Medication and Integrated Healthcare
Module 9
Marion Becker, PhD
School of Social Work
University of South Florida
Medication Issues in Integrated Healthcare
Module 9: Outline
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Common comorbid medical and mental illnesses
Prevalence of co-occurring mental health and substance use
disorders
Medication management in integrated healthcare
Social workers role in medication management
Medication monitoring
Medication management strategies
Medication side effects
Diabetes and metabolic syndrome
Medication assistance programs
Co-occurring Mental Health and Physical Health
Conditions
• Co-occurring mental and physical health disorders are not only
common, they are the norm 1
• The high prevalence of co-occurring disorders means that social
workers will be working with clients with multiple mental and
physical health disorders regardless of their clinical practice setting
• Co-occurrence of mental and physical health disorders increases
the complexity of assessment and treatment of each disorder which
is best accomplished with an integrative multidisciplinary approach
to effectively address all disorders present
Multi-directional Model of
Co-occurring Disorders
Psychiatric
Disorder
Substance
Abuse
Physical Health
Conditions
Common Co-occurring Mental Health and
Physical Health Conditions 2
Physical Condition
% with BH condition
All conditions
24.7%
Well
17.5%
Neurological Disease
37.5%
Heart Disease
34.6%
Chronic Lung Disease
30.9%
Cancer
30.3%
Arthritis
25.3%
Co-occurring Mental Health and Substance
Abuse Disorders
• Mental health (MH) and substance use disorders (SUD) frequently
co-occur. According to the National Co-morbidity Study Replication
(NCS-R) data more than half (53%) of persons with a lifetime
diagnosis of a drug use disorder also have a lifetime diagnosis of a
mental disorder 3
• A four-quadrant conceptual framework (based on symptom severity
rather than diagnosis) has been set forth by several researchers to
describe and treat co-occurring MH and SUD disorders. This
integrated assessment and treatment approach is described in detail
in the Treatment Improvement Protocol (TIP) available from the
Center for Substance Abuse treatment (CSAT) (2005) 4
Costs
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Research shows that treating mental health
and substance use disorders reduces costs of
healthcare overall
• Shorter hospital stays
• Fewer costly tests
• Reduced mortality
National Co-Morbidity Study Replication (NCS-R)
• Social workers should be aware of the patterns and extent of
psychiatric comorbidities that may exist
• Most authors quote the Kessler NCS-R Study data on cooccurring disorders. In that study all mental disorders were
strongly related to drug dependence (DD) 1
• Within the NCS-R study population, 78% had current cooccurring disorders (within 12 months).
• There was an 80% estimated prevalence for lifetime cooccurring mental health and substance use disorders.
NCS-R Results
 More than 17% of participants had a major depressive
episode (MDE) in their lifetime.
 10% had an episode of depression in the past 12
months.
 14% had lifetime prevalence of alcohol dependence,
and over 7% were dependent in past 12 months.
 13% had lifetime prevalence of social phobia
NCS-R Results
 27.7% reported two or more mental disorders and
17.3% had three or more
 Most common life-time disorders
 Major Depressive Disorder (16.6%)
 Alcohol abuse (13.2%)
 Social phobias (12.1%)
 Less than 20% of the study population accounted for
50% of the lifetime disorders 1
Co-occurring Trauma and PTSD
• Co-occurring substance use disorders, mental disorders
and previous traumatic experience or PTSD has emerged
as a major clinical, public health and research focus over
the past decade because this combination of disorders is
associated with poor physical health, poor treatment
outcome, severe illness course, and high service
utilization.5
Co-occurring Trauma and PTSD
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The NCS-R estimated the lifetime prevalence of PTSD
among adult Americans to be 6.8%. Current past year
PTSD prevalence was estimated at 3.5%.The lifetime
prevalence of PTSD among men was 3.6% and among
women was 9.7%. The twelve month prevalence was
1.8% among men and 5.2% among women.6
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Persons with a history of traumatic experience and/or
PTSD require (at a minimum) services that are trauma
informed and when possible should have access to
trauma specific services. 7
Persons with Co-occurring Mental Health and
Substance Use Disorders frequently have…
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Problems in regulating thought, affect and behavior.
Poor self esteem
Poor physical health
Modest or low income
Poor compliance with treatment recommendations and
increased risk of prescription drug abuse
The Fastest Growing Drug Abuse Problem is
Prescription Drug Abuse (PDA)
 PDA is defined as: “use of a prescription
drug other than in the manner or for the time
period prescribed, or by a person for whom
the drug was not prescribed” (WHO 2007)
Prescription Drug Abuse (PDA)
• Nationally, prescription drug problems account for 5 to 20%
of hospitalizations
• Estimated cost of healthcare for adults with drug events…..
