Transcript Mental Health Screening 2013x

MENTAL HEALTH IN PRIMARY CARE
Valerie Dzubur EdD APRN FNP-BC
Samuel Merritt University
Learning Objectives
1
• Familiarize yourself with
common disorder
2
• Discuss how to approach
the patient
3
• Review common comorbidities
• All medical care flows through the relationship
between physician (provider) and patient, and
the spoken word is the most important tool
Eric Cassell
All medical care flows through
the relationship between
physician (provider) and patient,
and the spoken word is the
most important tool Eric Cassell
Prevalence of mental illness
• 22% of U.S. adults (~44 million persons) have a
diagnosable mental disorder
• The most common problem in primary care
• 4 of 10 disability are mental disorder
• 50 % of the time depressed persons will be
treated by primary care provider
• 80 % of Rx written by non-psychiatrist
• Depressed persons use 50 – 75 % more health
care services than other chronic illnesses
Mental Health in Primary Care
• What is axis I?
• What is axis 2?
• 72 % of people with depression will be
treated by their primary care provider
• Anxiety and Depressions are the most
common mental health problems we will tx
Primary Care
• Clinical Tips
– Anxiety and Depression hold hands
– Future Focused Symptoms
• Consider Anxiety
– Past Focused Symptoms
• Consider Depression
Overview of Treatment
• Treatments
– Have referral information in hand
– Use Medications early for
• Symptom and Mood Management
– Counseling helps people
• Understanding cause & meaning
Counseling
Meaning is not something you stumble
across, like the answer to a riddle or the
prize in a treasure hunt. Meaning is
something you build into your life. You
build it out of your own past, out of your
affections and loyalties…out of the things
you believe in, out of the things and
people you love, out of the values for
which you are willing to sacrifice
something” John Gardner
Clinical Wisdom
Medications Management
A witches brew
Each persons treatment is
individualized
Consider side effect profile
Personal Goals
Use different combinations of
medications
Creating the recipe Making a
stew
• The history is the most
important tool in
establishing a diagnosis
• Developing rapport is key
• Both what the person say
and does not say, does and
does not do is important
• Consider body language
topic shifting as well
Sorting out the Diagnosis
• CC = in the patient own word
• HPI comprehensive chronological
– Include use of drugs & alcohol
– Level of severity
• Psychiatric History fully explored
– Previous treatments hospitalizations
– Therapies & medications ECT
Sorting out the diagnosis
• Medical History
– Consider head trauma seizures, neurological
illness HIV
• All medications & allergies & OTC
– Ask about a rash or dystonic reactions with any
medications
• Family History
– List each family member with psy disorder & age
Sorting out the diagnosis
• Social History
– Childhood History of Development/School
– Marital Relationship
– Occupational History
– Education History
– Religion
– Current living situation
Sorting out the diagnosis
• ROS
– Focus on medication side effects
– Mood
– Speech
– Actions
– Thoughts
– Thoughts of suicide within the past 3 mos = +
ROS for suicidal ideation
Sorting out the diagnosis
• General description
– Appearance
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Posture
Grooming
Poise
Clothing
Sorting out the diagnosis
• Behavior and psycho-motor activity
– Bizarre posturing
– Abnormal movements
– Agitation
– Rigidity
Sorting out the diagnosis
• Mood - underlies a person’s perception of
the world
– Ask how has your mood been?
– Rate it on a scale of 1 – 10
• Affect – the person’s emotional
responsiveness
– Range blunted constricted flat crying
Sorting out the diagnosis
• Speech
– Rate tone volume and rhythm
• Perception
– Hallucinations and illusions
• Thought process
– How not what
• Logical/coherent, tangential, flight of ideas, loose
associations, word salad/incoherent
Sorting out the diagnosis
• Thought content
– Delusions
– Fixed beliefs
– Preoccupations
– Phobias
– Poverty of content
– Suicidal or homicidal ideation
• Is there a plan?
Sorting out the diagnosis
• Sensorium and Cognition
– Brain function
– Intelligence
– Capacity of abstract thought
– Insight and judgment
Sorting out the diagnosis
• Orientation and memory
– Immediate memory
– Recent memory
– Long term memory
Sorting out the diagnosis
• PE
– Weight vital signs
– Thyroid enlargement
– Complete neurological exam
– Skin
– Dental problems
Sorting out the diagnosis
• Labs
– CBC TSH CMP
– Tox Screen
– Pregnancy test
– Drug levels as needed
– EKG if on TCA
Sorting out the diagnosis
• Labs with medications in mind
– Lithium – Kidney function, level ECG, pregnancy
test fasting glucose
– Clozapine - CBC
– TCA - EKB
– Carbamazepine – CBC with platelets, reticulocyte
count and serum iron if ok then monthly, drug
level, and LFTs
– Valproate LFTs and drug levels
Sorting out the diagnosis
• Based on DMS V
– Consider severity
– Render treatment based on disease
– Follow the response to treatment
Sorting out the diagnosis
• Seven fundamental questions
– What is the most likely diagnosis
– What should the next step be
– What is the most likely mechanism for this
process
– What are the risk factors for this condition
– What complications are associated
– What is the best therapy
– How can I confirm the diagnosis
Sorting out the diagnosis
• Need for hospitalizations
– Actively suicidal or homicidal
– Cannot complete ADLS, failure to thrive
– Quicker stabilization of psychotic symptoms
• There is a reciprocal relationship
– Between people who are depressed
– And the occurrence of major CV events
– People who are depressed are at risk for a
cardiovascular event
– People who have a cardiovascular event
are at risk for depression
• After an MI
– A person with clinical depression
– Has a 3 - 4 X > chance of death
– Within the next six months.
