Library - NAMI Stamford/Greenwich maintains a library of books on mental illness topics available to borrow for interested members. More details will be posted shortly.
ARTICLES OF INTEREST
HOUSING AND CONTINUITY OF CARE
By Peter Case
The Connecticut mental health system is not doing a good job of providing continuity of care for psychiatric patients discharged from hospitals. That was the assessment of James McCreath, Ph.D., President and CEO of St. Vincent’s Behavioral Health Services in Westport. He was speaking about continuity of care and medication adherence to a group of family members and consumers at NAMI Fairfield’s March 3rd speaker meeting.
“Half the people discharged from inpatient psychiatric care in Connecticut never make it to outpatient care,” he said. “The inpatient social worker needs to see that the discharged patient keeps his outpatient appointment, actually drive him there if necessary.” He said he was surprised on a visit to one of the southern states to find its continuing care success rate was better than Connecticut’s. The reason, he discovered, was that it does in fact support that kind of intensive follow-up.
It can sometimes take years of continuous care to ensure the discharged patient sticks to his or her medication plan, which is the most important factor in preventing relapse, he said. Despite recent technical advances like I-Phone medication reminder apps and longer-lasting, smoother injectable delivery systems, the patient’s family still needs to take the long view.
Asked about the role of housing, he said the trend is away from transitional group living or half-way houses that impose strict rules and rigidity. The preference is to live with family or in rental apartments in the community after discharge, under a program that provides intensive, flexible outpatient care. The trouble is, he said, there are not enough programs like that.
One program that meets Dr. McCreath’s criteria – and provides a glimmer of hope for Connecticut – was discussed at a housing symposium on February 25 at St. Vincent’s Behavioral Health Services. The program, called “Housing First,” was described by Sam Tsemberis, Ph.D., founder and CEO of Pathways to Housing, the New York City organization that developed it. Sharing the podium with him were Carol L. M. Caton, Ph.D., a Columbia University professor and the author of Homeless in America, and Barbara Geller, Director of Statewide Services for the Connecticut Department of Mental Health and Addiction Services (DMHAS).
Housing First is unique among supported housing programs in that participants are provided with their own apartments immediately upon discharge from inpatient psychiatric units, or directly from shelters or the street, without first having to complete a satisfactory program of psychiatric treatment. Nor is a period of sobriety or abstinence from drugs required. The participants have a role in selecting the apartment and its furnishings.
To balance the absence of admissions criteria, the program incorporates intensive outpatient care as an integral part. This care can be assertive community treatment (ACT), in which a multidisciplinary team works directly with the individual to provide individualized treatment planning and long term follow-up, or the less costly intensive case management (ICM), in which those providing the care broker existing community services on behalf of the individual.
The experts agreed that the Housing First program works, for several reasons:
- Having a place of one’s own with a choice in its selection is empowering and motivating.
- The individual signs a lease and has the same rights and responsibilities as other tenants.
- The rent is subsidized; the individual pays no more than 30% of his or her income.
- At least 80% of the apartments are occupied by “regular” tenants, so the individual feels like part of the larger community.
- The program’s housing and its clinical services are independent: a clinical crisis does not lead to eviction; an eviction does not mean discharge from services.
- The intensive care services are flexible and adapted to the individual’s personal needs.
The good news for Connecticut is that DMHAS is currently pilot testing the program in Hartford and New Haven. A total of ten people in each city will participate, five who have been discharged from hospitals and five homeless individuals. Local mental health authorities are providing clinical services and the Department of Social Services and the New Haven Housing Authority are subsidizing the rent. Chrysalis Center in Hartford and Continuum of Care in New Haven are providing intensive case management.
Four people in each city will have been housed as of May 1, according to the DMHAS Statewide Services Division. Five more in each city are in “active engagement.” There is a long way to go, but this is a promising first step.
ANY QUESTIONS FOR THE PHARMACIST?
By Diane Frost
Charles F. Caley, Pharm.D., addressed questions from audience members in the Brace Professor Auditorium at the Tully Health Center in Stamford on March 17th. The audience of 35 to 40 included NAMI Stamford/Greenwich affiliate board members, as well as those living with mental illnesses and their families.
Dr. Caley is an Associate Clinical Professor of Pharmacy Practice at the University of Connecticut, School of Pharmacy and a clinical psychopharmacology consultant at the Burlingame Center for Psychiatric Research and Education at The Institute of Living, in Hartford, Connecticut. As a member of the College of Psychiatric and Neurologic Pharmacists, Dr. Caley has worked with NAMI National on its Web site’s (www.nami.org) facts about medications.
