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An electronic circular of the Coalition's Center for Rehabilitation and Recovery
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No. 91, March 2013
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The Center for Rehabilitation and Recovery provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects. With this issue, we are beginning to roll out a revamped version of RECOVERe-works. We are trying to bring you fresh content, experts, and ideas about recovery and rehabilitation, along with familiar features, such as news from our benefits management team. And we want your feedback – are these articles of interest to you? Will you share them with your colleagues? What other topics would you like to read about? This newsletter is a work in progress, and we are eager to tailor the content to your needs. Please send your thoughts to RECOVERe-works Editor-in-Chief, Elizabeth Saenger, PhD, at [email protected]. - Naomi Weinstein, Director, Center for Rehabilitation and Recovery Using Cognitive Remediation to Move Toward Recovery: An Interview with Alice Medalia, PhD
Question: What is cognitive remediation? Dr. Medalia: Cognitive remediation is an evidenced based behavioral treatment that targets basic cognitive skills like attention, memory, problem-solving, and social cognition, with the intent of impacting functional outcome. It is, at its core, a learning activity. People are engaging in a learning activity to improve their cognitive skills so they can better function in everyday life. For example, someone with attention and memory problems may have difficulty following directions from their boss, or may lose track of important information that their friends and family tell them. People who have difficulty being organized and prioritizing information may find it hard to manage independent living, or going to school. Cognitive remediation provides the training to improve cognitive skills, so the person can function better. It is intended to help people who have experienced a decline in their cognitive skills, or who were not able to fully develop their skills because of illness. Many psychiatric illnesses cause cognitive problems. For example, schizophrenia and other psychotic disorders cause a decline in attention, memory and problem solving skills. Some people get confused between the similar sounding Cognitive Behavioral Therapy and Cognitive Remediation. Cognitive Behavior Therapy teaches you to think your way through emotionally challenging problems. Cognitive Remediation helps improve the underlying neuropsychological functions that help you think: attention, memory, planning, organization, abstract thinking. Question: And how does it help individuals move toward rehabilitation and recovery? Dr. Medalia: Cognitive impairment is one of the biggest reasons people with severe psychiatric disorders have difficulty functioning well in the community, and taking advantage of psychiatric and psychosocial treatments. It is difficult to work, go to school, or be a good friend if you cannot pay attention or remember what people say to you. Likewise it is difficult to remember to take your medications, or pay attention in therapy groups if you have cognitive deficits. For years, it was thought that symptoms like delusions or hallucinations were the primary reason people with psychotic disorders were having difficulty functioning. But research indicates that cognitive impairment, lack of motivation, and social withdrawal are the best predictors of how someone will function in the community. In particular, the cognitive deficits most associated with daily functioning are memory, attention, processing speed, problem-solving, and social cognition. Social cognition refers to the cognitive skills needed for social interactions, for example--how you read facial cues, or your ability to take someone else’s perspective. Now that we know that cognition is a primary determinant of functional outcome, and that the brain functions that underlie cognition are malleable—capable of changing--there is interest in developing treatments to improve cognitive functioning. Question: How can you do that? Dr. Medalia: The two primary approaches that people use to treat cognition are 1) restorative, and 2) compensatory. In clinical practice, many programs use what I would call a hybrid, a mix of these two approaches. Let me give a little more information about each approach. A restorative approach means that you engage in exercises to improve the cognitive skill that has been diminished, so you might do memory exercises on the computer, or you might do attention exercises, or you might engage in exercises to help improve your problem-solving. The goal is to restore the cognitive function. The compensatory approach means that you teach strategies to bypass, or compensate for, the deficit. So instead of directly targeting it, and trying to restore it, this approach helps the person find ways around it. For example, if your memory is not very good, you might make a list, set reminders on your phone, or use organizational skills like always putting an item in the same place. Question: So how do you begin working with a client? Dr. Medalia: The first step is to have an evaluation that establishes a link between the clients’ recovery goals and his or her cognitive functioning. For example, if the person has a work goal, but always arrives late for appointments, you could make the link between memory and organization, and arriving on time at work. So the first step is to draw connections between cognitive problems and recovery goals, and to explain that there is a treatment, and a possibility to change cognitive skills. Another step in the evaluation, is to get some sense of the client’s cognitive