An Overview of Psychiatric Disorders Commonly Seen in Primary Care

1. An Overview of Psychiatric Disorders Commonly Seen in Primary Care Bambi A. Carkey DNP,PMHNP-BC,NPP Clinical Assistant Professor SUNY Upstate Medical University College of Nursing

2. Depressive Disorders • According to the World Health Organization Major Depression ranks among the most burdensome diseases in the world. • The lifetime prevalence of Major Depression in the U.S. is reported to be between 16 % and 20%. • Approximately 5% -10% of primary care patients meet DSM-IV criteria for Major Depression and 3%-5% for Dysthymia. • The prevalence of Major Depression is estimated at 10%-20% in patients with medical illness, eg. heart disease and diabetes.

3. Depressive Disorders • Major Depression is a relapsing, remitting illness. • Following a first episode, the risk of recurrence over a two year period is about 40%. • After a second episode, the risk of recurrence within five years is 75%. • Between 10% and 30% of patients treated for Major Depression will have an incomplete recovery, with persistent symptoms or dysthymia.

4. Initial Evaluation • Patients who present with depressive symptoms should be evaluated by history, physical and labs ( CBC,CMP, thyroid studies, and vitamin D level) to rule out secondary medical causes , such as Thyroid Disease, Substance Abuse or Vitamin D Insuffiency. • Distinguish Unipolar vs. Bipolar Depression – screen for mood instability, agitation, episodic sleep dysregulation, periodic impulsivity, and irritability.

5. Initial Evaluation: R/O Bipolar DO • Distractibility • Indiscretion or Irritability • Grandiosity • Flight of Ideas • Activity increase • Sleep deficit ( decreased feeling of need for sleep) • Talkativeness (rapid, pressured speech)

6. Initial Evaluation: MDD • Sleep disorder (either increased or decreased, but most commonly trouble staying asleep • Interest deficit (anhedonia) • Guilt (feelings of worthlessness, hopelessness) • Energy deficit (anergia) • Concentration deficit • Appetite disorder (either increased or decreased) • Psychomotor retardation or agitation • Suicidality

7. Initial Evaluation • Potential for violence: history • Suicidal ideation: history of prior attempts, family history, recent exposure, intent, plan, lethality, access to means, psychotic symptoms (command hallucinations or severe anxiety), alcohol or substance abuse • Homicidal ideation – notification

8. Screening • History !!! • Beck Depression Inventory • Hamilton Depression Screen • Patient Health Questionnaire (PHQ-9) • Mood Disorder Questionnaire

9. Referral: to ED or Out- Pt. Psyche Eval. • Patients with severe depression, evidenced by: suicidal ideation, in whom out patient safety cannot be assured • Patients with significant weight loss, or psychomotor retardation/agitation • Intent to harm self or others • Depressed patients who present with psychotic features eg. delusions and/or hallucinations • Depressed patients with co-morbid substance abuse

10. Initial Treatment • Antidepressants : SSRIs (gold standard), SNRIs • Adjunctive Agents : Abilify, Cytomel, Stimulants • Psychotherapy : Cognitive Behavioral Therapy (CBT),

11. Generalized Anxiety Disorders • Lifetime prevalence of Generalized Anxiety Disorder (GAD) in the U.S. is estimated at 5.1% - 11.9% • GAD is one of the most common disorders in primary care settings • Approximately twice as common in women, and the most common anxiety d/o among the elder population • High incidence of co-morbidity – social phobia, specific phobia, panic disorder • GAD may also be associated with substance abuse, post- traumatic stress disorder (PTSD) and obsessive – compulsive disorder (OCD)

12. Generalized Anxiety Disorder • GAD is common among patients with medically unexplained chronic pain • Patients with GAD and co-morbid MDD tend to have a more severe and prolonged course of illness • GAD is considered to be a chronic illness with fluctuations in symptoms over time • Patients with GAD can have a significant degree of functional impairment

13. Initial Evaluation • History & physical exam when indicated • Substance abuse issues • Medical history • Family history • Social history – including hx of trauma, stressful lifestyle

14. Initial Evaluation: GAD • Muscle tension • Fatigue • Concentration difficulty • Restlessness or feeling of impending doom • Irritability • Sleep disturbance – specifically trouble getting to sleep • Worry, worry, worry!!!

15. Screening • Beck Anxiety Inventory • The Hospital Anxiety and Depression Scale (HADS) • Generalized Anxiety Disorder seven-item scale (GAD-7) • Penn State Worry Questionnaire

16. Initial Treatment • Anxiolytics – Benzodiazepines ( effective, potential for dependence, long term use may cause cognitive deficit • Antidepressants – SSRI’s • Cognitive – Behavioral Therapy • Evidence-Based Practice

17. Co - Morbidity • High degree of Patients have a co-morbid Substance Abuse Disor5der

18. Substance Abuse Disorder • Often masked under the guise of anxiety and/or depression • Characterized by denial and minimization • Look at Family History

19. Initial Evaluation • History • Labs : BAC, UTOX, CBC, CMP • CAGE questionnaire - 4 questions, 2 or more positive answers indicate a high probability of alcohol dependence

20. Summary • History • Mental Status exam / Physical Exam • Lab Studies • Referral • Treatment

21. Questions???

22. References Baldwin, D. (2013, March 28). Generalized anxietydisorder: Epidemiology, pathogenesis, clinical manifestations, course,assessment, and diagnosis. Retrieved from UpToDate: http://www.uptodate.com.libproxy2.upstate.edu/contents/generalize... Carlat, D. J. (2005). The Psychiatric Interview. Philadelphia: Lippincott Williams & Wilkins. Katon, W. &. (2013, March 21). Initial Treatment of Depression in Adults. Retrieved from UpToDate: www.uptodate.com.libproxy2.upstate.edu/contents/initial-trea...