He presented an educational discussion on the medications prescribed for serious mental illnesses. He answered questions both raised in advance of the event and raised by audience members.
Evolution in Pharmacy
His remarks began with comments about the “evolutionary stage” he perceives pharmacology to be in right now. He said that pharmacology was moving “more in the direction of patient care. We’re trying to move out from behind the counter to the people.”
One audience member asked if the purpose of treating mental illness with medication is an effort to prevent a psychotic episode.
Dr. Caley said, “I can tell you that if we work back in time to the 1950s, Thorazine was that hope. But as time has gone by…” the goal has become broader to control both the positive and negative symptoms of mental illness. Positive symptoms are things like paranoia, outbursts and hearing voices. It’s the positive symptoms that tend to lead to hospitalization. Negative symptoms are things like disinterest in activities, withdrawal and emotional flatness. Let’s find an interaction that addresses all these spheres.”
Monitoring Medication’s Effect and Interaction
Another audience member asked if medication stopped working after extended use.
Dr. Caley said that some people can be maintained on the same medications for a long time. Others’ benefit from medications for shorter periods, because the drugs can lose their effect, resulting in lose of work and relationship disruptions. He also said that he doesn’t know of predicative factors that would be able to place an individual in either group. He said, “I think there are people who can be maintained. It’s a loss of effect (for those for whom medications stop working). I know of nothing that can predict.
One of the questions concerned whether tracking reactions and interactions of medications once three drugs are in the bloodstream is possible. Dr. Caley responded that tracking is possible, but by a means that is not recommended for patients being treated for serious mental illnesses.
He said, “The scientific way to test for interactions between two drugs would be to stop one and observe the individual’s response, then restart it and again observe the individual’s response. Obviously you cannot do that with a patient you are treating for a serious psychiatric illness. So predictability is hard when it comes to psychiatric medications.”
He clarified the common types of reactions that can be expected from treatment with psychiatric medications. He referred to medication in general, in his example. He said, “There are two kinds of reactions. One is “dynamic reaction” where one drug magnifies the effect of the other. For example, Benadryl is sedating and so is wine. So you have to be careful about over-sedation if you drink wine while taking Benadryl. Manufacturers of antidepressants screen for dynamic reaction when developing drug formulas. The other is “pharmacokinetic interaction” where one drug tends to cancel out the effect of the other. For example, Prozac slows down enzyme activity and can thereby decrease the effectiveness of other drugs. If I see that medication in the profile, I ask about adverse reactions.”
He mentioned that as far as pharmacists using different databases to check for drug interaction, there are several databases available and not one is used singularly with the same information. It also depends on the drug. For example the mood stabilizer Depakote, often used in treating Bipolar disorder, was thought “not to be a problem,” he said. “(After) learning different things about it, we found that it is not as clean a drug as we thought.”
The good news is that there are more antidepressants and mood stabilizers that are evolving.
He spoke about the subjectivity in analyzing how medications affect the body. He pointed out that there are very few instrument oriented tests that can judge the effectiveness of a particular medication on a person being treated. Genetics also play a strong part as does the person’s compliance with taking medication as directed. A consumer may be resistant to the effect of medications, and/or not take medications as the treating physician has prescribed. He said, “It’s not like measuring blood pressure, where you can wrap the blood pressure cuff around someone’s arm and get a precise reading. A person’s individual genetics can influence his or her response to drugs. So can a person’s individual behavior when it comes to taking his or her medications.”
Many people exhibit what Dr. Caley referred to as “creative adherence” to their medication regimen. He commented, “People take medications creatively. I think genes are important, but so is human behavior.”
He added that a good way to live with mental illness is for the consumer to, “take medications, use supports, to be upfront about symptoms with your doctor and to reduce environmental stress. Sleep is an amazing thing for bipolar folks. Keep a good control on sleep habits.”
