Mental Health Clinical Advisory Group Regular Meeting
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Mental Health Clinical Advisory Group
Regular Meeting
November 5, 2020 | 1:00-3:00 PM | Zoom Virtual Meeting
https://www.zoomgov.com/j/1610269061?pwd=UUdaMTVFOEFGeTRXWk1OREJxcTJxdz09
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+1 669 254 5252 US (San Jose)
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Meeting ID: 161 026 9061
Password: 832436
*Agenda subject to change
_____________________________________________________________________________________
Officers: Nick Kashey, MD (Chair); Davíd Nagarkatti-Gude (Vice-Chair).
Appointed Members: Glena Andrews, Ph.D.; William Beck, PharmD; Chris Bouneff; Keith Cheng, MD;
Donald Dravis, MD; Neil Falk, MD; Joan Fleishman, PsyD; George Fussell, MD; Maggie Bennington-Davis,
MD; Bob Joondeph, JD; Lori Martin, MSN, PMHNP; Jill McClellan, PharmD; Mario Odighizuwa; Leah Werner,
MD.
MHCAG webpage: https://www.oregon.gov/oha/HSD/OHP/Pages/PT-MHCAG.aspx
TOPIC: Bipolar disorder and special populations PAGE TIME FACILITATOR
and breakthrough symptoms. Cross-diagnostic tip
sheet also to be reviewed.
Call to order 1-2 1:00-1:10pm Nick Kashey/OHA
Rollcall
Approval of Minutes from September
Updates from NAMI and OHA ------------ 1:10-1:20pm OHA/Chris Bouneff
Review edits from the 10/8/2020 meeting for the
document entitled:
3-6 1:20-1:30pm Nick Kashey
“Bipolar Disorder Clinical Practice Pearls for the
Treatment of Special Populations and People with Co-
Occurring Disorders”
Possible vote by the MHCAG
Review and edit the document entitled: “Breakthrough 7 1:30-1:50pm Nick Kashey
symptoms and bipolar disorder”
Public Comment ------------ 1:50-2:00pm Nick Kashey
Break ------------ 2:00-2:10pm AllReview and edit the document entitled: “Tips for 8-12 2:10-2:30pm Nick Kashey
finding a therapist” and the types of psychotherapies
table
MHCAG in 2021(meetings, goals, planning) 13 2:30- 3:00pm Nick Kashey/OHA
Next Regular Meeting: January 7, 2021 from 1:00-3:00pm
Next Special Meeting: February 3, 2021 from 1:00-3:00pm
Location: All 2021 meetings will use Microsoft Teams as their virtual meeting platform.
UPCOMING MHCAG MEETING SCHEDULE
Date Type of Meeting Format
ALL MEETINGS FROM
1:00-3:00PM IN 2021
December NO MEETING N/A
January 7th Regular Microsoft Teams- TBA
(Thursday)
February 3rd Special Microsoft Teams- TBA
(Wednesday)
March 4th Regular Microsoft Teams- TBA
(Thursday)Attendees: A quorum was present for voting purposes.
Mental Health Clinical Advisory Group Committee: Nick Kashey (Chair); David Nagarkatti-Gude (Co-
Chair); Keith Chang; George Fussell; Chris Bouneff; Neil Falk; Glena Andrews; Bob Joondeph; Lori
Martin; Maggie Bennington-Davis; Jill McClellan; Leah Werner; Joan Fleischman.
OHA Staff: Amanda Parish; Trevor Douglass; Jennifer Bowen; Sara Fletcher.
Public: Paul Thompson; Roy Lindfield; DeAnn (last name unclear); Samantha (last name unclear).
Welcome and call to order: The meeting was called to order by Nick Kashey (Chair) at 1:00 PM.
Review previous minutes: The minutes from March 5, 2020 regular meeting were reviewed.
Motion to approve minutes, motion seconded, and all were in favor.
Membership check-in about the impact of Covid-19
No voting occurred during this agenda item.
