Psychiatric Pearls for PCP’s

1. Psychiatric Pearls for PCP’s Steven Fogelman, MD Robert Woznicki, MD

2. The patient is a 36 year old male. • He works as a manager at a bank branch in town. • He comes at the urging of his wife, because he just doesn’t feel well. • He has multiple physical complaints. • He says that he feels tight in the shoulder and the neck and he has frequent headaches. • He’s not sleeping well and says that his body is exhausted at night but the minute he lies down, his mind starts to race.

3. The patient is a 36 year old male. • You ask him what he’s thinking about and he says its either thinking about the day that has past. • He says he “just can’t drop things” and will replay minor interactions that he had with subordinates or his supervisor. • He will also find himself thinking about the events for the next day. • Even if there is nothing special occurring, he will “blow things out of proportion” thinking about how badly the day may turn out.

4. The patient is a 36 year old male. • He says that he has been passed over for two supervisor opportunities in the last 5 years, both times being told that he is frequently short tempered and irritable, that he tends to argue, and he doesn’t foster independence in his team. • He tells you that he believes that things need to be done in a certain way, and that his staff needs to learn to do as he says. • He recalls a time when his supervisor scolded him in front of his team, saying that even though they were putting the reports together in a different way, they were perfectly fine. • He remembers coming in over the weekend and redoing all of the reports.

5. The patient is a 36 year old male. • He is bringing his stress home and is irritable and short-tempered with his family. • He says that he has trouble relaxing around the house. • He has found that having several drinks before bedtime help him sleep. • He takes two extra strength Tylenol every morning because of a lingering headache. • He says he goes through a container of over the counter-the-counter antacids in a week.

6. The patient is a 36 year old male. • He says that his parents always called him “our little worrier”. • He can remember getting anxious and tearful Sunday nights before the school week started. • He says he would pester his parents about every little thing, like when were they picking him up from soccer practice or when they would get home from social events. This often led to arguments and he would get frustrated and cry.

7. The patient is a 36 year old male. • He has few outlets and says that most people can’t stand to be around him. • He is frequently tired during the day, but gets so restless he can’t sit and relax. • His wife has taken over helping his 9 year son in Boy Scouts because they just couldn’t seem to finish any of the merit badge tasks with it ending in an argument.

8. The patient is a 36 year old male. • He feels his mood is low. • His concentration is poor because his mind races with minor worries. • His appetite is poor because his stomach always hurts. • He thinks he’s a good person but just wishes that he could let the small things go. • He has no thoughts suicide. • His heart rate is 110, his BP is 135/100. His SGOT (AST) is moderately elevated, his SGPT (ALT) is normal.

9. Anxiety Disorders

10. Treatment Comparison Benzos Antidepressants Late Onset Daily Administration Withdrawal Treats comorbid conditions • Immediate onset • Can be used “as needed” • Tolerance, Addiction, Withdrawal, Diversion • Does not treat comorbid conditions

11. Buspar (buspirone) Everything you ever wanted in a drug except efficacy.

12. Mary is a 52 year old female who you have seen in your practice for many years • She presents for her yearly physical which is always right after the new year. • You review her labs and her TSH is just outside of the normal range at 5.2 mU/L. She has been treated for hypothyroid disease for about 4 years. • The only other abnormality is mild Fe deficiency anemia. • She complains about the loss of regularity in her menstrual periods. • She has had several “hot flashes” at work, but says that “aren’t very bad”. • You give her a PHQ9 and she scores a 15.

13. Mary is a 52 year old female who you have seen in your practice for many years • When you talk to her she agrees that she been less interested in doing fun things, and is more easily fatigued. • She is more irritable and sad, and is down on herself because she has been overeating and has gained some weight. • You ask her if she has felt so bad she would ever hurt herself and she adamantly says “No”. • You ask her if she ever thought it would be better if she just feel asleep and didn’t wake up. • She says, “Doesn’t everybody feel that way sometimes? That’s why I circled the one on that test you gave me.”

14. Mary is a 52 year old female who you have seen in your practice for many years • You review Mary's history for previous antidepressant use. You notice that she has taken Zoloft up to 100 mg qd for a year, Lexapro up to 30 mg for 4 weeks, Effexor XR up to 112.5 mg for 2 months. • She reminds you that the Zoloft was pretty good but "petered out", and was briefly helpful again when the dose was increased. • The Lexapro was stopped because she was bruising a lot. • She stopped the Effexor XR on her own because she was losing sleep, her mind was racing, she was energetic but in an unsettled way, and she was just not herself.

18. Reasons for Antidepressant Failure • Noncompliance • Inadequate Dose • Inadequate Trial Length • Incorrect Diagnosis • Psychosocial Stressors • Comorbid Psychiatric Diagnoses • Comorbid Medical Diagnoses

19. Antidepressant Dosing

20. Is it Bipolar Disorder? • Early Onset • Family History of Bipolar Disorder • Multiple Episodes per Year • Abrupt onset and abrupt resolution • Antidepressant Failure or Misadventure • Seasonal or Atypical Pattern • Psychotic Symptoms

22. A couple comes into your office • The wife states that she is the patient’s second wife and that he is much older than her. She is 55 years old and the patient is 77 years old. • She is worried that he may be depressed again, something that he has suffered from over the years. • He seems much more forgetful. • Over the past two years she has had to take over paying the bills. He was overdrawing the checking account and getting letters saying their electric bill was overdue. She found a bunch of bills open and unpaid in a table drawer near the front door.

23. A couple comes into your office • At Xmas time they became lost coming back from dinner at their children’s home. They needed to take a slight detour, and her husband lost his way. She attributed it to him being “tired”. • He’s become less able at his chores around the house and she frequently finds things half done. • He’s repeating himself more and not paying attention to her. A year ago he would apologize or make up an excuse. He does not do that anymore. • The patient looks bored during the interview and does not offer much. When you ask him if he can add anything, he says “No, what my daughter says”.

24. Current Medications include: • diphenhydramine for allergies • Flomax for benign prostatic hypertrophy • cyclobenzaprine for lower back pain • oxycodone when the back pain gets worse • amitriptyline 125 mg for chronic depression • aspirin for suspected TIAs • a “blood pressure pill” • a multivitamin.

25. Early Signs of Dementia • Cognitive – Memory dysfunction, difficulty expressing oneself verbally, understanding spoken language, word finding difficulty, failure to carry out common activities (chores, hobbies, employment), getting lost • Psychiatric – depression, withdrawal/apathy, change in personality, paranoia, visual hallucinations

26. Reversible Dementias • CNS – chronic subdural hematomas, normal pressure hydrocephalus, space occupying lesions, infections (Syphilis, HIV) • Psychiatric – depression • Drugs- anticholinergics • Endocrine – thyroid, parathyroid, Wilson’s disease • Nutritional – B12, folate, thiamine • Other – heavy metals, sleep apnea

27. New Onset Dementia Workup- You guys are the experts • History, multiple informants • Physical • Laboratory tests • CNS Imaging Study • Initial Cognitive Screen • Regular, periodic cognitive screening screening