PIPC® Psychiatry In Primary Care

MOOD DISORDERSRobert K. Schneider, MD

Departments of Psychiatry, Internal Medicine

and Family Practice

The Medical College of Virginia at

the Virginia Commonwealth University

Richmond, Virginia

PIPC® Goals

• Effectively recognize, diagnose and treat mental illness in primary care

• Bring the psychiatry skills and knowledge base of the primary care physician on par with other medical specialty knowledge bases

Outline

• PIPC 1– Introduction

– PIPC® Interview– MAPS-O®

– Mood Disorders

– Suicide

Outline

• PIPC 2– Anxiety Disorders

• PIPC 3– Neurotransmitters

– The 3 Phases and the 5Rs

– Medications

– Cases and Discussion

“de facto mental health system” Regier,1978

• 54% of people with mental illness who

seek treatment are exclusively seen in

the “general medical sector”

• 25% of patients in primary care setting

have a diagnosable mental illness

Why Now?

• Great scientific evidence– Genetic basis for disease

• Twin studies and Human Genome Project

– Neuroscience Research• CT to MRI to PET to SPECT scanning• Neurotransmitter basic science

• Somatic Therapies– Psychiatric Medication Explosion (“SSRI

Surge”)

• Economic pressures (Managed Care)

PIPC® Interview

PIPC Interview

• Organized by “organ system” approach

– Hypothesis driven interview

• Makes psychiatric knowledge assessable

• Demonstrates holes in knowledge base for PCP

• Creates a foundation for evidence to be applied

Data Gathering:Hypothesis Driven Interview

• Notice cues from patient –pattern recognition

• Develop differential diagnosis

• Collect target symptoms

• Ask further questions to rule in or rule out

Example: Chest Pain

• Target symptoms– Chest pain, Shortness of Breath

• Differential diagnosis– Cardiac (ischemic, valvular, cardiomyopathy)– GI (esophageal spasm, PUD)– Pulmonary (COPD, pleuresy, pneumonia)– Musculoskeletal (intercostal spasm, rib fx)

• Further questions– Age, onset, associated symptoms, etc…..

Example: Depression• Target symptoms:

– Poor sleep, fatigue, isolation (no enjoyment)

• Differential diagnosis:– Major Depression (single episode vs recurrent)– Dysthymia (2 year history)– Bipolar (mania/hypomania)– Substance induced mood disorder (mood

during periods on abstinence)

• Further questions:– Age, onset, associated symptoms, etc…

Screening Strategies vs. Case Finding Strategies

• High false positives if everyone screened

• Practicing physicians think using case-finding strategies

• High comorbidity

• Different tools:

– Interviewing questions

– Diagnostic checklists

– Disease specific scales

How can a primary care doc make a reasonable psychiatric differential diagnosis?• Language:

– Symptoms– Diagnostic categories

• DSM-IV:– 6484 signs, symptoms, inclusion criteria– 405 diagnoses– 18 diagnostic categories

• DSM-IV PC starts the process but is inefficient and “psychiatric”

HELLO

DATA GATHERING

NEGOTIATION

CUES

HYPOTHESES (MAPSO©)

CASE FINDING QUESTIONS

DIAGNOSTIC CRITERIA (DSM-IV)Comorbidities (ROS)

DATA

GATHERING

DIAGNOSIS

TREATMENTS

PATIENT PREFERENCE

DIAGNOSIS & TREATMENT CHOICE

NEGOTIATION

EP DA UT C I AE TN IT O N

MAPS-O®

MAPS-O®

Mood Disorders

Anxiety Disorders

Psychotic Disorders

Substance Abuse

Other–“Organic”–Other Psych

MAPS-O®

• Most prevalent disorders in primary care

• Proven treatments available

• If “other” psychiatric disorder is diagnosed (somatization, personality disorders),

• Then successful treatment requires diagnosing one of these categories first

MAPS-O®

Mood Disorders

Anxiety Disorders

Psychotic Disorders

Substance Abuse

Other

MAPS-O®

Mood Disorders Major Depression, Dysthymia, Bipolar Disorder

Anxiety Disorders

Psychotic Disorders

Substance Abuse

Other

MAPS-O®

Mood Disorders

Anxiety Disorders GAD, Panic Disorder, PTSD,

OCD, Phobias (Social/Specific)

