NAMI Family Family - namiaac.org

NAMI Family-to-Family

A NAMI peer education program for family members of adults with mental illness

Participant Manual 2020

Developed by Joyce Burland, Ph.D. © 1997

Sixth Edition Revision Coordinated by Suzanne Robinson, MSW

Class 5

NAMI Family-to-Family 2020 Class 5 5.30

Class 5: Treatment Options Agenda

• Navigating systems

• Comprehensive approaches

• Collaborative care

• HIPAA: Health Insurance Portability and Accountability Act

• Treatment options

• Treatment settings

• Psychotherapeutic interventions

• Treatment providers

• Medication

• Hospitalization and Assisted Outpatient Treatment (AOT)

• Warning signs of relapse

• Biomedical approaches

• Complementary health approaches


Worksheet 1: NAMI’s Approach to Mental Health

Notes:


Worksheet 2: Bio-Psycho-Social Aspects of Mental Health Conditions

The three dimensions of mental health conditions — “bio-psycho-social” — are interdependent.

• No one dimension can ignore the knowledge base of the other two. • Focusing on one dimension alone is not sufficient for recovery.

Biological/Physical (Medical Dimension)

Science-based knowledge Course Focus: Medical aspects of illness Symptoms, diagnosis Recognizing mental health conditions Predicting what the condition may be in the future (prognosis) Intensive care when needed Best medical strategies to maximize recovery Current brain research Treatment options Treatment providers Medications (side effects, taking medication as prescribed) Recognizing early warning signs of relapse Impact of mental illness on overall health Insight into clinical realities of brain disorders

Psychological/Emotional (Personal Dimension)

Psychology-based knowledge

Course Focus: Subjective emotions and feelings How the condition feels to the person experiencing it Handling anger, frustration, and hopelessness Accepting the “new normal” Typical family responses to mental illness Impact on the family Self-care skills Value of peer understanding and support Recognizing personal strengths Challenges of different relative roles in the family

Social/Occupational (Rehabilitation Dimension)

Recovery-based knowledge

Course Focus: Self-renewal; Re-entry into community Problem solving skills Communication skills Support from systems and community Mental health system Making or restoring social connections Definition and testimonials of recovery Maximizing self-determination, personal fulfillment and quality of life Principles of rehabilitation Rebuilding after transitions (hospitalization, education, employment) Challenging negative stereotypes Long-term care and planning Advocacy for better services and fair policies Celebrating our progress


Worksheet 3: Collaborative Care

Notes:


Worksheet 4: Health Insurance Portability and Accountability Act (HIPAA)

Health care information that could be used to identify an individual person is called “protected health information,” or PHI. The HIPAA Privacy Rule created national standards to protect both the patients’ personal information and PHI. The HIPAA Privacy Rule limits the situations in which personal information and PHI can be used or shared by insurers, providers, and others involved in a person’s health care like hospitals and medical records companies. In order for a doctor, therapist, hospital or other health care provider to share any PHI, there must be a written authorization giving them permission to do so. This includes even confirming that someone is receiving services at a facility. When anyone goes to a health care provider, they are given HIPAA rules to read and a release form to sign. This form gives the provider permission to share medical tests with other providers if needed. It also allows the provider to share information with insurers for payment processing and to contact the person of our choice in an emergency.

Notes:


Worksheet 5: HIPAA Information for Families


Worksheet 6: Treatment Options & Treatment Settings

Notes:


Worksheet 7: Psychotherapeutic Interventions

Intervention Description Behavior Therapy Helps the person change negative behaviors and improve

behaviors through a reward and consequences system. In behavior therapy, goals are set and small predetermined rewards are earned to reinforce positive behavior.

Cognitive Behavioral Therapy (CBT)

Teaches people how to notice, take account of, and ultimately change their thinking and behaviors that impact their feelings. In CBT, the person examines and interrupts automatic negative thoughts that they may have that make them draw negative and inappropriate conclusions about themselves and others. CBT helps the person learn that thoughts cause feelings, which often influence behavior.

Cognitive Enhancement Therapy (CET)

Cognitive rehabilitation training program for adults with schizophrenia or schizoaffective disorder who are stabilized and maintained on antipsychotic medication and not abusing substances. CET is designed to provide cognitive training to help improve impairments related to neurocognition (including poor memory and problem-solving abilities), cognitive style (including impoverished, disorganized or rigid cognitive style), social cognition (including lack of perspective taking, foresight and social context appraisal), and social adjustment (including social, vocational and family functioning), which characterize these mental disorders and limit functional recovery and adjustment to community living. Participants learn to shift their thinking from rigid serial processing to a more generalized processing of the core essence or gist of a social situation and a spontaneous abstraction of social themes.

Dialectical Behavior Therapy (DBT)

A CBT-based approach with two key characteristics: a behavioral, problem-solving focus blended with acceptance-based strategies, and an emphasis on dialectical processes. "Dialectical" refers to the issues involved in treating patients with multiple disorders and to the type of thought processes and behavioral styles used in the treatment strategies. DBT has five components: (1) capability enhancement (skills training); (2) motivational enhancement (individual behavioral treatment plans); (3) generalization (access to therapist outside clinical setting, homework, and inclusion of family in treatment); (4) structuring of the environment (programmatic emphasis on reinforcement of adaptive behaviors); and (5) capability and motivational enhancement of therapists (therapist team consultation group). DBT emphasizes balancing behavioral change, problem solving, and emotional regulation with validation, mindfulness, and acceptance of patients. Therapists follow a detailed procedural manual.

Exposure Therapy Educates and teaches people about how to manage fears and worries to reduce their distress. The person is gradually exposed to threatening situations, thoughts, or memories that make him/her excessively anxious or worried.


