PIPC ® Psychiatry In Primary Care Educational System Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College of Virginia at the Virginia Commonwealth University Richmond, Virginia

“de facto mental health system” Regier, % of people with mental illness who seek treatment are exclusively seen in the “general medical sector” 25% of patients in primary care setting have a diagnosable mental illness

Why Now? Great scientific evidence –Genetic basis for disease Twin studies and Human Genome Project –Neuroscience Research CT to MRI to PET to SPECT scanning Neurotransmitter basic science Somatic Therapies –Psychiatric Medication Explosion (“SSRI Surge”) Economic pressures (Managed Care)

Perspective Psychiatry Mental illness of sufficient severity that when treated appropriately symptoms abate Mental Health Psychological aspects of all health issues Behavioral Health Broadest category that pertains to all behaviors in all disease and health states

PIPC ® Goals Effectively recognize, diagnose and treat mental illness in primary care Bring the skills and knowledge base in psychiatry of the primary care physician on par with other medical specialty knowledge bases

Hypothesis Driven Interview Notice cues from patient Collect target symptoms Develop differential diagnosis –pattern recognition Ask further questions to rule in or rule out

Example: Chest Pain Target symptoms –Chest pain, Shortness of Breath Differential diagnosis –Cardiac (ischemic, valvular, cardiomyopathy) –GI (esophageal spasm, PUD) –Pulmonary (COPD, pleurisy, pneumonia) –Musculoskeletal (intercostal spasm, rib fx) –Panic Attacks Further questions –Age, onset, associated symptoms, etc…..

Example: Depression Target symptoms: –Poor sleep, fatigue, isolation (no enjoyment) Differential diagnosis: –Major Depression (single episode vs recurrent) –Dysthymia (2 year history) –Bipolar (mania/hypomania) –Substance induced mood disorder (mood during periods of abstinence) Further questions: –Age, onset, associated symptoms, etc…

How can a primary care doc make a reasonable psychiatric differential diagnosis?

Depression Posttraumatic Stress Disorder Mania Psychosis Generalized Anxiety Disorder Somatization Disorder Dysthymia Obsessive Compulsive Disorder Bipolar Disorder Panic Disorder Schizophrenia Panic Attacks Personality Disorder Substance Abuse Social Phobia Specific Phobia Schizoaffective Disorder Eating Disorders Dementia ADHD Anxiety Agoraphobia

M ood A nxiety P sychosis S ubstances O ther

MAPS-O ® Organizes psychiatric knowledge like other specialties Most prevalent disorders in primary care Organized by “organ system” approach Makes psychiatric knowledge assessable Creates a foundation for the PIPC Interview

Mood Disorders Major Depression –Single episode –Recurrent Dysthymia “Double” Depression Bipolar Disorder –Mania –Hypomania Psychotic Depression

Mood Disorders Major Depression –Single episode –Recurrent Dysthymia “Double” Depression Bipolar Disorder –Mania –Hypomania Psychotic Depression

Major Depression – Case Finding Questions: Have you been feeling sad, blue or depressed? Have you lost interest in or do you get less pleasure from the things you used to enjoy?

Major Depression – Criteria: Weight change Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue Excessive guilt Decreased concentration Hopeless Recurrent thoughts of death or suicide

Mood Disorders Major Depression –Single episode –Recurrent Dysthymia “Double” Depression Bipolar Disorder –Mania –Hypomania Psychotic Depression

Mood Disorders – Dysthymia: Criteria Depressed mood for most of the day, for more days than not, for at least two years. –No episodes of major depression during the last 2 years –Symptoms have not gone away for more than 2 months at a time –Depressed plus 2 symptoms

Dysthymia – Questions: Same as major depression Longitudinal course and symptom density is the focus of questions

months 2+ years DEPRESSION NORMAL MOOD DYSTHYMIA PARTIAL RECOVERY DOUBLE DEPRESSION 5-8 Stahl S M, Essential Psychopharmacology (2000)

Mood Disorders Major Depression –Single episode –Recurrent Dysthymia “Double” Depression Bipolar Disorder –Mania –Hypomania Psychotic Depression

Mood Disorders – Mania and Hypomania Mania Distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least one week. Hypomania Like mania but less and lasts throughout at least 4 days. Clearly different from the usual nondepressed mood.

