PsychologyPsychology of Prescribingof Prescribing Psychopharmacology in College Psychopharmacology in College Mental HealthMental Health

Colleen Slipka, M.D.Colleen Slipka, M.D.PsychiatristPsychiatristCounseling & Student Development CenterCounseling & Student Development CenterJames Madison UniversityJames Madison University

DisclosuresDisclosures

NoneNone

Varner HouseJames Madison University

Kirsch, I., Moore, T. J., Kirsch, I., Moore, T. J., ScoboriaScoboria, A., , A., et alet al (2002) The emperor's new drugs: an analysis of antidepressant m(2002) The emperor's new drugs: an analysis of antidepressant medication edication data submitted to the U.S. Food and Drug Administration. data submitted to the U.S. Food and Drug Administration. Prevention and TreatmentPrevention and Treatment, 5, 23. , 5, 23.

ObjectivesObjectives

Identify factors that may influence a Identify factors that may influence a studentstudent’’s response to illness and/or s response to illness and/or medication.medication.

–– Attachment Style.Attachment Style.–– Character Structure.Character Structure.–– Locus of Control.Locus of Control.–– Transference Issues.Transference Issues.

Define splitDefine split--treatment and discuss how the treatment and discuss how the triad between student, prescriber, and triad between student, prescriber, and therapist may influence prescribing therapist may influence prescribing practices.practices.

AttachmentAttachment

Care-giving bond

Attachment

“Internal working model.” Worthy of care (view of themselves) Whether others can be trusted (view of others)(Bowlby, 1969)

Adult AttachmentAdult Attachment

Secure Secure –– Experienced consistently emotionally Experienced consistently emotionally responsiveresponsive care givingcare giving–– Positive views of themselves and othersPositive views of themselves and others–– Feel comfortable both with intimacy & independenceFeel comfortable both with intimacy & independence

Preoccupied Preoccupied –– Experienced inconsistently emotionally Experienced inconsistently emotionally responsiveresponsive care givingcare giving–– Negative views of themselvesNegative views of themselves–– Positive views of othersPositive views of others–– Dependent or clingyDependent or clingy

DismissiveDismissive–– Experienced consistently emotionally Experienced consistently emotionally unresponsiveunresponsive care givingcare giving–– Positive views of themselves Positive views of themselves –– Negative view of others Negative view of others –– Defensive or distantDefensive or distant

FearfulFearful–– Experienced consistently emotionally Experienced consistently emotionally harsh & criticalharsh & critical care givingcare giving–– Negative views of themselves and othersNegative views of themselves and others–– Initially engage then avoid due to fear of intimacyInitially engage then avoid due to fear of intimacy

Attachment Style & Health Care ServicesAttachment Style & Health Care Services

1.89

2.362.57

2.17

0

0.5

1

1.5

2

2.5

3

secure preoccupied (p=0.03) fearful (p=0.003) dismissing (p=0.21)

Attachment Categories

Mea

n Nu

mbe

r of

Rep

orte

d So

mat

ic S

ympt

oms

Ciechanowski, et al. (2002). Attachment theory: A model for health care utilization and somatization. Psychosomatic Medicine, 64, 660–667.

Ciechanowski, et al. (2002). Attachment theory: A model for health care utilization and somatization. Psychosomatic Medicine, 64, 660–667.

Adult Attachment and Hypochondriacal Concerns in College Students

05

1015202530354045

Preoccupied Secure Dismissive Fearful

Attachment Categories

Mea

n Sc

ore

on

Hyp

ocho

ndra

isis

Sca

le

Wearden, A., Perryman, K., & Ward, V. (2006) Adult Attachment, Reassurance Seeking and Hypochondriacal Concerns in College Students. J Health Psychology. 11; 877-886.

p <0.001

Hypochondriasis – excessive preoccupation or worry about having a serious illness or if there is a medical illness, the concerns are in far excess of what is appropriate for the level of disease

Attachment Style & AdherenceAttachment Style & Adherence

Ciechanowski, et al. (2004). Influence of Patient Attachment Style on Self-care and Outcomes in Diabetes. Psychosomatic Medicine, 66, 720-728.

Ciechanowski, P., Katon W., Russo, J., Walker, E. (2001). The Patient-Provider Relationship: Attachment theory and adherence to treatment in diabetes. American Journal of Psychiatry, 158, 29-35.