Intervention Description Eye Movement Desensitization and Reprocessing (EMDR)

A nontraditional type of psychotherapy. It's growing in popularity, particularly for treating post-traumatic stress disorder (PTSD). PTSD often occurs after experiences such as military combat, physical assault, sexual assault, or car accidents. EMDR does not rely on traditional talk therapy or medications. Instead, EMDR uses the individual’s own rapid, rhythmic eye movements and exposure to the traumatic events. These eye movements dampen the power of emotionally charged memories of past traumatic events. The premise is that EMDR weakens the effect of negative emotions and that disturbing memories will become less disabling.

Family Education and Support

Evidence-based practice in adult mental health. Designed to achieve improved outcomes for people living with mental illnesses by building partnerships among people, families, providers and others supporting the person and family. May be led by clinicians or by other family members. NAMI Family-to-Family is an example of this.

Interpersonal Therapy (IPT)

Designed for treatment of symptoms of depression. Examines relationships and transitions, and how they affect a person’s thinking and feeling. Focuses on the person and helps them manage major changes in their lives, such as divorce and significant loss, including the death of a loved one.

Psycho-educational Multifamily Groups (PMFG)

Treatment modality designed to help people with mental health conditions attain as rich and full participation in the usual life of the community as possible. The intervention focuses on informing families and support people about the illness, developing coping skills, solving problems, creating social supports, and developing an alliance between people with mental health conditions, practitioners, and their families or other support people. Practitioners invite five to six people and their families to participate in a psycho-education group that typically meets every other week for at least 6 months. "Family" is defined as anyone committed to the care and support of the person with mental illness. People usually choose a family member or close friend to be their support person in the group. Group meetings are structured to help people develop the skills needed to handle problems and to serve as problem solving consultants to each other.


Intensive Home and Community-Based Interventions Intervention Description Average Length of

Treatment Multisystemic therapy (MST)

Short-term and intensive home-based, family focused therapy for children and adolescents. MST therapists have small caseloads, designed to meet the immediate needs of families. The MST team is available 24 hours a day, seven days a week to work with families.

4 months with approximately 60 hours of contact with the MST Team

Mental Health Intensive Case Manager (MHICM), a servicer through the VA for veterans

Generally, relies on a single case manager assigned to work closely with the family and other professionals to develop an individualized comprehensive service plan for the veteran and family.

Long-term (no limit)

Wrap Around Services

A philosophy of care that includes a definable planning process involving the person and family that results in a unique set of community services and natural supports individualized for that particular person and family to achieve a positive set of outcomes.

Long-term (no limit)


Worksheet 8: Supportive Psychotherapy

Supportive psychotherapy refers to a variety of types of therapy. Supportive psychotherapies acknowledge the environmental factors that affect a person’s mental health, including systemic oppression and poverty. They aim to create a feeling of safety and trust between the person experiencing symptoms and the provider and often use positive reinforcement. The goals include:

• Helping the person improve their self-esteem • Developing the ability to have a realistic view of their experiences • Learning to cope with stress and anxiety

Some supportive psychotherapies include cognitive-behavioral and interpersonal models and techniques. A Psychology Today article defined Supportive psychotherapy as “…the attempt by a therapist by any practical means whatever to help patients deal with their emotional distress and problems in living.”

There are basic traits of how providers of supportive psychotherapy should approach their work, although there are variations depending on the person. Providers offer practical help and advice that supports people in managing their condition. In this approach, they listen empathetically and often comfort and reassure the person seeking treatment while helping them learn new skills. They may also help them advocate for services and treatments.

People receiving supportive psychotherapy don’t need to be highly motivated to engage in this treatment. It recognizes that mental health challenges often demoralize people and make them skeptical or reluctant about treatments. Providers should be willing to help persuade clients to accept and continue treatment, partly by being patient and trustworthy.

Common focuses of supportive therapies

• Education The client learns about their condition, their symptoms, treatment options, signs of overload, stress and relapse. They learn concrete problem solving around family and other relationships.

• Self-esteem The impact of mental health conditions have on daily life and relationships can deeply destabilize self-esteem. Supportive therapies help the person manage disappointment, rebuild their sense of self, and take gradual, steps towards progress.

• Mentoring Providers partly serve as mentors, helping the person become empowered to advocate for themselves in the health care system and in their community. It’s a collaborative partnership between the person and provider.

• Dynamic change Providers recognizes that their clients go through natural cycles of stability, relapse and remission. They shift therapeutic strategies to address these cycles as needed.

• Networks of support This approach recognizes that families, partners and friends can be invaluable allies in the treatment process. If the client wants to, the


provider can share information and suggest ways to support the client. With close collaboration between the person, the therapist and the important people in the client’s life, this can be a key part of the approach.

If your loved one is interested in therapy, they should look for a credentialed behavioral health professional such as a psychologist, licensed professional counselor, licensed clinical social workers or other licensed providers. Sources: NAMI Provider; Psychology Today; Psychiatric Times; see References for full citations

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Wor

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the

full

effe

cts.

M

edic

atio

ns m

ay w

ork

grea

t for

one

pe

rson

and

not

at a

ll fo

r ano

ther

—

even

if b

oth

have

the

sam

e di

agno

sis.

It is

diff

icul

t to

pred

ict

exac

tly w

ho w

ill re

spon

d to

wha

t m

edic

atio

n.

A nu

mbe

r of l

arge

-sca

le re

sear

ch

stud

ies

have

det

erm

ined

“firs

t-lin

e”

and

“sec

ond-

line”

med

icat

ions

bas

ed

on w

hich

med

icin

es o

ffer t

he b

est

sym

ptom

relie

f with

the

few

est s

ide

effe

cts.

Unf

ortu

nate

ly, m

any

rese

arch

st

udie

s on

med

icat

ions

and

oth

er

treat

men

t stra

tegi

es h

ave

faile

d to

in

clud

e ad

equa

te re

pres

enta

tion

from

raci

ally

and

eth

nica

lly d

iver

se

com

mun

ities

.

NAM

I Fam

ily-to

-Fam

ily 2

020

Cla

ss 5

5.

47

Why

are

ther

e so

man

y si

de e

ffect

s an

d ca

n an

ythi

ng b

e do

ne a

bout

them

?

