PHARMACOLOGICAL MANAGEMENT IN THE INTEGRATED...
Transcript of PHARMACOLOGICAL MANAGEMENT IN THE INTEGRATED...
Session ID: 1011‐16 American Psychiatric Nurses Association
Laura K. Melaro, DNP, APRN, FNP/PMHNP‐BC 1
PHARMACOLOGICAL MANAGEMENT IN THE
INTEGRATED BEHAVIORAL HEALTH SETTING
Laura K. Melaro
DNP, APRN, FNP/PMHNP-BC
DISCLOSURE
• Professor & Assistant Professor at University
• Consultant/Promotional Speaker for Otsuka/LundbeckPharmaceutical
• Psychiatric Nurse Practitioner & Consultant in Integrated Behavioral Health program in three Federally Qualified Health Centers
Session ID: 1011‐16 American Psychiatric Nurses Association
Laura K. Melaro, DNP, APRN, FNP/PMHNP‐BC 2
OBJECTIVES
• Explain the correlation between Accountable Care Organizations (ACO) and Integrated Behavioral Health (IBH).
• Recognize the different levels of collaboration/integration for delivery of Integrated Behavioral Health services.
• Explore the role of prescribers in Integrated Behavioral Health settings.
• Identify evidence based psychiatric treatment appropriate for the Integrated Behavioral setting.
HEALTH CARE REFORM
• Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA)
• 2010 Physical and Medical Health Care Coverage Parity
(United States Department of Labor, 2010)
• Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010
• 2010-2014 Patient Bill of Rights, Preventative Services, Accountable Care Organizations, Open Enrollment Insurance Marketplace
(U. S. Department of Health & Human Services, 2015)
Session ID: 1011‐16 American Psychiatric Nurses Association
Laura K. Melaro, DNP, APRN, FNP/PMHNP‐BC 3
MEDICAL HOME
• Model of the organization of primary care that delivers the core functions of primary health care
• Five Functions: Comprehensive Care, Patient-Centered, Coordinated Care, Accessible Services, Quality & Safety
• Primary Care focus (AHRQ, 2015)
• Meet the needs of high-risk/high-cost patients
• 2+ chronic illnesses & serious, persistent mental health condition
• Deliver comprehensive care management, care coordination, health promotion, comprehensive transitional care
• PCP consultant (PPACA, 2010)
HEALTH HOMES
ACCOUNTABLE CARE ORGANIZATIONS
ACCOUNTABLE CARE ORGANIZATIONS
National Medicaid Recommendations
Universal Screening
Navigators
Co-location
Health Homes
System-level integration
(Nardone, Snyder, & Paradise, 2014)
Session ID: 1011‐16 American Psychiatric Nurses Association
Laura K. Melaro, DNP, APRN, FNP/PMHNP‐BC 4
INTEGRATED BEHAVIORAL HEALTH
• Patients without Identified Mental illness
• 80% of people with a behavioral health disorder will visit a primary care provider at least once a year
• 50% of all behavioral health disorders are treated in primary care
• 48% of appointments for all psychotropic agents are with a non-psychiatric primary care provider
• 67% of people with a behavioral health disorder do not get behavioral health treatment
(Patient-Centered Primary Care Collaborative, 2015)
INTEGRATED BEHAVIORAL HEALTH
• Patients without Identified Mental illness
• 30-50% of patient referrals from primary care to an outpatient behavioral health clinic do not make the first appointment
• Two-thirds of primary care physicians report not being able to access outpatient behavioral health for their patients. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by primary care providers as critical barriers to mental healthcare access
(Patient-Centered Primary Care Collaborative, 2015)