Attachment Style & AdherenceAttachment Style & Adherence

Attachment Style & TreatmentAttachment Style & Treatment

PreoccupiedPreoccupied–– Positive view of others, negative view of selfPositive view of others, negative view of self–– Need for dependence on othersNeed for dependence on others–– Frequent & regularly scheduled brief appointments Frequent & regularly scheduled brief appointments -- not not

dependent on symptomsdependent on symptoms

DismissingDismissing–– Negative view of others, positive view of selfNegative view of others, positive view of self–– Respect autonomy & relay the importance of careRespect autonomy & relay the importance of care–– Humor, metaphors, & close monitoring of severe symptomsHumor, metaphors, & close monitoring of severe symptoms

FearfulFearful–– Negative view of others, negative view of selfNegative view of others, negative view of self–– Resisting the urge to withdrawResisting the urge to withdraw–– Numerous providers, team approachNumerous providers, team approach

Personality TraitsPersonality Traits

Enduring patterns of perceiving, relating to, Enduring patterns of perceiving, relating to, and thinking about the environment and and thinking about the environment and oneself that are exhibited in a wide range of oneself that are exhibited in a wide range of social and personal contexts.social and personal contexts.

Traits are relatively stable over timeTraits are relatively stable over timeTraits differ among individuals Traits differ among individuals Traits influence behaviorTraits influence behavior

(2000) "Diagnostic and Statistical Manual of Mental Disorders". Washington, D.C.: American Psychiatric Association 4 Text Revision.

Personality DisorderPersonality Disorder

Experience and behavior that deviates markedly from the expectations of the individual's culture.

Cognition (perception and interpretation of self, others and events) Affect (the range, intensity, lability, & appropriateness of emotional response) Interpersonal functioning Impulse control

Inflexible and pervasive across a broad range of personal and social situations.Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.Stable and of long duration and its onset can be traced back at least to adolesence or early adulthood.Not better accounted for as a manifestation or consequence of another mental disorder.Not due to the direct physiological effects of a substance or a general medical condition such as head injury.

Personality DisordersPersonality Disorders

Cluster A (odd or eccentric disorders)Cluster A (odd or eccentric disorders)ParanoidSchizoid Schizotypal

Cluster B (dramatic, emotional, or erratic disorders)Cluster B (dramatic, emotional, or erratic disorders)AntisocialBorderlineHistrionicNarcissistic

Cluster C (anxious or fearful disorders)Cluster C (anxious or fearful disorders)Avoidant DependentObsessive – compulsive

Borderline Personality DisorderBorderline Personality Disorder

Frantic efforts to avoid real or imagined abandonment.

Unstable and intense interpersonal relationships. (idealization and devaluation). Identity disturbance. Impulsivity (e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving). Recurrent suicidal behavior, gestures, threats or self-injuring behavior. Affective instability (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days). Chronic feelings of emptiness, worthlessness. Inappropriate anger or difficulty controlling anger. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

Borderline Personality DisorderBorderline Personality Disorder

Average of 47% of BPD patients in a therapists’ practice misuse prescription medications.

Meaning of medicine:– Overvalue / idealize medications / Nurturing agent– Physical assault / Poisons or addictive agents– Clinician’s intolerance – Clinician’s control & power

Under use:– Positive gain from illness

Over use:– Fill emptiness– Seek increased attention

Waldinger, JR, Frank, AF (1989). Clinicians experiences in combining Medication and Psychotherapy in the Treatment of Borderline Patients, Hospital and Community Psychiatry 40:7. 712-718.

Havens, L (1968) Some difficulties in giving schizophrenic and borderline patients medications. Psychiatry. 31: 44-50.

Locus of ControlLocus of Control

Internal Internal –– personal personal control through control through behaviors & actions behaviors & actions External External ––environment, environment, higher power, other higher power, other people, fate, people, fate, chancechance

External Locus of ControlExternal Locus of Control

Depression was associated with external LOC in college undergraduate students. External LOC corelated with phobic anxiety as compared to individuals without phobic anxiety.Agoraphobic individuals with phobic anxiety exhibit externalized LOC more than depressed individuals.

Abramowitz, S (1969) Locus of control and self-reported depression among college students. Psychiological Reports, 25, 149-150.