Th

ese

med

icat

ions

are

mor

e lik

e bu

cksh

ot; t

hey

hit t

he ta

rget

and

ev

eryt

hing

els

e ar

ound

it. I

n so

me

case

s, c

ells

out

side

of t

he b

rain

use

th

e sa

me

neur

otra

nsm

itter

s to

tra

nsm

it si

gnal

s; s

o th

ese

med

icat

ions

als

o di

rect

ly a

ffect

oth

er

parts

of t

he b

ody.

For e

xam

ple,

the

dige

stiv

e sy

stem

us

es s

erot

onin

to c

omm

unic

ate

betw

een

cells

whi

ch is

why

m

edic

atio

ns th

at a

lter s

erot

onin

le

vels

can

als

o ca

use

naus

ea o

r di

arrh

ea.

Just

like

with

any

oth

er m

edic

atio

n,

ever

yone

con

side

ring

usin

g ps

ycho

tropi

c m

edic

atio

ns fa

ces

a co

st/b

enef

it di

lem

ma.

Ofte

n sw

itchi

ng m

edic

atio

n, c

hang

ing

the

dosa

ge o

r add

ing

on a

sec

ond

med

icat

ion

can

coun

tera

ct d

iffic

ult s

ide

effe

cts.

Whi

le u

nder

stan

ding

how

med

icat

ions

wor

k in

the

body

is im

porta

nt, t

he m

ain

issu

es

man

y fa

milie

s st

rugg

le w

ith a

re e

mot

iona

l. It’

s di

fficu

lt w

atch

ing

a lo

ved

one

begi

n to

ex

perie

nce

the

sym

ptom

s of

men

tal i

llnes

s ag

ain

afte

r a p

erio

d of

reco

very

.

Keep

ask

ing

ques

tions

and

look

ing

for a

nsw

ers

in o

rder

to b

e su

ppor

tive

of y

our l

oved

one

as

they

mak

e de

cisi

ons

abou

t the

ir tre

atm

ent.

NAM

I Fam

ily-to

-Fam

ily 2

020

Cla

ss 5

5.

48

Wor

kshe

et 1

2: S

peci

fic M

edic

atio

ns

DEP

RES

SIO

N

Sele

ctiv

e Se

roto

nin

Reu

ptak

e In

hibi

tors

(SSR

I) an

d Se

lect

ive

Nor

epin

ephr

ine

Reu

ptak

e In

hibi

tors

(S

NR

I)

It’s

not u

ncom

mon

for s

omeo

ne w

ith a

men

tal

heal

th c

ondi

tion

to b

e pr

escr

ibed

a v

arie

ty o

f m

edic

atio

ns th

roug

hout

thei

r life

time.

It

frequ

ently

take

s a

com

bina

tion

of m

edic

ines

to

treat

the

sym

ptom

s an

d si

de e

ffect

s.

Fortu

nate

ly, t

here

are

a v

arie

ty o

f effe

ctiv

e m

edic

atio

ns a

vaila

ble.

Typi

cally

, the

firs

t cla

ss o

f med

icat

ions

us

ed to

trea

t dep

ress

ion

are

Sele

ctiv

e Se

roto

nin

Reu

ptak

e In

hibi

tors

(SSR

Is)

and

Sele

ctiv

e N

orep

inep

hrin

e R

eupt

ake

Inhi

bito

rs (S

NR

Is).

Onc

e th

e m

essa

ge h

as p

asse

d th

roug

h,

the

neur

otra

nsm

itter

s ar

e ei

ther

re

abso

rbed

by

the

send

ing

cell,

cal

led

reup

take

, or d

isso

lved

in th

e sy

naps

e,

calle

d m

etab

oliz

atio

n.

SSR

Is a

nd S

NR

Is b

lock

the

reup

take

of

parti

cula

r neu

rotra

nsm

itter

s. D

epen

ding

on

the

med

icat

ion

take

n, d

iffer

ent

neur

otra

nsm

itter

s ar

e st

oppe

d fro

m tr

avel

ing

back

into

the

axon

term

inal

. Thi

s in

crea

ses

the

leve

ls o

f the

se n

euro

trans

mitt

ers

in th

e sy

naps

es s

o m

essa

ges

can

pass

thro

ugh.

NAM

I Fam

ily-to

-Fam

ily 2

020

Cla

ss 5

5.

49

A pr

ovid

er w

ill st

art b

y pr

escr

ibin

g a

low

do

se a

nd s

low

ly in

crea

se d

osag

es to

a

leve

l tha

t is

effe

ctiv

e. F

ollo

win

g th

ese

inst

ruct

ions

will

redu

ce s

ide

effe

cts.

Side

effe

cts

can

incl

ude

naus

ea,

nerv

ousn

ess

or a

gita

tion,

diz

zine

ss, r

educ

ed

sexu

al d

esire

or s

exua

l per

form

ance

, dr

owsi

ness

, ins

omni

a, w

eigh

t gai

n or

loss

, he

adac

he, d

ry m

outh

, vom

iting

and

dia

rrhea

. Th

ese

unw

ante

d sy

mpt

oms

may

go

away

af

ter t

akin

g th

e dr

ug fo

r a fe

w w

eeks

.

Whe

neve

r sto

ppin

g an

SSR

I or S

NR

I m

edic

atio

n, it

’s n

eces

sary

to w

ork

with

the

pres

crib

er to

tape

r off

the

dosa

ge w

hile

br

ain

chem

ical

s ge

t use

d to

the

chan

ge.

Tric

yclic

s (T

CA

s)

Tr

icyc

lics,

or T

CAs

, wer

e fir

st d

evel

oped

in

the

1960

s to

trea

t dep

ress

ive

diso

rder

s. T

hey

are

still

used

toda

y w

hen

SSR

Is a

nd S

NR

Is fa

il to

wor

k.

Tric

yclic

ant

idep

ress

ants

blo

ck th

e re

upta

ke o

f the

neu

rotra

nsm

itter

s se

roto

nin

and

nore

pine

phrin

e, in

crea

sing

th

e le

vels

of t

hese

two

neur

otra

nsm

itter

s in

the

brai

n.