Psychotic Disorders

Substance Abuse

Other

MAPS-O®

Mood Disorders

Anxiety Disorders

Psychotic Disorders Schizophrenia, Schizoaffective

Substance Abuse

Other

MAPS-O®

Mood Disorders

Anxiety Disorders

Psychotic Disorders

Substance Abuse Alcohol, Cocaine, Nicotine, Other Psychoactive Substances

Other

MAPS-O®

Mood Disorders

Anxiety Disorders

Psychotic Disorders

Substance Abuse

Other “Organic”:

Stroke, Dementia, HIV, TBI

Other Psych:

Personality Disorders, ADHD, Somatization,Eating Disorders

MOOD DISORDERS

Mood Disorders• Major Depression

– Single episode– Recurrent

• Dysthymia• “Double” Depression• Bipolar Disorder

– Mania– Hypomania

• Psychotic Depression

DEPRESSION

NORMAL MOOD

RECOVERY OR REMISSION

EPISODE OF DEPRESSIONEPISODE OF DEPRESSION

TIME6 - 24 months

5-1 Stahl S M, Essential Psychopharmacology (2000)

Mood Disorders – Major Depression

5 or more of the 9 symptoms

at least 2 weeks (everyday, all day)

–Depressed mood

–Anhedonia

–Worthless/Guilt

–Death/Suicidal

–Appetite

–Sleep

–Fatigue

–Concentration

–Psychomotor

Major Depression – Questions:• How is your mood?

• Have you been feeling sad, blue or depressed?

• Have you lost interest in or do you get less pleasure from the things you used to enjoy?

• Has there been any change in your appetite? (5% weight change in 1 month)

• How have you been sleeping?

Major Depression – Questions:• Have you been more fidgety?

• Have you felt slowed down, like you were moving in slow motion or stuck in mud?

• How has your energy level been?

• How have you been feeling about yourself?

• Have you been blaming yourself for things?

• Have you had problems thinking or concentrating?

2+ years

DEPRESSION

NORMAL MOOD

DYSTHYMIADYSTHYMIA

5-7 Stahl S M, Essential Psychopharmacology (2000)

Mood Disorders – Dysthymia

• Depressed mood for most of the day, for more days than not, for at least two years.–No episodes of major depression

during the last 2 years–Symptoms have not gone away for

more than 2 months at a time–Depressed plus 2 symptoms

Dysthymia – Questions:

• Same as major depression

• Longitudinal course and symptoms density is the focus of questions

6 - 24 months2+ years

DEPRESSION

NORMAL MOOD

DYSTHYMIA PARTIAL RECOVERY

DOUBLE DEPRESSIONDOUBLE DEPRESSION

5-8 Stahl S M, Essential Psychopharmacology (2000)

Mood Disorders – Mania and Hypomania

ManiaDistinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least one week.

HypomaniaLike mania but less and lasts throughout at least 4 days. Clearly different from the usual nondepressed mood.

5-5 Stahl S M, Essential Psychopharmacology (2000)

DEPRESSION

NORMAL MOOD

MANIA

HYPOMANIA

MIXED EPISODE

Mania and Hypomania-Questions:• Have there been times lasting at least a

few days when you felt the opposite of depressed, that is when you were very cheerful or high and felt different than your normal self?

• Did you feel hyper, or like you were high on drugs, even though you hadn’t taken anything?

• Did anyone notice there was something different?

Mania and Hypomania-Questions:

• How long did it last?

• What was your self-esteem like?

• During this time did you sleep?

• Were you more talkative than usual?

• Did it feel like your thoughts were going very fast and racing through your mind?

• Were you easily distracted?

• Were you more active than usual?

SUICIDE

Suicide• More common in all psychiatric diagnoses;

not just depression

• Dispel myths:

talking about it probably makes it less likely to happen

• Symptom as well as outcome

• High risk groups (men, older, past history)

• Assess prohibitions to suicide

Suicide - Questions:

• When things have gotten really bad -

• Have you had increased thoughts about death and dying?

• Have you thought about hurting yourself?

• Have you ever acted on those thoughts?

• Do you have access to those means?

• What keeps you from doing this?

CASE

39 year old woman

• Intermittently depressed since age 28

• Treated with fluoxetine and sertraline in the past with success.

• Three weeks ago depression returned (SI, fatigue, poor sleep, poor appetite)

• On call doctor restarted her fluoxetine

2 weeks later

• Suicidal ideation gone

• BUT

– Not sleeping

– More irritable

– Has increased psychomotor now

Differential Dx, Cues, and Questions

• Differential Dx

– Mania

– Overstimulation from medications

– Substance abuse

– Worsening depression