1. Revised/Abridged UPDATE in PSYCHIATRY Robert K. Schneider, MD Assistant Professor Departments of Psychiatry and Internal Medicine The Medical College of Virginia of the Virginia Commonwealth University

2. September 16, 1999 Hurricane Floyd Cancels Schneider’s Update in Psychiatry Richmond Times-Dispatch

3. Update in Psychiatry Annals of Internal Medicine October 5, 1999 Drs Schneider and Levenson Psychiatric literature of 1998 reviewed Journal Editors and leaders in Consultation Liaison Psychiatry were polled Articles selected: –expanded or introduced psychiatric information important to the general clinical internist –sound experimental design

4. Update in Psychiatry Objectives Why now? Organizing principles. Choose one topic of clinical importance in the following Update in Psychiatry.

5. “de facto mental health system” Regier,1978 54% 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

6. Why Now? Epidemiology –ECA Study – “de facto mental health system” –Managed Care Genetic basis for disease –Twin studies –Human Genome Project Neuroscience Research –CT to MRI to PET to SPECT scanning –Neurotransmitter basic science Somatic Therapies –Psychiatric Medication Explosion (“SSRI Surge”)

7. Organizing Principles DSM-IV Affective Disorders Anxiety Disorders Psychotic Disorders Substance Abuse Other

8. Organizing Principles DSM-IV Affective Disorders Major Depression, Bipolar Disorder, Dysthymia Anxiety Disorders Psychotic Disorders Substance Abuse Other

9. Organizing Principles DSM-IV Affective Disorders Major Depression, Bipolar Disorder, Dysthymia Anxiety Disorders GAD, Panic Disorder, PTSD, OCD, Phobias Psychotic Disorders Substance Abuse Other

10. Organizing Principles DSM-IV Affective Disorders Major Depression, Bipolar Disorder, Dysthymia Anxiety Disorders GAD, Panic Disorder, PTSD, OCD, Phobias Psychotic Disorders Schizophrenia, Schizoaffective Substance Abuse Other

11. Organizing Principles DSM-IV Affective Disorders Major Depression, Bipolar Disorder, Dysthymia Anxiety Disorders GAD, Panic Disorder, PTSD, OCD, Phobias Psychotic Disorders Schizophrenia, Schizoaffective Substance Abuse Alcohol, Cocaine, Nicotine, Other Other

12. Organizing Principles DSM-IV Affective Disorders Major Depression, Bipolar Disorder, Dysthymia Anxiety Disorders GAD, Panic Disorder, PTSD, OCD, Phobias Psychotic Disorders Schizophrenia, Schizoaffective Substance Abuse Alcohol, Cocaine, Nicotine, Other Other Psychiatric Aspects of Medical Disease: Stroke, Dementia, HIV, CAD Other Psych: Personality Disorders, Eating Disorders, Somatization

13. Affective Disorders Update in the AHCPR Depression Guidelines Optimum length of continuation phase therapy in depression Intensive standardized treatments for depression reviewed

14. Treating major depression in primary care practice Schulberg HC, Katon W, Simon GE, Rush AJ. Arch Gen Psychiatry, 1998;55:1121-1127 AHCPR Depression Guidelines were published in 1993 Most of the evidence was from psychiatric patients from the specialty mental health sector Most Guidelines not validated in clinical practice

15. AHCPR Depression Guidelines: Update The Guidelines are effective on depressed patients from primary care setting There is a high attrition rate in patients treated for depression In patients with mild to moderate depression, antidepressants and time-limited depression- targeted psychotherapy are both effective A more prominent role for mental health specialists is needed in more severely depressed patients

16. AHCPR Depression Guidelines

17. Optimal length of continuation therapy in depression: A prospective assessment during long-term fluoxetine treatment Reimherr FW, Amsterdam JD et al. Am J Psychiatry, September 1998; 155:1247-1253 Fluoxetine 20 mg. daily for 12 weeks 395/839 (47%) full remission at 12 weeks Randomized to placebo or continued treatment –12 weeks (0 weeks continuation phase) –26 weeks (14 weeks continuation phase) –50 weeks (38 weeks continuation phase)

18. Optimal length of continuation phase

19. Continuation phase treatment should be at least 26 weeks (6.5 months) Total treatment is then 38 weeks (9 months) The study attempted to mimic primary care setting by not distinguishing between single episode depression, recurrent depression and bipolar II A fixed dosage and time were used during acute phase treatment

20. Cost-effectiveness of treatments for major depression in primary care practice Lave JR, Frank RG, Schulberg HC, Kamlet, MS. Arch Gen Psychiatry, 1998; 55:645-651. Treatment cost, cost offset, and cost- effectiveness of collaborative management of depression Von Korff MV, Katon W, Bush T, et. al. Psychosom Med, 1998; 60:143-149