NAM

I Fam

ily-to

-Fam

ily 2

020

Cla

ss 5

5.

50

Mon

oam

ine

Oxi

dase

Inhi

bito

rs (M

AO

I)

Com

mon

sid

e ef

fect

s of

TC

As a

re th

e sa

me

as th

ose

of S

SRIs

and

SN

RIs

plu

s bl

urre

d vi

sion

, urin

ary

rete

ntio

n, d

rop

in b

lood

pr

essu

re a

nd in

crea

sed

swea

ting.

The

bi

gges

t ris

k of

TC

As w

hen

pres

crib

ed fo

r de

pres

sion

is th

eir p

oten

tial t

o be

use

d to

at

tem

pt s

uici

de. O

verd

oses

of T

CAs

can

be

dead

ly.

M

AOIs

, or M

onoa

min

e O

xida

se In

hibi

tors

ha

ve a

long

his

tory

of u

se a

s a

treat

men

t fo

r dep

ress

ion.

M

AOIs

, or M

onoa

min

e O

xida

se In

hibi

tors

, st

op th

e br

eakd

own

of n

euro

trans

mitt

ers

in

the

syna

pse.

Thi

s m

akes

mor

e ne

urot

rans

mitt

ers

avai

labl

e in

the

syna

pse

whi

ch in

crea

ses

the

trans

mis

sion

of

mes

sage

s.

Thes

e m

edic

atio

ns h

ave

few

sid

e ef

fect

s,

but t

hey

have

ano

ther

ser

ious

pro

blem

all

thei

r ow

n. If

peo

ple

taki

ng th

ese

drug

s ea

t fo

ods

cont

aini

ng c

erta

in “a

min

es”,

They

m

ay h

ave

a se

vere

spi

ke in

blo

od

pres

sure

.

Ove

rdos

es u

sing

MAO

Is a

re a

lso

dead

ly. D

ue to

thes

e da

nger

s,

pres

crib

ers

only

reco

mm

end

MAO

Is

whe

n ot

her a

ntid

epre

ssan

ts h

ave

faile

d.

NAM

I Fam

ily-to

-Fam

ily 2

020

Cla

ss 5

5.

51

O

ne m

etho

d of

del

iver

ing

MAO

I m

edic

atio

n is

thro

ugh

a tra

nsde

rmal

pa

tch.

App

lyin

g a

daily

pat

ch d

oesn

’t ap

pear

to c

ause

the

spik

e in

blo

od

pres

sure

and

doe

sn’t

requ

ire a

ny d

ieta

ry

rest

rictio

ns w

hen

used

at t

he

reco

mm

ende

d do

sage

.

Star

ting

a ne

w a

ntid

epre

ssan

t m

edic

atio

n m

ay tr

igge

r a m

anic

epi

sode

in

som

eone

who

has

und

iagn

osed

bi

pola

r dis

orde

r. In

thes

e ca

ses,

gu

idel

ines

gen

eral

ly re

com

men

d st

artin

g a

moo

d-st

abiliz

ing

med

icat

ion

befo

re

pres

crib

ing

an a

ntid

epre

ssan

t.

Som

e de

pres

sion

is tr

eatm

ent-r

esis

tant

, m

eani

ng it

doe

sn’t

resp

ond

to fi

rst-l

ine

antid

epre

ssan

t med

icat

ion.

Psy

chia

trist

s m

ay

choo

se to

pre

scrib

e an

othe

r ant

idep

ress

ant i

n ad

ditio

n to

an

SSR

I or a

n SN

RI.

Som

e ne

wer

an

tidep

ress

ants

wor

k to

incr

ease

oth

er

neur

otra

nsm

itter

s. A

com

bina

tion

of

antid

epre

ssan

t med

icat

ions

ofte

n ef

fect

ivel

y tre

ats

depr

essi

on.

PSYC

HO

SIS

A

ntip

sych

otic

Med

icat

ion

An

tipsy

chot

ic m

edic

atio

n re

duce

s or

el

imin

ates

del

usio

ns a

nd h

allu

cina

tions

. An

tipsy

chot

ics

play

an

impo

rtant

role

in

treat

ing

schi

zoph

reni

a, s

chiz

oaffe

ctiv

e di

sord

er o

r any

of t

he o

ther

dis

orde

rs th

at

are

caus

ing

sym

ptom

s of

psy

chos

is.

NAM

I Fam

ily-to

-Fam

ily 2

020

Cla

ss 5

5.

52

D

elus

ions

and

hal

luci

natio

ns re

sult

whe

n th

ere

is to

o m

uch

dopa

min

e in

the

syna

pses

. Ant

ipsy

chot

ic d

rugs

pre

vent

do

pam

ine

from

bin

ding

to th

e re

ceiv

ing

dend

rite.

The

y do

this

by

occu

pyin

g th

e do

pam

ine

rece

ptor

site

s so

that

tra

nsm

issi

on is

blo

cked

.

The

term

use

d to

refe

r to

the

olde

r an

tipsy

chot

ic m

edic

atio

ns is

“firs

t ge

nera

tion.

” The

y ar

e hi

gh p

oten

cy,

mea

ning

they

blo

ck m

ore

dopa

min

e re

cept

ors,

are

less

sed

atin

g, a

nd a

re

avai

labl

e as

long

act

ing

inje

ctab

le (L

AI)

form

s th

at c

an b

e gi

ven

ever

y tw

o to

four

w

eeks

.

One

of t

he c

halle

nges

with

the

pow

erfu

l do

pam

ine

bloc

kade

of h

igh-

pote

ncy

antip

sych

otic

s is

that

they

can

affe

ct n

euro

ns

outs

ide

the

brai

n th

at m

ove

mus

cles

. Thi

s ca

n ca

use

mov

emen

t dis

orde

rs, s

uch

as T

ardi

ve

dysk

ines

ia w

hich

is a

n un

com

forta

ble,

ofte

n em

barra

ssin

g co

nditi

on in

whi

ch th

e br

ain

mis

fires

and

cau

ses

rand

om, u

ncon

trolla

ble

mus

cle

mov

emen

ts o

r tic

s in

the

arm

s, fi

nger

s,

legs

, toe

s or

faci

al m

uscl

es.

