Tipping the Scales in Favor of Collaboration

Mary Fry, ND
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In caring for patients with mental illness or distress as a naturopathic physician, I am either indirectly or directly working with the conventional (allopathic) mental health care system. I say this, as my patients do not exist in isolation; often a patient’s desire for ‘exclusively’ naturopathic approaches is a reaction against the current mental health care system, either philosophically or as a result of adverse experiences with provider(s), medication(s) or other administered treatment(s). I will not argue that the current mental health care system needs to evolve, but if I collude with patients in distancing them from conventional medical services and providers, I only serve to limit their recovery further and to polarize medical disciplines. (And as we have seen from politics of late, polarization does not lend itself to forward movement and growth, but rather limits it.)

However, there are numerous obstacles to overcome when it comes to working collaboratively in mental health; namely, the time that it takes and the absence of a common language between providers of disparate training.  I have found self-administered mental health (and general health) screeners to be invaluable in this regard. Screeners provide an efficient and effective means of communicating with other providers (general practitioners, psychiatric mental health nurse practitioners and psychiatrists). In addition, screeners help to capture symptoms and stressors that might otherwise be missed or underappreciated, empower the patient to be involved and interested in his/her progress, and can improve treatment outcomes.

In using such screeners, I have encountered resistance from a minority of patients who think that I am going to use them in order to label them with a disorder that they feel limits them. Upon explaining that they are not used diagnostically per se, but rather as an ongoing monitoring & collaborative tool, these patients are often more amenable to their use. Generally I find that my patients readily fill out the screeners and appreciate their use as one of many tools that can be employed to better understand and monitor their health and well-being. I have even had some take matters into their own hands and fill out every screener on my site – perhaps to be sure that I capture every condition and comorbidity that they may have!

There are a number of easy-to-use, sensitive and specific validated instruments that are available. I have found the following to be particularly helpful:

  • Patient Health Questionnaire- 9 (PHQ-9) for detecting Depression and monitoring its severity.
  • Mood Disorder Questionnaire (MDQ) to screen for possible Bipolar I disorder.
  • Generalized Anxiety Disorder-7 (GAD-7) to screen for and to monitor the severity of Generalized Anxiety, Panic, Social Anxiety & Post-Traumatic Stress Disorder (PTSD).
  • Yale-Brown Obsessive- Compulsive Scale (YBOCS) for monitoring symptom severity in Obsessive-Compulsive disorder.
  • Morningness-Eveningness Questionnaire (MEQ)  to assess circadian rhythm type so as to optimize the timing of the sleep-wake cycle and to determine when to administer bright light therapy used for seasonal affective disorder and other conditions.
  • Measure Your Medical Outcome Profile (MYMOP) to measure changes in a patient’s perception of his/her symptoms and overall well-being. This instrument is particularly helpful in monitoring the effects of holistic care (Naturopathy, Homeopathy, Chinese Medicine, Ayurvedic Medicine and other approaches). In working with patients naturopathically, this scale allows one to assess more than one condition at a time, gives insight into which symptoms are most distressing to a patient and reflects a patient’s overall sense of well-being.

There are additional screeners that can be helpful as well, including the Patient Health Questionnaire- 15 (PHQ-15) for Somatic Symptom Severity, the PTSD Civilian Checklist (PCL-C) for Post-traumatic Stress disorder, the Personal Inventory for Depression and S.A.D. (or Seasonal Affective Disorder) (PIDS) for Depression and S.A.D. and the  Structured Interview Guide for Hamilton Depression Rating Scale Seasonal Affective Disorder Version- Self-Administered (SIGH-SAD-SA) for Seasonal Affective Disorder.

Bipolar disorder is a condition that is important to monitor closely (due to its cyclical nature and the lack of insight* that accompanies hypomania and mania). (*Insight refers to the          widely-observed phenomenon that those in a hypomanic or manic phase of bipolar are generally not aware that their behavior has changed or that there is anything problematic about it).  There are a number of scales and symptom logs that I have found helpful in working with Bipolar; including the MDQ to detect possible bipolar I, a mood diary (adapted from the STABLE toolkit) for the patient to fill out on a daily basis and to bring to practitioner visits, and the Social Rhythm Metric (SRM-5 (click on the figures tab of this article to view)). There is also a more extended version of the Social Rhythm Metric, the SRM-17. (The Social Rhythm metric was developed by Ellen Frank, Ph.D.)

In addition, in working with those suffering from bipolar disorder, a timeline, documenting each manic, depressive and euthymic period since the first known episode is also immensely helpful in understanding each patient’s unique cycles, stressors and triggers and can be used to guide treatment. Including family to collaborate with providers (with the appropriate permissions) is imperative as well and is referred to as ‘collateral’ by clinicians. In some cases, I have even suggested that a trusted family member (let’s say ‘Jill’ for the sake of this example) fills out a mood diary on behalf of her family member, George, who is affected by bipolar. Then once a day Jill & George can compare how they each perceived George’s mood to be for that day as a way of monitoring and improving George’s well-being and maintaining rapport in difficult times.