Session ID: 1011‐16 American Psychiatric Nurses Association
Laura K. Melaro, DNP, APRN, FNP/PMHNP‐BC 5
INTEGRATED BEHAVIORAL HEALTH
• Patients with Identified Mental Illness
• Link patients to primary care services
• Encourage lifestyle changes to improve their overall
health
• Identify and overcome barriers to receiving care
• Track clinical outcomes in a registry format
(Heath Wise Romero, & Reynolds, 2013)
I. Interpersonal Communication
II. Collaboration & Teamwork
III. Screening & Assessment
IV. Care Planning & Coordination
V. Intervention
VI. Cultural Competence & Adaptation
VII. Systems Oriented Practice
VIII. Practice-Based Learning & Quality
Improvement
IX. Informatics
INTEGRATED CARE CORE COMPETENCIES
ROLE OF PROVIDERS
(HOGE, MORRIS, LARAIA, POMERANTZ & FARLEY, 2014)
Session ID: 1011‐16 American Psychiatric Nurses Association
Laura K. Melaro, DNP, APRN, FNP/PMHNP‐BC 6
1. Identify and assess behavioral health needs as part of primary care team
2. Engage and activate patients in their care
3. Work as a primary care team member to create and implement care plans that address behavioral health factors
4. Help observe and improve care team function and relationships
5. Communicate effectively with other providers, staff, and patients
6. Provide efficient and effective care delivery that meets the needs of the population of the primary care setting
7. Provide culturally responsive, whole-person and family-oriented care
8. Understand, value, and adapt to the diverse professional cultures of an integrated care team
CORE COMPETENCIES FOR BEHAVIORAL HEALTH PROVIDERS WORKING IN PRIMARY CARE
ROLE OF PROVIDERS
OFFICE-BASED SCREENING
• Conflicts between DSM-5 “emerging measures” versus IBH/HEDIS recommended screenings
• Primary Care recommended
• Patient Health Questionnaire (PHQ)-9 for depression
• Generalized Anxiety Disorder (GAD)-7 for anxiety disorders,
• Primary Care–Posttraumatic Stress Disorder Screen (PC-PTSD) for PTSD
• Audit as part of SBIRT for alcohol use (Narayana & Wong, 2014)
• Proposed HEDIS measures:
• SBIRT & PHQ-9 all patients 12 y/o and older
Session ID: 1011‐16 American Psychiatric Nurses Association
Laura K. Melaro, DNP, APRN, FNP/PMHNP‐BC 7
DEPRESSION
• Presenting Physical Symptoms
• Fatigue or loss of energy
• Significant change in appetite (weight loss or weight gain)
• Sleep disturbances (insomnia or hypersomnia)
• Leaden paralysis
• Pain: headache, musculoskeletal, abdominal/pelvic
• Changes in sexual drive
• Decline in physical function and overall health
DEPRESSION
PHQ-9 Score Depression Severity Initial Tx Considerations
0 – 4 None – Minimal None
5 – 9 Mild Monitor/repeat PHQ-9 at F/U
10 – 14 Moderate Consider counseling, ±pharmacotherapy, f/u 4-6wks
15 – 19 Moderately Severe Active treatment w/pharmacotherapy, f/u 2-4wks
20 - 27 Severe Address acute safety concerns.Immediate initiation of pharmacotherapy, f/u 1wkConsider PMH referral
Adapted from: The Patient Health Questionnaire (PHQ) Screeners. Available at: http://www.phqscreeners.com/overview.aspx?Screener=02_PHQ-9
Session ID: 1011‐16 American Psychiatric Nurses Association
Laura K. Melaro, DNP, APRN, FNP/PMHNP‐BC 8
DEPRESSION
Comorbid Disease StatesHypertension
Diabetes
COPD
Acute MI
Chronic Kidney Disease
Delirium
Sleep Disorders
Work-UpCBC
CMP
Liver Function Tests
TSH
Vitamin D
Pregnancy Test
Sleep Study
DEPRESSION
• Treatment in Primary Care
• Pharmacotherapy
• Initial Treatment with SSRIs
• Sertraline & Escitalopram = Efficacy/acceptability (Cipriani, et al, 2009)