BIP

OLA

R D

ISO

RD

ER

New

er, s

econ

d-ge

nera

tion

“Aty

pica

l” an

tipsy

chot

ic m

edic

atio

ns s

elec

tivel

y bl

ock

neur

otra

nsm

itter

rece

ptor

s in

the

brai

n to

pr

oduc

e sp

ecifi

c be

nefit

s. T

hese

sec

ond-

gene

ratio

n m

edic

atio

ns a

ren’

t nec

essa

rily

bette

r or w

orse

than

firs

t-gen

erat

ion,

but

they

do

hav

e di

ffere

nt s

ide

effe

cts.

Seco

nd-g

ener

atio

n an

tipsy

chot

ics,

un

fortu

nate

ly, a

re m

ore

likel

y to

resu

lt in

w

eigh

t gai

n. In

divi

dual

s on

thes

e m

edic

atio

ns p

ut o

n w

eigh

t due

to

seda

tion,

app

etite

stim

ulat

ion,

and

an

inab

ility

to “f

eel f

ull.”

NAM

I Fam

ily-to

-Fam

ily 2

020

Cla

ss 5

5.

53

Moo

d St

abili

zers

M

ood

stab

ilizer

s ar

e th

e m

ost c

omm

on

med

icat

ions

for t

reat

ing

the

moo

d sw

ings

as

soci

ated

with

bip

olar

dis

orde

r.

The

olde

st o

f the

m, L

ithiu

m, h

as b

een

in u

se fo

r ove

r 50

year

s an

d ha

s pr

oven

to b

e ve

ry e

ffect

ive,

par

ticul

arly

fo

r bip

olar

I di

sord

er. H

owev

er, r

egul

ar

bloo

d te

sts

are

a re

quire

men

t for

an

yone

taki

ng L

ithiu

m, w

hich

has

po

tent

ial s

erio

us s

ide

effe

cts

to th

e ki

dney

s an

d th

yroi

d.

A

NXI

ETY

Ant

i-Anx

iety

Med

icat

ion

Ther

e ar

e al

so m

edic

atio

ns n

ow a

ppro

ved

for u

se a

s m

ood

stab

ilizer

s th

at w

ere

orig

inal

ly c

reat

ed to

trea

t sei

zure

dis

orde

rs.

Thes

e ar

e kn

own

as a

ntic

onvu

lsan

ts a

nd

ofte

n w

ork

bette

r tha

n Li

thiu

m fo

r som

e pe

ople

. Moo

d st

abiliz

ers

can

prev

ent t

he

high

s of

bot

h m

anic

and

hyp

oman

ic

epis

odes

, and

als

o pr

even

t low

s or

de

pres

sive

epi

sode

s.

NAM

I Fam

ily-to

-Fam

ily 2

020

Cla

ss 5

5.

54

NEW

MED

ICA

TIO

NS

Ther

e is

one

mor

e ca

tego

ry to

tell

you

abou

t, an

d th

at is

ant

i-anx

iety

m

edic

atio

n. T

hese

wor

k to

redu

ce th

e em

otio

nal a

nd p

hysi

cal s

ympt

oms

of

anxi

ety.

Benz

odia

zepi

nes

can

treat

pan

ic d

isor

der,

soci

al p

hobi

a an

d ge

nera

lized

anx

iety

di

sord

er. H

eart

med

icat

ions

kno

wn

as b

eta

bloc

kers

are

als

o ef

fect

ive

at tr

eatin

g th

e ph

ysic

al tr

embl

ing,

sw

eatin

g an

d ot

her

phys

ical

sym

ptom

s ex

perie

nced

by

peop

le

with

pho

bias

or p

anic

dis

orde

r. An

ti-an

xiet

y m

edic

atio

n w

orks

qui

ckly

and

is v

ery

effe

ctiv

e in

the

shor

t-ter

m. H

owev

er, p

eopl

e pr

one

to

subs

tanc

e ab

use

may

bec

ome

depe

nden

t on

benz

odia

zepi

nes.

GEN

ERIC

MED

ICA

TIO

NS

The

Food

and

Dru

g Ad

min

istra

tion,

or

FDA,

regu

late

s al

l pre

scrip

tion

med

icat

ions

ava

ilabl

e in

the

U.S

. The

pr

oces

s of

get

ting

FDA

appr

oval

for a

ne

w m

edic

atio

n or

for a

n ol

d m

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Worksheet 13: Side Effects of Psychotropic Medications Anti-Cholinergic Side Effects (blocking action of acetylcholine):

• Blurred vision • Dizziness • Urinary retention • Confusion or delirium • Dry mouth • Orgasmic and erectile dysfunction • Drowsiness • Gastrointestinal disturbances (nausea/diarrhea/constipation) • Increased heart rate • Reduced sweating or elevated body temperature

Anti-Adrenergic Side Effects (blocking action of adrenaline):

• Dizziness • Decreased blood pressure • Tachycardia (rapid heartbeat) • Sedation • Weight gain

Antihistamine Side Effects:

• Substantial weight gain • Drowsiness

Serotonergic Side Effects:

• Diminished libido • Orgasmic and erectile dysfunction • Gastrointestinal disturbances (nausea/diarrhea/constipation)

Dopaminergic Side Effects:

• Parkinsonian symptoms (decreased facial movement, stiffness, rigidity) • Acute dystonia (involuntary muscle movement) • Akathisia (restlessness or discomfort when not moving) • Tardive dyskinesia (late onset, involuntary movements) • Sexual dysfunctions

Glucose Dysregulation:

• Increased risk for new onset Type II diabetes • Increased risk for cardiovascular disorder


Worksheet 14: Cost and Benefits of Taking Medication

Have you ever:

• Felt disoriented by a medication you were taking? • Felt sick because of a medication? • Stopped taking a medication when the symptoms you were originally taking it for

went away or got better? Do you:

• Usually finish all of the pills you were prescribed? • Still have expired medication at home?