Members described how their professional and personal lives have been impacted since the pandemic
began.
Reorienting to the Work of the MHCAG:
No voting occurred during this agenda item.
The MHCAG reviewed a list of documents published by the group from 12/2019 to the present and also
reviewed documents that remain in-process since their last regular meeting in March 2020.
Presentation of a draft Major Depressive Disorder medication algorithm for use with treatment
naïve patients.
No voting occurred during this agenda item.
Alberto Sandoval, Pharmacy Intern, PharmD Candidate 2021, presented the draft Major Depressive
Disorder (MDD) medication algorithm he created for the MHCAG. The intention of creating the
algorithm was to provide the membership with a jumping-off point for further work on an MDD
algorithm.
11/5/2020 REGULAR MEETING 1Planning for the remainder of 2020
No voting occurred during this agenda item.
The group chose to keep the current meeting schedule as-is moving forward. At the October 8th
meeting they will work on the document regarding the treatment of special populations with bipolar
disorder. The group‘s goal is to have this document finalized and voted on at the November 5, 2020
meeting.
Public comment: None
Meeting adjourned - 2:30 PM
11/5/2020 REGULAR MEETING 2Bipolar Disorder Clinical Practice Pearls for the Treatment of Special
Populations and People with Co-Occurring Disorders
For prescribing providers treating people with Bipolar Disorder who are members of one or more special
populations or have any of the co-occurring disorders mentioned in this document, a consultation with
OPAL (Oregon Psychiatric Advice Line) is recommended. A prescribing provider can call this line to speak
with a specialist Monday-Friday from 9:00-5:00pm at: 503-346-1000. Additionally, for providers treating
pregnant women, consultation with perinatology is recommended.
Populations requiring special attention when treating Bipolar Disorder
Women of childbearing age
• DO NOT USE Valproic Acid or Carbamazepine if pregnant or planning to become pregnant.
• Special care needs to be taken when prescribing mood stabilizers for women of childbearing age
due to teratogenic effects.
• Create plans with the patient:
o 1) to minimize the risk of unplanned pregnancies while taking medications,
o 2) to manage Bipolar Disorder should the patient wish to become pregnant, and
o 3) to treat Bipolar Disorder symptoms should they develop when the patient is pregnant
or nursing.
• Due to increasing risk of affective disorders, monitor more closely for symptoms during the
post-partum period and consider an early resumption of treatment.1
• Well-child visits should be considered an opportunity to screen both parents for mood
disorders.
Medication Absolutely Use with Insufficient Significant
Contraindicated Caution Data observational/retrospective
data exists
Valproic acid X
Carbamazepine X
Lithium X
Lamotrigine X
Oxcarbazepine X
Typical X
antipsychotics
Atypical X
antipsychotics
1
Rodriguez-Cabezas, L. and C. Clark (2018). "Psychiatric Emergencies in Pregnancy and Postpartum." Clinical
obstetrics and gynecology 61(3): 615-627.
11/5/2020 REGULAR MEETING 3Youth
Bipolar Disorder is often difficult to accurately diagnose in children and young adults, given a broad
differential diagnosis for such symptoms, as well as a high proportion of comorbidity with other
psychiatric diagnoses.
• Before initiating medications in children, the diagnosis of bipolar disorder should be confirmed
to the best of the clinician’s ability. Although not always possible, consultation with a
multidisciplinary team as well as people who have a longitudinal relationship with the child
would be ideal.
• Children and young adults are more prone to metabolic side effects from medications. The
diagnosis of Bipolar Disorder should be firm before initiating medications.
• The lowest effective dose should be used, and periodic reviews should assess for dose
reductions, if appropriate.
• Patients should be monitored closely for emergent side effects, with a low threshold for
medication changes should metabolic side effects develop.