• Lack of superiority in efficacy among antidepressants, selection based on:
(APA, 2010)
Safety
Side Effect Profile
Specific Symptoms
Comorbid Illnesses
Drug Interactions
Ease of Use
Pt Preference/Expectations
Cost
Patient Prior Response
Session ID: 1011‐16 American Psychiatric Nurses Association
Laura K. Melaro, DNP, APRN, FNP/PMHNP‐BC 9
DEPRESSION
• Psychotherapy
• Motivational Interviewing, CBT, Interpersonal Therapy
• Lifestyle Interventions
• Exercise
• Relaxation techniques
BIPOLAR DISORDER
• Presenting Physical Conditions
• Sexually Transmitted Diseases
• Substance Abuse
• Infections r/t drug use
• Social Issues
• Financial problems
• Relationship/marital problems
• Erratic employment history
Session ID: 1011‐16 American Psychiatric Nurses Association
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BIPOLAR DISORDER
• Screenings
• The Mood Disorder Questionnaire (MDQ)
• Bipolar Spectrum Diagnostic Scale (BSDS)
• STandards for BipoLar Excellence (STABLE): Composite
International Diagnostic Interview 3.0 (CIDI)
• Young Mania Rating Scale
• Mania-DIGFAST
BIPOLAR DISORDER
Work-Up
CBC
CMP
Liver Function Tests
TSH
Urinalysis
Pregnancy Test
Drug Screen
Comorbid Disease StatesHypertension and Cardiovascular disease
Migraines
Thyroid Disease
Obesity
Diabetes
COPD
HIV
Hepatitis C
Session ID: 1011‐16 American Psychiatric Nurses Association
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BIPOLAR DISORDER
• Treatment in Primary Care• Management of associated medical conditions• Initial Treatment for Bipolar Depression/Hypomania
• Lurasidone, Olanzapine & Quetiapine Monotherapy• Lamotrigine, Lithium & Depakote• Adjunct Omega-3 fatty acids (Stovall, 2015)
• Emergent referral for Mania/Psychosis• Medication Monitoring:
• Mood Stabilizers• Atypical Antipsychotics
ANXIETY
• Presenting Physical Symptoms• Headache
• GI complaints
• Muscle tension
• Palpitations
• Dyspnea
• Dizziness
• Pain
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ANXIETY
• Screening
• Generalized Anxiety Disorder 7-item (GAD-7)
• Beck Anxiety Inventory (BAI)
• Hamilton Anxiety Rating Scale (HAM-A)
ANXIETY
Comorbid Disease StatesTachycardia
Dyspnea
Irritable Bowel Syndrome
Migraines
Sleep Disturbances
Fatigue
Work-Up
CBC
CMP
TSH
EKG
Holter Monitor
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ANXIETY
• Treatment in Primary Care• SSRIs (First Line)
• SNRIs
• Adjunctive Treatments (Symptomatic)
• Buspirone
• Benzodiazepines
• Hydroxyzine
ANXIETY
• Treatment in Primary Care
• Psychotherapy
• CBT
• Behavioral (Relaxation)
• Simple breathing exercises
• Progressive muscle relaxation
• Grounding techniques
• Physical, Mental, Soothing
• Mindfulness exercises
Session ID: 1011‐16 American Psychiatric Nurses Association
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TRAUMA DISORDERS
• Presenting Physical Conditions• Anxiety
• Sleep disturbance
• Concentration difficulty
• Fatigue
• Weight gain
TRAUMA DISORDERS
• Screening• Primary Care PTSD Screen (PC-PTSD)
• PTSD Checklist (PCL-C)
• Life Event Checklist (LEC)
Session ID: 1011‐16 American Psychiatric Nurses Association
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TRAUMA DISORDERS
Work-Up
CBC
CMP
TSH
EKG
UA/UDS
Comorbid Disease StatesAnxiety/Depression
Dyspnea
Irritable Bowel Syndrome
Multiple Somatic Complaints
Sleep Disturbances
Substance Use
TRAUMA DISORDERS
• Treatment in Primary Care• SSRIs (First Line)
• SNRIs
• Buspirone
• Benzodiazepines
• Hydroxyzine