What would you do if you had to take a medication that made you feel sleepy, gain 45 pounds, gave you tremors and blocked your sexual responses?


Worksheet 15: Common Emotional Experiences that Affect Treatment

Lacking insight into the condition: “I’m not ill”

Lack of insight is a phenomenon where someone with a mental health condition doesn’t perceive that something problematic is happening with their health. This happens when a person is genuinely disconnected from the perceptions and beliefs shared by a wider community. A person lacking insight is unable to see the validity of other points of view. Because they don’t sense that anything is unusual, they don’t think there’s a reason to consider treatment.

This is called “anosognosia.” It’s especially common in schizophrenia and in episodes of mania. It’s so common that it’s considered one reliable sign of these conditions when making a diagnosis. People with depression also may not recognize when their condition is serious.

When people lack insight into their condition, they may continue to believe nothing is wrong, even if their symptoms improve with treatment. Many of the people who go voluntarily to the hospital go because someone has urged them to, but do not believe they need to. Using denial as a protective coping strategy: “I don’t need treatment”

When a person is overwhelmed or unequipped to address what’s happening, they may deny that the problem exists or ignore it, hoping it will go away. They may recognize that something is wrong but find it too painful to acknowledge to themselves or to others. As we’ve reiterated, people use denial to cope with many upsetting events and medical crises, not just mental health conditions. Being in denial temporarily protects the person. When someone is in denial, choosing treatment would be admitting that something is medically wrong. If they are in denial and do take medication anyway, they may be unlikely to tolerate side effects when they don’t see the benefits.


Missing the thrill of mania: “I’d rather feel pain than be numb or bored”

Some mental health treatments reduce the intensity of your emotions. Some people report not having emotions at all when taking certain medications. When a person’s emotional baseline changes, they must develop a new sense of what is normal, which can be frustrating and demoralizing. A person may prefer to tolerate the ups and downs of their condition rather than give up feelings they’re used to having or not feeling at all. When that’s the case, it’s understandable that someone might experiment with stopping and starting medication. Wishing to be seen as a person, not an illness: “I don’t want to be seen as broken”

People who choose to seek treatment and experience it as beneficial may decide not to continue long-term, even if they’re receiving benefits from it. Many people don’t like the idea of having a chronic condition that involves going to therapy or taking a medication indefinitely. People often say they feel they’re seen or treated as “just” their diagnosis, rather than as a full person with a variety of traits, needs and hopes.

This experience is true of people with many health conditions, not only mental illness. Being involved in treatment or taking medications long-term can seem like admitting you’ll never return to how you used to be. That can be extremely difficult to accept. When people start improving, they may stop treatment or stop taking medication because it seems, and they hope, that their need for treatment has gone away. Being reluctant to accept things as they are, or partial acceptance

When a person is unable to accept a situation or condition, it’s often because their experience feels too painful to tolerate. It may seem easier to disregard the problem even if there are negative consequences in the future.

Notes:


Worksheet 16: Assisted Outpatient Treatment (AOT) Overview

Introduction to AOT

When people are not being treated for their mental health symptoms, this is sometimes called “non-engagement,” meaning that they are not participating in or receiving mental health treatment. There are many reasons why someone might not participant in treatment. A few include:

• Insufficient community resources (agencies, social services, long waitlist, etc.) • Not having health insurance or coverage for services • Not being able to afford treatment (copays, sliding-scale fees, etc.) • Not enough providers or providers are too far away • Not having access to transportation to reach providers • Not being able to take time off work to access treatment • Substance use (interfering or making a person ineligible for services) • Discouraged by bad side effects of medications • Difficulty with executive functioning (making decisions, completing tasks, etc.) • Not trusting doctors/medical staff because of symptoms or bad past experiences • Feeling reluctant or ashamed because of stigma • Being unable to follow treatment plan consistently because of memory issues,

etc. • Anosognosia/lack of insight

Anosognosia is a symptom of a mental health condition that causes the person to not sense or believe that they’re experiencing symptoms. While the person’s personality, beliefs and behaviors may appear to be a mental health condition to others, it is not clear to the person with anosognosia. Anosognosia is not denial. It’s not a choice. It’s a biological, brain-based symptom that the person cannot control. Consequently, if a person does not believe he or she is ill, engaging with treatment would be illogical.

In some cases, not being treated for symptoms can put the person at risk of harm. It can also put other people at risk of harm. One way of helping to ensure that such individuals get treatment when they are not willing to do so voluntarily is called Assisted Outpatient Treatment (AOT). A person in AOT is required, by a civil court, to receive treatment. AOT is also called court-ordered outpatient treatment or outpatient civil commitment.


How AOT works

AOT works differently in each state (visit treatmentadvocacycenter.org, search “browse by state”). However, most state laws have some things in common. Most include these requirements:

• Someone files a petition (also called an affidavit or application) in the civil (or probate) court

o The petitioner describes in writing why he or she believes the person meets the legal criteria for AOT

o State laws vary on who may file the petition. In some states, family members are allowed to do so

• The court holds a hearing • The person described in the petition is legally entitled to “due process

protections,” such as a court-appointed lawyer • The person described in the petition is assumed to not need AOT until and

unless the petitioner convinces the court that the person does (“the burden of proof” is on the petitioner)

• Experts, including psychiatrists and other mental health professionals, provide testimony in support or opposition to the petition

• If the evidence that AOT is needed is clear and convincing, the judge (or a person representing the judge) may order the person to receive involuntary treatment

o AOT often begins with involuntary inpatient treatment and transitions to involuntary outpatient treatment

The ultimate goal of AOT is to encourage the development of an ongoing positive relationship between the treatment team and the participant so that in time the person voluntarily engages in treatment. The treatment team often uses evidenced based interventions such as shared decision making and motivational interviewing to increase the participant’s success.