• $77 billion for ambulatory care
• $8 billion for institutionalized persons including hospital
inpatients. 8
Some Things Severe Mental Illness &
Substance Dependence Have in Common
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Lifelong potential for relapse
Loss of control
Recovery despite on-going illness
Denial, guilt, shame, depression
Interventions need to be stage of change specific
Adherence with treatment recommendations is often
a major problem
Double Jeopardy
• The converging effects of ageism and sexism put older
adults with co-occurring disorders at a particular
disadvantage and increased risk of inadequate and
inappropriate care for their MH and SUD
Medication Management in Integrated
Healthcare (IC)
• Medication has been the mainstay of treatment for mental
disorders. Medication management of persons with cooccurring medical, mental and substance use disorders is
complicated and critical for treatment success
• Non-adherence with prescribed medication among psychiatric
patients is a very common problem that can undermine
treatment success 9
• Successful medication management of psychiatric patients
depends on the active involvement and collaboration of the
client, social worker and the entire healthcare team
Medication Treatment
• Psychopharmacology is ever-changing. Existing medications are
taken off the market and new medications are introduced at an
ever-increasing rate making it imperative that social workers
stay abreast of current and emerging information regarding
mechanism of action, therapeutic dosing, safety and efficacy of
psychiatric medications being prescribed.
• Their are four major classes of psychiatric medication
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Antipsychotics
Antidepressants
Mood Stabilizers
Anxiolytics and sleeping pills
Medication Treatment
• The module assigned reading on pharmacologic
competency provides detailed foundational information
on specific psychiatric medications and their use.
• For additional information use the medication-related
web-links provided in the course Toolkit to obtain the
most current real-time information on specific
psychiatric medications
• Remember that medication does not cure mental
illness. It is used to control symptoms and is most
effective when used in combination with psychotherapy
Alternative Approaches
• In addition to medication your client nay be using other
approaches to treatment? Inquire about the use of:
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Herbs
Vitamins
Light Therapy
Relaxation techniques
Meditation
Acupuncture
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Over the counter drugs
Caffeine
Alcohol
Marijuana
Any Other approaches
• Clients should be taught and encouraged to practice
recovery lifestyle habits to improve overall health and
wellness
Social Worker’s Role in Medication Management
• The social worker may know the client best and
influences treatment decision making by helping the
team decide on the most reasonable and effective
medication strategy
• Social workers educate and support clients in adhering
to recommended medication treatment and should
regularly ask the client about side effects, and inquire
about how they are actually taking their medication
Social Worker’s Role in Medication Management
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Social workers should know the client’s medication
history and what medications have been tried
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What medication has worked?
What medication has not worked?
What is the client willing to take?
What can the client afford?
Medication Management
• Sensitivity and a trusting client–provider relationship are
key to successful medication management
• Client non-compliance is a frequent focus of practitioners
attention but when clients stop taking medication it may
be useful to think about the ways in which the healthcare
system has fallen short and/or prescribed medication
that has not met the client’s expectation or led to the
achievement of the client’s treatment goals
Monitoring Medication
• Begin with what the prescriber and client is hoping the
medication will do then develop a detailed, specific and
concrete list of target symptoms and observable behaviors to
be improved with medication
• Monitor the client’s progress on the target symptoms. Focus
on the target symptoms that bother the client most or interfere
with functioning
• Use the monitoring information to make decisions on
medication management. Before changing a medication
investigate potential reasons the medication may not be
having its desired effect
Monitoring Medication
• A variety of psychiatric symptom assessment tools (e.g. Brief
Psychiatric Rating Scale, Behavior Symptom Index) are
available (see the APA Handbook of Psychiatric Measures).
• Social workers can also use a specific target symptom list
developed with the client and individualize a rating scale for
any one or a combination of the following measures
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Daily symptom checklist
Unwanted behavior check list
Mood monitor
Early warning checklist
Intensity rating scale
Reasons medications may be ineffective
• Despite taking medication, social and psychological
stress may be destabilizing the client
• Medication is not taken regularly or at all
• On-going substance use and abuse
• Unrecognized medical illness exacerbates or causes
behavior symptoms
• Medication type or dose is ineffective for the particular
client
Medication Management Strategies
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Wait and monitor progress
Increase medication
Decrease medication
Switch medication
Add a second medication
Subtract a medication
Continue the same prescription
Common Ways to Switch Medication
• Cross Taper: First medication is tapered down in stepwise
fashion as the new medication is tapered up. For most
medications, if possible, this is the preferred approach
• Crossover Switch: Start the new medication and increase
to full dose. Then slowly decrease and stop the first
medication. This is complicated but it is the safest way to
switch and has the least risk of relapse. It ensures the
patient always has a full therapeutic dose of medication.