Hoffart, A, & Martinsen, E. W. (1990). Agoraphobia, depression mental health locus of control, and attributional styles. Cognitive Therapy and Research, 14, 343–351.

Internal Locus of ControlInternal Locus of Control

Health BehaviorsHealth Behaviors–– seeking informationseeking information–– taking medicationtaking medication–– making & keeping physician appointmentsmaking & keeping physician appointments–– maintaining dietary restrictionsmaintaining dietary restrictions–– smoking cessationsmoking cessation

StudiesStudies–– Smoking cessation (Georgio & Bradley, 1992)Smoking cessation (Georgio & Bradley, 1992)–– Diabetes (Ferraro, Price, Desmond & Roberts, 1987)Diabetes (Ferraro, Price, Desmond & Roberts, 1987)–– Hypertension (Stantion, 1987)Hypertension (Stantion, 1987)–– Arthritis (Nicasio et al., 1985)Arthritis (Nicasio et al., 1985)–– Cancer (Pruyn et al., 1988) Cancer (Pruyn et al., 1988) –– Heart and lung disease (Allison, 1987)Heart and lung disease (Allison, 1987)

Internal Locus of ControlInternal Locus of Control

Strickland suggested that internal locus of control, as Strickland suggested that internal locus of control, as compared with external locus, improves mental health compared with external locus, improves mental health because it is associated with preventive behavior, efforts to because it is associated with preventive behavior, efforts to improve mental functioning, & development of coping improve mental functioning, & development of coping behaviors to deal with stress. behaviors to deal with stress. Individuals with internal locus of control suffered less from Individuals with internal locus of control suffered less from chronic depression & combatchronic depression & combat--related PTSDrelated PTSD

Strickland, B. R. (1978). Internal—external expectancies and health-related behaviors. Journal of Consulting and Clinical Psychology, 46, 1192–1211.

Abramson, L. Y., Seligman, M. E., & Teasdale, J. D. (1978). Learned helplessness in humans: Critique and reformulation. Journal of Abnormal Psychology, 87, 49-74.

Anderson, C. R. (1977). Locus of control, coping behaviors, and performance in a stress setting: A longitudinal study. Journal of Applied Psychology, 62, 446–451.

LOC & TreatmentLOC & Treatment

Individuals with Panic Disorder can Individuals with Panic Disorder can move LOC more move LOC more ‘‘internalinternal’’ with CBT with CBT than medications. than medications. LOC orientation is important in LOC orientation is important in evaluating the treatment plan for evaluating the treatment plan for patients with panic disorder. patients with panic disorder.

Bakker, A, Spinhoven, P, van der Does, A, van Balkom, A, van Dyck, R (2002). Locus of Control Orientation in Panic Disorder and the Differential Effects of Treatment. Psychotherapeutic Psychosomatic 2002;71:85-89

Adapted from The Wikipedia Signpost: The Helicopter Parent

Locus of Control Locus of Control ““NeedNeed”” for psychotropic drugsfor psychotropic drugs

Quick fix cultureQuick fix culture–– ““failure to performfailure to perform”” is a major issue in a is a major issue in a

competitive societycompetitive society–– problems are to be fixedproblems are to be fixed–– problemsproblems--inin--thethe--processprocess--ofof--beingbeing--fixed are fixed are

temporary disabilities, to which school temporary disabilities, to which school environments must accommodateenvironments must accommodate

Challenges are no longer lessons for learning, but Challenges are no longer lessons for learning, but problems to be solved as expediently as possibleproblems to be solved as expediently as possibleMedications viewed as a quick fixMedications viewed as a quick fix

Fromm, M (2007) The Escalating Use of Medications by College Students: What are they telling us, what are we telling them? Journal of College Student Psychotherapy, 21:3, 27-44.

Transference IssuesTransference Issues

Unconscious redirection of feelings for Unconscious redirection of feelings for one person to another. one person to another.

–– PositivePositive–– Negative Negative

Response to MedicationsResponse to Medications

Positive TransferencePositive TransferenceNegative TransferenceNegative Transference

Positive TransferencePositive Transference

Medication as a transitional object (even the Medication as a transitional object (even the prescription)prescription)Food Food –– fills a void/emptiness fills a void/emptiness -- medication hunger medication hunger GiftGiftTaking Away Taking Away –– demands the individual surrender demands the individual surrender his/her symptoms & illness (positive & negative)his/her symptoms & illness (positive & negative)Positive alliance with providerPositive alliance with provider

Powell, AD (2001) The Medication Life. Journal of Psychother Practice Res, 10:4. 217-222.