• Prazosin (Nighmares, Co-Occuring HTN)
• Psychotherapy: TF-CBT, Behavioral, Grounding Techniques
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SCHIZOPHRENIA
• Presenting Physical Symptoms• Negative Symptoms
• Cognitive Dysfunction
• Disorganized Speech
• Motor System Abnormalities
• Affective Symptoms
• Delusions and Hallucinations
• Extrapyramidal symptoms
• Symptoms of Comorbid medical conditions
SCHIZOPHRENIA
• Work-up/Screening
• No specific screening tool except mental status exam
• Work-up to rule out associated medical conditions that would cause secondary psychosis
• Screenings for Alcohol and Drug use
• Medication monitoring
• Routine screening for CVD, DM, Respiratory Disease
Session ID: 1011‐16 American Psychiatric Nurses Association
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COMORBID DISEASE STATES
• Diabetes
• Hyperlipidemia
• Cardiovascular Disease
• Obesity
• Lung Cancer
• Osteoporosis
• Anticholinergic Effects of Medications
• Extrapyramidal Symptoms
• Hyperprolactinemia
SCHIZOPHRENIA
SCHIZOPHRENIA
• Treatment in Primary Care
• Referral followed by Collaborative Care: communication between Primary Care Providers and Psychiatry
• Monitor for comorbid medical conditions associated with lifestyle factors and side effects of antipsychotic medications
• Ongoing screening for Comorbid Diseases
• Family/Caregiver psychoeducation
• Knowledge of medication side effects to prevent unnecessary medical referrals
Session ID: 1011‐16 American Psychiatric Nurses Association
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SUBSTANCE ABUSE
• Presenting Physical Symptoms/Comorbid Disorders
• Dermatologic: skin abscesses
• Cardiovascular: essential hypertension, angina, myocardial infarction, heart failure, arrhythmias, infective endocarditis, cardiomyopathies
• Respiratory: nasal septal perforation, COPD, asthma
• Gastrointestinal: viral hepatitis, hepatic carcinoma, peptic ulcer disease, IBD, pancreatitis, gastritis, cirrhosis, cirrhotic varices
• Hematologic: anemia, thrombocytopenia, coagulopathies
• Neurologic: stroke, encephalopathy, traumatic brain injury, epilepsy, epidural abscess, peripheral neuropathy, Wernicke/Korsakoff syndrome
• Endocrine: hypo/hyperthyroidism, type 2 diabetes mellitus, hypogonadism
• Immunologic: HIV, immune suppression leading to opportunistic infections (eg, TB, pneumonia), necrotizing vasculitis
• Metabolic: electrolyte abnormalities, hypoxia, dehydration
(Merrill & Duncan, 2014)
WORKUP
Audit-CCAGE
CRAFFT
DAST-10
ASSIST
Screening, Brief Intervention & Referral to Treatment (SBIRT)
SCREENING TOOLS
SUBSTANCE ABUSE
UDS
UA
CMP
CBC
HIV, RPR, Hepatits Panel, Tb Skin test
Session ID: 1011‐16 American Psychiatric Nurses Association
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SUBSTANCE ABUSE
• Treatment in Primary Care
• SBIRT
• Motivational Interviewing
• Harm Reduction
• Cognitive Behavioral
• 12-Step
SOMATIC DISORDER
• Presenting Physical Symptoms
• Chest pain
• Fatigue
• Dizziness
• Headache
• Dyspnea
• Back pain
Session ID: 1011‐16 American Psychiatric Nurses Association
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SOMATIC DISORDER
• Screening
• 8-Item Somatic Symptoms Scale (SSS-8)
• Depression and Anxiety Screenings
• BATHE Technique
• B=Background “What is going on in your life?”, “What brings you in today?”
• A=Affect “How do you feel about that?’
• T=Trouble “What bothers you the most about this situation?”
• H=Handling “How are you handling that?”
