Transcript Graham Scott ii mtg 8/9/98

Common Complex Mental Health
Presentations in Primary Care
(Or what the PPS Psychiatrists get to
see a lot of…)
ADHD in Adults
Atypical Depression
Bipolar II Disorder
Treatment Non-responsive Depression
Severe Anxiety Disorders
Adult ADHD
ADHD – Category vs Dimension
Number of People
“Not a disorder but a normally distributed
human trait!”
Attention/Concentration
Adult ADD/ADHD
MUST have had clear childhood ADD/ADHD
symptoms to diagnose –
past diagnosis
parental report/history of ADHD symptoms
school reports (disruptive, would do better if
concentrated on work more, etc)
Said to be common (5-10% of Adults) but
most often misdiagnosed and/or missed
Co-morbidity is the RULE
Adult ADD/ADHD
Common co-morbid conditions:
A+D – often polysubstance (NB response to
Amphetamines helpful in diagnosing)
Anxiety
Depression/BPAD
Antisocial
Learning disorders
Tend to respond poorly to treatment for
these conditions alone
Adult ADHD - Barriers to Diagnosis
No DSM criteria specifically for adult ADHD
Doctors are not aware and trained in
diagnosing adult ADHD
General disbelief of ADHD as a clinical entity
Patient embarrassment/stigma etc
Reluctance to treat with controlled substance
High incidence of substance abuse in ADHD
patients
Cross-over symptoms with co-morbid disorders
Adult ADHD - Diagnosis
Pervasive symptoms of ADD/ADHD all life
Attention/concentration problems
Inattention to boring tasks even if important
Inattention in social situations
Easily distracted
Hyperactivity uncommon/not necessary
At least 3 of:
Low stress tolerance
Impulsivity
Disorganisation
Easily irritated/angered
Mood swings/reactivity
Can’t complete tasks
Low self esteem
Adult ADHD - Diagnosis
High index of suspicion esp in patients
who have “never made a go of life” and
present with multiple MH symptoms
Screening using ASRS (Adult ADHD Self
Rating Scale)
Childhood symptoms of ADHD
Consensus criteria for diagnosis as in last
slide
Response to amphetamines if ever
exposed (paradoxical)
Adult ADHD - Treatment
Rx is mainstay of treatment –
Methylphenidate 20-80 mg/day – SA reqd
Dexamphetamine 5-20 mg/day – SA reqd
Atomoxetine (SNRA) – unfunded
Education/self management –
recommend “Driven to Distraction”
Once Rx, Psychological Intervention may
help – strategies to live with ADHD,
improve self-esteem, manage stress, etc.
Adult ADHD -Treatment
Treatment of Comorbidities:
Contract re NO A+D abuse, if necessary
random urines
Monitor progress, MAY see reduction in
symptoms OR may need to progress to
treatment of these in own right
ADD plus Anxiety – may tolerate stimulants
poorly – Atomoxetine best BUT unfunded
Atypical Depression
Atypical Depression
Depression that differs from “typical”
depression by virtue of:
Increased sleep (even if broken)
Increased eating and/or weight
Increased interpersonal sensitivity
“Weighed down” heavy feeling of tiredness
Importance of recognition:
Non- or partial-response to most
antidepressants – poor outcome
Atypical Depression
Effective treatments:
Self-management strategies esp exercise
Medications:
Paroxetine (NNT – 6) – first line Rx
Venlafaxine (anecdotal evidence only)
Phenelzine (NNT – 3)
Cognitive Behaviour Therapy – most
effective treatment
Bipolar II Disorder
Bipolar II Disorder
Common – 15% of people with depression
Depression - commonly atypical profile
Only present when depressed – hypomania
seldom brings people to attention
Tend to do poorly with treatment with
antidepressants alone –
Incomplete treatment response for depressive
episodes
Risk of triggering hypomania, OR of triggering or
worsening rapid cycling (NB – rapid cycling
common)
Bipolar II Disorder - Diagnosis
Depressive episodes PLUS at least one
period of significant hypomania
Elevated/irritable mood state, PLUS
Increased confidence, feel “bullet proof”
Increased energy, overactivity
Increased rate of thinking and talk
Reduced need for sleep
Impulsivity
Impaired judgement – spending, sexual
behaviour, interpersonal behaviour
Bipolar II Disorder - Treatment
Mainstay of treatment is Mood Stabilising
Medication:
Rapid cycling – Na Valproate (600-800 mg nocte)
Slow cycling (less than 3 cycles per year) – Lithium
Carbonate (500-750 mg nocte)
Blood monitoring required for both – aim for low
therapeutic level
Hypomania goes rapidly, depression slowly
(may take a number of months to resolve)
Bipolar II Disorder - Treatment
May require treatment with Antidepressant
once stabilised on lithium/valproate
Self-management important – education,
exercise, stress, etc.