Placebo EffectPlacebo Effect

Placebo Placebo -- any therapy prescribed knowingly or any therapy prescribed knowingly or unknowingly by a clinician for its therapeutic effect unknowingly by a clinician for its therapeutic effect on a symptom / disease, but which actually is on a symptom / disease, but which actually is ineffective or not specifically effective for that ineffective or not specifically effective for that symptom / diseasesymptom / diseasePlacebo Response Placebo Response –– the behavioral change in the the behavioral change in the person receiving the placeboperson receiving the placeboPlacebo Effect Placebo Effect –– the part of the change attributable the part of the change attributable to the symbolic effect of the medicationto the symbolic effect of the medicationIn antidepressants, placebo effect may account for In antidepressants, placebo effect may account for up to 75% of effectivenessup to 75% of effectiveness

Kirsch, I., & Sapirstein, G. (1998). Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medication. Prevention & Treatment.

Harrington (eds) The Placebo Effect. First Harvard University Press, 1999.

Kirsch, I., Moore, T. J., Kirsch, I., Moore, T. J., ScoboriaScoboria, A., , A., et alet al (2002) The emperor's new drugs: an analysis of antidepressant m(2002) The emperor's new drugs: an analysis of antidepressant medication edication data submitted to the U.S. Food and Drug Administration. data submitted to the U.S. Food and Drug Administration. Prevention and TreatmentPrevention and Treatment, 5, 23. , 5, 23.

Negative TransferenceNegative Transference

NonNon--compliance (between 25compliance (between 25--75%)75%)Requesting PRN medications Requesting PRN medications Lack of effectivenessLack of effectivenessBeing prescribed medications = no responsibility for actionsBeing prescribed medications = no responsibility for actions

Powell, AD (2001) The Medication Life. Journal of Psychother Practice Res, 10:4. 217-222.

NoceboNocebo EffectsEffects

NoceboNocebo effects effects –– the causation of sickness by the expectations of the causation of sickness by the expectations of sickness and the associated emotional statessickness and the associated emotional states–– Specific Specific –– the individual expects a particular negative the individual expects a particular negative

outcome & that outcome consequently occursoutcome & that outcome consequently occurs–– Generic Generic –– the individual has vague negative expectations the individual has vague negative expectations

(pessimistic) & their expectations are realized in terms of (pessimistic) & their expectations are realized in terms of symptoms or sicknesssymptoms or sickness

Placebo side effect Placebo side effect –– when expectations of healing produce when expectations of healing produce sicknesssicknessChinese patients on lithium rarely report polydipsia & polyuria Chinese patients on lithium rarely report polydipsia & polyuria as as annoying side effects because they believe water consumption annoying side effects because they believe water consumption and excretion are positive effects of the medication. Lithium cand excretion are positive effects of the medication. Lithium can an deplete the body of toxins & aid in digestion through these deplete the body of toxins & aid in digestion through these effects.effects.

Harrington (eds) The Placebo Effect. First Harvard University Press, 1999.

Tseng, W, and Streltzer, J (eds) Culture and Psychotherapy: A Guide to Clinical Practice. American Psychiatric Publishing, Inc, 2001.

Meaning of MedicationMeaning of Medication

Physical characteristics– Caucasians: white capsules - analgesics; black capsules - stimulants– African Am: white capsules - stimulants; black capsules - analgesics – Netherlands: red, yellow, and orange are associated with a stimulant

effect, while blue and green are related to a tranquilizing effect. – Europeans: Yellow pills - antidepressants.

Mode of Administration, Cost, Packaging

Tseng, W, and Streltzer, J (eds) Culture and Psychotherapy: A Guide to Clinical Practice. American Psychiatric Publishing, Inc, 2001.

Split TreatmentSplit Treatment

Synonyms of split treatmentSynonyms of split treatment–– Collaborative treatmentCollaborative treatment–– Combined treatmentCombined treatment–– Concurrent careConcurrent care–– Divided treatmentDivided treatment–– Integrated treatmentIntegrated treatment–– Parallel treatmentParallel treatment–– Shared treatmentShared treatment–– Triangular treatmentTriangular treatment

Bietman, BD, Blinder, BJ, Thase, ME, Riba, M, Safer, DL (eds) Integrating Psychotherapy and pharmacotherapy. W.W. Norton & Company, Inc, 2003.

