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Primary Care Psychiatry and Integrated Care

Primary Care Psychiatry and Integrated Care. Dr. Jennifer Kennedy, MD, Psychiatrist VA Dr. Mike Olson, Ph.D., Faculty SMFMR Dan Blocker, MS, Doctoral Fellow. Objectives. Review Integrated Care Team and Model Discuss common psychiatric themes/topics that come up for primary care providers

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Primary Care Psychiatry and Integrated Care

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  1. Primary Care Psychiatry and Integrated Care Dr. Jennifer Kennedy, MD, Psychiatrist VA Dr. Mike Olson, Ph.D., Faculty SMFMR Dan Blocker, MS, Doctoral Fellow

  2. Objectives • Review Integrated Care Team and Model • Discuss common psychiatric themes/topics that come up for primary care providers • Review ITE Psychiatry and Behavioral Health questions

  3. Stages of Behavioral Health Integration Source: Agency for Healthcare Research and Quality, 2011.

  4. Level I Stepped–Care Approach Level II “Specialty Care”“Population-based Care” “A lot to a little” “A little to a lot” Level III Level IV

  5. General Psychiatry Questions • Categories/themes that came up from resident’s questions

  6. ITE Board Review

  7. Question 1:M141 Missed by 15 Which one of the following antidepressants can prolong the QT interval and should be avoided with concomitant QT-prolonging agents such as atypical antipsychotics? A) Bupropion (Wellbutrin) B) Citalopram (Celexa) C) Mirtazapine (Remeron) D) Sertraline (Zoloft) E) Venlafaxine

  8. Answer: BM141 Missed by 15 B) Citalopram (Celexa) Prolongation of the QT interval is an important medication adverse effect to consider. This is particularly true in patients taking multiple medications, because this effect can be additive and increases the risk of life-threatening arrhythmias such as torsades de pointes. Among commonly used antidepressants, citalopram and escitalopram may prolong the QT interval. Other SSRIs, as well as bupropion, venlafaxine, and mirtazapine, do not have this effect. Both tricyclic antidepressants and antipsychotics, commonly used in patients also taking SSRIs, can cause QT prolongation, making their combined use problematic. Ref: Muench J, Hamer AM: Adverse effects of antipsychotic medications. Am Fam Physician 2010;81(5):617-622. 2) Price AL, Marzani-Nissen GR: Bipolar disorders: A review. Am Fam Physician 2012;85(5):483-493. 3) Kovich H, DeJongA: Common questions about the pharmacologic management of depression in adults. Am Fam Physician 2015;92(2):94-100.

  9. Question 2:M038 Missed by 14 A 42-year-old female visits your office. She has alcohol use disorder and wants to quit drinking. She recently went through inpatient detoxification and is attending Alcoholics Anonymous meetings and counseling. She continues to have strong cravings and is fearful of a relapse. Her medical history is notable for renal disease and osteopenia. Which one of the following would be most appropriate for this patient? A) Acamprosate B) Disulfiram (Antabuse) C) Naltrexone (ReVia) D) Bupropion (Wellbutrin)

  10. Answer: CM038 Missed by 14 C) Naltrexone (ReVia) Medications are effective for alcohol use disorder and should be offered in conjunction with psychosocial interventions. Oral naltrexone is the most effective medication to prevent relapse. Acamprosateis moderately effective but is contraindicated in patients with renal disease. A recent meta-analysis indicated that disulfiram is not effective for preventing relapse. Bupropion is used for smoking cessation. Ref: Jonas DE, Amick HR, Feltner C, et al: Pharmacotherapy for adults with alcohol use disorders in outpatient settings: A systematic review and meta-analysis. JAMA 2014;311(18):1889-1900. 2) Centers for Disease Control and Prevention. Fact sheets—Alcohol use and your health. 3) Hendry S, Mounsey A: PURLS: Consider these medications to help patients stay sober. J FamPract 2015;64(4):238-240.

