the ages of 18 and 25 who are admitted into our services. I love that because we catch people early in the course of their illness and it means that we are more likely to ensure they are treated in a holistic way and maybe prevent the next episode in their illness – which means we might make a bigger difference in their lives. We work with adults of any age and have people in their 60’s and even 1 person in his early 70’s. But I’m happy to see this spike in our young adult census because it really gives us an opportunity to help people have a good experience in the mental health system earlier.

When you look at what the admission diagnoses are of our new patients in the years of 2007, 2008 and 2009 we lump these two together – bipolar disorder and major depressive disorder as mood disorders and we lump together schizophrenia and schizo-affective disorder – schizo-affective disorder is a combination of schizophrenia plus a mood disorder – but we call it a primary psychotic disorder. So when we lump these things together in 2009, 8 out of 10 newly admitted patients had a mood disorder. This is really important because I think that Skyland Trail has a reputation in the community of being a treatment facility for people with schizophrenia, and while we are expert at helping people with schizophrenia recover, we actually work much more frequently with people who have a mood disorder. We do a great job there as well. Most people with anxiety disorders don’t come to get treatment and then the other category is sort of – when we get to know a patient when after they have lived in our program for 45 days and gotten to know our staff and we understand they don’t have a psychotic disorder or a mood disorder but they in fact have a substance abuse disorder or they have a personality disorder. So those are the three categories of mental illnesses – mood disorders, psychotic disorders and anxiety disorders.

We know that people with bipolar disorder – manic depression – about 85% have some kind of substance mis-use problem and the most common one is alcohol abuse. It makes sense if you think about it. If someone is manic they are kind of revved up, using a depressant like alcohol sort of brings you back down and it makes a lot of sense to me. If you are depressed people might use alcohol because it feels like you can kind of get out of your body for a while, or stimulants, which makes more sense to bring people back up. So there is a high co-morbidity between substance misuse problems and mental illnesses. We work very well with people who have both. The problem is if the substance misuse disorder precedes any of the symptoms of the mental illness, we might actually be looking at a substance abuse problem that looks like a mood disorder or psychotic disorder rather than both of them occurring at the same time. So for that group of people we would refer them to a substance abuse treatment facility.

A guy by the name of George Valiant out of Harvard says that you cannot make the diagnosis of a primary mental illness outside of substance abuse until somebody is clean and sober for 6 months. So that is sort of the party line. We don’t use 6 months as our cutoff, but we want to make sure that the substance abuse is followed by the symptoms rather than precede it.

What we’ve seen, and particularly in 2010 is younger people are being admitted earlier, but are staying for shorter periods of time because of the economy. We had more admissions in the first half of 2010 up until the middle of June. We had more admissions in that period of time than in any other year. That creates some challenges for the program, and we hope that people still benefit even though their length of stay is shorter, but we are trying to maintain fidelity to what we have to offer so that people maximally benefit from our program.

The people with whom we work are smart people. And I know that the party line for people with mental illnesses have cognitive problems. That is partially something we want to prevent. A researcher by the name of Jeff Lieberman, who happens to be on our National Advisory Board, did a great study that showed – every next day of NOT having treatment when somebody is actively in the middle of a psychotic episode or a manic episode produces cognitive decline, so that is bad. We want to make sure that people get treated early and get treated assertively so that we can prevent the cognitive ramifications. However, our patients come to us with a lot of education and a lot of capacity to be able to learn new things and learn new coping strategies, so they can apply the things that we teach them during group therapy to their own personal life. About 8% of the clients who came to Skyland Trail in 2009 have at least some college experience if they didn’t graduate from college. So that is really a benefit for our program.

There are the social determinates of illness – if you start off at a higher socio-economic level – if you have decline you are still sort of above. Whereas if you start off with the same illness and you have psychosocial problems such as no money, no housing, no ability to go to college, no food or whatever, the illness will make a bigger difference in your life.

So when we developed the Skyland Trail Integrated Medical Recovery model we did a comprehensive literature search about what is considered to be or what are considered to be the best practices in psychiatry. What we found is that this idea of recovery is really important. It is really the idea that people with mental illnesses can get better and lead functional, happy, productive lives just like any of the rest of us. There are two variables that predict whether or not somebody with a mental illness such as schizophrenia will get better. The first one is having a good social support system such as family involvement; a spouse or somebody the patient can rely on. The second variable is having a staff work with that patient who has high expectations. So we expect that people will recover from their mental illness when they are here. And that is what we work on. We call it the N+1 philosophy. If you are at level N that is great, but what is next for you? What is N+1? The second thing is engagement. We work really, really hard to get people to buy into their recovery. We know that not taking medications is a real part of what happens with people who have mental illness such as schizophrenia or bipolar disorder. In the Katy trial again, 18 months after a patient with schizophrenia was started on medication 76% of all of those patients 18 months after that initial day were off all medications. And the number one reason is because of patient preference. People don’t like having the sexual side effects, people don’t like having to remind themselves that they are sick and have to take a medication every day, and people don’t necessarily like how it makes them feel, especially if they are used to being manic, because being manic feels really good. So we work hard to engage people not only to take their medication but through our adjunctive therapy programs so people will want to come here and learn what we have to teach.