Geriatric
Many patients with Bipolar Disorder experience a change in cycling as they age, with cycles generally
becoming more frequent and symptoms becoming less intense, often with an increase in manic or
hypomanic symptoms relative to depressive symptoms
• Be conscious of teasing out emerging cognitive impairment from bipolar disorder symptoms.
• The geriatric population is at an extremely high risk of drug interactions and polypharmacy.
• Medication doses often need to be lowered to account for changes in factors such as physiology
and bioavailability. Monitor renal function, weight and orthostatic changes closely.
• Medication side effects may cause more impairment and risk as patients age.
• Assessment for dose reduction should occur frequently in this population.
o Atypical antipsychotics medications pose an increased risk of cardiovascular mortality.
• Psycho-socio-spiritual supports are very important for this population.
11/5/2020 REGULAR MEETING 4Treating People with Co-occurring Disorders
Anxiety Disorders
Patients with co-occurring Bipolar Disorder and anxiety disorders may experience unique challenges, as
their anxiety symptoms may benefit from the use of antidepressants,
• Generally, patients with these co-occurring issues are best served by treating their anxiety
without the use of antidepressants.
o Consider trying various psychotherapies, relaxation techniques/exercises, EMDR,
hypnosis, acupuncture, etc
• If an antidepressant is used, clinical practice suggests that SSRI’s or buspirone are the safest
options.
• SNRI’s appear to present a higher risk of conversion to mania than SSRI’s and should be used
with more caution.
• TCA’s present a high enough risk to be contraindicated.
• Benzodiazepines present no risk of conversion to mania and can be helpful in managing manic
symptoms, but they should be used with the usual precautions concerning tolerance/addiction
issues.
5 – ADHD
Patients with both ADHD and Bipolar Disorder also experience unique challenges, as their ADHD
symptoms may benefit from the use of stimulants, however:
• Bipolar disorder may become more difficult to manage with the use of stimulants due to the risk
of conversion to mania.
• Generally, those with these co-occurring issues are best served treating their ADHD without the
use of stimulants.
o Instead, non-pharmacologic treatments for ADHD should be considered, including
behavioral therapies, cognitive behavioral therapy, occupational therapy, increasing
physical activity, increasing “green time,” biofeedback, acupuncture, etc.
• However, if a stimulant is used, clinical practice suggests that it be used at the lowest dose
necessary.
• While atomoxetine and bupropion may present a slightly lower risk of conversion to mania than
stimulants and should be used with caution.
6 - Substance Use
More than 50% of patients with Bipolar Disorder are also diagnosed with a substance use disorder
(reference?) and many symptoms of substance intoxication or withdrawal mimic symptoms of mania or
depression.
• The risk of suicide is higher for those with Bipolar Disorder and co-occurring substance use.
• In general, a diagnosis of Bipolar Disorder should be made only if symptoms (recent or
historical) occurred during a period of sobriety lengthy enough that symptoms could not be
attributed solely to substance intoxication or withdrawal.
11/5/2020 REGULAR MEETING 5• If no such period of sobriety exists, a detailed chronology plotting substance use intensity and
affective symptom intensity may be able to establish a connection (or lack thereof) between the
2 issues, thus clarifying diagnoses.
• While clarifying diagnosis, consider using non-medication treatments for substance use as these
treatments often overlap.
• Once a diagnosis is established, medications should be chosen so as to balance clinical
effectiveness while minimizing substance-medication interactions.
Partial reference List
Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges
Richard A Epstein,1 Katherine M Moore,2 and William V Bobo2
Drug Healthc Patient Saf. 2015; 7: 7–29.