  11. Question 3:M224 missed by 9 A 44-year-old male complains of feeling tired and sad for the last few months. He has a past medical history of obesity, diabetes mellitus with painful peripheral neuropathy, and seizure disorder. He has also noticed that he is not as interested in his usual hobbies and is eating more than usual. You diagnose depression. Which one of the following would be the most appropriate agent for this patient, considering his comorbidities and symptoms? A) Bupropion (Wellbutrin) B) Citalopram (Celexa) C) Duloxetine (Cymbalta) D) Nortriptyline (Pamelor)

  12. Answer: CM224 missed by 9 C) Duloxetine (Cymbalta) SSRIs and SNRIs are both effective in reducing depressive symptoms, but SNRIs have been shown to be superior to SSRIs for management of neuropathic pain (SOR A). Bupropion would effectively treat the patient’s depression and could cause weight loss, but it is contraindicated in patients with seizure disorders (SOR A). Tricyclic antidepressants such as nortriptyline could also help with the pain but might also worsen the patient’s obesity and fatigue (SOR A). Ref: Kovich H, DeJong A: Common questions about the pharmacologic management of depression in adults. Am FamPhysician 2015;92(2):94-100.

  13. Question 4: M165 missed by 8 A 24-year-old female sees you for follow-up of her chronic abdominal pain. You have diagnosed her with somatization disorder. You have scheduled regular, frequent visits and she has been in counseling for a few months. She still has significant anxiety about her symptoms and you would like to start her on a medication. Which one of the following medications would be most appropriate for this patient? A) Amitriptyline B) Aripiprazole (Abilify) C) Bupropion (Wellbutrin) D) Carbamazepine (Tegretol) E) Lamotrigine (Lamictal)

  14. Answer: AM165 missed by 8 A) Amitriptyline Somatic disorders usually require a multifaceted approach to treatment. It is important to schedule regular visits at short intervals to establish a collaborative relationship with the patient. It is also important to limit diagnostic testing and reassure the patient that serious diseases have already been ruled out, and to screen for other mental illnesses. Referral for counseling using cognitive-behavioral therapy and mindfulness-based therapies is also effective. SSRIs and tricyclic antidepressants have been found to be the most effective pharmacotherapy (SOR B) for somatic symptom disorders. Amitripityline is the most studied tricyclic antidepressant, and trials have shown that it has a greater likelihood of success compared to SSRIs. Other antidepressants, anticonvulsants, and antipsychotic medications are ineffective and should be avoided (SOR B). Ref: Kurlansik SL, Maffei MS: Somatic symptom disorder. Am Fam Physician 2016;93(1):49-54.

  15. Question 5:M066 missed by 6 A 45-year-old male reports being held up at gunpoint while on vacation 3 months ago. Since that time he has had intrusive memories of the event, as well as nightmares. Further questioning reveals that he has been having dissociative reaction flashbacks and meets the criteria for posttraumatic stress disorder. Which one of the following is the most appropriate pharmacotherapy for this patient? A) Clonazepam (Klonopin) B) Clonidine (Catapres) C) Mirtazapine (Remeron) D) Sertraline (Zoloft) E) Risperidone (Risperdal)

  16. Answer: DM066 missed by 6 D) Sertraline (Zoloft) The dissociative reactions (flashbacks) in this patient are consistent with the diagnosis of posttraumatic stress disorder (PTSD). The first-line medications for this disorder are SSRIs and SNRIs. Paroxetine and sertraline have FDA approval for PTSD. Other antidepressants such as mirtazapine would be second-line therapy. The effectiveness of central "2-agonists such as clonidine are unknown, and even though benzodiazepines might help with hyperarousal symptoms, they can worsen other symptoms. Atypical antipsychotics such as risperidone are not recommended. Ref: Warner CH, Warner CM, Appenzeller GN, Hoge CW: Identifying and managing posttraumatic stress disorder. Am Fam Physician 2013;88(12):827-834.

  17. Question 6:M122 missed by 6 The preferred method for diagnosing psychogenic nonepileptic seizures (pseudoseizures) is A) inducing seizures by suggestion B) postictal prolactin levels C) EEG monitoring D) video-electroencephalography (vEEG) monitoring E) MRI of the brain