Third, we have a holistic program, and this is a word that I think is misused a lot, and what we mean by holistic is that we provide services and encourage people to think about their recovery from soup to nuts. It is not just about the symptoms of your mental illness, it is about your physical health. About having healthy eating and active living lifestyle. It is about making sure you feel connected to something bigger than yourself. All of those things are important and things that we work on during the time somebody is at Skyland Trail.

Finally, we know that this model is useful. We measure what happens. There is a durf of evidence in mental health that what people do and the money that people pay for treatment produces good results and we have data to support that – that what we do is actually very effective.

The model that we developed is called the Recovery Community Model, and I want to show you a visual of what this looks like. So in this wheel each one of the concentric circles represents an individual staff person or an individual function – so the patient of course is at the center and he or she drives the treatment based on what they say they want to do with their life. We have case managers; we have vocational services counselors, residential counselors, adjunctive therapy counselors, a nurse practitioner, primary care counselors, pastoral counselor, psychiatrists, etc. And once a week each slice of this pie gets together to talk about every patient enrolled in that recovery community. It is between 10-15 patients, all of whom have the same diagnosis and work with the same kind of psychotherapeutic modality. So let me give you an example. If somebody comes to Skyland Trail and they are in the middle of a major depressive episode, we know from the research literature that cognitive behavioral therapy is the best treatment for that in addition to medications. So we have cognitive behavioral therapy or a CBT track for people who have depression. And every day everybody who is on the CBT track will get together and have a core group with their primary counselor and learn from one another based on their homework, the manual that we give them to study, and the things that we teach them that are based on Cognitive Behavioral Therapy. We have an analogy to all those other kinds of recovery communities. We have Personality Disorder community with DBT, we have a dual diagnosis recovery community for people who have substance abuse problems and another mental illness, schizophrenia first episode recovery community, and together this can be very individualized and targeted interventions for people with specific needs. This is a new model and we are one of the only places in the country that uses this kind of targeted psychotherapy. Everybody on the team, or everybody in one of the wedges of the pie is versed in using the kind of psychotherapeutic interventions that have been shown to be the best for those patients.

To work in some redundancy to this model, we have what we call a flex track, and the flex track is meant for people who don’t necessarily fit in only one of these wedges of the pie. It gives us some capacity to provide this kind of modality or a combination of the modalities to people who need that combination. That has been a very useful kind of way to make sure we can accommodate the individual needs of everybody who comes for admission.

Before this model was instituted, primary counselors were assigned patients based on census. So I might be a really good primary counselor but I have no idea what CBT is, but if I’m up for an admission, I’d get the next person to be on my caseload even though I don’t know the kind of psychotherapy that would be best suited for that person. The second thing is that the staff used to meet once a week together and you can’t talk about every person’s recovery plan when you meet for one hour and you have 90 patients. You talk about the problems. And what that did was – it made us focus on how to make sure people were not getting into trouble rather than pushing patients to the next level of their recovery process.

We have a very robust vocational, educational and volunteer program. Thinking again about the negative symptoms of schizophrenia – that is a key component of what we do and what I think every recovery facility should do. It is the thing that is most often left out of treatment facility’s models, but we teach people how to socialize, how to interview, how to put together a resume, how to take care of their hygiene and their physical appearance so people will not make assumptions about them. We think this is a real component of recovery. We also have an on-sight primary care clinic so we don’t let patients with mental illnesses not get the same kind of excellent care that you and I get when we go to see our internal medicine doctor. We have a pastoral counseling program and we try to encourage people to think spiritually about their recovery. Our pastoral counselor can be helpful in understanding what that means in somebody’s life and he will gladly participate in somebody’s recovery. Again, this is a very different model, and in a system of mental health services where they don’t provide all this array of services, these are the things that tend to get left out. But these are probably the more important things, if you think about it, that helps somebody live a healthier, happy, productive life.

We have lots of collaborations in the community. We have collaboration with the School of Medicine at Emory, the School of Public Health, the School of Theology and other Universities, and we have a very robust way of making sure we are providing services to professionals in our community that they want. We have a Professional Advisory Board where we caucus Atlanta physicians and clinicians, we have a national Advisory Board where the thought leaders in psychiatry convene every other year and talk about the next best thing in psychiatry. We use all of those as springboards for further developing our model of care.

We actually measure outcomes and I want to share this with you because I think you can really get a sense of what we do. The Basis 32 is a 32 item survey that the patient himself/herself reports- it measures things about symptoms and functionality as well as social relationships. On this graph – higher is worse – it means you have more symptoms and lower is better. You and I would be somewhere between 0 and 1 based on what is going on is our work life or social life. So we can see that when people are admitted to Skyland Trail – and these are the years 2007, 2008 and 2009, they have a significant amount of dysfunction as well as symptoms. It is roughly an average of 1.93 or 1.94.

At the time of discharge, their basis 32 score falls off significantly, and in 2009 the disparity between 1.93 and 0.55 was roughly 72% improvement in their functionality and social relationships and symptom control. So this is not only a statistically significant finding to a P-value of <. 05, which means that this change can be no greater than 5% due to chance – there is something causing that change. That drop-off is a clinically significant change in how somebody is appearing. So I can tell the difference between somebody who had a Basis 32 score of .5 and somebody who had a score of 2. That would be a very obvious change.