1 Mental Health Screening in Primary CareValerie Dzubur EdD APRN FNP-BC This presentation will discuss mental health screening with a focus on Anxiety and Depression as these are the most prevalent diagnosis in mental health often taken care of in the primary care setting

2 Mental Health 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

3 Psychiatric DisordersObjectives: Identify & Rx Psychiatric disorders in Primary Care Discuss Co-morbidities For each of the diagnosis we will discuss the prevalence, essential features, common treatments, education, and co-morbidities

4 Psychiatric DisordersDepressive Disorders Anxiety Disorders Suicidal Ideation Personality Disorders The difficult patient Somatoform Disorder This includes Depressive Disorders Anxiety Disorders Suicidal Ideation Personality Disorders The difficult patient Somatoform Disorder

5 Why Concerned? Prevalence of mental illness (NIMH)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 Why should we be concerned? Prevalence of mental illness (NIMH) 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

6 From: The Global Burden of Disease C. Murray (Harvard) and AFrom: The Global Burden of Disease C. Murray (Harvard) and A. Lopez (WHO) (www.who.int/msa/mnh/ems/dalys/intro.htm This table shows you the global burden of disease for mental illness

7 Psychiatric DisordersAxis I Neurosis & Psychosis A clinical disorder that can be effectively relieved with interventions Mood disorders Thought disorders Anxiety disorders Just to review… remember the term Axis I and Axis II Neurosis & Psychosis A clinical disorder that can be effectively relieved with interventions Mood disorders Thought disorders Anxiety disorders

8 Psychiatric DisordersAxis II Personality & Developmental Disorder Long standing Ingrained in the developmental process of childhood May causes major life-long dysfunction in many spheres of life Can be difficult to treat Axis II Personality & Developmental Disorder Long standing Ingrained in the developmental process of childhood May causes major life-long dysfunction in many spheres of life Can be difficult to treat

9 Primary Care Setting 74% of Americans seeking help for depressionWill go to a PC provider Not a mental health professional [Montano B: Journal of Clinical Psychiatry 1994] For better or worse74% of Americans seeking help for depression Will go to a PC provider Not a mental health professional So we need to be ready [Montano B: Journal of Clinical Psychiatry 1994]

10 Primary Care Clinical Tips Anxiety and Depression hold handsFuture Focused Symptoms Consider Anxiety Past Focused Symptoms Consider Depression Clinical Tips Anxiety and Depression hold hands Future Focused Symptoms Consider Anxiety Past Focused Symptoms Consider Depression

11 Primary Care Clinical Tips Anxiety and Depression hold handsFuture Focused Symptoms Consider Anxiety Past Focused Symptoms Consider Depression Clinical Tips Anxiety and Depression hold hands Future Focused Symptoms Consider Anxiety Past Focused Symptoms Consider Depression

12 Primary Care Treatments Have referral information in handUse Medications early for Symptom and Mood Management Counseling helps people Understanding the cause & meaning Treatments Have referral information in hand Use Medications early for Symptom and Mood Management Counseling helps people Understanding the cause & meaning

13 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 Don’t under estimate the power of conversation It can be especially power if it comes without a lot of advise giving I am reminded of these words from John Gardner 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

14 Mental Health Clinical Wisdom Medications Management A witches brewEach persons treatment is individualized Consider side effect profile Personal Goals Use different combinations of medications Creating the recipe Making a stew And this tip comes from a dear friend of mine who has been an FNP and Psy NP for many years 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

15 Co-morbidity People seen in a PC Setting People in the hospital% will have depression People in the hospital 10 to 14% [National Institute of Mental Health, “Co-occurrence of Depression with Medical, Psychiatric and Substance Abuse Disorders,” People seen in a PC Setting % will have depression People in the hospital 10 to 14% [National Institute of Mental Health, “Co-occurrence of Depression with Medical, Psychiatric and Substance Abuse Disorders,”

16 Co-morbidity There is a reciprocal relationshipBetween 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 There is a significant co morbidity between depression and cardiovascular disease and It is a reciprocal relationship Between people who are depressed And the occurrence of major CV events

17 Co-morbidity Heart Disease and Depression Depression occurs in40 to 65 % who have had an MI 18 to 20 % who have CAD W/O MI Here are some numbers for you Heart Disease and Depression Depression occurs in 40 to 65 % who have had an MI 18 to 20 % who have CAD W/O MI

18 CAD & Depression After an MI After an MIA person with clinical depression Has a X > chance of death Within the next six months. [http://www.nimh.nih.gov/depression/co_occur/heart.htm.] After an MI A person with clinical depression Has a X > chance of death Within the next six months. [http://www.nimh.nih.gov/depression/co_occur/heart.htm.]