Psychological intervention helpful – address
vulnerability factors, improve stress
management – improves outcome/reduced
relapse risk
Poorly Treatment
Responsive Depression
Poorly Treatment Responsive
Depression
Defined as non- or partial-response to an
adequate dose of medication, for an
adequate duration, with good adherence
Effectively means 20-40 mg SSRI for 4-6
weeks (NB if no response at 20 mg after 2-3
weeks, trial increase to 40 mg)
Should be seen as a trigger for further
assessment re cause of poor response
Poorly Treatment Responsive
Depression
Review diagnosis/presentation –
?adherence (common…) – ?why - address
?psychosocial issues/trigger – need CBT
?bipolar depression – need mood stabiliser
?atypical depression – need effective ADs/CBT
?comorbid A+D – need A+D Intervention
?other comorbidity - anxiety disorder, ADHD, etc
Intervention for these as appropriate
Poorly Treatment Responsive
Depression
If above factors excluded, evidencebased treatment options for treatment
non-responsive depression are:
Substitute option 1 – Alternate SSRI*
Substitute option 2 - Venlafaxine or TCA
Augment option – Lithium, T3
Addition option – CBT
Continued non-response OR unsure Indication for Psychiatric Consultation
*Note that non-response to 1 SSRI is NOT highly predictive of non-response to a second,
so first-line strategy should be trial of a second SSRI.
Severe Anxiety Disorders
Severe Anxiety Disorders
Severe anxiety disorders tend to follow
relapsing/remitting chronic course
Cause very high levels of suffering/distress
and disability – “heart-sink” patients
Somatisation/physical symptoms ++
Co-morbidity is the rule rather than
exception:
Other anxiety disorders
Depression
A+D abuse/dependence
Treating Severe Anxiety Disorders
Treatment of choice (greatest efficacy) for
mild to moderate anxiety disorders is CBT
HOWEVER optimal treatment of severe
anxiety disorders is combined Rx and CBT
(patients often struggle to make progress
overcoming symptoms with CBT alone)
THUS… key to improving outcome for severe
anxiety is optimal Rx PLUS CBT/Psychological
Intervention, plus assertive management of
co-morbidities
Treating Severe Anxiety Disorders
NB – CBT ineffective in patients who are also
prescribed BZP for treatment of anxiety
Avoid BZP for all but brief use for severe
acute anxiety (e.g., severe panic disorder –
use PRN Lorazepam as backup to behav.
anxiety management techniques)
Mainstay of drug treatment is the non-BZP
medications effective in anxiety disorders
Treating Severe Anxiety Disorders
Effective medications (start low go slow):
OCD: SSRI (higher dose), Clomipramine
Panic D/O: Paroxetine, Imipramine
GAD: Imipramine, Paroxetine, Buspirone
PTSD: SSRI, Venlafaxine, TCA esp. Imipramine
Social Anxiety: Paroxetine, Phenelzine
Other medications:
Venlafaxine/TCA: Helpful in mixed
anxiety/depression
Quetiapine: Low-dose (25-75 mg) helpful for
sleep/anxiety, instead of BZP
Questions and Cases