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

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.

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.

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.

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)

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

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

Screening

     History !!!

Beck Depression Inventory Hamilton Depression Screen Patient Health Questionnaire (PHQ-9) Mood Disorder Questionnaire

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

Initial Treatment

   Antidepressants : SSRIs (gold standard), SNRIs Adjunctive Agents : Abilify, Cytomel, Stimulants Psychotherapy : Cognitive Behavioral Therapy (CBT),

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)

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

Initial Evaluation

     History & physical exam when indicated Substance abuse issues Medical history Family history Social history – including hx of trauma, stressful lifestyle

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!!!

Screening

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

Initial Treatment

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

Co - Morbidity

 High degree of Patients have a co-morbid Substance Abuse Disor5der

Substance Abuse Disorder

   Often masked under the guise of anxiety and/or depression Characterized by denial and minimization Look at Family History

Initial Evaluation

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

Summary

     History Mental Status exam / Physical Exam Lab Studies Referral Treatment

Questions???

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...