19 CVA & Depression Depression occurs in 10 - 27 % of CVA survivorcan last one year % of CVA survivors experience some symptoms of depression within two months after the stroke. [http://www.nimh.nih.gov/depression/co_occur/stroke.htm] Depression occurs in % of CVA survivor can last one year % of CVA survivors experience some symptoms of depression within two months after the stroke. [http://www.nimh.nih.gov/depression/co_occur/stroke.htm]

20 CVD & Depression Reciprocal relationship Psychosocial risk factorsLoss of social roles/independence after MI or CVA contributes to depression. Depression may result in impaired adherence to treatment and interfere with physical rehabilitation. 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.

21 Physiology of DepressionHypercortisolemia 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). So what are some of the mechanism involved with this special relationship between depression and cardio vascular events 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).

22 Depression & CV DiseaseThis slide shows you a scematic of this pathophysiology

23 Depression and DiabetesPeople with adult onset diabetes 25% have depression. People with diabetic complication 70% have depression [Lamberg L: JAMA 1996] There is also a significant relationship with some other important diseases, for example DM People with adult onset diabetes 25% have depression. People with diabetic complication 70% have depression [Lamberg L: JAMA 1996]

24 Importance of TreatmentPeople who tx for co-occurring depression An improvement in overall health Better compliance with medical care Better quality of life Depression effect the treatment outcomes for People with these disease so it is important to tx the co-occurring depression as well has treating the blood sugar and cholesterol levels When we do the research shows that patients experience An improvement in overall health Better compliance with medical care Better quality of life

25 Importance of Treatment80% of people with depression can be treated Medication psychotherapy Combination of both Treatment works! 80% of people with depression can be treated Medication psychotherapy Combination of both

26 Importance of TreatmentEarly diagnosis and tx reduces Patient discomfort Morbidity Cost Suicide Early diagnosis and tx is important and reduces Patient discomfort Morbidity Cost Suicide

27 ANXIETY DISORDERS So let think now about anxiety. We need some anxiety – it is the brain energy that keeps us upright, moving, doing, responding to our environment. So everyone has anxiety. We need to ask the question is the anxiety work for us or against us. Does it interfere with function, is it spoiling life? This face certainly congers up a feeling of worry.

28 Anxiety Prevalence 2.5 – 8% of the populationWomen affected twice as often as men 20 % will have co-morbid substance abuse problems A symptom A Syndrome A Disorder Anxiety is a complex human experience Prevalence 2.5 – 8% of the population Women affected twice as often as men 20 % will have co-morbid substance abuse problems A symptom A Syndrome A Disorder

29 Prevalence of Anxiety Common Medical Complaints% with Anxiety 33% 26% 28% 35% 31% Symptom Chest pain Fatigue Headache Insomnia And lots of medical complaints are really anxiety a good share of the time. Symptom Chest pain 33 % Fatigue 26 % Headache 35 % Insomnia 31 %

30 Anxiety Disorders Panic Disorder (+/- agoraphobia)Generalized Anxiety Disorder Obsessive-Compulsive Disorder Post-traumatic Stress Disorder Social Phobia Specific Phobia Secondary to a Generalized Medical Condition Substance-Induced There are many different kinds of anxiety related mental health conditions Panic Disorder (+/- agoraphobia) Generalized Anxiety Disorder Obsessive-Compulsive Disorder Post-traumatic Stress Disorder Social Phobia Specific Phobia Secondary to a Generalized Medical Condition Substance-Induced

31 Medical Causes of AnxietyEndocrine: Hyper/Hypo Thyroid Pheochromocytoma Hypoglycemia Carcinoid syndrome Hypo-parathyroidism Insulinoma Cushing’s syndrome Acute intermittent porphyria And before we can diagnosis an anxiety disorder we need to consider biological causes such as: Endocrine: Hyper/Hypo Thyroid Pheochromocytoma Hypoglycemia Carcinoid syndrome Hypo-parathyroidism Insulinoma Cushing’s syndrome Acute intermittent porphyria

32 Medical Causes of AnxietyRespiratory COPD Hypoxia from any cause PE Asthma Respiratory COPD Hypoxia from any cause PE Asthma

33 Medical causes of AnxietyNeurological Disorders Aura of migraine Early dementia Cerebral neoplasia Delirium Partial complex seizures Demyelinating disease Post concussive disorder Withdrawal from sedative- hypnotics, caffeine, or nicotine Neurological Disorders Aura of migraine Early dementia Cerebral neoplasia Delirium Partial complex seizures Demyelinating disease Post concussive disorder Withdrawal from sedative-hypnotics, caffeine, or nicotine

34 General Anxiety DisorderManifested by unrealistic or excessive anxiety or worry about two or more life circumstances that persists for 6 months or longer After you have ruled out a medical cause you can consider an anxiety disorder General Anxiety Disorder is very common and defined as: Manifested by unrealistic or excessive anxiety or worry about two or more life circumstances that persists for 6 months or longer

35 GAD Symptoms Restlessness/nervousness FatigueConcentration difficulties Irritability Tension Sleep disturbances GAD symptoms includes: Symptoms Restlessness/nervousness Fatigue Concentration difficulties Irritability Tension Sleep disturbances

