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Mental Health Software Treats Patients as Partners in Care



Valley News Staff Writer
Monday, April 11, 2016

By Rick Jurgens

Valley News Staff Writer

Lebanon — A new program at West Central Behavioral Health that seeks to give a voice to patients in determining their treatment during short, routine appointments was created by an expert with ties to Dartmouth College and first-hand knowledge of serious mental illness.

The CommonGround software program that West Central, a Lebanon mental health clinic, began using earlier this year was developed by Patricia Deegan, a Massachusetts resident who is an adjunct professor at the Geisel School of Medicine.

Every working day, employees of West Central who are themselves living with mental illness, use CommonGround to help patients formulate medical and personal goals and prepare for doctors’ appointments.

“It’s fundamentally different from anything we’ve done before,” Suellen Griffin, West Central’s executive director, said at a Jan. 27 open house. “It makes people feel that they are not alone.”

CommonGround aims to make patients active partners in the periodic “med check” appointments that comprise the backbone of much of the care delivered to seriously ill patients at West Central and in most community mental health clinics around the country.

Deegan is an influential critic of a long-standing approach to mental health care that aims to stabilize and maintain patients. “A diagnosis of mental illness is not a death sentence,” she said in a recent interview. “It does present challenges but it certainly is possible to go on and lead a full and meaningful life.”

Challenging that paradigm has been a central theme in the personal and professional life of Deegan, who grew up in Massachusetts and in 1972, at the age of 17, was diagnosed with schizophrenia.

“I was advised to take high-dose, anti-psychotic medications for the rest of my life,” she recalled. “I was told explicitly to avoid stress and to not try to do things like go to school and finish my education because things like this would cause me to relapse.”

Her future prospects were as bland as they were grim. “Basically, what my life consisted of at the ripe old age of 18 was sitting in a room, smoking cigarettes, drinking high-test Coca-Cola and doing nothing day in and day out and day in and day out,” she said recently. “And this was considered a great outcome, a good outcome by my treatment providers.”

In what she characterizes as an act of “angry indignation,” Deegan decided to defy that convention. She realized that “I needed to form active partnerships with my care team and, most importantly, I needed to become an expert in how to take care of myself. I needed to get activated and engaged.”

But she needed help to find her way out of the doldrums of days spent smoking cigarettes on a couch in the living room of her family home, challenged only by “my little Irish grandmother with a fourth-grade education,” according to Deegan.

“She would come in the room every day and she’d say, ‘Patricia, would you like to go food shopping?’ And I would every day dismiss her and say no. And then one day, many many months later for reasons that I can’t account for, I said, ‘Yes, but I’ll only push the cart.’”

Deegan said that seemingly minor decision was vital: “I pushed a shopping cart down the aisle of a supermarket. But without that first step I wouldn’t have taken a second one.”

Getting active unlocked bigger aspirations, according to Deegan: “I decided to become a clinical psychologist and work toward changing the mental health system.”

In 1977, she graduated from Fitchburg State College, and in 1984 she earned a Ph.D. in psychology from Duquesne University. In 1997, her innovative technique for exposing caregivers to some mentally ill people’s experience of hearing voices was featured in This American Life on National Public Radio.

A few years ago, Deegan became an adjunct professor of community and family medicine at Geisel. Meanwhile, the mental health consulting company that she and Deborah Anderson, another psychiatric survivor, launched in 2001 continues to work to spread the use of CommonGround.

Deegan has worked to promote the so-called recovery paradigm for mental health care. “We now know through world-wide studies of recovery that half to two-thirds of people diagnosed with serious mental illness do go on to lead full and meaningful lives in the community,” she said.

Deegan said that she became interested in Dartmouth College because of the institution’s important role in the promotion of “shared decision making.” That’s a concept, incorporated in her view of mental health care, that sees, in her words, “two experts in the room” in a medical appointment: the doctor and the patient. She and other patients receiving treatment for mental illness, she said, “need to be active and part of making decisions about what treatment is right for us.”

Helping patients at West Central’s Lebanon clinic become active partners in their treatment is a key part of the job of Angela Montano, a member of the peer support staff.

Montano speaks frankly about her own battles with mental illness and substance abuse: “I have different diagnoses, and they are part of who I am, but they’re not who I am.”

Montano works in a small, windowless office with patients who are about to go into their regular appointments with psychiatrists to assess their current symptoms and the effectiveness and side-effects of their medication.

