Transcript An Overview of Psychiatric Disorders Commonly Seen in

An Overview of Psychiatric Disorders
Commonly Seen in Primary Care
Bambi A. Carkey DNP,PMHNP-BC,NPP
Clinical Assistant Professor
SUNY Upstate Medical University
College of Nursing
Depressive Disorders
 According to the World Health Organization Major
Depression ranks among the most burdensome diseases in
the world.
 The lifetime prevalence of Major Depression in the U.S. is
reported to be between 16 % and 20%.
 Approximately 5% -10% of primary care patients meet
DSM-IV criteria for Major Depression and 3%-5% for
Dysthymia.
 The prevalence of Major Depression is estimated at 10%20% in patients with medical illness, eg. heart disease and
diabetes.
Depressive Disorders
 Major Depression is a relapsing, remitting illness.
 Following a first episode, the risk of recurrence over a two
year period is about 40%.
 After a second episode, the risk of recurrence within five
years is 75%.
 Between 10% and 30% of patients treated for Major
Depression will have an incomplete recovery, with persistent
symptoms or dysthymia.
Initial Evaluation
 Patients who present with depressive symptoms should be
evaluated by history, physical and labs ( CBC,CMP, thyroid
studies, and vitamin D level) to rule out secondary medical
causes , such as Thyroid Disease, Substance Abuse or Vitamin
D Insuffiency.
 Distinguish Unipolar vs. Bipolar Depression – screen for
mood instability, agitation, episodic sleep dysregulation,
periodic impulsivity, and irritability.
Initial Evaluation: R/O Bipolar DO
 Distractibility
 Indiscretion or Irritability
 Grandiosity
 Flight of Ideas
 Activity increase
 Sleep deficit ( decreased feeling of need for sleep)
 Talkativeness (rapid, pressured speech)
Initial Evaluation: MDD
 Sleep disorder (either increased or decreased, but most
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commonly trouble staying asleep
Interest deficit (anhedonia)
Guilt (feelings of worthlessness, hopelessness)
Energy deficit (anergia)
Concentration deficit
Appetite disorder (either increased or decreased)
Psychomotor retardation or agitation
Suicidality
Initial Evaluation
 Potential for violence: history
 Suicidal ideation: history of prior attempts, family history,
recent exposure, intent, plan, lethality, access to means,
psychotic symptoms (command hallucinations or severe
anxiety), alcohol or substance abuse
 Homicidal ideation – notification
Screening
 History !!!
 Beck Depression Inventory
 Hamilton Depression Screen
 Patient Health Questionnaire (PHQ-9)
 Mood Disorder Questionnaire
Referral: to ED or Out- Pt. Psyche Eval.
 Patients with severe depression, evidenced by: suicidal
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ideation, in whom out patient safety cannot be assured
Patients with significant weight loss, or psychomotor
retardation/agitation
Intent to harm self or others
Depressed patients who present with psychotic features eg.
delusions and/or hallucinations
Depressed patients with co-morbid substance abuse
Initial Treatment
 Antidepressants : SSRIs (gold standard), SNRIs
 Adjunctive Agents : Abilify, Cytomel, Stimulants
 Psychotherapy : Cognitive Behavioral Therapy (CBT),
Generalized Anxiety Disorders
 Lifetime prevalence of Generalized Anxiety Disorder (GAD)
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in the U.S. is estimated at 5.1% - 11.9%
GAD is one of the most common disorders in primary care
settings
Approximately twice as common in women, and the most
common anxiety d/o among the elder population
High incidence of co-morbidity – social phobia, specific
phobia, panic disorder
GAD may also be associated with substance abuse, posttraumatic stress disorder (PTSD) and obsessive – compulsive
disorder (OCD)
Generalized Anxiety Disorder
 GAD is common among patients with medically unexplained
chronic pain
 Patients with GAD and co-morbid MDD tend to have a more
severe and prolonged course of illness
 GAD is considered to be a chronic illness with fluctuations in
symptoms over time
 Patients with GAD can have a significant degree of functional
impairment
Initial Evaluation
 History & physical exam when indicated
 Substance abuse issues
 Medical history
 Family history
 Social history – including hx of trauma, stressful lifestyle
Initial Evaluation: GAD
 Muscle tension
 Fatigue
 Concentration difficulty
 Restlessness or feeling of impending doom
 Irritability
 Sleep disturbance – specifically trouble getting to sleep
 Worry, worry, worry!!!
Screening
 Beck Anxiety Inventory
 The Hospital Anxiety and Depression Scale (HADS)
 Generalized Anxiety Disorder seven-item scale (GAD-7)
 Penn State Worry Questionnaire
Initial Treatment
 Anxiolytics – Benzodiazepines ( effective, potential for
dependence, long term use may cause cognitive deficit
 Antidepressants – SSRI’s
 Cognitive – Behavioral Therapy
 Evidence-Based Practice
Co - Morbidity
 High degree of Patients have a co-morbid Substance Abuse
Disor5der
Substance Abuse Disorder
 Often masked under the guise of anxiety and/or depression
 Characterized by denial and minimization
 Look at Family History
Initial Evaluation
 History
 Labs : BAC, UTOX, CBC, CMP
 CAGE questionnaire - 4 questions, 2 or more positive
answers indicate a high probability of alcohol dependence
Summary
 History
 Mental Status exam / Physical Exam
 Lab Studies
 Referral
 Treatment
Questions???
References
Baldwin, D. (2013, March 28). Generalized anxietydisorder:
Epidemiology, pathogenesis, clinical manifestations, course,assessment,
and diagnosis. Retrieved from UpToDate:
http://www.uptodate.com.libproxy2.upstate.edu/contents
/generalize...
Carlat, D. J. (2005). The Psychiatric Interview. Philadelphia:
Lippincott Williams & Wilkins.
Katon, W. &. (2013, March 21). Initial Treatment of Depression in
Adults. Retrieved from UpToDate:
www.uptodate.com.libproxy2.upstate.edu/contents/initialtrea...