36 GAD Treatment Treatment Patient Education – Life style modificationAvoid caffeine, nicotine, alcohol, & other stimulants Increase exercise Sleep hygiene Stress management acupressure/acupuncture, reflexology Psycho Therapy – client centered Behavior cognitive therapy Support groups Complimentary medicine, meditation, massage Treatment requires persistence Treatment Patient Education – Life style modification Avoid caffeine, nicotine, alcohol, & other stimulants Increase exercise Sleep hygiene Stress management acupressure/acupuncture, reflexology

37 Social Phobias Occurs > in women than men Crosses all socialCultural & class lines The fears are life changing Social Phobias Occurs > in women than men Crosses all social Cultural & class lines The fears are life changing

38 Social Phobia Numbness Tingling Chills Hot flashes Nausea VomitingSymptoms include Palpitations Pounding heart Increase HR sweating trembling Chest pain Dizziness SOB Fear of dying Numbness Tingling Chills Hot flashes Nausea Vomiting Abdominal pain Symptoms include Palpitations Pounding heart Increase HR sweating trembling Chest pain Dizziness SOB Fear of dying Numbness Tingling Chills Hot flashes Nausea Vomiting Abdominal pain

39 Social Phobias The key behavior changes… Avoid datingFear they will never marry Avoid classes or jobs that require working in groups The key is that the phobia causes behavior change to accommodate the phobia Avoid dating Fear they will never marry Avoid classes or jobs that require working in groups

40 Social Phobias Decide not to go to collegeAvoid employment opportunities Work at a lower level than ability Avoid public places Stay at home more and more Avoid anxiety producing events For Example : Decide not to go to college Avoid employment opportunities Work at a lower level than ability Avoid public places Stay at home more and more Avoid anxiety producing events

41 Social Phobias As social phobia worsens if begins to effect every aspect of life and leads to Depression Substance Abuse Isolation Family disruption As social phobia worsens if begins to effect every aspect of life and leads to Depression Substance Abuse Isolation Family disruption

42 Social Phobias The patient’s fears direct the patients choicesLimit their opportunities Spoiling their life As they adapt to accommodate the social phobia The patient’s fears direct the patients choices Limit their opportunities Spoiling their life As they adapt to accommodate the social phobia

43 Social Phobias Treatment Medications Name the disorderSSRI 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 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

44 Social Phobias Goal of treatment Focus on small gains over timeFocus to improve or minimize symptoms Avoidance behaviors Goal of treatment should be to… Focus on small gains over time Focus to improve or minimize symptoms Avoidance behaviors

45 Panic Disorder Panic Attacks or Episodes When the panic is recurrentEffects 5 million Americans 30% will have an isolated episode When the panic is recurrent With anticipatory anxiety Diagnosis = anxiety disorder Panic Disorder Panic Attacks or Episodes Effects 5 million Americans 30% will have an isolated episode When the panic is recurrent With anticipatory anxiety Diagnosis = anxiety disorder

46 Panic Disorder Patients with panic disorderDiscrete episodes of intense fear A sense of physical discomfort Episodes vary in frequency & severity Patients with panic disorder Discrete episodes of intense fear A sense of physical discomfort Episodes vary in frequency & severity

47 Panic Disorder Panic Episodes Sometimes described as a waveHappen for no apparent reason Last from 10–30 minutes Panic Episodes Sometimes described as a wave Happen for no apparent reason Last from 10–30 minutes

48 Panic Disorder Over time the anxiety becomes pathological…

49 Panic Disorder The person beginsavoiding the situation where the attacks first occur As more and more attacks occur There are more and more situations to avoid The person begins avoiding the situation where the attacks first occur As more and more attacks occur There are more and more situations to avoid

50 Abrupt Onset 4 or > Sweating Trembling Shaking Shortness of breathPalpations Increased heart rate Chest Pain Nausea GI Distress Feels like choking Diff. breathing Abrupt Onset of 4 or more of the following symptoms Sweating Trembling Shaking Shortness of breath Palpations Increased heart rate Chest Pain Nausea GI Distress Feels like choking Diff. breathing

51 Abrupt Onset 4 or > Dizzy Light-headed De-realizationDepersonalization Fear of losing Going crazy Fear of dying Paresthesias Chills or Hot flashes Dizzy Light-headed Derealization Depersonalization Fear of losing Going crazy Fear of dying Parestheisia Chills or Hot flashes

52 Panic Disorder In the Worst Case The person becomes houseboundAvoiding all possible situations That might bring on an attack In the Worst Case The person becomes housebound Avoiding all possible situations That might bring on an attack

53 Panic Disorder 50 % of the time People also suffer from depression

54 Treatment SSRI & SSSRNIs Benzos (?) Client Centered counselingCognitive Behavior Therapy Support Groups Patients Education Treatment options include SSRI & SSSRNIs Benzos (?) Client Centered counseling Cognitive Behavior Therapy Support Groups Patients Education

55 Medication Choices

56 OCD Reoccurring obsessions and or compulsions that are severe enough to be time consuming ( > 1 hours per day) These behaviors cause significant distress or impairment The person may recognize that the obsession or compulsion is excessive or unreasonable but they can not resist 4 th most common anxiety disorder, can begin at any age, 50 % of the time begins in childhoods

