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IOP model helps calm, assist patients by Heather Woolwine Public Relations The Institute of Psychiatry’s annual Day of Discovery on March 23 focused on assessing and managing violence in psychiatric patients, as well as discussing adolescent substance abuse and its treatment. Participants were treated to a wealth of information designed to aid them in treating patients with brain disorders. The following two sections review some of the topics discussed. Psychiatric Assessment in the Emergency Room As MUSC strives to instill excellence in all health care professionals who work here, learning the most appropriate and humane way to assess and manage psychiatric patients when they arrive at MUSC is as important as helping any other kind of patient.  Most psychiatric patients arrive at the emergency room, according to Susan Hardesty, M.D., Institute of Psychiatry medical director. Implementing an engagement model enables health care professionals to appropriately deal with patients who present with mental disorders, she added.   Dr. Susan Hardesty “On a recent visit to the emergency room with my mother, I began to look around and notice certain things; the noises of other patients, sometimes moaning; the beeping of machines, the noise levels created by staff and family members. If I were a psychiatric patient in crisis, an emergency room would seem incredibly frightening,” Hardesty said. “It’s understandable why things can escalate when someone in crisis is being asked to sit still, take this medication, and so on. We have to ask ourselves what kind of experience is it for a patient with psychiatric illness when they arrive at the emergency room and how is it best to handle him or her when they become agitated, irritated, or violent.”   Hardesty described a typical psychiatric patient who presents at the emergency room as someone usually in crisis, functioning at their historical worst, having little or no support system, and often under the influence of drugs or alcohol. These patients may be intent on harming themselves or others, are in custody of law enforcement (voluntarily or involuntarily), are tired, hungry, angry, or ill, and may be experiencing distorted visual or auditory cues.   “Again, imagine this person with a distorted perception of reality not being able to distinguish real sounds, voices, commands, or images from ones within their head,” Hardesty said.   Historically, psychiatric patients were evaluated in emergency rooms based solely on the current episode requiring care. Hardesty argued that instead, a case by case method would work better, thus providing caregivers an opportunity to look at the entire picture and make a better assessment of what’s bothering or hurting the patient. Psychiatric patients often are admitted to seclusion, if available, otherwise they are placed in settings that afford little privacy. They often are restrained, shackled, or handcuffed and, more often than not, immediately managed with aggressive medication. Their comfort is limited. They sometimes have access to dangerous items (instruments, needles, etc.), and the show of force by police or other kinds of enforcement can be intimidating. If their medical history is limited or even discounted, real medical complaints or the reason for crisis may be overlooked or discounted because of the fact of their mental disorder. In turn, Hardesty reported a common assumption of malingering by health care professionals, or an assumption that drugs or alcohol are present in each case. Of course, these judgments usually are based on appearance, not medical history. Most staff in emergency rooms, while very competent and caring people, have a lack of training in dealing with psychosis. Staff are concerned for staff safety, they are under large amounts of stress,  and can be fearful of psychotic patients. Some previously experienced adverse outcomes related to this type of patient. If a patient is unwilling or unable to cooperate, it’s not difficult to see the path to an adverse outcome.   “Chris Frueh, Ph.D, and numerous collaborators from the IOP, VA, and Department of Mental Health have done research in the SC Department of Mental Health and with the Charleston-Dorchester Mental Health Center. Among their findings were that persons with severe mental illness have trauma prevalence ranging from 51 to 98 percent, and post-traumatic stress disorder [PTSD] often is undiagnosed or untreated. Most clinicians receive little trauma training, and those same physicians underestimate prevalence of trauma,” Hardesty said. “Of 505 patients at the C/DMHC, 91 percent had a lifetime trauma history of exposure to violence and other trauma.”   Hardesty further explained that hospital or treatment experiences for these types of patients, based on historical models of care, produced traumatic memories and experiences. She continued with information gleaned from another study by Frueh and his collaborators. “In psychiatric care settings, of the 142 clients of C/DMHC in-day hospital program, 31 percent experienced physical assault, 8.5 percent sexual assault, and 63.4 percent witnessed traumatic events,” she said. “Potentially harmful experiences included inadequate privacy, verbal intimidation, and coercive measures. Most of them had also experienced some kind of institutional measures of last resort as well, including more than half had been in seclusion or handcuffed transport, and one third had been restrained.”   