• Stop and Start: Stop the first medication before the new
medication is started. This approach has the highest risk of
relapse. It is used when a rapid switch is needed because of
intolerable side effects
Medication Side Effects
• All medications have risks, benefits, and the potential for side
effects. Side effects that have been discussed will be less
alarming than those that are unexpected. Therefore, social
workers should know and discuss the known risks and
potential side effects of the specific medications prescribed so
clients can make an informed decision about what to take.
• Medication side effects should also influence the choice of
medication. For example, for an underweight client medication
that causes weight gain may be the good choice and that
same medication would not be the preferred choice for an
overweight client.
Diabetes and Metabolic Syndrome
• Type II Diabetes and metabolic syndrome are of particular
concern for people with major mental illness.
• Type II Diabetes is the leading cause of blindness, leg
amputation, and kidney failure. It is also associated with
stroke and heart disease.
• 13% of people with schizophrenia have Type II diabetes.
Although the biggest single risk factor is obesity some
medications may be associated with diabetes apart from
weight gain. 10
• Many medications lead to weight gain but second generation
(atypical) anti-psychotic medication is of particular concern.
Metabolic Syndrome
• Metabolic Syndrome is a set of risk factors that increase
the chance that a person will develop diabetes and
cardiovascular disease. Risk factors include:
• Abdominal obesity waist >40 inches men, >35 inches
women
• Low HDL cholesterol < 40 mg/dl in men or < 50 mg/dl in
women
• High triglycerides .150 mg/dl
• Fasting blood glucose .110mg/dl
• Elevated blood pressure >135/85mm Hg
Medication Management
• Social workers should be sure that anyone taking any
antipsychotic medication, or anyone with schizophrenia should
have regular screening that includes obtaining weight and waist
circumference, blood pressure, and fasting blood tests. Family
history of diabetes should also be obtained.
• If a client is taking psychiatric medication that can cause weight
gain , talking about this side effect and recommending strategies
to manage the problem is essential. It is important that the
treatment team provide services to help manage the problem or
link the client to a provider who can provide needed care.
• Concern about weight gain and diabetes should be one of the
considerations in making medication decisions
Medication Assistance Programs
• What can be done when clients can’t afford medication?
• Social workers should acquaint themselves with the many
patient medication assistance programs available to low and
no income clients (e.g. Patient Medication Assistance
Inc. is one of the leaders in helping individuals receive free
medications.
• In addition, most drug companies provide medication
directly to patients who meet their program
requirements.
Medication Assistance Programs
• A list of web-links to medication assistance programs is
provided in the course Toolkit, They can be used to
complete the assignment for this module.
• Although there are many medication assistance
programs available, the eligibility criteria vary greatly so
the client’s characteristics must match the program
eligibility criteria for the client to receive medication
assistance.
References
1. Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K. & Walters.
W. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV
Disorders in the National Comorbidity Survey Replication. Archives of
General Psychiatry 62(6) 593-602.
2. Tesson. M., Degenhardt, L., Proudfoot, H. (2005). How common is
comorbidity, why does it occur? Austrian Psychologist 40 (2) 81-87.
3. Kessler, R.C., Chiu, W.T., Demler, O., Merikangas, K.R., & Walters, E.E.
(2005). Prevalence, severity, and comorbidity of 12-month DSM-IV
disorders in the National Comorbidity Survey Replication. Archives of
General Psychiatry, 62(6): 617-627.
4. Center for Substance Abuse Treatment (2005). Substance abuse treatment
for persons with co-occurring disorders (Treatment Improvement Protocol
(TIP) Series 42 DHHS Publiation No SMA 05-3992) Rockville. MD.
Substance Abuse Mental Health Services.
References
5.
Center for Substance Abuse Treatment. (2006b). Screening, assessment, and treatment
planning for persons with co-occurring disorders. COCE Overview Paper 2. DHHS
Publication No. (SMA) 06-4164. Rockville, MD: Substance Abuse and Mental Health
Services Administration, and Center for Mental Health Services.
6. Kessler, R.C., Sonnega, A., Bromet, E. Hughes, M., & Nelson, C.B. (1995). Posttraumatic
stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12),
1048-1060.
7. Weissbecker , I. & Clark, C. (2007) The Impact of Violence and Abuse on Women’s
Physical Health: Can Trauma-Informed Treatment Make a Difference? Journal OF
Community Psychology, 35, (7) 909–923
8. Substance Abuse and Mental Health Services Administration, Results from the 2010
National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series
H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental
Health Services Administration, 2011.
9. Awad, A. G., & Voruganti, L. N. (2004). New antipsychotics, compliance, quality of life, and
subjective tolerability—Are patients better off? Canadian Journal of Psychiatry, 49(5),297–
302.
10. Llorente, M.D. & Urrula, V. (2006). Diabetes, Psychiatric Disorders, and the Metabolic
Effects of Antipsychotic Medications. Clinical Diabetes 24 (1) 68-74