57 OCD At first the person can not finish anything than as things get worse the person can not start anything The Hall Mark of Obsessive Compulsive Disorder or OCD is At first the person can not finish anything than as things get worse the person can not start anything

58 OCD Obsessions Recurrent, persistent thoughts, images, impulses, etc.Intrusive, inappropriate Marked anxiety/distress Not excessive real-life worries Attempts to ignore/suppress Compulsions Repetitive behaviors with driven quality Rigidly applied rules Aimed at reducing distress or preventing a dreaded event or outcome but are unrealistic or excessive Obsessions Recurrent, persistent thoughts, images, impulses, etc. Intrusive, inappropriate Marked anxiety/distress Not excessive real-life worries Attempts to ignore/suppress Compulsions Repetitive behaviors with driven quality Rigidly applied rules Aimed at reducing distress or preventing a dreaded event or outcome but are unrealistic or excessive

59 OCD Left untreated symptoms will worsen leading to Loss of employmentIsolation Depression Divorce or other family disruption Left untreated symptoms will worsen leading to Loss of employment Isolation Depression Divorce or other family disruption

60 OCD - Treatment Medications are the mainstay Name the disorderSSRI - high doses Behavior focused therapy Patient Education Not a moral/character failing Relief from a sense of shame Medications are the mainstay of treatment of OCD Name the disorder SSRI - high doses Behavior focused therapy Patient Education Not a moral/character failing Relief from a sense of shame

61 OCD Goal gradual improvement over time as the person begins to be able to let go of unwanted thoughts You may not see any improvement from medication for months

62 Traumatic Stress Disorder ATSD & PTSDAcute Traumatic Stress Symptoms < 3 months Post Traumatic Stress Symptoms > 3 months Delayed Onset Symptoms can occur 6 mos - 30 yrs

63 PTSD Delayed Onset The Kindling EffectThe process in which repeated sub-threshold stimulation of a neuron eventually generates an action potential

64 PTSD The Origin is Trauma Child Abuse Beatings Sexual assaultSerious accident Incurring a significant injury Sudden unexpected death Captivity War PTSDThe Origin is Trauma Child Abuse Beatings Sexual assault Serious accident Incurring a significant injury Sudden unexpected death Captivity War

65 ATSD/PTSD Exposure to a traumatic event in which both of the following were present: Events involved threat of actual death of self or other serious injury of self or other Disintegration of the integrity of self/others Response involves intense fear helplessness horror Exposure to a traumatic event in which both of the following were present: Events involved threat of actual death of self or other serious injury of self or other Disintegration of the integrity of self/others Response involves intense fear helplessness horror

66 PTSD Persistent re-experiencing of trauma (1 or more)Recurrent, intrusive images, thoughts, perception Distressing dreams, flashbacks, illusions, hallucinations Intense psychological & physical distress in response to symbolic internal or external cues Persistent re-experiencing of trauma (1 or more) Recurrent, intrusive images, thoughts, perception Distressing dreams, flashbacks, illusions, hallucinations Intense psychological & physical distress in response to symbolic internal or external cues

67 PTSD Persistent avoidance & numbing 3 or moreAvoidance of thoughts & feelings Avoidance of activities, places or persons associated with or triggering recall of trauma Inability to recall important aspects of trauma Disassociation from time or place Persistent avoidance & numbing 3 or more Avoidance of thoughts & feelings Avoidance of activities, places or persons associated with or triggering recall of trauma Inability to recall important aspects of trauma Disassociation from time or place

68 PTSD Persistent avoidance & numbing3 or more Diminished interest or participation Feeling detached or estranged from others Restricted affect Sense of a foreshortened future Persistent avoidance & numbing 3 or more Diminished interest or participation Feeling detached or estranged from others Restricted affect Sense of a foreshortened future

69 PTSD Persistent arousal 2 or > Sleep disturbanceIrritability or outbursts of anger Unstable mood Difficulty concentrating Hyper-vigilance Exaggerated startle response Persistent arousal 2 or > Sleep disturbance Irritability or outbursts of anger Unstable mood Difficulty concentrating Hyper vigilance Exaggerated startle response

70 PTSD Treatment The first principle of recovery is empowerment of the survivor A person must be the author and arbiter of recovery. Restoration of control Treatment The first principle of recovery is empowerment of the survivor A person must be the author and arbiter of recovery. Restoration of control

71 PTSD Treatment Client Center Counseling Cognitive Behavior TherapyDisclosure therapy Support Groups Complimentary Medicine < stress Patient Education Treatment Client Center Counseling Cognitive Behavior Therapy Disclosure therapy Support Groups Complimentary Medicine < stress Patient Education

72 PTSD Recovery unfolds in a spiral First central task of therapySafety Second task of therapy Remembrance and mourning Third task of therapy Reconnection with ordinary life Recovery unfolds in a spiral First central task of therapy Safety Second task of therapy Remembrance and mourning Third task of therapy Reconnection with ordinary life

