Attending to Affective Disorders in Primary Care :
Medicate, Refer, or Both?
APPLIED PSYCHOLOGY LABORATORY
East Tennessee State University
http://www.etsu.edu/apl/
Johnson City, Tennessee
Druery R. C., Steffey, S. K., Miesner, M.T., & Dula C.S.
INTRODUCTION
RESULTS
•It is known that patients with mental illness will more readily seek
treatment from their primary care physician (PCP) than a mental
health expert. Approximately 80% of treated patients will receive
their treatment from a primary care physician (Strosahl, 1998).
Data were subjected to a Chi Square. Mental Health Referrals differed as a
function of Affective Disorders , X2 (2)=9.05, p <.001
Affective Disorders Noted in Chart vs. Mental Health Referral
60
• The National Comorbidity Survey ( NCS) and the NCS- replication
reported having a 60% overlap between anxiety symptoms &
Mental
lifetime major depression disorder. Kessler et al. (1996)
Health
• Research indicates that only one third of patients in primary care
are properly diagnosed as having a mood disorders. Up to 50% of the
potentially effected may be incorrectly diagnosed (Munoz et al.,
1994). Further research demonstrated 72% of the positive screeners
sought professional help for the symptoms of mood disorders, only
8.4% were actually diagnosed with said disorder (Das et al., 2005).
DISCUSSION
Referrals
No
50
40
No
Yes
30
20
Yes
None
50
0
Anxiety
30
7
Mood
Disorder
31
7
Note: 26 patients were diagnosed with
anxiety and mood disorders.
10
0
None
Anxiety
Mood Disorder
Affective Disorders Noted
Note: 6 of the 7 overall mental health
referrals had both anxiety and mood
disorders.
LIMITATIONS
Affective Disorders and Treatments Given
• In 2006 Wagner, et al., demonstrated that primary care assessments,
of those with anxiety disorders often failed to detect anxiety as the
key problem, and subsequently, those with anxiety disorders reported
longer delays in reaching specialist care (>9 years).
20
HYPOTHESES
 H1: It was hypothesized that mood disorders and anxiety are
commonly recognized in primary care, with a positive correlation,
but are rarely referred to a mental health expert.
 H2: When affective disorders are treated in primary care they are
done so in a pharmacological manner using combinations of
Selective Serotonin Reuptake Inhibitors (SSRI) or Tricyclic
Antidepressants (TCA), Antipsychotics, and Benzodiazepines.
 H3: A significant amount of patients with an affective disorder will
not be treated or referred to a mental health expert by their primary
care physician, or PCP.
None
Anxiety
Mood Disorder
SSRI's TCA's
4
2
18
7
19
6
• There was no way to verify that the medical charts were
complete in regards to the patients medical history.
• The scope of this project limited us from accurately gathering
the type of affective disorder as well as the severity of the disorder
due to medical chart review nature.
18
16
14
None
Anxiety
Mood Disorder
12
Treated
Patients 10
8
6
Note: Some
patients were
given multiple
medications.
4
2
0
SSRI's
TCA's
Antipsychotics
Medication Prescribed by PCP
Future studies are planned, in which multiple interventions will be
tested. Interventions such as education to physicians about affective
disorders, providing brief assessment tools, and strategies on how to
refer their patients with affective disorders to mental health
providers in integrated primary care.
Das, A. K., Olfson, M., Gameroff, M. J., Pilowsky, D. J., Blanco, C., Feder, A.,
et al. (2005). Screening for bipolar disorder in a primary care practice.
JAMA : the journal of the American Medical Association, 293, 956-63.
Noted in Chart but Untreated
with no Referral
Noted in
chart but
untreated/
no referral
15
Untreated
10
Patients
Without
Referrals
5
IMPLICATIONS & FUTURE DIRECTIONS
SELECTED REFERENCES
Benzodiazepines
METHOD
 Method: Data was collected using 8 undergraduates trained to
review medical charts in the integrated primary care practice.
Information that was obtained relative to affective disorders was the
treating physician, first notation of an affective disorder, method of
treatment, any medications which could be used (including off label
uses) to treat the particular affective disorder, and if a mental health
referral occurred.
• Data was only collected from one primary care site.
Antipsychotics Benzodiazepines
1
2
5
6
8
4
20
 Participants : 100 medical charts were reviewed at a rural family
medicine clinic.
• One of the problems in detecting a mental health disorder in
primary care is the ability for a patient to effectively communicate
with their PCP. This may be in part to many patients having trouble
overcoming the negative stigma associated with receiving mental
health treatment. The findings of this pilot study concerns the
amount of affective disorders noted, and additionally, how these
disorders were handled.
• During chart review, it was found that when a possible serious
affective disorder was noted often no record of a referral to a mental
health expert was made by a PCP. While impossible to draw
definitive conclusions from the pilot study regarding how well
affective disorders are being treated by PCP’s, it is possible to
conclude that interventions in primary care is necessary to help
physicians detect these disorders and treat them more effectively .
Kessler, R.C, Nelson, C.B., McGonagle, K.A., Liu, J., Swartz, M., Blazer, D.G.,
(1996). Comorbitidy of DSM-III-R major depressive disorders in the
general population: results from the US National Comorbidity Survey. Br. J.
Psychiatry 17-30 Suppl.
Anxiety
11
Mood
Disorder
Muñoz, R. F., Hollon, S. D., McGrath, E., Rehm, L. P., & VandenBos, G. R.
(1994). On the AHCPR Depression in Primary Care guidelines: Further
considerations for practitioners. American Psychologist, 49, 42-61.
17
Strosahl, K. (1998). Integrating behavioral health and primary care services: The
primary mental health care model. In A. Blount (Ed.), Integrated primary
care: The future of medical and mental health collaboration.(pp 139-166).
New York: W.W. Norton & Co., Inc.
0
Anxiety
Mood Disorder
Affective Disorders Noted
Note: Some patients are being represented more than once due to multiple diagnoses, treatments,
and / or misdiagnosis.
CONTACT: Ryne_Druery@yahoo.com or Chris S. Dula, dulac@etsu.edu
Wagner, Renate; Silove, Derrick; Marnane, Claire; Rouen, David; Journal of
Anxiety Disorders, Volume 20(3), 2006. pp. 363-371.