MENTAL HEALTH ISSUES IN PRIMARY CARE Marianne Borelli, PhD,
PMHCS-BC, ANP-BC
Slide 2
Common Problems in Mental Health Care Chest pain, abdominal
pain, back pain Fatigue, dizziness, swelling Insomnia, shortness of
breath, headache Many mental health problems present as physical
symptoms
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Relevant Questions What should I be looking for? Why is this
patient seeking treatment now? What questions should I ask? Then
what do I do? How do I follow-up? Where are the resources? How do I
collaborate?
Slide 4
Linda Linda, 25 yo female, came to primary care with concerns
about feeling fatigued, having difficulty concentrating, insomnia,
and anxiety. She has no hx of treatment for depression, anxiety, or
ADHD. She has been tx for irritable bowel syndrome and asthma. She
is concerned that her performance review will not be reflective of
her abilities because she has such trouble concentrating and
fatigue.Your learn she has a family hx of depression.
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Linda What history would be important to get from her? What
would you assess for? What PE would be important? What labs? How
would you treat on the initial visit? What screening tools would be
useful?
Slide 6
Common Presentations in Primary Care Depression, anxiety,
insomnia, fatigue are frequent complaints in primary care
Depression and anxiety frequently present as somatic symptoms
Headaches, neck and back aches, insomnia, little energy, are often
symptoms presented Hypothyroidism, anemia, adrenal fatigue, vitamin
B or D deficiencies need to be R/O
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Assessment Time spent taking a history is time well spent First
episode, family history, recent loss, substance use, other medical
conditions, previous treatment successes and failures, family
history of response to medications Use standardized screening tool
for depression as PHQ9 or Beck Depression Inventory, and the GAD7
for anxiety Assess for anxiety, depression, and insomnia Ask about
substance use
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Dysthymia Depressed mood for most of the day, for more days
than not, for at least 2 years(DSM-IV-TR) Has not been without the
symptoms for more than 2 months at a time. Presence of 2 or more of
the following: poor appetite or overeating, insomnia or
hypersomnia, low energy or fatigue, low self- esteem, poor
concentration, difficulty making decisions, feelings of
hopelessness
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Depression FIVE OF THE FOLLOWING SYMPTOMS DURING THE SAME 2
WEEK PERIOD AND THIS MUST BE A CHANGE FROM PREVIOUS FUNCTIONING
Depressed mood most of the day, nearly every day Little interest or
pleasure in all or almost all activities One of the 2 symptoms
above must be present
Slide 10
Depression Criteria Significant weight loss or weight gain,
change in appetite Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation Fatigue or loss of energy
Feelings of worthlessness or guilt
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Depression Criteria Continued Diminished ability to concentrate
or indecisiveness nearly every day Recurrent thoughts of death,
recurring suicidal ideation w/wo plan or previous attempt Symptoms
not due to a medical condition, substance use or withdrawal, or
bereavement
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Manic Episode A distinct period of elevated, expansive or
irritable mood lasting at least 1 week with 3 or more of the
following present: Inflated self-esteem, decreased need for sleep,
pressure to keep talking, flight of ideas, distractibility,
excessive involvement in pleasurable activities that have high
potential for negative consequences, psychomotor agitation.
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Clinical Tips Ask how these symptoms are affecting life Ask
about supplements, OTC medications, and previous psychiatric
medications Realize this will take time, schedule another visit
Convey hope that this is treatable
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Clinical Tips Develop a relationship with the patient Explore
losses, stressors, changes in family or work situations Assess
support systems, e.g. friends, church community Ask about family
history of depression, anxiety or other mental health issues
Slide 15
Relevant Labs To R/O a physical cause for depression, anxiety,
or insomnia TSH, free T3, freeT4, CBC, CMP Vit B12, vit D, Sleep
study if long standing insomnia
Slide 16
Medication Management Second generation antidepressants to
treat SSRIs(prozac, zoloft, celexa, lexapro), SNRIs(effexor,
cymbalta), NDRI(wellbutrin). Avoid benzodiazepines except for short
term anxiety management; e.g. treat panic attacks Trazodone
preferred for insomnia over drugs that are more likely to be
addictive
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Depression Treatment Educate pt. about time for medication to
take effect, expected SE, timing of doses SSRIs effective for
anxiety and depression, but benzodiazepines may be needed at first
for anxiety management, especially with panic attacks Will need to
be on med for 9-12 months to treat depression. A common mistake is
to quit when starts to feel better
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Behavioral Changes Set small, achievable goals, e.g., walk 15
min every day, decrease use of caffeine, decrease use of alcohol,
call a friend, family member, do one nice thing for self daily
Encourage therapy-Cognitive Behavioral Therapy most effective
Consider a 12 step program Use rating scales initially and at each
visit to evaluate progress
Slide 19
Follow Up F/U 2-4 weeks after starting a medication For
moderate-severe depression, F/U in 1-2 weeks Dont change med for at
least 3 mo. unless the SE are not tolerated by patient Can increase
the dose after 1-2 weeks for most When stop medication, always best
to taper
Slide 20
Anxiety Disorders Generalized Anxiety Disorder Excessive
anxiety and worry, more days than not, for at least 6 mo.