Mania and Hypomania- Questions: Have there been times, lasting at least a few days when you felt the opposite of depressed, that is when you were very cheerful or high and felt different than your normal self? Did anyone notice there was something different?

5 Anxiety Disorders Generalized Anxiety Disorder Panic Disorder Posttraumatic Stress Disorder Obsessive Compulsive Disorder Phobias –Specific –Social

Anxiety Disorders Generalized Anxiety Disorder Panic Disorder Posttraumatic Stress Disorder Obsessive Compulsive Disorder Phobias –Specific –Social

Generalized Anxiety Disorder GAD Excessive anxiety for 6 months (more days than not) Difficult to control the worry (a “worrier”) Associated with 3 or more of the following: – Restlessness – Easily fatigued – Difficulty concentrating – Irritability – Muscle tension – Sleep disturbance (initial insomnia, fragmented)

GAD – Screening Questions Have you frequently been worried or anxious about a number of things in your daily life? –Do people say you worry about things too much? –Do you think your anxiety is unrealistic or excessive? Is it hard for you to control or stop your worrying?

Anxiety Disorders Generalized Anxiety Disorder Panic Disorder Posttraumatic Stress Disorder Obsessive Compulsive Disorder Phobias –Specific –Social

Panic Attack: 4 or more Fear of DyingFear of Losing Control SweatingDerealization TremblingNausea SOBChoking feeling ParesthesiasHot flashes Chest Pain

Panic “Attack” Do you have episodes (spells) where it comes at once; the fear (anxiety) and physical symptoms (choking, chest pain)? Often they last only 10 –15 minutes? Are they associated with anything or do they come out of the blue? Do you get anxious when you anticipate the possibility of a panic attack?

Panic Attack  Panic Disorder Major Depression GAD Panic Disorder PTSD OCD Phobias Substance Induced (Intoxication and Withdrawal)

Panic Disorder – Screening Questions: Have you had sudden rushes of intense fear, anxiety, or discomfort that come on from out of the blue for no apparent reason or in situations where you did not expect them to occur? Do you worry a lot about having more of them? Have you changed your behavior since these attacks began?

Anxiety Disorders Generalized Anxiety Disorder Panic Disorder Posttraumatic Stress Disorder Obsessive Compulsive Disorder Phobias –Specific –Social

Posttraumatic Stress Disorder PTSD Common following life-threatening or overwhelming experiences The person’s response involved intense fear, helplessness or horror Most common “trauma” is the sudden death of a loved one A “civilian” disorder

Symptoms Re-experience the trauma –Flashbacks, Nightmares,Intrusive thoughts –Intense reaction when exposed to “triggers” Avoidance or Numbing –Avoidance of associated thoughts, feelings, activities, or places. –Detachment, restricted range of affect Hyperarousal –Sleep problems, Irritability, Hypervigilance –Exaggerated startle

PTSD – Stressor Criteria Screening Questions: Have you ever seen or experienced a traumatic event in which your life was actually in danger or you thought your life was in danger? How did you react to the trauma? –Were you frightened or horrified? –Did you feel helpless and out of control?

PTSD Screening Questions: Do memories about the [ ] still bother you? Do you try to block out thoughts or feelings related to the [ ]? Since the trauma have you… –.. had problems sleeping? –…been more irritable? –….been on the alert? –…..easily startled?

Anxiety Disorders Generalized Anxiety Disorder Panic Disorder Posttraumatic Stress Disorder Obsessive Compulsive Disorder Phobias –Specific –Social

Obsessive Compulsive Disorder OCD Obsessions: persistent ideas, thoughts, impulses, or images that are experienced as intrusive, inappropriate, and increase anxiety Compulsions: repetitive behaviors or mental acts that are aimed at preventing or reducing anxiety and distress caused by the obsessions

Obsessive Compulsive Disorder OCD Patients are often secretive about this and have increased shame. Starts early in life, adolescence or early adulthood.