73 PTSD Pharmacotherapy Mood Stabilizer Anti-anxiety Rx with cautionSedative hypnotics Rx with caution Buspirone (BuSpar) Antidepressants Pharmacotherapy Mood Stabilizer Anti-anxiety Rx with caution Sedative hypnotics Rx with caution Buspirone (BuSpar) Antidepressants

74 DEPRESSION Depression

75 Major Depression At least 4 of the following present for at least 2 weeks Low mood Anhedonia Sleep disturbance Appetite disturbance Suicidal ideation Poor concentration Low energy Guilt or worthlessness Pessimism or hopelessness Agitation or retardation Loss of libido At least 4 of the following present for at least 2 weeks Low mood Anhedonia Sleep disturbance Appetite disturbance Suicidal ideation Poor concentration Low energy Guilt or worthlessness Pessimism or hopelessness Agitation or retardation Loss of libido

76 Depression Screening SALSA Sleep disturbance Anhedonia Low Self esteemAppetite decreased 97% sensitivity 94% selectivity (Brody, Arch Int Med, 1998) Screening for depression SALSA Sleep disturbance Anhedonia Low Self esteem Appetite decreased 97% sensitivity 94% selectivity (Brody, Arch Int Med, 1998)

77 Depression Screening Depressed Mood Plus: Sleep decreasedSIG-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 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

78 Pharmacology SSRI SSRNI TCA Mood Stabilizer Sleeping MedsAnti-psychotics Atypical More than One Rx My advice is to remember depression is painful, treat it aggressive There are many pharmacological choices to consider SSRI SSRNI TCA Mood Stabilizer Sleeping Meds Anti-psychotics Atypical More than One Rx

79 TCAs Avoid the use of TCAs with co-morbid CV“Dirty”- non-selective with many side effects Altered cardiac conduction increases risk of arrhythmia. (Class I anti-arrhythmic effect) Orthostatic hypotension (alpha-adrenergic) Exacerbation of hypertension (noradrenergic) Avoid the use of TCAs with co-morbid CV “Dirty”- non-selective with many side effects Altered cardiac conduction increases risk of arrhythmia. (Class I anti-arrhythmic effect) Orthostatic hypotension (alpha-adrenergic) Exacerbation of hypertension (noradrenergic)

80 TCAs Clomipramine (Anafranil) Class TCA Starting does 25 – 50 mgsDosage Range 100 – 250 mgs Approved of OCD Clomipramine (Anafranil) Class TCA Starting does 25 – 50 mgs Dosage Range 100 – 250 mgs Approved of OCD

81 SSRI Selective Serotonin Reuptake Inhibitors 2D6 inhibitorsCitalopram, Sertraline, Fluoxetine, Paroxetine, Escitalopram Weight gain, sleep disturbance, sexual dysfunction, may reduce platelet aggregation. Selective Serotonin Reuptake Inhibitors 2D6 inhibitors Citalopram, Sertraline, Fluoxetine, Paroxetine, Escitalopram Weight gain, sleep disturbance, sexual dysfunction, may reduce platelet aggregation.

82 SSRI Clinical Tip: They will all work Think about the side effectsConsider Escitalopram for crying They all cause sexual dysfunction Consider a lower dose Drug Holidays Check Akathisia Avoid in bi-polar can cause mania 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

83 SSRI Fluvoxamine (Luvox) Class SSRI Starting dose 25 – 50 mgsDosage Range 100 – 300 mgs Approved for OCD SAD depression Careful management of interactions Fluvoxamine (Luvox) Class SSRI Starting dose 25 – 50 mgs Dosage Range 100 – 300 mgs Approved for OCD SAD depression Careful management of interactions

84 SSRI Paroxetine (Paxil) Starting dose 10 – 20 mgsDosage Range 40 – 60 mgs Approved for PD OCD SAD depression Paroxetine (Paxil) Starting dose 10 – 20 mgs Dosage Range 40 – 60 mgs Approved for PD OCD SAD depression

85 SSRI Sertraline (Zoloft) Starting dose 25 mgsDosage Range 50 – 200 mgs Approved for PD OCD (adults children) PTSD depression Sertraline (Zoloft) Starting dose 25 mgs Dosage Range 50 – 200 mgs Approved for PD OCD (adults children) PTSD depression

86 SSRI Fluozetine (Prozac) Starting Dose 10 – 20 mgsDosage Range 20 – 80 mgs Approved for OCD anxiety depression Fluozetine (Prozac) Starting Dose 10 – 20 mgs Dosage Range 20 – 80 mgs Approved for OCD anxiety depression

87 SSRNI Venlafaxine - Effexor 37.5 - 150 mgsMay exacerbate HNT Take at the same time each day, don’t miss a dose Taper to discontinue or use prozac Cymbalta - Duloxetine HCL mgs If diabetic monitor glucose Venlafaxine - Effexor 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 mgs If diabetic monitor glucose