21. Intensive standardized treatments for depression are better than “usual care” Lave et. al. 276 primary care patients with major depression standardized nortriptyline therapy by PCP IPT by mental health professionals PCP usual care Von Korff et. al. 217 and 153 primary care patients with major depression “collaborative care” (2 models used) PCP usual care

22. Intensive standardized treatments for depression Improve outcomes, but do not produce a “cost offset” “Cost Offset” The theory that more effective treatment of a mental illness will reduce general medical costs The value of intensive treatment of depression in primary care is better health outcomes, not spending less money

23. Anxiety Disorders Health care phobias are common, but rarely treated Assaultive and non-assaultive traumas that produce PTSD are very common in the community setting

24. The epidemiology of blood-injection-injury phobia Bienvenu OJ, Eaton WW Psychological Medicine, 1998; 28:1129-36 1920 community residents in the Baltimore Epidemiologic Catchment Area (1993-1996) Lifetime prevalence of 3.5% (onset age 5.5 years) 80% had symptoms in the last 6 months More than 1/2 had told their treating clinicians None received treatment

25. 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

26. Story

27. Trauma and PTSD in the community, The 1996 Detroit area survey of trauma Breslau N, Kessler RC, et. al. Arch Gen Psychiatry, July 1998;55:626-632 A representative sample (2181) persons aged 18- 45 years old in the Detroit metropolitan area screened for traumatic events 90% of respondents had experienced one or more traumas Most prevalent trauma: the unexpected death of a loved one Contingent risk for PTSD (all traumas) –women: 13%men: 6.2%

28. Categories of traumatic events Personally experienced assaultive violence (37.7%) –combat, rape, mugging Other injury or shocking experience (59.8%) –MVA, diagnosis with life-threatening illness, witnessing someone being seriously injured Learning of about traumas to others (62.4%) –a close friend or loved one experiencing the above Sudden unexpected death of a loved one (60.0%)

29. Schizophrenia and Psychotic Disorders Continuing trend of “deinstitutionalization’ More patients with severe mental illness in the community “Atypical” neuroleptic usage becoming more widespread

30. “Other” Mental Health Services Psychiatric Aspects of Medical Disease Geropsychiatry Somatoform Disorders Personality Disorders Eating Disorders

31. Mental Health Services Care of patients with severe mental illness has further shifted from public mental hospitals to general hospitals and the community

32. Changing patterns of psychiatric inpatient care in the United States, 1988-1994 Mechanic D, McAlpine DD, Olfson M. Arch Gen Psychiatry, 1998; 55: 785-791 Data from 1988-1994 National Hospital Discharge Survey Inventory of Mental Health Organizations and General Hospital Mental Health Services

33. Further “Deinstitutionalization” 1988-1994 Decrease 12.5 million inpatient days in mental hospitals Increase 1.2 million inpatient psychiatric days in general medical hospitals 90% increase in discharge rates of patients with SMI in private nonprofit general hospitals decreased private funding (40% to 25%) Increased public funding (45% to 60%)

34. Geropsychiatry “Standard” dose haloperidol (2-3mg./day) is effective for psychosis and disruptive behaviors in Alzheimer’s patients Tardive dyskinesia is 3-5 times more likely in the elderly taking neuroleptics than in younger patients

35. A randomized, placebo-controlled dose- comparison trial of haloperidol for psychosis and disruptive behaviors in Alzheimer's disease. Devanand DP, Marder K, Michaels KS, et al. Am J Psychiatry, 1998; 155:1512-1520. 2 phases (6 weeks), randomized, double blind, placebo controlled 71 outpatients with Alzheimer’s disease Three dosages: –0.5-0.75 mg/day (“low dose”) –2-3 mg/day (“standard dose”) –placebo

36. Haloperidol for psychosis and disruptive behaviors in Alzheimer's disease

37. Prospective study of tardive dyskinesia in the elderly: rates and risk factors. Woerner MG, Alvir JMJ, Saltz BL, et al. Am J Psychiatry, 1998; 155:1521-1528 261 neuroleptic-naïve patients Older than 55 years (mean 77years) Prospectively followed (mean 115 weeks) Haloperidol prescribed for 68% of patients

38. Tardive dyskinesia is 3-5 times more likely in the elderly

39. Tardive Dyskinesia is 3-5 times more likely in the elderly Tardive Dykinesia associated with –higher doses –longer treatment –EPS signs early in treatment (20% at “standard dose”) –previous ECT However- –Spontaneous Tardive Dyskinesia occurs at rates ranging from 5-37% in the elderly

41. Update in Psychiatry Conclusions There is an explosion of clinically relevant psychiatric information occurring The need for primary care physicians trained to recognize, diagnose and properly manage mental illnesses is only going to increase Internists need a matrix to organize this new psychiatric information This first Update in Psychiatry is one source for the internist to advance knowledge in this area

42. Where’s Waldo