Differences between mental health court and AOT

Mental health court is a criminal court process and is for individuals who have committed a crime. The purpose of mental health court is to reduce the number of people with mental illness in jails and prisons and to help prevent them from committing crimes in the future. The goal is to link the person to treatment services, provide him or her with intensive supervision by the court, and hold the person accountable for sticking to the court ordered treatment. If a person in mental health court does not follow through with treatment, a judge may order him or her to go to jail. A person who


successfully completes mental health court generally has his or her criminal case dismissed.

AOT is a civil court process and is for individuals who have not committed a crime. The purpose of AOT is to address treatment non-engagement by leveraging the power of the court to influence behavior. A judge can order a person in AOT to follow a treatment plan, but the person cannot be placed in jail for not following through with court ordered treatment. However, there are consequences that may be imposed by the judge. These include:

• Being ordered to appear in front of the judge • Increasing the length of time the person is on AOT • Being ordered to receive a mental health evaluation to determine if the person is

a danger to self or others • Being placed in the hospital if the evaluation determines that the person meets

the criteria for inpatient treatment

When to file an AOT petition

The best time to begin the AOT process is as the person is leaving a hospital, jail or prison. At this point, the person should have received care that has stabilized his or her mental health condition and is better able to understand the court’s expectations. In some states, a family member is allowed to file the AOT petition. However, the best person to file the petition is usually the doctor who’s been overseeing the person’s care, because the doctor has the information and expertise to explain to the court why AOT is necessary.

Paying for AOT

Often, people who meet criteria for AOT are on Medicaid or are eligible to receive subsidized services provided by the public mental health system. In that situation, Medicaid or the public mental health system covers the cost of treatment. If the person has private insurance, his or her insurance company would be billed for the costs.

Learning more

For more information on AOT, including how to get a program started in your community if one doesn’t exist, contact the Treatment Advocacy Center at treatmentadvocacycenter.org. Source: Treatment Advocacy Center, 2019


Worksheet 17: Supporting Your Loved One During Treatment

• If your loved one with the mental health condition is willing to discuss treatment, help them to understand how medications and talk therapy work and how they can help.

• You need to have a workable plan for monitoring medications (for treatment and safety).

• All medication issues need to be discussed openly.

• Sometimes adherence increases by avoiding the “mental illness” connotation of these medications (addressing the impact of the treatment on the symptoms that are causing distress rather than the diagnosis itself).

• It’s helpful to keep written records of the medications your loved one has taken, the dosages and the side effects that have been troublesome.

• Confidentiality will not be a barrier to communication with a treatment provider if your loved one gives permission. If permission isn’t granted, you may speak to the provider but the provider cannot give you information in return.

• If your loved one refuses treatment, it’s a good idea to prepare yourself for the possibility of a crisis.


Worksheet 18: Warning Signs of Relapse

• Feeling more tense or nervous*

• Having more trouble sleeping*

• Feeling that people are talking about them*

• Change in level of activity*

• Having more trouble concentrating*

• Having more nightmares or bad dreams

• Hearing voices or seeing things

• Feeling more depressed

• Feeling that someone else is controlling them

• Not taking care of personal hygiene

• Feeling badly for no apparent reason

• Losing interest in things they like doing

• Feeling angrier over little things

• Spending less time with friends

• Thinking about hurting themselves

• Enjoying things less

• Feeling more aggressive or pushy

• Feeling too excited or overactive

• Eating less

• Having trouble relating to family

• Having more religious ideas

• Having frequent aches and pains

• Preoccupied with one or two ideas

• Having trouble making sense when talking

• Increased substance use (alcohol or other drugs)

• Feeling like they are forgetting things

• Feeling worthless

• Thinking about hurting someone else

• Fear they are losing control of their mind or thoughts

(*) Universal Warning Signs McFarlane, W., Terkelson, K., “New Approaches to Families Living With Schizophrenia.” Institute, 62nd Annual Ortho-Psychiatric Meeting. N.Y.


Worksheet 19: Psychiatric Advance Directives (PAD)

What is a psychiatric advance directive (PAD)?

It is a legal document that allows people with mental illness to state their preferences for treatment in advance of a crisis. They can even consent to or refuse treatment during such a crisis. There are two kinds of legal documents in a PAD: (1) “Advance Instructions” to list treatment preferences and (2) “Health Care Power of Attorney” to appoint a trusted person to make decisions.

How are they used?

If a person is in crisis, and not capable of speaking for him or herself, medical professionals can refer to the PAD to get a clear description of the person’s preferences for treatment and if there is a trusted person who can help make decisions. PADs are only used temporarily, and only when the person is incapable of making or communicating treatment decisions.

What are the benefits of PADs?

PADs help people clarify their preferences and plan for crises — including having conversations that can sometimes help to prevent crises from occurring.

In research studies, PADs have been found to reduce the need for involuntary commitment and help people get the treatment they prefer.

What is a health care power of attorney?

A person can legally appoint another person to represent their interests when incapacitated by giving them power of attorney for healthcare decisions. The person in this role is called a health care agent, and only speaks for the person when the person is incapacitated — that is, unable to make or communicate healthcare decisions.

Notes: Source: Crisis Navigation Project at Southern Regional Area Health Education Center and Duke University Medical Center crisisnavigationproject.org


Worksheet 20: Guide to Psychiatric Advance Directives

Do you want more say in your mental health treatment? If you are someone who is in psychiatric treatment, you might be interested in finding out how to have more say in your treatment, especially when you are in crisis. This guide will help you understand how a psychiatric advance directive (PAD) might be useful to you.

It’s always a good idea to start with your psychiatrist or other mental health treatment provider if you are interested in creating your own PAD. Ask if they know about PADs, and if they can help you create one. If they don’t know about them, you can share this brochure with them so they can learn more, too. There are also volunteers in your community who will help you create a PAD.