• E=Empathy
SOMATIC DISORDER
Comorbid Disease States
Cardiovascular Disease
COPD
Chronic Pain Disorders
Depression
Anxiety
Work-Up
Physical Examination
Diagnostic testing determined by objective evidence of potential disease process
Avoid unnecessary, repetitive, or invasivediagnostic testing
Session ID: 1011‐16 American Psychiatric Nurses Association
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SOMATIC DISORDER
• Treatment in Primary Care
• Education: Interaction of psychosocial stressors and symptoms
• Treatment of Comorbid Psychiatric Disorders
• SSRIs and SNRIs
• Psychotherapy
• Collaborative Care
• Actively involve the patient in treatment goals
DEVELOPMENTAL DISORDERS
• Screening (9, 18 & 24-30 months)• Ages and Stages Questionnaire (ASQ-3)
• Parent Evaluation of Developmental Status (PEDS)
• Child Development Inventory (CDI)
• M-Chat-R
• Adults• Decision-Making Capacity; Surrogate Decision Makers
• Screen for polypharmacy, chemical restraint, abuse/victims violence, Reflux/Swallowing issues, Epilepsy, Undiagnosed pain/atypical illness presentation, disease risk specific to types of DD/medications, anxiety, depression, sleep disturbances (Daaieman, 2016; Nicolaidis, Kripke & Raymaker, 2014)
• Health Care for Adults with Intellectual and Developmental Disabilities: Toolkit for Primary Care Providers (Vanderbilt Kennedy Center, 2016)
Session ID: 1011‐16 American Psychiatric Nurses Association
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CHILD & ADOLESCENT ISSUES
(Foy, 2010)
CHILD & ADOLESCENT ISSUES
• American Academy of Pediatrics (2016) Bright Futures Recommendations for Preventive Pediatric Health Care, Age appropriate Questionaires and Parent Education
• Early Childhood Materials for Early Identification, Substance Abuse and Mental Health Services Administration
• Pediatric Symptom Checklist (This checklist can be used with children and youth ages 3-16.)
• American Academy of Child & Adolescent Psychiatry: Resources for Primary Care (2016)
Session ID: 1011‐16 American Psychiatric Nurses Association
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MEDICAL CONDITIONS WITH NEUROPSYCHIATRIC SYMPTOMS
(Isaac & Larson, 2014)
GERIATRIC ISSUES
• Delirium• Confusion Assessment Measures (CAM)
• Polypharmacy, medications, metabolic imbalance, and infections
• Dementia• Mini-Mental State Examination, Mini-Cog, Montreal Cognitive
Assessment, Saint Louis University Mental Status Examination
• Substance Use
• Beer Criteria
• Comorbid Disease Coordinated Treatment
• Caregiver Support/Screening
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REFERENCES
American Academy of Child & Adolescent Psychiatry. (2016). Resources for primary care. Retrieved from http://www.aacap.org/aacap/resources_for_primary_care/Home.aspx
American Academy of Pediatrics. (2016). Bright Futures: Clinical Practice. Retrieved from https://brightfutures.aap.org/clinical-practice/Pages/default.aspx
American Psychiatric Association:. (2010. ). Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition,. Retrieved from http://psychiatryonline.org.ezproxy.uthsc.edu/guidelines.aspx
Bentley, S. M., Pagalilauan, G. L., & Simpson, S. A. (2014). Major depression. Medical Clinics of North America 98(2014), 981-1005. http://dx.doi.org/10.1016/j.mcna.2014.06.013
Bystritsky, A. (2016). Pharmacotherapy for generalized anxiety disorder. In M. B. Stein (Ed.), UpToDate. Retrieved from http://www.uptodate.com/home
Cipriani A, Furukawa TA, Salanti G, Geddes JR, Higgins JP, Churchill R, Watanabe N, Nakagawa A, Omori IM, McGuire H, Tansella M, Barbui C. (2009). Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Lancet. 373, 746-758.