So whether you are suffering from a mental health condition and seeking to optimize your care, have a friend or family member affected by mental illness, or are a clinician working with patients suffering from mental illness, screeners may be of help to you. Screening instruments have the capacity to improve both the detection and monitoring of mental health conditions, can facilitate collaboration between healthcare providers and can improve the outcomes of treatment. If you are suffering from a mental health condition, you may wish to print out the appropriate screening instrument(s), complete the form(s) and bring a copy to your provider(s). Not only can this empower you in your road to recovery, but it can be a powerful way to advocate for greater integration and collaboration in your care, and hopefully the care of others in the future.

Resources:

The screening instruments listed herein are largely available from my website.  Scoring information for the PHQ & GAD-7 scales can be found at the PHQ screeners site.  And for the MDQ, see the STABLE toolkit (p.14 ). The YBOCS has both self-administered and clinician- administered scoring information. For the self-administered scoring information, see the OCD Center.org.  The PCL-C scoring information can be found at the US Department of Veterans Affairs site.  For automated online assessment versions of the PIDS, SIGH-SAD & MEQ, see the Center for Environmental Therapeutics site. Clinicians can purchase these instruments for use with patients from the same site. MYMOP scoring and other information can be found at the MYMOP dedicated site. Click here for other videos and information on the MYMOP.

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16 COMMENTS

  1. Dr. Fry,

    When I saw the first article (at least that I’m aware of) from a Naturopathic Physician on this site, I was hopeful that it would be insightful… something new.

    And although some of what you had to say was unique, I found that the article turned out to be more of the same, with a conventional approach.

    In short, I was greatly dissapointed.

    Duane Sherry, M.S., CRC-R
    http://discoverandrecover.wordpress.com/wellness

    • I fully agree with you Duane Sherry.

      ‘screeners’, are nothing but quack questionnaires, dressed up in the false pseudomedical language of ‘screening’ as if to hitch a wagon to real medicine like ‘prostate screening’ or some such.

      Screeners are quackery, so is naturopathy. The last thing anyone in jeopardy of being harmed by psychiatry needs, is another parasitic quack profession preying on them, gaining their trust, tricking them into developing a dependency on their dubious ‘credentials’.

      It really is tragic and sad to hear the word ‘physician’ and ‘patient’ in relation to this quackery.

      I think wikipedia sums naturopathy up best when it says

      “Non-scientific health care practitioners, including naturopaths, use unscientific methods and deception on a public who, lacking in-depth health care knowledge, must rely upon the assurance of providers.”

  2. “So whether you are suffering from a mental health condition and seeking to optimize your care, have a friend or family member affected by mental illness, or are a clinician working with patients suffering from mental illness, screeners may be of help to you. Screening instruments have the capacity to improve both the detection and monitoring of mental health conditions, can facilitate collaboration between healthcare providers and can improve the outcomes of treatment. If you are suffering from a mental health condition, you may wish to print out the appropriate screening instrument(s), complete the form(s) and bring a copy to your provider(s). Not only can this empower you in your road to recovery, but it can be a powerful way to advocate for greater integration and collaboration in your care, and hopefully the care of others in the future.”

    What you are actually encouraging here, is the same “mind reading” diagnosing of others which created this unholy mess of a health care system, in the first place. Its the fallacy of “I think therefore I am, so can’t feel my own presence,” superior intellectualism which has gone way to far, in our Western culture?

    This is the shore upon which we have washed up?

    WE CANNOT PERCEIVE WHAT WE CANNOT CONCEIVE:
    We can only perceive, or literally see, what we can conceive of. We must have neuronal firing in our brains, whether it be in the imaginable state or actual perceptual state, for us to register an object as a reality.

    Example: When Magellan’s fleet sailed around the tip of South America he stopped at a placed called Tierra del Fuego. Coming ashore he met some local natives who had come out to see the strange visitors. The ship’s historian documented that when Magellan came ashore the natives asked him how he had arrived. Magellan pointed out to his fully rigged sailing ships at anchor off the coast. None of the natives could see the ships. Because they had never seen ships before they had no reference point for them in their brains, and could literally not see them with their eyes. Therefore, it is to our advantage to expose our brains to varied stimulus so that the proper neuronal connections are forged. In this way we expand and enrich our ability to experience more of our environment in a meaningful way.

    Please think about this insane “I think therefore I am,” cognitive way of life we’ve adopted?

  3. David, you should have posted your story with the rest of the recovery stories. It is very interesting and tallies with my own experience in the British medical system. My son’s section was not lifted though inspite of the pack of lies told by the Doctors and he was force-fed drugs instead. It all was like a big bad farce.
    Mary Fry believes in the concept of “mental illness”, and that is why everything goes wrong from the start. There is no alternative in what she is offering. What we want is a different approach to distress, not the same old…

    • I’ve been pointing out a different approach for over a year Alix:))

      Yet people within the recovery movement and its hierarchy seem to believe there is nothing new in science that can help us?

