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Approaches to Diagnosis and Treatment of Common Psychiatric Problems in General Medicine, and When to Refer. Patsy Hoyer, CFNP October 27, 2010. The Original Title: What To Do Until The Psychiatrist Arrives The psychiatrist rarely arrives!. Providers have to deal with a lot!. STATISTICS.
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Approaches to Diagnosis and Treatment of Common Psychiatric Problems in General Medicine, and When to Refer Patsy Hoyer, CFNP October 27, 2010
The Original Title: What To Do Until The Psychiatrist Arrives • The psychiatrist rarely arrives!
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%
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
1/1000 Schizophrenia • Personality disorders may be as high as 10%-15% • The take away: There is a lot of suffering
Presentation may be obscuring of dx • Often one or more co-morbid conditions • Alcohol and drug abuse may be present
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
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
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
FAMILY Social and Genetic Hx • Genetics is not a diagnosis, but it can give a clue
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
buproprion • remeron • Cymbalta and Pristiq--niches
Irritability • Anxiety—don’t disrupt • Depressed---leave me alone • Bipolar spectrum—intense, random • Longitudinal and family hx helpful with this
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
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
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!
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.”
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