Psych Update v5n2 2013 - MC7900-1213

In 2011, doctors wrote more than 131 mil-lion prescriptions for hydrocodone, making it the most widely prescribed drug in the United States. Along with oxycodone, it is also the most abused. Both opioids have fueled an epidemic of addiction and fatal overdoses that outpace those from heroin and cocaine combined.

The problem is not just that opioid prescriptions for chronic noncancer pain have doubled in the last decade. It is also the drugs’ lack of long-term efficacy. Patients need higher doses over time to achieve the same level of pain control, leading to an increased risk of dependence, addiction and overdose and to reduced quality of life,

Psychiatry and Psychology News From Mayo Clinic

PsychUpdate

INSIDE THIS ISSUE

2 40 Years of Addiction Treatment

3 Mayo Clinic Depression Center Offers Innovative, Integrated Care

4 Transitions Program Reduces Psychiatric Hospital Admis-sions, Fills Gaps in Care

Vol. 5, No. 2, 2013

Pain Rehabilitation Center Improves Pain and Function Without Opioids

Mayo Unveils Destination Medical Center PlanAt a time when health care in general is shrinking, Mayo Clinic is expanding. Last spring, it announced a 20-year, $5.6 billion economic development plan aimed at making Mayo Clinic and, by extension, Rochester, Minn., one of the leading medical destina-tions in the world.

In addition to doubling the size of the Minnesota campus, the plan calls for turn-ing Rochester into a vibrant destination city — a thriving intellectual and cultural community with high-end hotels, restaurants and sports facilities.

Each year, Mayo Clinic attracts more than 1,650,000 outpatients from all 50 states and 150 countries. Bradly J. Narr, M.D., chair of anesthesiology and director of the new Destination Medical Center initiative, says expanding Mayo Clinic’s highly successful practice model and medical assets will help ensure its status as a global medical com-munity for decades to come.

Mark A. Frye, M.D., chair of the Depart-ment of Psychiatry and Psychology, says the expansion presents “a wonderful opportunity

for the department to broaden its ability to provide the best possible care to patients worldwide. Our three flagship programs — Mayo Clinic Depression Center, Pain Reha-bilitation Center and Addiction Services — are exemplary models of integrated care with the goal of providing the best care every day to every patient who struggles with depres-sion, pain and addiction.”

2 MAYO CLINIC | PsychUpdate

40 Years of Addiction TreatmentIn September 2013, Mayo Clinic held its fifth Frontiers of Addiction Treatment conference in Rochester, Minn. The two-day meeting, which highlighted advances and current issues in the field, coincided with the Clinic’s 40th anniver-sary of addiction treatment.

More than 200 people attended the anni-versary celebration, including Robert M. Morse, M.D., an emeritus professor of psychiatry and founding director of Mayo Clinic Addiction Services, who was honored for his ground-breaking work in the treatment of alcoholism and other addictive disorders.

“Dr. Morse developed a therapeutic model that addressed the psychiatric and medical disor-ders that often co-occur with substance abuse,” says psychiatrist Terry D. Schneekloth, M.D. “It’s a model that is increasingly emulated today, but 40 years ago it was a profoundly novel approach.” Dr. Morse and longtime colleague, Joseph Davis,

Ph.D., exemplify the fruitful partnership between psychology and psychiatry at Mayo Clinic as well as an ongoing commitment to advancing understanding of addictive disorders.

according to Larissa L. Loukianova, M.D., Ph.D., an addiction psychiatrist at Mayo Clinic in Minnesota.

Barbara K. Bruce, Ph.D., L.P., clinical director of Mayo Clinic Comprehensive Pain Rehabilita-tion Center adds, “Sixty-five percent of adults admitted into our program have experienced chronic pain for an average of 10 years and are on daily opioids, with an average morphine equivalent of 130 milligrams. Yet despite high doses of these medications, their functioning is poor and their pain levels are very high.”

Mayo Clinic has one of the largest adult and pediatric pain rehabilitation programs in the country, treating more than 700 patients a year. It also has one of the most skilled and experi-enced programs for safe and effective tapering of low- and high-dose opioids. “Our adult pain rehabilitation program has been in operation since 1974. One of the goals has always been to taper narcotics completely over the course of the program,” Dr. Bruce says. “But we don’t just taper medications, we taper them in the context of many other strategies for pain management, including physical and occupational therapy, stress management and relaxation techniques, biofeedback, and cognitive behavioral therapy.”