These so-called med checks — short, periodic appointments lasting about 15 minutes — have become a standard venue for patient-doctor interaction in the mental health care system.

The CommonGround software is used prior to med checks to pose a series of multiple-choice or rating questions and elicit comments from patients. The software converts patient responses and comments into one-page health reports that are intended to ensure that patients’ questions, goals and values get addressed during the limited time in which they interact with doctors.

Some elements of the CommonGround experience, including asking patients to describe their personal medicine — an activity that makes them feel better — or compose a power statement, can be challenging, Montano said: “Many people are not used to being able to advocate for themselves.”

Yet Montano seems enthusiastic about the new tool. “It’s just a matter of people realizing that they have a voice, and (that) their voice is heard,” she said.

West Central managers say that few patients have declined to use CommonGround. Diane Roston, West Central’s medical director, said that patients and doctors are talking about how CommonGround has helped them “make better use of their appointments” and that the clinic has just begun a quantitative assessment of how the program affects patients, including their attendance rates.

David Rettew, a psychiatrist at the University of Vermont Medical Center, has written articles criticizing the reliance on med checks as a symptom of “a mental health care system that is overloaded, uncoordinated and over-focused on pharmacological solutions.”

Rettew, in an interview, reiterated his criticism of the med check as a mental health care tool — “it’s too much about the meds” — but said that the use of software to enhance collaboration and interaction between patients and doctors “sounds like a nice development.”

Deegan’s company released CommonGround in October 2006 and now charges a sliding scale licensing fee that begins at $3,000 per year for up to 100 users, according to the company website.

In March 2015, the New Hampshire Charitable Foundation awarded West Central a $20,000 grant to support the introduction of CommonGround into its patient services.

Kevin Peterson, a senior program officer with the foundation, said that the grant was seen as an opportunity to help bring “national best practices into New Hampshire.”

The foundation found “strong evidence that (CommonGround) was resulting in better patient outcomes,” Peterson said. “It came pretty highly recommended.”

Among local authorities who speak enthusiastically of CommonGround is Robert Drake, former director of New Hampshire-Dartmouth Psychiatric Research Center and former medical director at West Central.

CommonGround represents a new and necessary approach, Drake said. “Relying on professionals to inform (mental health patients) completely about the scientific evidence and about their choices has not worked very well,” he said. “The professionals are much too influenced by their own training … and the information they get from the pharmaceutical industry.”

Drake worked with Deegan as a co-author of a 2010 journal article that said that early research showed that the CommonGround program improved care but had not yet established the program’s long-term benefits for patients’ health. Among the challenges facing clinics attempting to use the software were “clinician buy-in, start-up costs, initial time investments, and computer literacy,” the article said.

A 2013 journal article reported that patients using CommonGround in a Pennsylvania study did not increase their adherence to their medication regimens. Additional studies would be needed to measure the program’s effectiveness in strengthening the “therapeutic alliance” between providers and patients and helping patients “take greater responsibility for illness management and be less dependent on the mental health system over time,” the article said.

But Drake, although he was listed (last) among the seven co-authors, dismissed that work as “a typical psychiatric study that is poorly conceived and doesn’t really answer the question” of CommonGround’s effects on patients and treatments.

Greg McHugo, a professor of psychiatry at Geisel, is working with Deegan and others on a new study that will compare how CommonGround and another, more top-down approach affect medication visits and improve patient involvement in decision-making. It will also look at the impact on such other patient outcomes as symptoms, hopefulness, quality of life, empowerment and activation, he said. That two-year study began in November 2014, he said.

Even as CommonGround proves its worth in the clinical trenches, backers believe that more needs to be done to improve mental health care. Drake said that he and Deegan are “both very skeptical about the psychiatric care system in this country and the over-reliance on medication.”

Drake and Deegan were among the co-authors of a 2010 journal article that cited studies that found that only one in six Americans with serious mental illness received even minimally adequate treatments based on evidence-based practices and the premise that many patients could recover and lead full lives.

Deegan concluded a recent interview by emphasizing that it is not the mystery of the disease or ignorance about proper treatment that stands in of the way of better mental health care.

“It’s not rocket science to help people recover from mental illness,” Deegan said. “We absolutely know how to do it.”

“It would help if they stop slashing budgets with every legislative session,” she added. “But we need the leadership and the will to make it happen.”

Rick Jurgens can be reached at rjurgens@vnews.com or 603-727-3229.

Correction

David Rettew is a psychiatrist at the University of Vermont Medical Center. An earlier version of this story misspelled his last name.