      Because I’m an unknown “rank” outsider, my views are predictably ignored, in our “acting out” of our so-called reasoned intelligence.

      Never mind, when one is born to psychosis through innate sensitivity, the mistress muse is the master, not oneself, and I can only go with her inspiring flow?

      Several hundred times now I’ve said that Stephen Porges “The Polyvagal Theory” is the new paradigm in mental health, another brilliant American mind.

      http://www.amazon.com/gp/product/images/0393707008/ref=dp_image_z_0?ie=UTF8&n=283155&s=books

      But hey, what do I know?

      I’m just some idiot that thinks its a good idea to “act out” three full term psychosis online, to try to show its NOT a diseased brain process.

      All documented in a black & white timeline, which is undeniable unless you really need to hang to your “I think therefore I am,” cognitive (homeostasis) need?

  4. The MYMOP was new to me and sounds of interest, as it could be used for clients to determine what outcomes they’re interested in and track on them. Otherwise, the screening tools you mention seem to continue the effort to label and categorize people according to “symptoms” rather than engaging the client in the process of self-discovery that leads to real healing. Your comments on Bipolar Disorder I found particularly disturbing, in that, in my direct clinical experience, huge percentages of people so diagnosed are either 1) suffering from trauma that results in “mood swings” and “psychotic symptoms” based on triggers, nightmares, and flashbacks they may be having throughout the day, or 2) suffering from the side effects of such “helpful” drugs as SSRI/SNRI antidepressants or stimulants. That’s not counting the ones who get the diagnosis secondary to recreational drug use.

    Of course, the whole concept of “Bipolar Disorder” is an invention with no scientific grounding and incredibly vague descriptions and boundaries, such that many very normal people could be described that way if one believed in looking for this “disorder.” Not to say that some people don’t meet the description rather well – it’s that the description itself is scientifically meaningless, as are pretty much all the DSM categories.

    You seem to be promoting an alternative “treatment” for the same “disorders” that psychiatry has already defined for us. While herbal approaches are generally less harmful than drugs, I think you’re doing a disservice to your clients and to the profession by buying into the deceptive and greed-motivated DSM diagnostic process. I strongly suggest you work toward creating a more client-friendly and empowering paradigm that is more consistent with the general holistic philosophy that I understand to underlie naturopathic medicine.

    — Steve

  5. Pilot studies and research are essential in order to demonstrate that there are healing and recovery alternatives to medications, which although may work for some, at least in the short run, long term are creating iatrogenic mental illness for many others!

    Mary, I like what you are saying about the potential uses of these concrete tools to bridge the communication gap between those with lived experience and their physicians, or between progressive healers and physicians in order to concretely and in a language docs can readily understand, (they already use the tools!) demonstrate the efficacy of more healing alternative approaches to mental distress.

    I believe we must continue to strive toward dialogue with the prescribers whose first line standard of care is the use of drugs (and without full disclosure!) With the ACA (Affordable Care Act, ie: Obamacare) today surviving the Supreme Court, there will be potentially tons more patients coming onto health insurance rosters who, with the current paradigm, will be put on meds for life–so the sooner we can get moving on something concrete to try and reach the prescribers, the better, as far as I am concerned! The tools you suggest can readily be used in a pilot study/research project among progressive healers to communicate with the more rigid and hard to reach top end prescribers, and is an ongoing essential part of creating a new paradigm of care.

  6. Dr. Fry,

    I appreciate the use of quantitative instruments to assess various domains of change of symptoms/experience. It’s amazing how so many clinicians in evaluating clients/patients miss/assume important domains of information, that having a more systematic approach would capture. I particularly appreciate more structured assessments of subjective experience because when done well (proper consent, introduced well, etc.), allows patients to share difficult things and have a conversation with a clinician on more equal footing (as opposed to feeling examined/judged/probed etc.). It also lets clinicians and patients have a conversation about how accurate the assessments seem, if they have missed anything, and what are the more important domains for clients to focus on at a particular time. To assess change, they help guide a conversation about differences in experiences that can be difficult to assess/remember just from individual memory.

    I am wary, however, of to what extent they are “validated,” and especially communicating between paradigms of mental health, that scores or changes in scores reflect much more than what they actually indicate. People sloppily use screeners as diagnostic tools for disorders that have not shown to have validity in the first place. In that regard, a couple of questions are used to label someone indefinitely with disorders that can have really negative effects on people’s lives for little reason. Perhaps one clinician may see more nuance in interaction besides use of screeners, but often just a screener score moves with a file, and patients can be stuck with people reading much more into it than should be.

    • Isn’t that a core problem for a lot of people, lydia? People’s inability to articulate and express, to the point that others are able to understand?

      And if we are able to communicate our “problems” – pains, fears and troubles – and if the listener understands …

      WHO knows how to respond correctly?

      911 is “emergency RESPONDERS”. I’ve never met one person in the “health” industry who has known how to respond to me. They truly do not know how.