Most pain center patients enter a three-week, hospital-based outpatient program, though a two-day program also is available. In addition to treating a broad range of pain types, the programs address co-occurring medical and mental health disorders.

Dr. Bruce says the primary aim is functional restoration and improved quality of life — “the ability to work, volunteer, be a productive par-ent and spouse.”

Eighty-four percent of patients who complete the three-week program report better pain control despite discontinuing pain medications, 93 percent note an increase in aerobic activity and more than 80 percent report fewer depres-sive symptoms. Longitudinal data show that the majority continue to experience significant and sustained improvements in pain severity and functioning six months after treatment.

Pediatric pain programIn 2010, Mayo created a pediatric pain reha-bilitation program co-led by Tracy E. Harrison, M.D., a pediatric anesthesiologist and pain physician, and Karen E. Weiss, Ph.D., L.P., a pediatric psychologist.

The pediatric and adult programs have similar structures, but the issues and stressors teens face are very different. “By the time chil-dren enter our program, they have often been out of school for two or three years, have seen multiple physicians, and are on all kinds of pain medications — about 20 percent on opioids,” Dr. Harrison explains. “We taper them off their medications and work with families and educa-tors to get them back into school, into sports, into their lives. We give them hope and a very clear trajectory.”

Barbara K. Bruce, Ph.D., L.P.

Terry D. Schneekloth, M.D., presents Robert M. Morse, M.D., with the Founders Award in recognition of his pioneering work in addiction treatment.

MAYO CLINIC | PsychUpdate 3

The World Health Organization estimates that depression will be the world’s second most common health problem by 2020. To meet the growing need for effective care, Mayo Clinic Depression Center, under the direction of Mark A. Frye, M.D., offers four innovative, offers four innovative, evidence-based programs for people with bipolar disorder or major depression.• The Mood Clinic provides comprehensive

outpatient assessment for adults with depres-sive symptoms.

• A 16-bed inpatient unit serves people whose depression significantly affects their safety, func-tioning or quality of life. More than 600 patients a year receive intensive individualized treatment, which may include cognitive behavioral therapy, medications, and family or group therapy.

• A 10-day, outpatient group psychotherapy program helps patients manage interpersonal issues using interpersonal social rhythm therapy, mindfulness-based cognitive therapy and behavioral activation.

• A comprehensive consultation service addresses issues specifically related to mood disorders in women, especially initiation and mainte-nance of pharmacologic therapy during and after pregnancy.

Each Depression Center program is compre-hensive and highly individualized. “Medicine doesn’t get more personalized than this,” says William V. Bobo, M.D., a psychiatrist specializ-ing in the evaluation and treatment of depression at Mayo Clinic in Minnesota. “For one thing, we have the luxury of time. Because we have much

longer appointment times than most, patients can tell their whole story and we have a chance to ascertain as many relevant factors as possible.”

The Depression Center is also fully inte-grated with Mayo Clinic, allowing for the simul-taneous evaluation and treatment of mental health and co-occurring medical disorders. “If a Depression Center patient needs to see a cardi-ologist, for example, we coordinate the entirety of care, and the efficiency with which that is accomplished is stunning,” Dr. Bobo says.

He adds, “Patient care is our foremost mis-sion, but as an integrated practice, we are also committed to research. Our investigations span the translational spectrum from basic bench science work to population health studies and include epigenetic, pharmacogenetic and brain-imaging studies as well as clinical trials.”

For instance, Mayo researchers recently reported in the Journal of Psychopharmacol-ogy that low-dose intravenous ketamine can rapidly reduce depressive symptoms and suicidal ideation. Dr. Frye, senior study author, says outstanding clinicians and investigators, such as Dr. Bobo, Osama A. Abulseoud, M.D., Susannah J. Tye, Ph.D., and Marin Veldic, M.D., enable the Depression Center to combine the highest quality patient care with clinically relevant research and education.

For more informationRassmussen KG, et al. Serial infusions of low-dose ketamine for major depression. Journal of Psychopharmacology. 2013;27:444.