Supplements as Treatment
Another pre-posed question that Dr. Caley answered concerned the use of supplements in the place of psychiatric medications in treatment for mental illness. The supplements asked about were omega 3 fish oil, vitamin B-12 and Vitamin D. Dr. Caley said that he doubted that supplements alone would have a lasting benefit in treatment and ward off a potential crisis. In responding to the example of a consumer living with schizoaffective disorder, who replaced prescribed Trileptal, Prozac and Wellbutrin with the three supplements, Dr. Caley voiced skepticism. He said, “The value of supplements should not be discounted, especially the value of omega 3 fish oil. However, if your son was stable on those three prescriptive medications and is now taking only supplements, he could be heading for a crisis down the line. Of course, even when someone is on psychiatric medications, crises occur, but they are more likely to occur when the individual is off meds, and I’m not sure that supplements alone are enough to take their place. Generally, supplements are prescribed along with antipsychotic medication.” He expanded on this, saying, “If I had a family member, I’d be sensitive to the possibility of decompensation. I’d never want to discourage (their use), but I think we need to be realistic of the support network they provide
A Question of Safety
Are psychiatric drugs safe? And what damage can they cause to the brain? Dr. Caley responded with some good news, that the brain and body have high capacities for protecting themselves from harm to their tissues and cells when medications enter the bloodstream. But his good news was tempered by the fact that visible side effects can come from prolonged use of certain medications. He said, “Some drugs do carry long term risks. Tardive Dyskinesiathe uncontrollable body movements that some drugs, such as Haldol, can cause, can become permanent, even after use of the drug is stopped.”
He emphasized, “I don’t think I’ve ever met anyone who doesn’t have their patients’ interests at heart. What this profession doesn’t do well is measure. We can take blood pressure, but if you’re depressed, it’s a subjective opinion.” He added, “There’s no question that these medications can have harmful effects on the body. The purpose of pharmacy is to reduce these effects.”
Trial and Error
As much as pharmacology has evolved, Dr. Casey pointed out that finding and treating a patient with the right medication or combination follows the same rule of thumb that has been used for many years. He said, “Trial and error is a key reality that one has to accept when trying to find psychiatric medications that work – but have minimal side effects – for a given individual. If Zyprexa is intolerable, Abilify and Geodone are possible substitutes.”
As part of the movement to make treatment easier on the body, especially the digestive tract, some medications come in different “delivery forms.” One of these drugs is Zyprexa.
According to Dr. Caley, it “now comes in injectable form. Because it enters the blood stream directly when injected, a risk is too much concentration in the blood stream, which can lead to sedation and trips to the emergency room. Sedation should not happen when one is not in the hospital.”
New drugs are still being developed and being put before the Food & Drug Administration for approval. Dr. Caley reported that, “Two of the newer drugs are Fanapt, which is like Geodone, and Saphris. In other discussion, Dr. Caley said we are still waiting for a really new formula in psychiatric medications. For example, all antidepressants, from the earliest monoamine oxidase inhibitors (MAOIs) to the latest new brand, Prystiq, work on the chemicals serotonin and norepinephrine in the brain.”
Treatment for Schizophrenia
When the question was raised as to whether there was a medication that would cease the voices that those living with schizophrenia hear, Dr. Caley said that the best pharmacology can do at the present time is to quiet these voices and make them less intense, but not as yet make them disappear.
One of the audience members referred to a report on the news magazine program “20/20” about three young girls who have schizophrenia. In answer to her question concerning a drug, Saphris, one of them was being treated with, Dr. Caley said that a new drug was indeed on the market called Saphris.
Addressing a concern from an audience member who had recently read that there have been “sudden unexplained deaths” with the usage of the drug Gabapentin/Neurontin, Dr. Caley said that while he didn’t know of the incidence, he was sure that it wasn’t common or that the FDA would not have approved it.
He said, “Gabapentin carries warnings about risk of sudden death when taken for treatment of epilepsy. As with many drugs, the warnings are part of the extensive information contained in package inserts or on medication Web sites. We should always be aware of warnings, he said, but not disproportionately concerned about them.”
Another audience member posed the question of the helpfulness and delivery methods associated with MAOI’s. The question was, “The person in my family with depression responded well to Parnate, an MAOI, but gave it up because of the severe risks associated with certain foods when taking it. I had heard it was available in a patch, which would eliminate the risks because delivery is through the skin, not the digestive system.” Is this true? Dr. Caley clarified this concern and offered a bit of knowledge on the probability that MAOI patches will be prescribed widely. He said, “MAOIs in patch form are on the drug store shelves now. They come in three dosages. The highest of the three still carries a warning about eating certain foods. However, it is worth considering. Prescribing drugs can be very provincial: the doctors in one county will prescribe a certain drug routinely, while in the next county they will hardly prescribe it at all.”
Hope for the Future
Dr. Caley gave some advice to the audience. He said,” Be critical of whether or not (medication) has helped. What we’ve got is a puzzle. What (medications) do is to plug in to get these people to where we want them to be.”
He added a philosophical comment when asked for some hope in treating mental illnesses from the pharmaceutical development and prescribed use of psychiatric medications. He said, “We’re not working from where we know these illnesses. We’re working backwards.”
He ended his remarks, in saying that the question pharmacologists always ask is, “How is this drug different from the last?”