Patsy Hoyer, CFNP October 27, 2010

1. Approaches to Diagnosis and Treatment of Common Psychiatric Problems in General Medicine, and When to Refer Patsy Hoyer, CFNP October 27, 2010

2. The Original Title: What To Do Until The Psychiatrist Arrives • The psychiatrist rarely arrives!

3. Providers have to deal with a lot!

4. STATISTICS • 20% of general population, 25% office • 1/3 adult problems begin in childhood • Anxiety most prevalent • Depression more elusive • Adult depression, 21 million • Adult depression 5-10% of practice • CDC Study • Postpartum Blues 80% , Depression 20%

5. Adults with depression 16 % ADHD • Childhood ADHD 7% • ADHD Adults present a anx/dep • OCD, 50% have ADHD • 10-12% Children ADHD have mood disorder • 1% true bipolar • 4% spectrum conditions

6. 1/1000 Schizophrenia • Personality disorders may be as high as 10%-15% • The take away: There is a lot of suffering

7. Presentation may be obscuring of dx • Often one or more co-morbid conditions • Alcohol and drug abuse may be present

8. Major variation in provider management

9. Take time and fit it in • Suck it up, it is important to do • Psychcentral.com • Primary care sees patients over time • Follow-up is key • Refer suicidal

10. History is important! • Current functioning • Perceived issues/precipitating event • Sleep • Appetite • Mood • Functioning/work/school, family, relationships • Recent drugs, alcohol, etc • Suicidal ideation • Specific other questions toward co-morbitities

11. Longitudinal History • What were they like before, high school the last several years • Grades in school, jobs, troubles in job. law, marriage • Treatments in past • ---Key in ADHD, mood disorders, mania, previous suicide, etc

12. FAMILY Social and Genetic Hx • Genetics is not a diagnosis, but it can give a clue

13. ANXIETY • Higher doses of SSRI’s • Inderal La may help instead of xanax • Clonazepam—sometimes it is needed • DEPRESSION • STAR D-uses citalopram • Most of us use by side effect • New Recommendations

14. buproprion • remeron • Cymbalta and Pristiq--niches

15. Irritability • Anxiety—don’t disrupt • Depressed---leave me alone • Bipolar spectrum—intense, random • Longitudinal and family hx helpful with this

16. Atypicals • Small doses, just might help • Refractory anxiety, depression, family hx, sleep • Side effect issues, weight, metabolic syndromes—need to discuss and monitor • “Activation” not mania

17. Personality Disorders—how they make you feel • Proposed Classifications in DSM 5 • A—odd/eccentric-Odd ways of thinking—what was that? • C—anxious/fearful—down and depressed • B—dramatic/emotional—suck the life out of you

18. When do you refer? • Diagnosis ?—Personality disorders • Treatment Plan not working • Not comfortable with the medicine • Therapy,life coaching, CBP, skills training would help—most of the time!

19. Refer with information about your question. • Refer with some history—esp of meds used • Refer with possible goals for therapy • Refer with your question for testing—not just “see a psychologist.”

20. Improve your skills • Talk to colleagues • Subscribe to Current Psychiatry • Buy Primary “Care Psychiatry” • Let Lafayette Medical Education know what topics you would like next year