88 Other Buspar Class azapirones Starting dose 15 mgsDose Range 15 – 60 mgs Therapeutic Response 3 – 6 weeks Buspar Class azapirones Starting dose 15 mgs Dose Range 15 – 60 mgs Therapeutic Response 3 – 6 weeks

89 Other 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 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

90 SDRI Bupropion (Wellbutrin) 150 - 300 mgsReduce seizure threshold dose related Activating, smoking cessation Use for couch potatoes and grazers Bupropion (Wellbutrin) mgs Reduce seizure threshold dose related Activating, smoking cessation Use for couch potatoes and grazers

91 Serotonin Syndrome A potentially fatal toxic encephalitis ConfusionAgitation Rigidity Hyper-reflexia Fever Hyperthermia Serotonin Syndrome A potentially fatal toxic encephalitis Confusion Agitation Rigidity Hyper-reflexia Fever Hyperthermia

92 Serotonin Syndrome Usually a drug interaction that raises the blood level of serotonin Needs hospitalization for support Check medication profile for drug interactions Any selective 5HT receptor antagonist for example Zofran Usually a drug interaction that raises the blood level of serotonin Needs hospitalization for support Check medication profile for drug interactions Any selective 5HT receptor antagonist for example Zofran

93 Tetracyclic Mirtazipine (Remeron) 15, 30, 40 mgs Causes weight gainGood for sleep Good for nausea Mirtazipine (Remeron) 15, 30, 40 mgs Causes weight gain Good for sleep Good for nausea

94 Triazolopyridine Trazadone 50 -300 mgs Good for sleepGood for alcoholics - not addictive Priapism Avoid with an acute MI Urinary Retention Trazadone mgs Good for sleep Good for alcoholics - not addictive Priapism Avoid with an acute MI Urinary Retention

95 Suicide Annual suicide rate (U.S.) = 11.2/100,0009th leading cause of death Annual suicide rate (U.S.) = 11.2/100,000 9th leading cause of death

96 Suicide Risk Factors 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 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

97 Suicide Risk Factors Recent stressors Psychiatric disorderHealth, Financial Marital, Family Legal, Occupational Psychiatric disorder Depression Anxiety (panic) Schizophrenia Bipolar Disorder Personality disorder Alcohol/drug use Command Hallucinations Previous attempts Family history Recent stressors Health, Financial Marital, Family Legal, Occupational Psychiatric disorder Depression Anxiety (panic) Schizophrenia Bipolar Disorder Personality disorder Alcohol/drug use Command Hallucinations Previous attempts Family history

98 Suicide Risk AssessmentAsk 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 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

99 Suicide Risk AssessmentIf 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 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

100 Suicide Risk AssessmentSuicide 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. 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.

101 Suicide Risk AssessmentWhen 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 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

102 BIPOLAR DISORDER

103 Bipolar Disorder Manic Episode:elevated, expansive, or irritable mood, lasting at least 1 week three (or more) of the following symptoms inflated self-esteem or grandiosity decreased need for sleep Hyper-verbal or pressured speech Manic Episode: elevated, expansive, or irritable mood, lasting at least 1 week three (or more) of the following symptoms inflated self-esteem or grandiosity decreased need for sleep Hyper-verbal or pressured speech

104 Bi-Polar insomnia or hypersomnia psychomotor agitation or retardationflight of ideas or racing thoughts distractibility increase in goal-directed activity at work or psychomotor agitation excessive involvement in pleasurable activities that have a high potential for painful consequences insomnia or hypersomnia psychomotor agitation or retardation flight of ideas or racing thoughts distractibility increase in goal-directed activity at work or psychomotor agitation excessive involvement in pleasurable activities that have a high potential for painful consequences

105 Bipolar Disorder 25% suicide attemptw/o treatment 15% successful attempt Recurrent illness 80-90% Repeat events-progressive deterioration Untreated 9 year < in life expectancy 14 year < in productivity Treatment > yrs 25% suicide attempt w/o treatment 15% successful attempt Recurrent illness 80-90% Repeat events-progressive deterioration Untreated 9 year < in life expectancy 14 year < in productivity Treatment > yrs

106 Variations of Bipolar DisorderBipolar I=periods of mania +/- depression Bipolar II=periods of depression/hypomania Mixed states=periods of mania & depression Rapid Cycling = 4 episodes in 12 mos More common in bipolar II Bipolar I=periods of mania +/- depression Bipolar II=periods of depression/hypomania Mixed states=periods of mania & depression Rapid Cycling = 4 episodes in 12 mos More common in bipolar II

107 Pharmacotherapy Lithium Anticonvulsants Atypical antipsychoticsTraditional antipsychotics Antidepressants Lithium Anticonvulsants Atypical antipsychotics Traditional antipsychotics Antidepressants

108 Mood Stabilizers Lamictal 12.5 - 200 mgs bidStop for any rash (life threatening) Raise dose q 2 weeks 25 mgs Trileptal mgs bid Small dose in am Larger dose in pm Lamictal mgs bid Stop for any rash (life threatening) Raise dose q 2 weeks 25 mgs Trileptal mgs bid Small dose in am Larger dose in pm