REFERENCES
Combs, H., & Markman, J. (2014). Anxiety disorder in primary care. Medical Clinics of North America 98(2014), 1007-1023. http://dx.doi.org/10.1016/j.mcna.2014.06.003
Croicu, C., Chwastiak, L., & Katon, W. (2014). Approach to the patient with multiple somatic symptoms. Medical Clinics of North America, 98(2014), 1079-1095. http://dx.doi.org/10.1016/j.mcna.2014.06.007
Daaieman, T. P. (2016), Primary care of adults with intellectual and developmental disabilities. Southern Medical Journal, 109(1), 12-16.
Foy, J. M. (2010). Enhancing pediatric mental health care: Algorithms for primary care. Pediatrics, 125, (Suppl. 3), S109-S125.
Hoge, M.A., Morris, J.A., Laraia, M., Pomerantz, A., & Farley, T. (2014). Core competencies for integrated behavioral health and primary care. Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions.
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REFERENCES
Isaac, M. & Larson, E. B. (2014). Medical conditions with neuropsychiatric manifestations. Medical Clinics of North America, 98, 1193-1208.
Merrill, J. O., & Duncan, M. H. (2014) Addiction Disorders. Medical Clinics of North America, 98, 1097–1122. http://dx.doi.org/10.1016/j.mcna.2014.06.008
Narayana, S., & Wong, C. J. (2014). Office-based screening of common psychiatric conditions. Medical Clinics of North America (2014)98, 959-980. http://dx.doi.org/10.1016/j.mcna.2014.06.002
Nicolaidis,C., Kripke, C. C. & Raymaker, D. (2014). Primary care for adults on the Autism Spectrum. Medical Clinics of North America, 98, 1160-1191.
Novick, J. S., Stewart, J. W., Wisniewski, S. R., Cook, I. A., Manev, R., Nierenberg, A. A., … Rush, A. J. (2005). Clinical and demographic features of atypical depression in outpatients with major depressive disorder: Preliminary findings from STAR*D. Journal of Clinical Psychiatry, 66, 1002-1011.
Patient-Centered Primary Care Collaborative. (2016). Benefits of integration of behavioral health. Retrieved from https://www.pcpcc.org/content/benefits-integration-behavioral-health
REFERENCES
Pilling, S., Anderson, I., Goldberg, D., Meader, N., & Taylor, C. (2009). Depression in adults, including those with a chronic physical health problem: Summary of NICE guidance. British Medical Journal, 339. http://doi.org.ezproxy.uthsc.edu/10.1136/bmj.b4108
Saltz, R. (2015). Screening for unhealthy use of alcohol and other drugs in primary care. In R. Hermann (Ed.). UpToDate, Retrieved from http://www.uptodate.com/home
Stovall, J. (2015). Bipolar disorder in adults: Pharmacotherapy for acute depression. In D. Solomon (Ed). IUpToDate, Retrieved from http://www.uptodate.com/home
U. S. Department of Health & Human Services. (2015). Key features of the Affordable Care Act by year. Retrieved from http://www.hhs.gov/healthcare/facts-and-features/key-features-of-aca-by-year/index.html#
U.S. Department of Labor,. (2010). The mental health parity and addiction equity act of 2008 (MHPAEA),Retrieved from http://www.dol.gov/ebsa/newsroom/fsmhpaea.htm
Vanderbilt Kennedy Center. (2016). Health Care for Adults with Intellectual and Developmental Disabilities: Toolkit for Primary Care Providers. Retrieved from http://vkc.mc.vanderbilt.edu/etoolkit/
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REFERENCES
Vermani, M., & Katzman, M. (2011). Rates of detection of detection of mood and anxiety disorder in primary care: A descriptive, cross-sectional study. Primary Care Companion CNS Disorder 2011: 13(2). http://dx.doi.org/10.4088/PCC.10m01013.
Wittchen, H. U., & Hoyer, J. (2001). Generalized anxiety disorder: Nature and course. Journal of Clinical Psychiatry, 62(Suppl 11): 15-9 [discussion: 20-1].