William V. Bobo, M.D.

Mayo Clinic Depression Center Offers Innovative, Integrated Care

Building on notable developments in genet-ics over the last 20 years, Mayo established the Samuel C. Johnson Genomics of Addictions Research Program, with the long-term goals of predicting, treating and preventing alcoholism and other chemical dependencies. Studies also are underway to identify alcohol-dependent patients who may benefit from new pharma-cologic agents, broaden understanding of the neurobiology of addiction, and investigate the effect of co-occurring psychiatric disorders on alcoholism vulnerability and recovery.

Another change in the last decade was a transition from inpatient addiction treatment to a 30-day residential program that allows

patients, many of them successful, highly func-tioning professionals, personal independence within a supportive structure.

“We are very pleased with the feedback from patients and their families about benefits from our program and their successful outcomes in maintaining abstinence. For the past two years, we’ve had a nearly continuous waiting list for program admission,” Dr. Schneekloth says. “Our understanding of substance abuse has changed significantly over the past four decades, but we remain committed to Dr. Morse’s original goal of providing innovative, highly individual-ized care in a respectful environment.

MC7900-1213

Mayo Clinic PsychUpdate

Medical Editor:Barbara K. Bruce, Ph.D., L.P.

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In Minnesota, as elsewhere, mental health services are strained. Escalating demand and dwindling resources have led to a short-age of psychiatric beds and overburdened emergency departments, leaving acute care patients waiting days or weeks for treatment. Patients discharged from acute hospitaliza-tion often endure equally long waits to see a new therapist or enter a program.

Mayo Clinic Psychiatric Hospital in Rochester, Minn., under medical director Timothy W. Lineberry, M.D., is finding inno-vative ways to address these problems. One is the new Transitions program, an intensive outpatient program for adults leaving acute hospitalization or needing additional care after an emergency department visit.

Bruce Sutor, M.D., program founder and chair of the clinical practice committee in the Department of Psychiatry and Psychol-ogy at Mayo Clinic in Minnesota, explains, “Transitions is a structured, multidisciplinary program designed to meet the different needs of different patients. The main populations we want to serve are people who have chemi-cal dependency issues along with psychiatric issues and those with parasuicidality or significant life stressors. These patients have the greatest need for services when they leave the hospital.”

Dr. Sutor says the idea for Transitions was prompted by the suicides of two young men awaiting treatment for chemical dependency. “There was a long gap from the time they left the hospital until they successfully completed suicide, and that really struck a chord,” he explains. “I realized that people’s lives were on the line and we needed to do something.”

Transitions has two main goals. One is

to get patients out of the hospital sooner — typically two to three days earlier than nor-mal — and provide them with immediate outpatient treat-ment. The other is to prevent unnecessary hospitalizations by diverting ED patients who don’t require inpatient care into the program. In both cases, hospital beds become available for people experiencing significant mental health crises and all patients receive seamless and appropriate care.

Dr. Sutor tells the story of a young woman contemplating suicide who called for help late one evening. “Normally she would have been admitted to the hospital,” he says. “But because she asked for help, had structure and support at home, and could do an intake with Transitions in the morning, we let her spend the night with her family. That would not have been possible if she had to wait weeks to get an appointment with a therapist. But I felt comfortable knowing she would be seeing experienced clinicians the next morning.”

Transitions operates five days a week, with two sessions running simultaneously in the early and late afternoon. Patients can participate in various groups, including skills building, stress management and dialectical behavioral therapy for those in significant distress. A psychiatric nurse practitioner, licensed alcohol and drug counselor, regis-tered nurse and other staff provide treatment under the medical direction of Brian A. Palmer, M.D.

Transitions Program Reduces Psychiatric Hospital Admissions, Fills Gaps in Care

Bruce Sutor, M.D.

Upcoming CoursesFor more information or to register for courses, visit www.Mayo.edu/cme/psychiatry-and-psychology, call 800-323-2688 (toll-free) or email [email protected].

Psychiatry in Medical Settings Jan. 23-25, 2014, in Fort Lauderdale, Fla.

Translational Bridges to Mood and Addiction Sept. 4-6, 2014, in Rochester, Minn.

Acute Care Psychiatry Clinical Review Sept. 18-20, 2014, in Las Vegas