[http://www.nimh.nih.gov/depression/co_occur/heart.htm.]
• Depression occurs in
– 10 - 27 % of CVA survivor
• can last one year
– 15 - 40% of CVA survivors
• experience some symptoms of depression
within two months after the stroke.
[http://www.nimh.nih.gov/depression/co_occur/stroke.htm]
• Reciprocal relationship
• Psychosocial risk factors
– Loss of social roles/independence after MI
or CVA contributes to depression.
– Depression may result in impaired
adherence to treatment and interfere with
physical rehabilitation.
• Hypercortisolemia increases the risk of
arteriosclerosis.
• Depression is associated with increased
heart rate variability
– (interferes with parasympathetic function)
and increases the risk of arrhythmia.
• Depressed people have been shown to
have increased platelet activation
– (serotonergic mechanism).
• People with adult onset diabetes
– 25% have depression.
• People with diabetic complication
– 70% have depression [Lamberg L: JAMA 1996]
• People who tx for co-occurring
depression
– An improvement in overall health
– Better compliance with medical care
– Better quality of life
• 80% of people
• with depression can be treated
– Medication
– psychotherapy
– Combination of both
• Early diagnosis and tx reduces
– Patient discomfort
– Morbidity
– Cost
– Suicide
What are some diagnostic categories of anxiety?
• Panic Disorder (+/agoraphobia)
• Generalized Anxiety
Disorder
• ObsessiveCompulsive Disorder
• Post-traumatic
Stress Disorder
• Social Phobia
• Specific Phobia
• Secondary to a
Generalized Medical
Condition
• Substance-Induced
What are some medical causes of anxiety?
• Endocrine:
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–
Hyper/Hypo Thyroid
Pheochromocytoma
Hypoglycemia
Carcinoid syndrome
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–
–
–
Hypo-parathyroidism
Insulinoma
Cushing’s syndrome
Acute intermittent
porphyria
• Neurological
Disorders
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Aura of migraine
Early dementia
Cerebral neoplasia
Delirium
– Partial complex
seizures
– Demyelinating
disease
– Post concussive
disorder
– Withdrawal from
sedative-hypnotics,
caffeine, or nicotine
• Treatment
– Patient Education – Life
style modification
• Avoid caffeine,
nicotine, alcohol, &
other stimulants
• Increase exercise
• Sleep hygiene
• Stress management
• acupressure/acupunct
ure, reflexology
• Psycho Therapy –
client centered
• Behavior cognitive
therapy
• Support groups
• Complimentary
medicine, meditation,
massage
• Treatment
– Medications
• SSRI
– Name the disorder
• people get relief by knowing they have a recognized &
treatable condition
– Patient education
• Act to rebuild self esteem
– Cognitive Behavior & Support Groups
• learn new coping skills
Medication Choices
• Clinical Tip:
– They will all work
– Think about the side effects
– Consider Escitalopram for crying
– They all cause sexual dysfunction
– Consider a lower dose
– Drug Holidays
– Check Akathisia
– Avoid in bi-polar can cause mania
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•
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Buspar
Class azapirones
Starting dose 15 mgs
Dose Range 15 – 60 mgs
Therapeutic Response 3 – 6 weeks
• Beta Blockers
– Inderal 10 – 20 mgs TID or QID
– Metoprolol 25 – 50 mgs BID
– Atenolol 50 – 100 mgs QD
• Careful history and assessment of B/P,
HR, Lungs, History of CHF, arrhythmia,
COPD, Asthma
• At least 4 of the
following present for at
least 2 weeks
• Low mood
• Anhedonia
• Sleep disturbance
• Appetite disturbance
• Suicidal ideation
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Poor concentration
Low energy
Guilt or worthlessness
Pessimism or
hopelessness
• Agitation or retardation
• Loss of libido
SALSA
Sleep disturbance
Anhedonia
Low Self esteem
Appetite decreased
97% sensitivity
94% selectivity
(Brody, Arch Int Med, 1998)
• SIG-E-CAPS
• Depressed Mood Plus:
• Sleep decreased
• Interest decreased in
activities (Anhedonia)
• Guilt or worthlessness
(Not a major criteria)
• Energy decreased
• Concentration
difficulties
• Appetite disturbance
or weight loss
• Psychomotor
retardation/agitation
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SSRI
SSRNI
TCA
Mood Stabilizer
Sleeping Meds
Anti-psychotics
Atypical
More than One Rx
• Venlafaxine - Effexor 37.5 - 150 mgs
– May exacerbate HNT
• Take at the same time each day, don’t miss a
dose
Taper to discontinue or use prozac
• Cymbalta - Duloxetine HCL 20 - 60 mgs
– May exacerbate HTN
• If diabetic monitor glucose
Sorting out the medications
• How are SSRIs different from SSRNIs?