109 Single Agent Therapy Mood Stabilizer May use a higher dose

110 Adjunctive Therapy When one medication is not enoughMood instability at the end of the day Break through symptoms Nothing works Stopped working Medication failure New symptoms Adjunctive 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

111 Adjunctive Therapy Add a mood stabilizer Depakote 125 - 1500 mgs bidblood level, Liver Function Lithium bid blood levels, narrow therapeutic range Lamictal mgs bid Add a mood stabilizer Depakote mgs bid blood level, Liver Function Lithium bid blood levels, narrow therapeutic range Lamictal mgs bid

112 Adjunctive Therapy Add a mood stabilizer Topomax 25 - 100 mgs bid -may cause glaucoma, expensive Trileptal mgs bid Tegretol mgs bid blood levels, interactions Zyprexa mgs bid Weight gain diabetes Add a mood stabilizer Topomax mgs bid - may cause glaucoma, expensive Trileptal mgs bid Tegretol mgs bid blood levels, interactions Zyprexa mgs bid Weight gain diabetes

113 Adjunctive Therapy Add an antipsychotic Navane 5 mgs bidTrilafon mgs bid Abilify mgs qd Add an antipsychotic Navane 5 mgs bid Trilafon mgs bid Abilify mgs qd

114 Adjunctive Therapy Add an antipsychotic Seroquel 25 mgs bidRisperdal mgs bid Geodon 40 mg - 60 mgs bid Add an antipsychotic Seroquel 25 mgs bid Risperdal mgs bid Geodon 40 mg - 60 mgs bid

115 Adjunctive Therapy Titrate the dose up according to the patient’s mood q weeks Need a lower dose as adjunctive When stable consider QD dosing Change to HS is sleepy Change to am if activated If suddenly can’t sleep change dose earlier in the evening Titrate the dose up according to the patient’s mood q weeks Need a lower dose as adjunctive When stable consider QD dosing Change to HS is sleepy Change to am if activated If suddenly can’t sleep change dose earlier in the evening

116 Changing medications Taper one medicationStart new medication low & slow Increase dose every days Use Prozac 20 mgs for self taper off of SSRI Listen to your patient Taper one medication Start new medication low & slow Increase dose every days Use Prozac 20 mgs for self taper off of SSRI Listen to your patient

117 The Frustrating Patient

118 The Frustrating PatientAs 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 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

119 The Frustrating Patient15% 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 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

120 Personality DisordersCharacterized 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 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

121 Personality Disordersfrequently co-occur with other psychiatric & substance use disorders depressed, emotionally labile, & prone to suicidal ideation High users of medical and psychiatric services

122 Treatment Severe disorders require Treatment includesreferral to mental health services. Treatment includes psychotherapy medication for depression Severe disorders require referral to mental health services. Treatment includes psychotherapy medication for depression

123 The Frustrating PatientSelf-awareness: acknowledge frustration Allow more time Set limits Monitor for “burn-out” Seek consultation Verbalize concerns Schedule regular f/u visits Cultivate participation & partnership 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

124 Dialectical Behavior TherapyDeveloped in the 1980’s by Dr. Linehan Emphasis Acceptance that encourages change Firmness with flexibility Nurturance with benevolent demands Non-re-enforcement of self destructive behaviors Patient completes behavior change analysis Developed in the 1980’s by Dr. Linehan Emphasis Acceptance that encourages change Firmness with flexibility Nurturance with benevolent demands Non-re-enforcement of self destructive behaviors Patient completes behavior change analysis

125 DBT Developed out of research on suicidal behaviorCombines Western and Eastern points of view Radical acceptance Self Responsibility for change Developed out of research on suicidal behavior Combines Western and Eastern points of view Radical acceptance Self Responsibility for change

126 Somatoform Disorder Physical complaintscan not be completely or adequately explained by a general medical condition substance abuse mental disorder Somatoform Disorder Physical complaints can not be completely or adequately explained by a general medical condition substance abuse mental disorder

127 Somatoform Disorder Symptoms must be Clinically significantCause distress Functional impairment Symptoms are not intentional Symptoms must be Clinically significant Cause distress Functional impairment Symptoms are not intentional

128 Unexplained Symptoms Disorders Include Somatization DisorderUndifferentiated somatoform disorder Conversion disorder Pain disorder Hypochondriasis Body Dysmorphic Disorder Somatoform disorder See hand out Disorders Include Somatization Disorder Undifferentiated somatoform disorder Conversion disorder Pain disorder Hypochondriasis Body Dysmorphic Disorder Somatoform disorder See hand out

129 Unexplained Symptoms There are no specific Dx or RxStandard medical evaluation assess for treatable cause There are no specific Dx or Rx Standard medical evaluation assess for treatable cause

130 Unexplained Symptoms Considerations History of sexual/physical abuseConsider Hypochondriasis Unexplained Symptoms Considerations History of sexual/physical abuse Consider Hypochondriasis