More than More than ‘‘splitsplit’’ treatmenttreatment

Patient / ClientPatient / ClientTherapist Therapist Medication prescriber Medication prescriber –– PsychiatristPsychiatrist–– Health center physicianHealth center physician–– Nurse practitioner Nurse practitioner –– Physician assistant Physician assistant

ParentParentHome physicianHome physicianFamily therapist (home Family therapist (home therapist)therapist)NutritionistNutritionistSports Medicine Sports Medicine University University AdministrationAdministrationLegal / Judicial AffairsLegal / Judicial AffairsResidence LifeResidence Life

Therapeutic TriadTherapeutic Triad

Patient/Client, Therapist, Medication Prescriber Patient/Client, Therapist, Medication Prescriber

Therapy Therapy –– passivepassivePrescribing Prescribing –– active / directiveactive / directive

Referral Referral –– Referral for therapy vs. referral for medicationsReferral for therapy vs. referral for medications–– Reaction to an event vs. request by patient / clientReaction to an event vs. request by patient / client

Client Transference to TherapistClient Transference to Therapist Response to ReferralResponse to Referral

Positive Positive –– Therapist who refers:Therapist who refers:

Understand severity of symptomsUnderstand severity of symptomsTake the client seriouslyTake the client seriously

–– Therapist who does not referTherapist who does not referStrongly focused on therapeutic workStrongly focused on therapeutic workValues and encourages talkValues and encourages talkConfident in the client and the therapeutic processConfident in the client and the therapeutic process

NegativeNegative–– Therapist who refers: Therapist who refers:

Therapist has given upTherapist has given upII’’m too sickm too sickMy therapist is incompetent / helplessMy therapist is incompetent / helplessI lack the capacity to resolve my problems without the benefit oI lack the capacity to resolve my problems without the benefit of a chemical f a chemical

–– Therapist who does not referTherapist who does not referDo not understand severityDo not understand severityIs not taking client seriously Is not taking client seriously

Mintz, DL (2005) Teaching the Prescriber’s Role: The psychology of psychopharmacology. Academic Psychiatry, 29:2. 187-194.

Powell, AD (2001) The Medication Life. Journal of Psychother Practice Res, 10:4. 217-222.

Client Transference to PrescriberClient Transference to Prescriber Response to Medication RecommendationResponse to Medication Recommendation

Positive: If a positive response to medications. Positive: If a positive response to medications. Prescriber viewed as supportive, nurturing, life Prescriber viewed as supportive, nurturing, life saving, believing in the illness/symptoms. saving, believing in the illness/symptoms. Negative: If a negative response to medications. Negative: If a negative response to medications. Prescriber viewed as dismissing the person with Prescriber viewed as dismissing the person with chemicals to get rid of the individual, discouraging chemicals to get rid of the individual, discouraging talk, intolerant to address real suffering. talk, intolerant to address real suffering. Transference to the prescriber (either positive or Transference to the prescriber (either positive or negative) may further influence +/negative) may further influence +/-- transference to transference to the therapist & vice versa. the therapist & vice versa.

Mintz, DL (2005) Teaching the Prescriber’s Role: The psychology of psychopharmacology. Academic Psychiatry, 29:2. 187-194.Powell, AD (2001) The Medication Life. Journal of Psychother Practice Res, 10:4. 217-222.

CountertransferenceCountertransference:: Therapist or PrescriberTherapist or Prescriber

Uncomfortable about needing help / needing to ask for helpUncomfortable about needing help / needing to ask for helpManage personal feelings of helplessnessManage personal feelings of helplessnessExpose difficulty in managing certain problemsExpose difficulty in managing certain problemsWork is known to a 3Work is known to a 3rdrd partypartySeparate from the client Separate from the client –– disrupt / prevent a relationshipdisrupt / prevent a relationshipControl the client / patient (control against strong emotions Control the client / patient (control against strong emotions or transference)or transference)Need to share power of treatment Need to share power of treatment -- Narcissistic injury Narcissistic injury Financial motivatorsFinancial motivatorsClients viewed passively Clients viewed passively –– clinicians are authoritarianclinicians are authoritarianCompetition between providersCompetition between providers

Powell, AD (2001) The Medication Life. Journal of Psychother Practice Res, 10:4. 217-222.