Obsessive Compulsive Disorder OCD Do you have thoughts that you obsess on and find hard to control? –Contamination, germs –Sex Do you have rituals that you do over and over again that are difficult to control? –Counting –Washing –Checking

Anxiety Disorders Generalized Anxiety Disorder Panic Disorder Posttraumatic Stress Disorder Obsessive Compulsive Disorder Phobias –Specific –Social

Social Phobia - Screening Questions: Fear of embarrassment, and social interaction Some people have very strong fears of being watched or evaluated by others. Do you worry that you might do or way something that would embarrass you in front of others, or that other people might think badly of you? …what about the situation bothers you?

Specific Phobias Health care-related phobias Examples of health care-related phobias –needles –the sight of blood or open wounds –pain –anesthesia –dental procedures Effectively treated with systematic desensitization

Psychotic Disorders Schizophrenia Schizoaffective Disorder

Screening Questions: Psychotic Disorders Does your mind play tricks on you? Do you hear or see things others don’t, that are difficult to explain? Do you have experiences that are hard to explain?

Substance Induced Caffeine OTC Herbs Alcohol Cocaine MJ Heroin Prescription Drugs

Screening Questions: Substance Abuse Remember: Ask about ALL psychoactive substances, not just ones of abuse. –Caffeine –Herbals –Nonprescription drugs

Other “Organic” –Dementia –TBI –HIV Other Psych –Personality Disorders –Somatization –ADHD

Screening Questions: Other – “Organic” Have you or others noticed any changes in your memory? Have you ever had an injury where you have lost consciousness? High risk behaviors that may increase your risk of HIV infection? Always review the list of medications.

Screening Questions: Other Psych Have you ever received treatment for your nerves or a psychiatric condition? Has anyone in your family? Should anyone have received treatment and didn’t? Questions specific to the “other” psychiatric diagnosis

PIPC ® Psychiatry In Primary Care Wrap-up Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College of Virginia at the Virginia Commonwealth University Richmond, Virginia

SP Cases Wrap-up Dysthymia, Major Depression (“Double Depression”) and PTSD GAD, Psychoactive substance use (EtOH abuse/dependence) –Effective? –Problems? –Changes in the cases?

HELLO DATA GATHERING NEGOTIATION 3 Parts of ANY Interview

INTRODUCTIONS PURPOSE OF VISIT STRUCTURE OF VISIT FOCUSED OPEN-ENDED QUESTION HELLOHELLO

TARGET SYMPTOMS (CUES) HYPOTHESES (MAPS-O © ) CASE FINDING QUESTIONS DIAGNOSTIC CRITERIA (DSM-IV) Comorbidities (ROS) DATAGATHERINGDATAGATHERING

DIAGNOSIS TREATMENTS PATIENT PREFERENCE DIAGNOSIS & TREATMENT CHOICE NEGOTIATIONNEGOTIATION

How can a primary care doc make a reasonable psychiatric differential diagnosis?

Depression Posttraumatic Stress Disorder Mania Psychosis Generalized Anxiety Disorder Somatization Disorder Dysthymia Obsessive Compulsive Disorder Bipolar Disorder Panic Disorder Schizophrenia Panic Attacks Personality Disorder Substance Abuse Social Phobia Specific Phobia Schizoaffective Disorder Eating Disorders Dementia ADHD Anxiety Agoraphobia

MAPS-O ® Mood Disorders Anxiety Disorders Psychotic Disorders Substance Abuse Other

MAPS-O ® Mood Disorders Major Depression, Dysthymia, Bipolar Disorder Anxiety Disorders Psychotic Disorders Substance Abuse Other

MAPS-O ® Mood Disorders Anxiety Disorders GAD, Panic Disorder, PTSD, OCD, Phobias (Social/Specific) Psychotic Disorders Substance Abuse Other

MAPS-O ® Mood Disorders Anxiety Disorders Psychotic Disorders Schizophrenia, Schizoaffective Substance Abuse Other

MAPS-O ® Mood Disorders Anxiety Disorders Psychotic Disorders Substance Abuse Alcohol, Cocaine, Nicotine, Other Psychoactive Substances Other

MAPS-O ® Mood Disorders Anxiety Disorders Psychotic Disorders Substance Abuse Other “Organic”: Stroke, Dementia, HIV, TBI Other Psych: Personality Disorders, ADHD, Somatization,Eating Disorders

M ood A nxiety P sychosis S ubstances O ther