Published online 2014 Dec 24. doi: 10.2147/DHPS.S50556
Atomoxetine Induced Hypomania in a Patient with Bipolar Disorder and Adult Attention Deficit Hyperactivity
Disorder
Vijaya Kumar and Shivarama Varambally1
Indian J Psychol Med. 2017 Jan-Feb; 39(1): 89–91.
doi: 10.4103/0253-7176.198954
11/5/2020 REGULAR MEETING 6BREAKTHROUGH SYMPTOMS AND BIPOLAR DISORDER
Breakthrough symptoms refer to the emergence of symptoms during treatment. In bipolar disorder they
may signal a shift from one mood state to another. Not infrequently they will be associated with
inconsistency in taking medications and sometimes the use of drugs or alcohol. They may also indicate
that the prescribed treatment is no longer adequate. For instance, medication changes including dose
adjustment are often required with the emergence of a manic phase.
Monitoring closely for changes in mood, energy level, appetite, and duration of sleep can be invaluable
in maximizing treatment.
11/5/2020 REGULAR MEETING 7Tips for Finding a Therapist
Finding the right therapist for you is important. Therapists are not “one size fits all”. It is ok to decide
not to return to a counselor who is not right for your needs. This does not mean you use this as an
excuse to avoid treatment. There are many counselors with many strengths.
Make sure the person is licensed in their field. You can ask for their licensed number. You can look up
their license on the internet.
Ask people you trust to recommend a counselor or therapist
https://psychcentral.com/blog/10-ways-to-find-a-good-therapist/
Insurance companies will have a list of approved therapists. Get the list and ask others if they know
anyone on the list they would recommend.
Company Human Resource professionals will have a list of EAP providers. This is a good and free way to
try out a new therapist.
Do you need:
To talk to someone: Counselor, Clinical Social Worker, Clinical Psychologist
To find a drug and alcohol counselor: CDAC counselor
To have testing: Clinical Psychologist, Clinical Neuropsychologist
To be evaluated for medications: Psychiatrist, Psychiatric Nurse Practitioner
When you call:
Ask how they work with clients (theoretical orientation)
Ask if they are licensed and by what State Board (there are no national licenses for therapists)
Ask the fee or if they accept and bill your insurance.
Give a very brief statement about what you are needing from a therapist
Pay attention to how you experience the person during the short phone call
Possible Sources for Professionals:
Therapists: https://www.psychologytoday.com/us/therapists/oregon?utm_content=5kh3kJHx-
dc_pcrid_81295161494593_pkw_psychology%20today_pmt_be_slid__pgrid_5565528245_ptaid_kwd-
134277008109:loc-4119_&utm_source=bing&utm_medium=cpc&utm_campaign=%5BUS%5D%20-
%20Oregon%20-%20Brand&utm_term=psychology%20today
Psychologists: https://www.opa.org/find-a-psychologist
11/5/2020 REGULAR MEETING 8Psychotherapy Commonly treats: *Average Length of Treatment Emphases of Treatment
Depression, anxiety (Craske et al, Up to 20 Mindfulness, acceptance of
2014) thoughts, feelings and
Acceptance and Commitment Psychosis (Bach, 2011) sensations, acting in accordance
Therapy Adult Depression (better than with personal values. Developing
Mindfulness Based Cognitive behavioral treatments; Chen et psychological flexibility
Therapy al, 2014)
Multiple issues. Draws upon a variety of
Client-Directed Outcome- Evidence-based for depression, counseling theories and
Informed Therapy anxiety (Barkham et al, 2017) techniques. Guided by client
Person-Centered Therapy feedback on the therapeutic
Existential Therapy process
Mood disorders, anxiety (Craske Up to 20 sessions Cognitive distortions (e.g.
et al, 2014)disorders eating 5.7 (Barkham et al, 2017) challenges unhelpful automatic
disorders, insomnia, phobias Most researched modality (Chen thinking), behavior change, life
(Craske et al, 2014), substance et al. 2014) goals
use disorders
Post-natal depression (Stamous
Cognitive Behavioral Therapy et al, 2018)
Generalized Anxiety (Hayes et al, Focus on reinforced behavior
Behavioral Therapy 2013 change
Mood disorders, high self- A unique combination of CBT and
criticism social, developmental, Buddhist
Schizophrenia, depression (Leavis psychology, evolutionary
& Uttley, 2015) psychology and neuroscience.