Anxiety/worry associated with 3 of these 6 symptoms: Difficulty
concentrating, mind going blank Irritability
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Anxiety Symptoms Being easily fatigued Restlessness, feeling
keyed up Muscle tension Sleep disturbances Irritability These
symptoms cause clinically significant distress or impairment
Slide 22
Panic Disorder Recurrent unexpected panic attacks:
palpitations, sweating, trembling, shaking, sensation of shortness
of breath, feeling of choking, chest pain, nausea, dizzy, light
headed, fear of losing control, going crazy or dying, paresthesias,
chills or hot flushes concern about having another attack, and a
change in behavior related to attacks
Slide 23
Anxiety Treatment SSRIs first line for both anxiety and
depression Prozac, zoloft, celexa, lexapro Benzodiazepines are
useful for tx panic attacks and until the SSRI begins to work but
carry risk of dependence, overdose, and accidents; falls in elderly
Trazodone 50 mg effective for sleep Cognitive behavioral therapy
effective and highly recommended
Slide 24
Behavioral Techniques Exercise, deep breathing, progressive
relaxation Establish a winding down routine in evening, create a
boundary between work/school and bedtime Reduce or eliminate
caffeine, alcohol, marijuana, other substances
Slide 25
Tracking Response to Treatment Patient Health Questionnaire 9,
Generalized Anxiety Disorder 7, available in English and Spanish
These help to assess for specific symptoms and evaluate response to
treatment Use at initial visit and every subsequent visit to assess
response to tx and document Always ask about thoughts of self
harm
Slide 26
Adolescent Depression Prevalence of MDD estimated at 0.4%-8.3%
of adolescents, female to male 2:1Familial vulnerability Patients
with high genetic risk more susceptible to negative life events and
environmental stressors Risk factors include: increased family
conflict, death of a parent, divorce, physical or sexual
abuse/neglect,lack of supportive relationships
Slide 27
Adolescent Depression Diagnosis made according to criteria
previously listed Must have depressed or irritable mood and
anhedonia for 2 weeks or longer, and at least 5 symptoms listed
from DSM-IV Screening tools: Adolescent PHQ9 or Beck Depression
Inventory Screening for suicidal ideation, plans, means
Slide 28
Adolescent Depression Screen for substance use/abuse Major risk
factors for suicide are : previous attempt, substance use and
presence of another psychiatric diagnosis, e.g. bipolar or
personality disorder Family hx of suicide or suicide of someone
known to pt. increase risk. Ask about available means, firearms in
the home, alcohol, substance abuse by family members
Slide 29
Adolescent Depression Explore physical causes with PE and labs
CBC, CMP, TSH, T3,T4, Epstein -Barr, pregnancy test Pt. needs to
feel provider is taking symptoms seriously and working in
partnership Schedule another visit within 1 week Explore support
systems, family, teachers, therapists
Slide 30
Treatment of Adolescent Depression SSRIs used with knowledge of
black box warning for increased risk of suicide Prozac and Lexapro
are FDA approved for tx of adolescent depression; Zoloft and Celexa
are also used Start low(Prozac 10mg qD, Lexapro 10mg qD) and
increase dose in 1-2 weeks if necessary Closely monitor behavior
and response
Slide 31
Treatment of Adolescent Depression Usually stay on med for 1
year Common mistake is to stop med when feels better; educate about
this Limit alcohol intake, educate about this Involve family,
caregivers, significant others
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Psychosocial Treatment CBT and Interpersonal therapy CBT is
based on premise that thoughts influence feelings which influence
behavior Is concrete, focused on identifying errors in thinking,
challenging them, and creating more accurate thinking. Requires a
sound therapeutic alliance and teaches pt. to be own therapist
Slide 33
Interpersonal Therapy Interpersonal Therapy - focus on
relationships and conflicts and ones own role in them
Slide 34
Treating Adolescent Depression Refer to a mental health
specialist if pt. doesnt respond to pharmacologic tx, exhibits
signs of manic behavior, has suicidal or homicidal ideation,