After describing how the brain responds to stimuli, stress, and arousal via biochemical signaling and neurological processes, Hardesty introduced participants to the engagement model for assessing psychiatric patients. Adopted by Salem Hospital’s psychiatric unit in 2002, the model derives from a sanctuary style theme and the work of Sandra Bloom, M.D. As Hardesty continued, she said the IOP currently is consulting with Salem Hospital to implement this model. The first concept states that before people can engage therapeutically, they must feel safe. Next, people live up to others’ expectations (positive or negative), and they will respond to a safe and nonviolent environment. In addition, people behave in response to social and physical environment. By no means does this concept negate the occasional use of restraint or seclusion, but instead is designed to minimize the number of patients requiring that kind of traumatic care, Hardesty explained. “If we create a favorable environment, then the patients should respond favorably,” she said.   According to the literature, social norms are the most useful source of power, and customer service values apply to mental health care. “It may not seem like much to offer the incoming patient a warm cup of coffee, something to snack on and a nice waiting room while they wait to be assessed. But by offering these things, patients feel as if they’re being treated appropriately and are therefore much less likely to respond violently or become agitated,” Hardesty said.   Essentially, trauma-informed care/engagement models rely on the fact that if an environment can be normalized, then people will act how they’ve been conditioned all their lives, which is usually within social norms. The model calls for health care professionals to treat persons with special needs due a trauma history in a sensitive and respectful way, while recognizing that certain ways of delivering care may unintentionally trigger stress responses. For example, grabbing someone’s shoulder while saying hello may trigger an unwelcome response for the patient who also has been the victim of assault. Seclusion rooms in this model are outfitted with food, drink, and comfortable furniture. By minimizing triggers, patients’ gain a sense of control and when given simple choices about their treatment, comply more easily. “Instead of ‘I’m going to give you this medication,’ try ‘would you like some coffee or medication to help calm you down? Which one works better for you?’ When you give them some control over their situation, they become less frightened and the risk of experiencing further trauma through the health care setting or getting hurt during a restraint process is less likely,” Hardesty said.   Interestingly, Hardesty also described what psychiatric patients have reported about their experiences with restraint in particular. For most, the power differential involved makes patients experience it in a similar sense that rape victims experience their attacks. They feel the same about forced medication as well.   “How else are they supposed to view three large men sticking them with a sharp needle? And they should see this as help?” Hardesty asked. Other benefits related to trauma-informed emergency room care are its minimization of implicit and explicit coercion (rules, locked doors, keys, strip searches, commitment, and demeaning language) and minimization of power differentials. An informed and prepared trauma emergency room also seeks to understand the patient in context of present events and past trauma, and seeks collaboration and shared decision-making via education and compromise between patients and staff. Positives outcomes with this model show a reduction in the use of force, seclusion, restraint, staff needed for restraint and seclusion monitoring, and paperwork. In addition, staff morale and patient satisfaction increase, staff receive fewer injuries, patient flow improves, and litigation risks are reduced.   Health care professionals do not operate in a bubble, so Hardesty elaborated on how the model works better for staff, too. She said police, emergency services personnel, and hospital emergency department staff have trauma rates comparable to those of psychiatric patients. Many have undiagnosed PTSD, and should learn to recognize the signs in themselves and peers. Some things to consider include: intrusive thoughts of past trauma; nightmares or flashbacks; exaggerated reactions to triggers, avoidance of people, places, or conversation about an event; loss of interest; feeling detached; increased substance abuse; somatic problems; frequent headaches; or high use of antacids. Hardesty offered pointers for debriefings held after critical events that address the complexity of caregivers’ thoughts and feelings, as well as reminding participants to think about how they react to patients and whether it’s a result of a real threat or past experiences. “The best we can do is to adopt this model of care and then train ourselves to handle extreme violence when it does happen (3 percent of patients don’t respond to social cues),” Hardesty concluded.     