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Transcript of PIPC ® Psychiatry In Primary Care MOOD DISORDERS Robert K. Schneider, MD Departments of Psychiatry,...
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PIPC® Psychiatry In Primary Care
MOOD DISORDERSRobert K. Schneider, MD
Departments of Psychiatry, Internal Medicine
and Family Practice
The Medical College of Virginia at
the Virginia Commonwealth University
Richmond, Virginia
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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
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Outline
• PIPC 1– Introduction
– PIPC® Interview– MAPS-O®
– Mood Disorders
– Suicide
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Outline
• PIPC 2– Anxiety Disorders
• PIPC 3– Neurotransmitters
– The 3 Phases and the 5Rs
– Medications
– Cases and Discussion
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“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
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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)
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PIPC® Interview
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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
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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
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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…..
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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…
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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
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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”
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HELLO
DATA GATHERING
NEGOTIATION
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CUES
HYPOTHESES (MAPSO©)
CASE FINDING QUESTIONS
DIAGNOSTIC CRITERIA (DSM-IV)Comorbidities (ROS)
DATA
GATHERING
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DIAGNOSIS
TREATMENTS
PATIENT PREFERENCE
DIAGNOSIS & TREATMENT CHOICE
NEGOTIATION
EP DA UT C I AE TN IT O N
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MAPS-O®
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MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other–“Organic”–Other Psych
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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
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MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
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MAPS-O®
Mood Disorders Major Depression, Dysthymia, Bipolar Disorder
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
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MAPS-O®
Mood Disorders
Anxiety Disorders GAD, Panic Disorder, PTSD,
OCD, Phobias (Social/Specific)
Psychotic Disorders
Substance Abuse
Other
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MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders Schizophrenia, Schizoaffective
Substance Abuse
Other
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MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse Alcohol, Cocaine, Nicotine, Other Psychoactive Substances
Other
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MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other “Organic”:
Stroke, Dementia, HIV, TBI
Other Psych:
Personality Disorders, ADHD, Somatization,Eating Disorders
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MOOD DISORDERS
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Mood Disorders• Major Depression
– Single episode– Recurrent
• Dysthymia• “Double” Depression• Bipolar Disorder
– Mania– Hypomania
• Psychotic Depression
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DEPRESSION
NORMAL MOOD
RECOVERY OR REMISSION
EPISODE OF DEPRESSIONEPISODE OF DEPRESSION
TIME6 - 24 months
5-1 Stahl S M, Essential Psychopharmacology (2000)
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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
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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?
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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?
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2+ years
DEPRESSION
NORMAL MOOD
DYSTHYMIADYSTHYMIA
5-7 Stahl S M, Essential Psychopharmacology (2000)
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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
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Dysthymia – Questions:
• Same as major depression
• Longitudinal course and symptoms density is the focus of questions
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6 - 24 months2+ years
DEPRESSION
NORMAL MOOD
DYSTHYMIA PARTIAL RECOVERY
DOUBLE DEPRESSIONDOUBLE DEPRESSION
5-8 Stahl S M, Essential Psychopharmacology (2000)
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Mood Disorders – Mania and Hypomania
ManiaDistinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least one week.
HypomaniaLike mania but less and lasts throughout at least 4 days. Clearly different from the usual nondepressed mood.
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5-5 Stahl S M, Essential Psychopharmacology (2000)
DEPRESSION
NORMAL MOOD
MANIA
HYPOMANIA
MIXED EPISODE
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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?
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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?
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SUICIDE
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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
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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?
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CASE
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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
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2 weeks later
• Suicidal ideation gone
• BUT
– Not sleeping
– More irritable
– Has increased psychomotor now
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Differential Dx, Cues, and Questions
• Differential Dx
– Mania
– Overstimulation from medications
– Substance abuse
– Worsening depression
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