  18. Answer: DM122 missed by 6 D) video-electroencephalography (vEEG) monitoring Inpatient video-electroencephalography (vEEG) monitoring is the preferred test for the diagnosis of psychogenic nonepileptic seizures (PNES), and is considered the gold standard (SOR B). Video-EEG monitoring combines extended EEG monitoring with time-locked video acquisition that allows for analysis of clinical and electrographic features during a captured event. Many other types of evidence have been used, including the presence or absence of self-injury and incontinence, the ability to induce seizures by suggestion, psychologic tests, and ambulatory EEG. While useful in some cases, these alternatives have been found to be insufficient for the diagnosis of PNES. Elevated postictal prolactin levels (at least two times the upper limit of normal) have been used to differentiate generalized and complex partial seizures from PNES but are not reliable (SOR B). While prolactin levels are often elevated after an epileptic seizure, they do not always rise, and the timing of measurement is crucial, making this a less sensitive test than was previously believed. Other serum markers have also been used to help distinguish PNES from epileptic seizures, including creatinephosphokinase, cortisol, WBC counts, lactate dehydrogenase, pCO2, and neuron-specific enolase. These also are not reliable, as threshold levels for abnormality, sensitivity, and specificity have not been determined. MRI is not reliable because abnormal brain MRIs have been documented in as many as one-third of patients with PNES. In addition, patients with epileptic seizures often have normal brain MRIs. Ref: Alsaadi TM, Marquez AV: Psychogenic nonepileptic seizures. Am Fam Physician 2005;72(5):849-856. 2) RopperAH, Samuels MA, Klein JP: Adams and Victor’s Principles of Neurology, ed 10. McGraw-Hill, 2014, p 332. 3) Goldman L, Schafer AI (eds): Goldman’s Cecil Medicine, ed 25. Elsevier Saunders, 2016, p 2403.

  19. Question 7:M218 missed by 4 A 19-year-old female high school student is brought to your office by a friend who is concerned about the patient cutting herself on the wrists. The patient denies that she was trying to kill herself, and states that she did this because she “just got so angry” at her boyfriend when she caught him sending a text message to another woman. She denies having a depressed mood or anhedonia, and blames her fluctuating mood on everyone who “keeps deserting her,” making her feel like she’s “nothing.” She admits that she has difficulty controlling her anger. Her sleep quality and pattern appear normal, as does her appetite. She denies hallucinations or delusions. The wounds on her wrists appear superficial and there is evidence of previous cutting behavior on her forearms. Her vital signs are stable. Which one of the following would be most beneficial for this patient? A) Clonazepam (Klonopin) B) Fluoxetine (Prozac) C) Quetiapine (Seroquel) D) Inpatient psychiatric admission E) Psychotherapy

  20. Answer: EM218 missed by 4 E) Psychotherapy This patient displays most of the criteria for borderline personality disorder. This is a maladaptive personality type that is present from a young age, with a strong genetic predisposition. It is estimated to be present in 1% of the general population and involves equal numbers of men and women; women seek care more often, however, leading to a disproportionate number of women being identified by medical providers. Borderline personality disorder is defined by high emotional lability, intense anger, unstable relationships, frantic efforts to avoid a feeling of abandonment, and an internal sense of emptiness. Nearly every patient with this disorder engages in self-injurious behavior (cutting, suicidal gestures and attempts), and about 1 in 10 patients eventually succeeds in committing suicide. However, 90% of patients improve despite having made numerous suicide threats. Suicidal gestures and attempts peak when patients are in their early 20s, but completed suicide is most common after age 30 and usually occurs in patients who fail to recover after many attempts at treatment. In contrast, suicidal actions such as impulsive overdoses or superficial cutting, most often seen in younger patients, do not usually carry a high short-term risk, and serve to communicate distress. Inpatient hospitalization may be an appropriate treatment option if the person is experiencing extreme difficulties in living and daily functioning, and pharmacotherapy may offer a mild degree of symptom relief. While these modalities have a role in certain patients, psychotherapy is considered the mainstay of therapy, especially in a relatively stable patient such as the one described. Ref: Dean L, Falsetti SA: Treating patients with borderline personality disorder in the medical office. Am FamPhysician 2013;88(2):140-141.