Adolescent substance abuse assessment Kevin Gray, M.D., assistant professor of Psychiatry and Behavioral Sciences-Youth Division, provided a detailed analysis of adolescent substance abuse in regards to the Monitoring the Future Survey (MTFS) prepared by various researchers through grant money provided by the National Institutes of Health. Gray first addressed why monitoring and assessing adolescent substance abuse is so important. “According to a 1997 study, for each year that drinking onset is delayed, the risk for alcohol dependence is reduced by 14 percent,” he said. “Substance abuse in adolescence is also associated with high-risk sexual behavior, short and long-term health problems, motor vehicle accidents, homicide, and suicide. Historically, health care providers have also been generally poor at screening and diagnosing adolescent substance abuse problems.”   Dr. Kevin Gray Gray continued by telling participants that adolescent substance abuse is not random, and in fact can be traced to risk factors called constitutional predisposition, environmental factors, and life events. The three concepts intertwine and bounce off one another to make certain adolescents more susceptible to substance abuse than others. For example, adolescents with a genetic risk for substance abuse may then watch their parents abusing alcohol or drugs (environmental influence) and paired with school or academic failure, may then become substance abusers themselves. Substance abuse may also derive from constitutional predispositions to novelty-seeking or risk-taking, aggression, and psychopathology. From there environmental influences like lack of parental monitoring or involvement, peer substance abuse, or deviant peer groups can then interact with life events like abuse or neglect, exposure to violence, or victimization by assault and thus result in adolescent substance abuse.   The MTFS has polled high school students since 1975. The 2005 survey included 50,000 students in a nationally representative sample and monitors lifetime, annual and 30-day prevalence of substance abuse. It also tracks daily and binge use of particular substances. By the 12th grade, the lifetime prevalence of use for alcohol was 75 percent, cigarettes was 50 percent, and illicit substances (including marijuana, amphetamines, narcotics other than heroin, inhalants and cocaine) was 50 percent, according to data collected for 2005. Daily reported use among 12th graders was 14 percent for cigarettes, 5 percent for marijuana and 3 percent for alcohol. Twenty-eight percent of 12th graders reported an alcohol binge of at least five drinks in row in the two weeks prior to the survey. Gray also reported that new substances, including OxyContin and inhalants, are gaining increased use among the nation’s adolescents.   What is driving adolescents to climb aboard the substance abuse wagon? Gray suggested some neurobiological explanations beyond the pervasive “raging hormones” theories. Some evidence suggests that adolescents may be at heightened risk for substance abuse because rapid changes in dopamine architecture in prefrontal and limbic regions (involved in motivation, drive, and self-control) may parallel dysregulation noted in adult addiction studies. A potential for lasting implications exists with adolescent substance abuse as the structure in transition is most vulnerable to damage, and with reported alterations in dopaminergic response in alcohol abusing and nicotine dependent adolescents. Hippocampal volumes also were reduced in adolescent drinkers, the study found.   Unfortunately, Gray didn’t have much good news in terms of adolescent screening. In a study by Harvard’s Celeste Wilson, M.D., of 533 adolescents presenting for well visits or urgent care, providers identified only 18 with substance abuse problems out more than 100 who met substance abuse criteria. The same providers also identified none of the 36 with substance dependence.   Gray further discussed appropriate screening techniques like the CRAFFT method (www.crafft.org), with two or more positive responses suggesting a significant problem warranting additional investigation. Another issue facing diagnosing adolescents with substance abuse lies within the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 5th revision). Evidence suggests that some criteria does not  make sense for many adolescents, and other diagnostic methods don’t create a perfect fit. While some health care professionals cite urine testing, this method is still widely debated.   In terms of treatment, controlled studies show the most support for cognitive/behavioral and family-based/multisystemic approaches, as reported by Deborah Deas, M.D., associate dean for admissions and Psychiatry and Behavioral Sciences professor. The level of care should be determined by acuity and severity of the patient’s presentation, and a potential for pharmacologic approaches does exist. Gray concluded his presentation by reminding participants to consider constitutional predisposition, environmental influence and life events when making treatment decisions, and underscored points made throughout his presentation.     Friday, April 14, 2006 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Island Publications at 849-1778, ext. 201.