131 Unexplained Symptoms Use primary care management principlesScheduling regular brief visits Avoid many tests and subspecialty referrals Avoid disputing the realty of the complaint Use symptom management Give reassurance Listen Be flexible Use primary care management principles Scheduling regular brief visits Avoid many tests and subspecialty referrals Avoid disputing the realty of the complaint Use symptom management Give reassurance Listen Be flexible

132 Unexplained Symptoms Consider Cognitive Behavior TherapyUtilize complementary and alternative medicine intervention Aim for function not disability Time management Reassurance Avoid saying nothing is wrong Consider Cognitive Behavior Therapy Utilize complementary and alternative medicine intervention Aim for function not disability Time management Reassurance Avoid saying nothing is wrong

133 Unexplained Symptoms Reassurance can include Legitimize the sufferingExplain symptoms without tests Symptoms are non-progressive Expect gradual improvement Reassurance can include Legitimize the suffering Explain symptoms without tests Symptoms are non-progressive Expect gradual improvement

134 Unexplained Symptoms Consider neurological symptom Unexplained painconsider conversion disorder Unexplained pain Consider pain disorder Multiple Unexplained symptoms undifferentiated somatoform disorder somatization disorder Consider neurological symptom consider conversion disorder Unexplained pain Consider pain disorder Multiple Unexplained symptoms undifferentiated somatoform disorder somatization disorder

135 Unexplained Symptoms If suspect symptoms are intentionally feignedMalingering or Factitious Disorder To note in the record unexplained medical complaint suspect symptoms are intentionally feigned Malingering or Factitious Disorder To note in the record unexplained medical complaint

136 Motivational InterviewingWhy Respectful Accepts The Client Encourages Self Responsibility Mobilizes Inner Resources Why Respectful Accepts The Client Encourages Self Responsibility Mobilizes Inner Resources

137 Motivational InterviewingMotivation is a key to change Motivation is multidimensional Motivation is a dynamic and fluctuating state Motivation is interactive The clinician’s style influences the client’s motivation Motivation is a key to change Motivation is multidimensional Motivation is a dynamic and fluctuating state Motivation is interactive The clinician’s style influences the client’s motivation

138 Motivational InterviewingIn contrast with confrontational/denial A label is not necessary Focus on personal choice (does not force disease model Elicits client’s concerns instead of telling the client what to be concerned about Resistance is seen as interpersonal, influenced by the therapist/NP Resistance is met with reflection, not argument In contrast with confrontational/denial A label is not necessary Focus on personal choice (do not force disease model) Elicits client’s concerns instead of telling the client what to be concerned about Resistance is seen as interpersonal, influenced by the therapist/NP Resistance is met with reflection, not argument

139 Motivational InterviewingAs the interviewer you want to Develop Discrepancy Avoid Argument Roll with Resistance Express Empathy Support Self Efficacy Used along with the stages of change model can be a very effective method to support people with making changes in their lives As the interviewer you want to Develop Discrepancy Avoid Argument Roll with Resistance Express Empathy Support Self Efficacy Used along with the stages of change model can be a very effective method to support people with making changes in their lives

140 Motivational InterviewingStrategies of motivational interviewing might include Focus on the person’s strengths Respect their autonomy and decisions Individualize/patient centered treatment Avoid labels - they are dehumanizing Develop a therapeutic relationship Focus on early interventions or less intensive treatments Strategies of motivational interviewing might include Focus on the person’s strengths Respect their autonomy and decisions Individualize/patient centered treatment Avoid labels - they are dehumanizing Develop a therapeutic relationship Focus on early interventions or less intensive treatments

141 Motivational InterviewingIs a therapeutic style or way of interacting with people that facilitates an exploration of stage-specific motivational conflicts that can that hinder future progress Is a therapeutic style or way of interacting with people that facilitates an exploration of stage-specific motivational conflicts that can that hinder future progress

142 Motivational InterviewingSuccessful motivational interviewing includes being able to Express empathy through reflective listening Communicate respect and acceptance of the person and their feelings Establish a nonjudgmental, collaborative relationship Be supportive a knowledgeable consultant Compliment rather than denigrate Successful motivational interviewing includes being able to Express empathy through reflective listening Communicate respect and acceptance of the person and their feelings Establish a nonjudgmental, collaborative relationship Be supportive a knowledgeable consultant Compliment rather than denigrate

143 Motivational InterviewingListen rather than tell Gently persuade with understanding Develop discrepancy Between the person’s goals/values & behavior Support people to recognize the discrepancies Between where they are and where they hope to be. Listen rather than tell Gently persuade with understanding Develop discrepancy Between the person’s goals/values & behavior Support people to recognize the discrepancies Between where they are and where they hope to be.

144 Motivational InterviewingTip Treatment Improvement Protocol U.S Department of Health and Human Services National Clearinghouse for Alcohol and Drug Information DHHS Publication No. (SMA ) Tip Treatment Improvement Protocol U.S Department of Health and Human Services National Clearinghouse for Alcohol and Drug Information DHHS Publication No. (SMA )