profile - to understand what their particular cognitive strengths and weaknesses are. While we know that, in general, a disease like schizophrenia affects verbal memory, processing speed, working memory, and attention, there is variability from person to person. It is important to get some kind of evaluation of the cognitive profile, so you know which cognitive exercises to give them. Question: How receptive are individuals and other stakeholders to cognitive remediation? Do they think of it as something new and untested, or do they accept it? Are they really motivated to incorporate it into their schemes for treatment? Dr. Medalia: There is tremendous interest and motivation and enthusiasm from the clients and their families for cognitive remediation. In fact their interest has far, and more quickly, surpassed the response from other stakeholders, for example, the insurance companies and the programs themselves. So, there is a tremendous demand for cognitive remediation, and it is one of the most acceptable treatments for recipients--people like it. This is a treatment that people typically seek out and enjoy. Question: It seems like it might be accepted by the individuals who are getting the treatments because it is not invasive, and they can probably see their progress as they continue to go to treatment. Dr. Medalia: Yes. Of course, it depends on how one sets up the program, but to the extent that it is clear they are making progress, and that it links to their goals, and the exercises chosen are motivationally enhancing, there is usually enthusiasm for the treatment. There is a range of cognitive exercises available from many companies, and there is evidence that cognitive exercises that have certain motivationally enhancing features promote the greatest treatment response. In addition, because cognitive remediation programs are not terribly difficult or expensive to set up and operate. Increasingly around the United States, many programs are offering the treatments, as one service that is bundled into an overall day rate. Question: Apart from a formal cognitive remediation program, what can agencies do to help their clients develop cognitive skills that are relevant to recovery goals? Dr. Medalia: The first step is to promote a system wide understanding of the role of cognition in recovery. This includes understanding that cognition is different from intelligence, that improving cognitive skills can help people achieve their recovery goals, and that cognitive skills can be improved--they are trainable. If you start to think about how memory, problem-solving, time management, and attention might be impacting someone’s ability to pay attention during group, or follow through with medications, then you realize that failure is not necessarily due to a motivation problem, but may be due to the person simply not remembering. Then the question becomes: What can we do to help them with that? Interview edited for the Coalition of Behavioral Health Agencies, Inc.
Antipsychotic Side Effects: A Physician’s Perspective for Non-Prescribers Primum non nocere–Above all, do no harm—has resonated in medicine for the past 350 years. Coined by Thomas Sydenham, an English physician and superstar in the medical world of the late 1600s, this Latin phrase embodied a principle Sydenham applied to the treatments of his day, and followed as he side-stepped “accepted practice.” All treatments, including Sydenham’s own innovation, tincture of opium, carry potential for harm as well as therapeutic effect. The role of the prescriber is to carefully balance values of the patient with available treatments, to inform caregivers and/or patients of the indications and risks of a medication, and to closely monitor treatment effects, both beneficial and adverse. The latter task is the greatest challenge for the prescriber. “Medication management” interactions are typically brief, and infrequent relative to counseling visits. With constrained time, prescribers may not know the usual behaviors and demeanor of a patient. Recognizing adverse effects of chronic psychiatric medication is a challenge. Therapists and other mental health workers are the vanguard in detecting harm due to medication effects, and alerting prescribers. For adults, antipsychotics are most used to treat internal disorders of thought or mood (schizophrenia, depression, bipolar mania). Children, on the other hand, typically receive antipsychotic medication to decrease specific, targeted behaviors. Most often, disruptive, maladaptive behaviors in children can be found linked to external factors (challenges at home, post-traumatic stress, past or ongoing abuse, learned responses to attract attention or “get their way”). Adverse effects may appear rapidly, or insidiously. Some are obvious, such as weight gain; others, such as akathisia (a feeling of “restlessness” or inability to sit still) may be subtle. All antipsychotic adverse effects have the potential to result in permanent harm, and this is especially disturbing as children appear more likely than adults to suffer neurologic or movement-related disorders associated with antipsychotics. For example, akathisia is a very common adverse effect of aripiprazole (Abilify) when used for adults and children, but children are less able to identify and articulate these problems. Weight gain great enough to warrant stopping an antipsychotic may occur even after only a few weeks of treatment. Consequently, while not usual tools in the mental health care professional’s arsenal, using a balance scale, and, for children, a growth chart, too, at every visit, is essential to detect this potential harm. The key to detection of movement disorders is careful, repeat observation. Abnormal facial movement or vocalizations, cognitive delay, or muscle