Not necessarily more effective
than other treatments (Leaviss &
Uttley (2015)
Compassion Focused Therapy Group therapy modality
Borderline personality disorder Work is done on acceptance and
Dialectical Behavioral Therapy (Soler et al. 2012) change-oriented strategies.
Social Anxiety (Shahar et al, Short-term therapy focusing on
2017) relationship and attachment or
Emotion-Focused Therapy bonding.Bipolar disorders (Schottle et al,
Family-Focused Therapy 2011)
depression (Stewart et al, 2014), 12-16 weeks Brief, attachment-focused
post-partum depression (Nylen et therapy centered on resolving
al 2010) interpersonal problems.
depression and trauma Structured and time-limited
Interpersonal Psychotherapy (Duberstein et al, 2018)
Bipolar disorder Focus is stabilizing the circadian
Interpersonal and Social Rhythm rhythm disruptions. Draws from
Therapy interpersonal therapy.
Mood disorders
Motivational Enhancement Substance use disorders 4 sessions Time-limited focusing on alcohol
Therapy and substance abuse treatment
Depression Up to 12 sessions Focus is on the problem of the
moment, short-term, structured
Problem-Solving Therapy problem solving
Bipolar I with psychosis (Mehl- 16-22 weeks. Depth psychology work with
Psychodynamic therapy Madrona &Mainguy, 2017) unconscious content of the
Narrative therapy person’s psyche
Depression Approach that helps a person
identify irrational beliefs and
Rational Emotive Behavioral negative thought patterns that
Therapy lead to problems
Short-Term Psychodynamic Depression (Dekker et al, 2013)
Therapy
Depression 4-10 sessions Goal-directed collaborative
Suicidal ideation (Kondrat et al, approach to change.
Solution-Focused Brief Therapy 2012)
Depression with older adults,
substance use disorders (Krishna,
et al, 2011)
Bipolar disorders (Schottle et al,
Group Therapy 2011)Psychotic disorders (Petrovic, et
al, 2010)
References
Bach, P., Hayes, S., & Gallop, R (2011), Long-term effects of brief acceptance and commitment therapy for psychosis. Behavioral Modification,
36(2), 165-181.
Barkham, M, Moller, N., & Pybis, J. (2017). How should we evaluate research on counseling and the treatment of depression? As case study on
how the National Insitute fo Health and Care Excellence’s draft 2018 guidelines for depression considered what counts as best evidence.
Counselling and psychotherapy research, 17(4) 2533-268.
Chen, P. et al. (2014). Quantity and quality of psychotherapy trials for depression in the past five decades. Journal of Affective Disorders, 165,
190-195.
Craske, M, Niles, A., Burkund, L, Wolitzky-Taylor, K, Vilardaga, J., Arch, J, Saxbe, D & Lieberman, M, (2014) Randomized controlled trial of
cognitive behavioral therapy and acceptance and commitment therapy fo social pobia: Outcomes and moderators. IJournal of Consulting and
Clinical Psychology, 82(6), 1034-1048.
Dekker, J., Van Henricus, L, Hendriksen, M., Koelen, J & Schoevers, R. (2013)., What is the best sequential treatment strategy in the treatment of
depression? Adding pharmacotherapy to psychotherapy or vice versa? Psychotherapy and Psychosomatics, 82(2), 89-98.
Duberstein, P, Ward, E., Chaudron, L, He, H., Toth, S., Wange, W., Van Orde, K., Gable, S, & Talbot, N. (2018). Effectiveness of interpersonal
psychotherapy-trauma for depressed women with childhood abuse history. Journal of Consulting and Clinical Psychology, 86,(10), 868-878.
Hayes-Skelton, S., Roemer, L, Orsillo, S (2013) A randomized clinical trial comparing and acceptance-based behavior therapy to applied relaxation
for generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 81(5), 761-773.
