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

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

Outline PIPC 1 –Introduction –PIPC ® Interview –MAPS-O ® –Mood Disorders –Suicide

Outline PIPC 2 –Anxiety Disorders PIPC 3 –Neurotransmitters –The 3 Phases and the 5Rs –Medications –Cases and Discussion

“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)

PIPC ® Interview

PIPC Interview Organized by “organ system” approach –Hypothesis driven interview Makes psychiatric knowledge assessable Demonstrates holes in knowledge base for PCP Creates a foundation for evidence to be applied

Data Gathering: Hypothesis Driven Interview Notice cues from patient –pattern recognition Develop differential diagnosis Collect target symptoms 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, pleuresy, pneumonia) –Musculoskeletal (intercostal spasm, rib fx) 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 on abstinence) Further questions: –Age, onset, associated symptoms, etc…

Screening Strategies vs. Case Finding Strategies High false positives if everyone screened Practicing physicians think using case- finding strategies High comorbidity Different tools: –Interviewing questions –Diagnostic checklists –Disease specific scales

How can a primary care doc make a reasonable psychiatric differential diagnosis? Language: –Symptoms –Diagnostic categories DSM-IV: –6484 signs, symptoms, inclusion criteria –405 diagnoses –18 diagnostic categories DSM-IV PC starts the process but is inefficient and “psychiatric”

HELLO DATA GATHERING NEGOTIATION

CUES HYPOTHESES (MAPSO © ) CASE FINDING QUESTIONS DIAGNOSTIC CRITERIA (DSM-IV) Comorbidities (ROS) DATAGATHERINGDATAGATHERING

DIAGNOSIS TREATMENTS PATIENT PREFERENCE DIAGNOSIS & TREATMENT CHOICE NEGOTIATIONNEGOTIATION E P D A U T C I A E T N I T O N

MAPS-O ®

M ood Disorders A nxiety Disorders P sychotic Disorders S ubstance Abuse O ther –“Organic” –Other Psych

MAPS-O ® Most prevalent disorders in primary care Proven treatments available If “other” psychiatric disorder is diagnosed (somatization, personality disorders), Then successful treatment requires diagnosing one of these categories first

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

MOOD DISORDERS

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

DEPRESSION NORMAL MOOD RECOVERY OR REMISSION EPISODE OF DEPRESSION TIME months 5-1 Stahl S M, Essential Psychopharmacology (2000)

Mood Disorders – Major Depression 5 or more of the 9 symptoms at least 2 weeks (everyday, all day) –Depressed mood –Anhedonia –Worthless/Guilt –Death/Suicidal –Appetite –Sleep –Fatigue –Concentration –Psychomotor

Major Depression – Questions: How is your mood? 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? Has there been any change in your appetite? (5% weight change in 1 month) How have you been sleeping?

Major Depression – Questions: Have you been more fidgety? Have you felt slowed down, like you were moving in slow motion or stuck in mud? How has your energy level been? How have you been feeling about yourself? Have you been blaming yourself for things? Have you had problems thinking or concentrating?

2+ years DEPRESSION NORMAL MOODDYSTHYMIA 5-7 Stahl S M, Essential Psychopharmacology (2000)

Mood Disorders – Dysthymia 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 symptoms 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 – 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.

5-5 Stahl S M, Essential Psychopharmacology (2000) DEPRESSION NORMAL MOOD MANIA HYPOMANIA MIXED EPISODE

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 you feel hyper, or like you were high on drugs, even though you hadn’t taken anything? Did anyone notice there was something different?

Mania and Hypomania- Questions: How long did it last? What was your self-esteem like? During this time did you sleep? Were you more talkative than usual? Did it feel like your thoughts were going very fast and racing through your mind? Were you easily distracted? Were you more active than usual?

SUICIDE

Suicide More common in all psychiatric diagnoses; not just depression Dispel myths: talking about it probably makes it less likely to happen Symptom as well as outcome High risk groups (men, older, past history) Assess prohibitions to suicide

Suicide - Questions: When things have gotten really bad - Have you had increased thoughts about death and dying? Have you thought about hurting yourself? Have you ever acted on those thoughts? Do you have access to those means? What keeps you from doing this?

CASE

39 year old woman Intermittently depressed since age 28 Treated with fluoxetine and sertraline in the past with success. Three weeks ago depression returned (SI, fatigue, poor sleep, poor appetite) On call doctor restarted her fluoxetine

2 weeks later Suicidal ideation gone BUT –Not sleeping –More irritable –Has increased psychomotor now

Differential Dx, Cues, and Questions Differential Dx –Mania –Overstimulation from medications –Substance abuse –Worsening depression