rigidity or tremor are warning signs for adverse effects. Recognition of these effects does not require special skills, and a there are a number of tools, including widely-used and freely available. The Abnormal Involuntary Movement Scale (AIMS), which is simple to use and can aid in recognition, is available online at no cost. Sydenham wrote that at times, "I have consulted my patients' safety and my own reputation most effectually by doing nothing at all." For various reasons, this advice seems more difficult to follow in our “Get-It-Done” culture. Where we must do something, even if we are unsure of the long-term helpfulness, it is most important to use all means available to monitor for, and avoid, harms. Mark E. Helm, MD, MBA, FAAP, a practicing pediatrician in Arkansas, co-authored a significant study on the inappropriate prescribing of antipsychotics, and is working to improve this problem nationally. Dr. Helm is a member of the Medical and Scientific Advisory Board of the National Center for Youth Law's PsychDrugs Action Campaign. Snapshot: Making Room for Voices Berta Britz When I heard voices for the first time, the young woman who had been my main source of love and acceptance had just died. She and her family had been a life preserver for me in surviving storms of abuse in my family of origin. As a young child I was sexually abused by the other person in my family who was a source of love and acceptance for me. I lost them both. I experienced my powerlessness, and the voices took over. At seventeen I was hospitalized. I spent the next forty years battling harsh voices. The harder I fought my voices, the more aggressive they became. I was given a lot of Thorazine, Stelazine, and Haldol over the years, and still my voices were relentless. I spent a good portion of those forty years in hospitals, though I was able to complete college and graduate school. Most of that time I was on the very high doses of psychotropic medications that I continue to take, but the power of the voices was insurmountable. In 2007 I learned about a different approach to hearing voices—working with them. I accepted my voices as my own, and I changed my relationship with them from one of powerlessness to one of equality. I learned to be assertive with my voices instead of being aggressive with them. And I learned that they served a purpose in my recovery. For me there is time and space for voices and a full life. The Latest Research Post-Hospitalization Syndrome and Its Relevance to Peers In what will probably be my favorite New England Journal of Medicine article for 2013, Yale cardiologist Harlan M. Krumholz, MD, puts post-hospitalization syndrome on the map. He notes that both during admission and a stay in the hospital, treatment providers focus on the cause of hospitalization. However, they ignore the stress of spending time in the hospital, which makes patients vulnerable to re-admission in the thirty days after discharge. Consequently, return visits increase, due to a host of ailments, such as heart failure and pneumonia, unrelated to the initial hospitalization. Disturbances in sleep-wake cycle, including sleep deprivation, may cause the disabilities of jet lag. Pain can influence cognitive and metabolic functioning, and the immune system. A decrease in the usual degree of movement and exercise causes deconditioning, increasing the risk of falls. Oversedation and undersedation exact a price. The profusion of health care professionals, and unpredictable schedules, can exacerbate confusion and uncertainty. What is worse, some shortcomings, such as malnutrition, are common, if not routine, even though hospitals might be expected to make solving them a priority. For example, one study found that a fifth of elderly patients received less than half of their calculated maintenance energy needs; another study found that weight loss and decreased blood albumin levels after discharge predicted readmission within a month. The debilitating side effects of hospitalization may hold two lessons for behavioral health. First, in weighing the pros and cons of commitment and treatment options, post-hospitalization syndrome needs to be added to the balance. Hospitalization has very real physical costs for mental health consumers. Consequently, the Parachute hospital diversion model New York is now developing, with four crisis respite centers to be located in Manhattan, Brooklyn, Queens, and the Bronx, makes clinical sense. Second, continuing peer support for thirty days after discharge might be advantageous because individuals are vulnerable to re-hospitalization then. This proactive measure is supported by a randomized, controlled 2011 study which found that assigning consumers a peer mentor upon discharge significantly reduced re-hospitalization and hospital days among consumers for nine months after they left the hospital.[1] Perhaps in part due to the peer empowerment movement, budget reductions, and an administrative willingness to explore new solutions, the behavioral health system may be ahead of the curve in finding solutions to post-hospitalization syndrome with peers. Article Krumholz, HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N Engl J Med. 2013;368:100-102. doi: 10.1056/NEJMp1212324. Article Reference 1. Sledge WH, Lawless M, Sells D, Wieland M, O'Connell MJ, Davidson L. Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations. Psychiatr Serv. 2011;62:541-544. doi: 10.1176/appi.ps.62.5.541. Abstract Affordable First-line Treatments for Depression Self-help books, websites, and limited professional attention can help those with severe depression as much as those with mild depression, and may be as effective as more intensive treatment by therapists, according to a meta-analysis of individual patient data from 16 datasets. The study compared how patients with different degrees of depression improved with low-intensity vs traditional treatment. In a way, this was a test of Britain's stepped up model of care, which has two key features. First, it offers clients the least resource-intensive, but generally effective, treatments first, followed by more resource-intensive care only if the first treatments do not work. (The exceptions to this rule are patients who are a danger to self or others, or who have a history of treatment failure. These patients automatically begin with more intensive treatment, such as 12-16 sessions of conventional cognitive therapy.) Second, mandatory scheduled reviews with objective outcome measures allow for mid-course corrections if patients are not getting better. Administrators may resist this model, fearing rules that will restrict their discretion, or changes that will inspire budget cuts, or they may welcome less resource-intensive ways to help more people. Clinicians may feel devalued by the new emphasis on self-help vs professionals, or they may welcome the chance to concentrate on clients who are the most needy. How will service recipients react? The authors acknowledge that patients may give up on receiving services altogether if the low-intensity care they receive does not work. They also note that merely being assigned low-intensity services, if they want intensive services, might affect the usefulness of these treatments. However, they point to evidence that suggests that, at least in research where people are randomly assigned to different therapies, being able to have the treatment you want may increase the chances that you will accept treatment, but has no impact on the effectiveness of therapy, should you take it. 24/7 self-help on demand might be the empowering default option of the future. I think of this positive characterization because when I was in private practice as a psychologist, I often lent clients self-help materials. For example, on several occasions, at the end of intake sessions, I told individuals with panic attacks about a cognitive therapy workbook that was highly effective with this problem. All but one of these people decided to use this book, and, I believe, were successful. Article Bower P, Kontopantelis E, Sutton A et al. Influence of initial severity of depression on effectiveness of low intensity interventions: meta-analysis of individual patient data. BMJ 2013;346:f540 ArticleTax Breaks for the Working Poor, and Free Help with Filing If you are a member of the working poor, you may know about the Child Tax Credit, which is worth up to $1,000 for eligible single or married workers. But did you know that you might also be eligible for a tax break called the Earned Income Tax Credit (EITC)? The EITC is money the federal government gives eligible low and moderate income workers even if they don’t have to file or pay taxes. Although your EITC can be thousands of dollars, only about one in four eligible workers claim the EITC they earn. This means that millions of dollars due to eligible individuals goes unclaimed every year. If you are eligible, you can receive up to $5,891 from the government depending on your income and family size. How can you tell if you are eligible? Use the EITC Assistant, available in English and Spanish on the IRS website. According to the IRS, for tax year 2012, both earned income and adjusted gross income must each be less than certain amounts. For example, if you have no children, your income must be less than $13,980 ($19,190 married filing jointly). If you have three children, your income must be less than $45,060 ($50,270 married filing jointly). To receive EITC money, you have to file an income tax form, even if you don’t need to for any other reason, and fill out a Schedule EIC. If this is difficult, you can get free tax help from some of the programs described below. Free Help Filing Some tax preparation assistance is available at no cost for people with low or moderate incomes.
Most sites expect you to bring:
If filing electronically on a married-filing-joint tax return, both spouses must be present to sign the required forms. Get 24/7 access on Website IRS.gov. Day or night, the website IRS.gov has the tax forms and answers you need when you need them. Also, several tax forms are available in Spanish. “Where’s My Refund?” You can check on the status of your refund within 24 hours after receipt of an e-filed return. The tracker tool shows the progress of your refund from receipt, approval and the date to expect your refund. Lastly, if you are a victim of Hurricane Sandy, check the site IRS.gov for any considerations or accommodations that may apply to you.
More information and online registration for these workshop can be found on our website at: http://www.coalitionny.org/the_center/training/ Trauma-Informed Care
Introduction to Benefits Management
Maximizing IR Services in PROS Programs
Integrating Peer Specialists into Your Mental Health Program
Curriculum Development - for PROS Programs
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What is cognitive remediation, and why is it critical in recovery? To find out, newsletter editor-in-chief Elizabeth Saenger, PhD, interviewed Alice Medalia, PhD, Professor of Clinical Psychiatry; Director of Psychiatric Rehabilitation, Columbia University Medical Center; and an international authority on how to help people with psychotic disorders using this treatment. Dr. Medalia pioneered NEAR (Neuropsychological & Educational Approach to Remediation), and professional and advocacy groups have given her awards for her contributions in research, clinical care, and policy development.The Coalition Home | Center for Rehabilitation and Recovery | Site Map
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