Kondrat, D., & Teater, B. (2012) Solution-focused therapy in an emergency room setting: Increasing hope in persons presenting with suicidal
ideation. Journal of Social Work, 12(1), 3-15.
Krishna, M, Jauhari, A., Lepping, P, Turner, J, Crossley, D, & Krishnamoorthy, A. (2011), Is group psychotherapy effective in older adults with
depression? A systematic review. International Journal of Geriatric Psychiatry, 26(4), 331-340.
Leaviss, J., & Uttley, L. (2015). Psychotherapeutic benefits of compassion-focused therapy: An early systematic review. Psychological Medicine
45(5), 927-945.Mehl-Madrona, L. & Mainguy, B. (2917). Comparisons of narrative psychotherapy to conventional CBT for psychotherapy of psychosis and bipolar disorder. European Psychiatry, 41(supplement), 5779. Nylen, K., O’Hara, M., Brock, R., Moel, J., Gorman, L & Stuart, S. (2010). Petrovic, B., Oreskovic-Krezler, N., bogovic, A., Mihanovic, M. Grah, M. & Mayer, N. (2010). Influence of psychodynamic group orientated psychotherapy on quality of life in patients with psychotic disorders, European Psychiatry, 25 (Supplement), 1091. Schottle, D., Huber, C., bock, T., & Meyer, T., (2011), Psychotherapy for bipolar disorder: A review of the most recent studies. Current Opinion in Psychiatry, 24(8), 549-555. Shahar, B., Bar-Kalifa, E & Alon, E. (2017). Emotion-focused therapy for social anxiety disorder: Results from a multiple-baseline study. Journal of Consulting and Clinical Psychology, 85(30), 238-249. Soler, J., Valdeperez, A., Feliu-Soler, A., Pascual, J, Portella, Ml, Martin-Blanco, A, Alvarez, E & Perez, V. (2012) Effects of the dialectical behavioral therapy-mindfulness module on attention in patients with borderline personality disorder. Behaviour Research and Therapy, 50(2), 150-157 Stamous, G., Garcia-Palacios, A., & Botella, C (2018). Cognitive-Behavioral therapy and interpersonal psychotherapy for the treatment of post- natal depression: a narrative review, BMC Psychology, 6, Doi: 10:1186/s40359-018-0240-5 Steward, M., Raffa, S., Steele, J., Miller, S., Clougherty, K., Hinrichsen, G. &Karlin, B. (2014). National dissemination of interpersonal psychotherapy for depression in veterans: Therapist and Patient-Level outcomes, Journal of Consulting and Clinical Psychology, 82(6), 1201- 1206.
PUBLISHED MHCAG DOCUMENTS FROM 12/2019- CURRENT
BIPOLAR DISORDER DOCUMENTS
Documents Remaining Published 2020 Published 2019
Treatment of special Differential diagnosis and Quick look-bipolar disorder
populations bipolar disorder
Breakthrough symptoms Comparative overview of the Acute bipolar depression
side effect profiles of algorithm
medications used in the
treatment of bipolar disorder
Symptom scales Differentiating between mood Acute bipolar mania algorithm
cycling conditions
Use of clozapine for clients with Bipolar disorder diagnostic
bipolar disorder criteria
PUBLISHED ANTIPSYCHOTIC-RELATED DOCUMENTS
Documents Remaining Published 2020 Published 2019
None Management of antipsychotic Antipsychotic related side
related side effects effects
PUBLISHED CROSS-DIAGNOSTIC DOCUMENTS
Documents Remaining Published 2020 Published 2019
Cannabis herbs and Differentiating between cycling Cross-diagnostic psychosocial
supplements guidance mood conditions assessment and intervention
flow chart
Tips for finding a therapist
Cross-diagnostic stabilization
and management flow chart
Resources for patients, families
and natural supports
Suicide prevention
OPAL
Education for Patients
11/5/2020 REGULAR MEETING 9You can also read