• Consider side effect profile?
• Consider adjuvant therapy
• When one medication is not enough
– Mood instability at the end of the day
– Break through symptoms
– Nothing works
– Stopped working
– Medication failure
– New symptoms
• Add a mood stabilizer
– Depakote 125 - 1500 mgs bid
• blood level, Liver Function
– Lithium 300 - 600 bid
• blood levels, narrow therapeutic range
– Lamictal 12.5 - 200 mgs bid
• Add a mood stabilizer
– Topomax 25 - 100 mgs bid • may cause glaucoma, expensive
– Trileptal 1200 - 1500 mgs bid
– Tegretol 100 - 1200 mgs bid
• blood levels, interactions
– Zyprexa 2.5 - 5 mgs bid
• Weight gain diabetes
• Add an antipsychotic
– Navane 5 mgs bid
– Trilafon 2 - 8 mgs bid
– Abilify 5 - 20 mgs qd
• Titrate the dose up according to the
patient’s mood q 1 - 2 weeks
– Need a lower dose as adjunctive
– When stable consider QD dosing
– Change to HS if sleepy
– Change to am if activated
– If suddenly can’t sleep change dose earlier
in the evening
• Bupropion (Wellbutrin) 150 - 300 mgs
– Reduce seizure threshold dose related
– Activating, smoking cessation
– Use for couch potatoes and grazers
• Mirtazipine (Remeron) 15, 30, 40 mgs
– Causes weight gain
– Good for sleep
– Good for nausea
• Taper one medication
• Start new medication low & slow
– Increase dose every 3 - 4 days
– Use Prozac 20 mgs for self taper off of SSRI
– Listen to your patient
• Trazadone 50 -300 mgs
– Good for sleep
– Good for alcoholics - not addictive
– Priapism
– Avoid with an acute MI
– Urinary Retention
• Socio-demographics
– Elderly (men>70 years)
– Unmarried
– Native American or Caucasian
– Male (white men = 70% of U.S. suicides)
– Living alone
– Increasing rates among adolescents
• Recent stressors
– Health, Financial
– Marital, Family
– Legal, Occupational
• Psychiatric disorder
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Depression
Anxiety (panic)
Schizophrenia
Bipolar Disorder
– Personality disorder
– Alcohol/drug use
– Command
Hallucinations
• Previous attempts
• Family history
• If patient responds positively
– Do you have a plan
– How would do this
– Are there means available
– Have you rehearsed or practiced
– How strong is your intent
– Do you tend to be impulsive
– Can you resist the impulse
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Ask about suicidal ideation
Check for risk factors
Listen to comments about suicide
If the patient discusses
– Putting affairs in order
– Care of pets
– Other cues and clues
• Suicide Contract
– Dependent on the strength of relationship
– Agreement to call provider
– Use support system, resources, suicide
prevention
– Inform family, significant other, close friend
– Close follow-up
– Referral to mental health provider
– If unable to contract or at imminent risk refer for
emergency psychiatric assessment.
• When treating a patient for depression
– The risk for suicide may increase
– In the early phase of treatment
– As the patient’s energy levels lifts.
– The patient simply develops enough
– New energy to carry out a plan
• As the Provider you may experience:
– You’re working hard but getting no where
– 4 or more problems vaguely or unrelated
– Everything has been tried – nothing worked
– Consider the diagnosis of Personality
Disorder
• 15% or more of patients (Hahn et al J Gen Intern
Med, 1996)
– Overly dependent,
• “clinging”
– Demanding
• “entitled” “manipulative,
– Unwilling to accept recommendations
• “self destructive” (Groves, NEJM, 1976)
• Consider personality disorder
• Characterized by chronic
– Rigid maladaptive behaviors
• Persons with personality disorders
– may appear odd or eccentric
• cluster A
– dramatic, emotional, or erratic
• cluster B
– anxious and fearful
• cluster C
• Self-awareness:
acknowledge frustration
• Allow more time
• Set limits
• Monitor for “burn-out”
• Seek consultation
• Verbalize concerns
• Schedule regular f/u
visits
• Cultivate
participation &
partnership