What is a psychiatric advance directive? A psychiatric advance directive is a legal document that tells treatment providers your preferences for treatment in a crisis. It goes into effect if you are incapacitated — that means if you are in a state of mind where you cannot speak for yourself. An example of being incapacitated would be if you were unconscious, or couldn’t speak, or were experiencing significant confusion.

If you have a Wellness Recovery Action Plan, or WRAP Plan, or a Crisis Plan, there are some similarities with a PAD. A PAD is different because it is a legal document. To make it official, it must be signed in front of a notary public and two witnesses.

Treatment providers are required to follow your wishes stated in the PAD, unless those wishes include something they cannot do (like send you to a hospital in another state, or to a hospital that has no beds available), or it’s an emergency and they need to preserve your safety or the safety of others.

Where did the idea for PADs come from? Medical advance directives have been used in medical settings for years for people who wanted more control over their medical care at times when they had a serious medical illness and knew they would not be able to express their wishes on their own — like if someone was at the end of life. They were created as the result of the Patient Self-Determination Act of 1990, a federal law designed to give all patients more say in healthcare decisions.


Are PADs always respected? We hear from some people that their PAD was not followed during a crisis. They are not used often, and medical providers are just starting to learn more about them. By getting more PADs out there, we hope to strengthen the voice of people who live with mental illness and to encourage more shared decision making with their treatment providers.

Do you have a trusted person who will help you in a crisis? A PAD can include a health care power of attorney (HCPA). The HCPA is a legal document that lets you put someone in charge of communicating your wishes to medical providers if you are not able to. The person appointed by the HCPA is called your health care agent. That person can speak for you in a crisis. It’s your choice to have a health care agent or not. Sometimes family members are in this role, and sometimes friends or another person you trust and who can help you in a crisis.

Are there other benefits to having a PAD? The process of creating a PAD helps you think through what you can do to prevent a crisis, what to do during a crisis, and how best to recover from a crisis. The conversations with your treatment providers, your family and friends, can help you take control of your mental health and improve communication.

What do I need to think about before I create a PAD? What kind of treatment is helpful to you? What medications work for you? What medications don’t work for you? Is there a hospital that you prefer? Who should be contacted if you are in a mental health crisis? What practical matters in your life — like childcare, pet care, contacting your employer or paying your rent — need to be tended to if you are not able? You can include additional instructions tailored to what support you need in your PAD.

Where can I get more information about PADs?

National Resource Center on Psychiatric Advance Directives:

http://www.nrc-pad.org/ For information about PADs nationwide.

https://www.youtube.com/watch?v=eBSZ4ooRoZ8

Crisis Navigation Project: http://www.crisisnavigationproject.org/

A project to promote the use of PADs. Go to the link for North Carolina resources.

Source: The Crisis Navigation Project is a collaborative project to promote the use of psychiatric advance directives. It is based at the NC Evidence Based Practices Center at Southern Regional Area Health Education Center, in affiliation with Duke University Medical Center. Funding for the project is provided by The Duke Endowment. NAMI North Carolina is a key partner in the initiative.

http://www.nrc-pad.org/

https://www.youtube.com/watch?v=eBSZ4ooRoZ8

http://www.crisisnavigationproject.org/


Worksheet 21: Biomedical Approaches Electroconvulsive Therapy, or ECT, is a procedure where controlled electric currents are passed through the brain while the person is under general anesthesia. The currents cause a brief, controlled seizure that affects neurons and chemicals in the brain. ECT is usually used to treat severe depression, including depression with psychosis, that has not responded to other treatments. Some people report loss of memory as a side effect of ECT.

Transcranial Magnetic Stimulation, or TMS, involves placing an electromagnetic coil on a person’s scalp, near the forehead and directing short pulses into an area of the brain that’s believed to control moods. TMS was cleared by the FDA in 2008 for treatment resistant depression and more recently for OCD.

Vagus Nerve Stimulation, or VNS, uses a small implant in the upper chest to stimulate the vagus nerve with electrical impulses. The vagus nerve manages communication between your brain and the organs in your body. VNS can be used for treatment resistant depression and other medical conditions, including epilepsy.

Deep Brain Stimulation, or DBS, was originally developed to reduce tremors from Parkinson’s disease. The FDA cleared DBS as a treatment for OCD. This is usually used when other treatments such as medication and exposure response therapy are unsuccessful. DBS uses a small implant in the upper chest to send electrical impulses to electrodes attached directly to the brain.

Like other treatments, brain stimulation therapies can have side effects. It’s important to talk with a doctor about the risks and benefits of these treatments if your loved one is considering them.


Worksheet 22: Complementary Treatments

Some examples of complementary approaches are:

• Supplements, like vitamins and minerals. It’s important to know the ingredients of any supplement you consider and to review them with your prescriber.

• Omega-3 fatty acids which are groups of chemicals found in different foods, including fish and nuts that may help in the management of both medical and mental illnesses

• Folate, a vitamin required for the human body to perform many essential processes on a day-to-day basis. Also called folic acid or vitamin B9, folate is a compound that the human body is unable to make on its own.

• Medical foods, which are made with or without specific nutrients and aim to treat a health condition

• CBD oil • Exercise, yoga and Tai Chi • Meditation • Animal-assisted therapy

o Trained service animals (recognized by the Americans with Disabilities Act or ADA)

o Equine-Assisted Therapy, or EAP, which teaches individuals how to groom, care for and ride horses

o Therapy animals o Emotional support animals

• Art therapy

The National Center for Complementary and Alternative Medicine, or NCCAM, describes three types of approaches:

1. Complementary methods where non-traditional treatments are given in addition to standard medical procedures

2. Alternative methods of treatment used instead of established treatment

3. Integrative methods that combine traditional and non-traditional as part of a treatment plan

Remember: It’s critical that you discuss any over-the-counter medications or supplements with a doctor and pharmacist. Even vitamins can interact with medication. Certain substances can be safe to use with one prescription medication but make another medication less effective or dangerous.

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