  21. Question 8:M181 missed by 2 A 43-year-old male presents to your office for an urgent visit because he has a feeling that he is being followed and is fearful for his life. He tells you someone is listening to his cell phone conversations and has stolen files from his laptop, and he has observed “shadowy figures” watching him. He reports that the police have done nothing to protect him, and he has considered hiring a private investigator. He reports that he has been living out of his car for the past month. Upon further questioning the patient admits that he lost his job as an accountant a year ago and is estranged from his family. His overall appearance is unkempt and his speech is pressured and rapid. His heart rate is 88 beats/min, blood pressure 138/80 mm Hg, and temperature 37.0°C (98.6°F). In ruling out medical causes for his psychosis, which one of the following would be most useful? A) The PHQ-9 questionnaire B) Urine toxicology C) MRI of the brain D) HIV antibody testing E) A serum calcium level

  22. Answer: BM181 missed by 2 B) Urine toxicology Illicit substance use is the most common medical cause or secondary cause of acute psychosis. Conditions diagnosed by brain imaging, blood chemistry, and HIV tests (intracranial mass, paraneoplastic syndrome, and HIV infection, respectively) are less common medical causes of acute psychosis. Major depression with psychosis would be considered a psychiatric or primary cause of psychosis. Ref: Griswold KS, Del Regno PA, Berger RC: Recognition and differential diagnosis of psychosis in primary care. Am Fam Physician 2015;91(12):856-863.

  23. Question 9:M231 missed by 2 An 18-year-old male comes to your office because of the recent onset of recurrent, unpredictable episodes of palpitations, sweating, dyspnea, gastrointestinal distress, dizziness, and paresthesias. He says he is always concerned about when the next attack will occur. His physical examination is unremarkable except for moderate obesity. Laboratory findings, including a CBC, blood chemistry profile, and TSH level, reveal no abnormalities. The most likely diagnosis is A) mitral valve prolapse B) paroxysmal supraventricular tachycardia C) pheochromocytoma D) generalized anxiety disorder E) panic disorder

  24. Answer: EM231 missed by 2 E) panic disorder Panic disorder typically presents in late adolescence or early adulthood with unpredictable episodes of palpitations, sweating, gastrointestinal distress, dizziness, and paresthesias. The attacks are sporadic and last 10–60 minutes. Generalized anxiety disorder is more common, and common symptoms include restlessness, fatigue, muscle tension, irritability, difficulty concentrating, and sleep disturbance. Pheochromocytomais associated with headache and hypertension, and usually occurs in thin patients. Paroxysmal supraventricular tachycardia is usually not associated with gastrointestinal distress or paresthesias. While mitral valve prolapse can be associated with anxiety and panic disorder, the physical examination would not be normal. Ref: Kasper DL, Fauci AS, Hauser SL, et al (eds): Harrison’s Principles of Internal Medicine, ed 19. McGraw-Hill, 2015, pp 2708-2709.

  25. Question 10:M119 missed by 1 During a routine health maintenance visit, a 24-year-old female admits that she is not feeling well due to being overwhelmed with stress. She feels she has always worried more than most people, but recent troubles at home and at work have made things much worse. She says she is irritable with people around her, has trouble focusing at work, and feels fatigued late in the day. Despite her fatigue, she has difficulty falling asleep at night. The patient denies anhedonia, suicidal thoughts, or a persistently depressed mood. She limits her caffeine intake, does not smoke or drink alcohol, and is not using any illicit drugs. In addition to psychotherapy, which one of the following medications is recommended for this patient? A) Alprazolam extended release (Xanax XR) B) Clonazepam (Klonopin) C) Gabapentin (Neurontin) D) Quetiapine (Seroquel) E) Sertraline (Zoloft)

  26. Answer: EM119 missed by 1 E) Sertraline (Zoloft) This patient’s symptoms are consistent with the DSM-5 criteria for generalized anxiety disorder. First-line treatments for this condition are SSRIs, SNRIs, and tricyclic antidepressants. Quetiapine and gabapentin are considered second-line medications for anxiety if control cannot be obtained with more traditional agents. Benzodiazepines such as alprazolam and clonazepam are sometimes necessary for short-term control of anxiety symptoms but are generally discouraged due to sedating side effects, the potential for abuse or diversion, and gradual tolerance. Ref: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 5. American Psychiatric Association, 2013, pp 189-264. 2) Combs H, Markman J: Anxiety disorders in primary care. Med Clin North Am 2014;98(5):1007-1023. 3) Locke AB, Kirst N, Shultz CG: Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician 2015;91(9):617-624.

