Primary Care of the “County Mental Health” Patient

1. Primary Care of the “County Mental Health” Patient James A. Bourgeois, O.D., M.D. Alan Stoudemire Professor of Psychosomatic Medicine University of California, Davis Medical Center (1/11/04)

2. Learning Objectives • At end of seminar, attendees will be able to: • Define the concept of “target population” psychiatric patients • Be able to use clinical literature specific to the primary care management of serious psychiatric illness • Verbalize understanding of the mission and clinical personnel in the community mental health paradigm • Apply interviewing and observation techniques to communicate with chronically mentally ill patients

3. Community Mental Health • Movement began in 1960s • In concert with two major trends, without which chronic hospitalization would have been inevitable • Development of practical antidepressant and antipsychotic medications • Trend towards libertarianism and empowerment of even impaired persons (“mainstreaming”)

4. Community Mental Health Centers • Mandated program with federal legislation • Various and complex funding models • Meant to be arranged county-by-county • Much local control • Localities tend to define scope of population served • Intent in multidisciplinary service, focus on concurrent “medical” and “social” models • Need access to inpatient units for “crises” and some long-term patients

5. Personnel at CMHCs • Psychiatrists (M.D., D.O) • Psychologists (Ph.D., Psy.D., some M.S.) • Social Workers (M.S.W., some B.S.) • Clinical Nurses (R.N., many with masters) • “Clinicians” (various backgrounds, many are psychologists and social workers in pursuit of training closure and licensure) • Case Managers (various backgrounds)

6. Who is served? • Common fallacy – CMHC exists to serve “all” psychiatric illness • Reasonable assumption given psychiatric training, but: • Intent is “serious mentally ill” • Using Sacramento example, “Core/Target Population”

7. “Target Population” (Sacramento) • Schizophrenia • Schizoaffective disorder • Bipolar disorder • Psychotic disorder NOS • Major depression, recurrent • Borderline personality disorder

8. Notable exceptions • Substance abuse • Dementia • Child conditions • Eating disorders • Developmental disability • PTSD • Panic disorder

9. Implications for Primary Care • Serious mentally ill patients may not communicate cogently and may not seek timely primary care • Increased risk of smoking and other maladaptive behaviors • Despite mental illness, considered “competent” unless judicially conserved

10. How to Deal With These Patients • Understand clinical presentation of the core population illnesses (separate topical lectures) • Alert to medical side effects of common psychotropic medications • Willingness to collaborate with CMHC personnel

11. Medical Concerns With Psychotropic Medications • A broad area, but will summarize here • Antipsychotics • Mood Stabilizers • Anxiolytics • Antidepressants

12. Antipsychotics • Atypical >> Typical is the contemporary standard of care • Risperidone, Olanzapine, Quetiapine, Ziprasidone, Aripiprazole, Clozapine • EPS • Prolonged QTc • Neutropenia (Clozapine) • DM, lipids (Clozapine, Olanzapine notably but some risk with all)

13. Antipsychotics • Neuroleptic Malignant Syndrome • Fever • Rigidity (typically high CPK) • Delirium • Unstable VS • Can occur at any time during antipsychotic Rx • Admit to ICU

14. Mood Stabilizers • Lithium • Depakote • Tegretol

15. Lithium • Neurotoxicity • Dermatologic • Increased WBCs • Hypothyroidism • Renal

16. Depakote • Increased LAE, increased NH3 • Pancreatitis • Weight gain • Sedation • Thrombocytopenia

17. Tegretol • Blood dyscrasias • Sedation

18. Anxiolytics • Sedation • Withdrawal syndrome • Cognitive effects with high sustained doses

19. Antidepressants • SSRI side effects • TCA side effects • Caution about TCA with Paxil and Prozac • Caution no MAOI with or “near” SSRI

20. Emergency Management • A whole separate topic • Quick review • For any toxic ingestion: STAT Chem 7, LAE, NH3, UDS, blood alcohol, tylenol level, EKG • Accept no arguments

21. Acute Mental Status Changes in “Psychiatric Patient” • All “suicide attempt labs” (prior) • Plus: CPK (looking for NMS) • Low threshold for CT or LP • STAT blood levels of prescribed meds, e.g. anticonvulsants, Lithium, TCA

22. Other Considerations • Arrange pre-emptive communication channels between all personnel seeing patient at CMHC and your clinic’ • Arrange for records transfer to-fro • Use case managers and other “day-to-day” therapists as confederates • You need a means of access to PROMPT CMHC follow-up, specifically including psychiatry follow-up

23. Discussion/References • Primary Psychiatry 8(8) Aug 2001 several helpful articles on Primary Care of Psychiatric Patients • Integrate Telepsychiatry into care plan, esp. if local psychiatric resources are sparse