substance abuse. Keep lines of communication open between primary
care and specialist
Slide 35
ADHD Pattern of behavior- inattention or impulsivity present
over at least 6 months to a degree that is maladaptive or
inappropriate for developmental level Inattention includes
carelessness, difficulty sustaining attention in activities, not
listening, no follow through, disorganization, avoidance of tasks
that require sustained mental effort, loss of important items,
easily distracted, forgetful
Slide 36
ADHD Hyperactive/Impulsive criteria includes squirms, fidgets,
unable to stay seated, runs/climbs excessively, cant play or work
quietly, on the go, feeling driven by a motor, excessive talking,
blurts out answers, cant wait for turn, intrudes and
interrupts
Slide 37
ADHD Can use short form(Adult ADHD-RS-IV) in primary care that
needs to be administered by provider; takes 30-40 min. More
extensive evaluation, neuropsych testing, provided by
psychologists, psychiatrists is preferable Often not covered by
insurance plans Need an assessment before prescribing a med R/O
medical cause; assess anxiety, depression
Slide 38
ADHD Treatment Ritalin immediate release, sustained
release(Ritalin SR), or long acting(Concerta), Adderall immediate
release or AdderallXR, Vyvanse Affects dopamine and norepinephrine
in several areas of the brain Monitor for insomnia, hypertension,
tachycardia, do EKG if any preexisting cardiac diagnosis or
symptoms Monitor BP, tachycardia, do EKG prior to starting with any
preexisting cardiac problem
Slide 39
ADHD treatment 30 day supply at a time unless pt. is well
established on med and known to you For established pt., can pick
up script at office for 2 intervening months and return q 3 mo. All
are schedule II drugs with high abuse potential
Slide 40
When to Refer Active suicidal thoughts, previous suicide
attempt Suspected drug use or abuse Instability, difficult to
manage in primary care Multiple medications or high doses, usually
not given in primary care
Slide 41
case study Gloria, 58, comes to primary care as a new pt. to
the practice. She has DM Type2, hyperlipidemia,, HTN, depression
and obesity. She has recently separated from a long term marriage
in which her spouse was consistently verbally abusive. She wants to
get back on track with her own health after doing little self- care
while so preoccupied with her situation. Social supports include an
adult daughter and a sister. Finances are strained.
Slide 42
case study Meds she brought in: GlucophageXR 1000mg BID,
Lisinopril 10mg, Crestor 10mg, Klonopin 1 mg BID. What would be
important to do on this first visit? Labs? Medications? Other
tests?
Slide 43
Referral Sources Make your own list of mental health providers
in your community If has insurance for behavioral health tx, access
list of participating providers from company website and review
with pt. Can get reimbursement for an out of network provider at a
lower rate of reimbursement Local county may have some limited
services, most often for pts. on Medicaid or Medicare Clinical
trials, NIH, NIMH
Slide 44
References American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorder. 4th ed.. Washington, DC,
2000. Hamrin V, Antenucci M, Magorno, M. Evaluation and management
of pediatric and adolescent depression. Nurse Practitioner,
2012;37(3), 22-29. Krautner R, Cook,S. Pharmacogenetics and the
pharmacological management of depression. Nurse Practitioner. 2011;
36(10), 15-21.
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References MacArthur Initiative on Depression in Primary Care.
www.depression-primarycare.orgwww.depression-primarycare.org OBrien
P, Flemming, L. Recognizing anxiety disorders. Nurse Practitioner.
2012;37(10) 35-42. Qaseem A, Snow V, Denberg T, Forciea, MA Owens
D. Using second generation antidepressants to treat depressive
disorders: A clinical practice guideline from the american college
of physicians. Annals of Internal Medicine. 2008;
149(10)725-734.
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References Krautner R, Cook,S. Pharmacogenetics and the
Pharmacological Management of Depression. Nurse Practitioner. 2011;
36(10), 15-21. Stahl S. Essential Psychopharmacology: The
Prescribers Guide. 2nd ed. Cambridge University Press, 2009.