  27. Question 11:M031 missed by 1 Which one of the following is effective in preventing seizures associated with alcohol withdrawal syndrome? A) Carbamazepine (Tegretol) B) Chlordiazepoxide C) Clonidine (Catapres) D) Gabapentin (Neurontin) E) Phenytoin

  28. Answer: BM031 missed by 1 B) Chlordiazepoxide Benzodiazepines, such as chlordiazepoxide, can prevent alcohol withdrawal seizures. Anticonvulsants such as carbamazepine, gabapentin, and phenytoin have less abuse potential than benzodiazepines but do not prevent seizures. Clonidine, an "-adrenergic agonist, reduces the adrenergic symptoms associated with withdrawal but does not prevent seizures. Ref: Muncie HL Jr, Yasinian Y, Oge L: Outpatient management of alcohol withdrawal syndrome. Am FamPhysician 2013;88(9):589-595.

  29. Question 12:M121 missed by 0 Which one of the following is most likely to improve outcomes in schizophrenia? A) Combining antipsychotic medication with psychosocial treatment B) Prescribing two second-generation antipsychotic medications together in small dosages C) Initial treatment in the outpatient rather than inpatient setting D) Using only one first-generation, or typical, antipsychotic medication combined with an antidepressant medication

  30. Answer: AM121 missed by 0 A) Combining antipsychotic medication with psychosocial treatment The combination of antipsychotic medication and psychosocial treatments, including cognitive-behavioral therapy, family therapy, and social skills training, is associated with the best outcomes in patients with schizophrenia (SOR B). Antipsychotic medications should not be combined. Hospitalization, especially for the first episode of schizophrenia, is also recommended for the best outcome (SOR C). Antidepressant medication will treat depression associated with schizophrenia but will not necessarily improve the symptoms of schizophrenia. Ref: Holder SH, Wayhs A: Schizophrenia. Am Fam Physician 2014;90(11):775-782.

  31. Question 13:M173 missed by 0 A 19-year-old female college student is referred to you by her dentist for a medical evaluation related to dental problems. The patient states that she feels well and exercises at least 2–3 hours every day. On examination her teeth are stained and there are enamel erosions. She has nontender enlargement of both parotid glands. The remainder of the examination is normal. Which one of the following is associated with these findings? A) Bacterial parotitis B) Bulimia nervosa C) Cat scratch disease D) Mononucleosis E) Mumps

  32. Answer: BM173 missed by 0 B) Bulimia nervosa Bulimia nervosa is an eating disorder associated with recurrent binge eating and induced vomiting. There is also a history of excessive physical activity in many cases. Because of vomiting, the teeth are stained and there is destruction of the enamel from stomach acid. Parotid swelling is also noted frequently. With mumps and bacterial parotitis the patient feels sick and parotid glands are tender. Cat scratch disease and mononucleosis affect lymph glands. Ref: Harrington BC, Jimerson M, Haxton C, Jimerson DC: Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. Am Fam Physician 2015;91(1):46-52.

  33. Question 14:M178 missed by 0 In an adult patient with significant depression and no other health problems, which one of the following is the best initial choice for pharmacotherapy? A) Amitriptyline B) Duloxetine (Cymbalta) C) Fluoxetine (Prozac) D) Mirtazapine (Remeron) E) Trazodone (Oleptro)

  34. Answer: CM178 missed by 0 C) Fluoxetine (Prozac) Depression can be treated with counseling and/or medication. The choice of medication depends on many factors including side effects, dosing schedule, cost, patient preference, and comorbidities. In a patient with significant depression and no comorbidities, a second-generation SSRI should be the initial medication choice. Fluoxetine is the only SSRI choice listed. Duloxetine is an SNRI that may lead to sweating, tachycardia, urinary retention, and elevation of blood pressure. It is indicated if the patient has fibromyalgia. Trazodone is associated with somnolence, orthostatic hypotension, and priapism. It may be used in low doses as an adjuvant in patients with insomnia. Mirtazapine can cause sedation, weight gain, increased appetite, dry mouth, dizziness, and constipation. It is helpful for patients with significant insomnia and loss of appetite. Amitriptyline is a tricyclic antidepressant and has significant anticholinergic side effects. It is also associated with conduction abnormalities that can lead to arrhythmias. Ref: Drugs for psychiatric disorders. Treat Guidel Med Lett 2013;11(130):53-64. 2) Kovich H, DeJong A: Common questions about the pharmacologic management of depression in adults. Am Fam Physician 2015;92(2):94-100.

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