Benefits of Split TreatmentBenefits of Split Treatment

More time with CliniciansWorking with two clinicians (50 min therapy, 10-30 min medication management)Vacations may be covered between clinicians

Cost effective mild-moderate cases are seen by therapist only (no meds yet)severe cases are referred to prescribing clinicians

Greater choice for client Enhanced support for clinicians

difficult clients / patientsprofessional education (therapist learns about medications / prescriber learns about therapy dynamics)

Enhanced Adherence – therapist encourages medication adherence, prescriber encourages continued therapy

Bietman, BD, Blinder, BJ, Thase, ME, Riba, M, Safer, DL (eds) Integrating Psychotherapy and pharmacotherapy. W.W. Norton & Company, Inc, 2003.

Disadvantages of Split TreatmentDisadvantages of Split Treatment

Interdisciplinary Issues– Unfamiliarity with other clinicians– Inequality about professions– Political tension about prescribing privileges– Educational differences (LCSW, EdS, PsyD, PhD)

Communication– If done poorly – misperceptions or misunderstanding

Transference & CountertransferenceLegal Risks– Psychiatrists who used to do both, now doing just one, less time, less

knowledge, less relationship, same liability riskEthical Problems– Why was split treatment decided? How is split treatment dictated?

Resources (10 therapists & 1 psychiatrist); Managed care companies– Roll of prescribers: supervisory v. consultative v. collaborative

Bietman, BD, Blinder, BJ, Thase, ME, Riba, M, Safer, DL (eds) Integrating Psychotherapy and pharmacotherapy. W.W. Norton & Company, Inc, 2003.

Successful Split TreatmentSuccessful Split Treatment

BeginningCommunication between clinicians & clientConfidentialityDiagnostic impressions Comprehensive treatment plan & adherence (written contract)On-call issuesManagement of riskWhich symptoms go whereUnderstanding of beliefs about medications & therapy between all clinicians (acknowledgement of background & training)Barriers to optimal careWho will communicate to 3rd parties / family membersHandle & deal with conflict & problemsDifferences in fees, schedules, cancellations, etc

Successful Split TreatmentSuccessful Split Treatment

MiddleTransference & countertransferenceAdherence to treatment planReview of treatment planDiscuss end of split treatment

EndBest time for termination – stagger vs. simultaneously Follow-up and recurrence of symptoms

Bietman, BD, Blinder, BJ, Thase, ME, Riba, M, Safer, DL (eds) Integrating Psychotherapy and pharmacotherapy. W.W. Norton & Company, Inc, 2003.

Putting it all togetherPutting it all together……

Initial AppointmentInitial Appointment–– Review symptom presentation, treatment plan, benefits & side effReview symptom presentation, treatment plan, benefits & side effectsects–– Hypothesis on attachment, character, or LOCHypothesis on attachment, character, or LOC–– Inquire about expectations of pharmacotherapy Inquire about expectations of pharmacotherapy –– Address resistance to identify illness or need for treatmentAddress resistance to identify illness or need for treatment–– Split treatment Split treatment –– referring clinician can also explore these questionsreferring clinician can also explore these questions

FollowFollow--Up AppointmentsUp Appointments–– Explore side effects, compliance & residual symptomsExplore side effects, compliance & residual symptoms–– Understand the meaning of medications, identity of Understand the meaning of medications, identity of ““sicksick””–– Explore fears about medication (loss of control, addiction, lossExplore fears about medication (loss of control, addiction, loss of of

personality)personality)–– Differentiate normal emotional responses from side effects or syDifferentiate normal emotional responses from side effects or symptomsmptoms–– Split treatment Split treatment –– communicate these concerns before & after communicate these concerns before & after

appointmentsappointmentsMaintenanceMaintenance–– Combating stigma (Mental illness in famous individuals)Combating stigma (Mental illness in famous individuals)–– Split treatment Split treatment –– discuss end of treatment strategies & promote discuss end of treatment strategies & promote

compliance to treatment plancompliance to treatment plan

Patient centered Patient centered –– not provider centerednot provider centered

QuestionsQuestions