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 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

Major variation in provider management

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.”

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