MENTAL HEALTH
ISSUES IN PRIMARY
CARE
Marianne Borelli, PhD, PMHCS-BC, ANP-BC
Common Problems in Mental Health Care
•
Chest pain, abdominal pain, back pain
•
Fatigue, dizziness, swelling
•
Insomnia, shortness of breath, headache
•
Many mental health problems present as
physical symptoms
Relevant Questions
What should I be looking for?
Why is this patient seeking treatment now?
What questions should I ask?
Then what do I do?
How do I follow-up?
Where are the resources?
How do I collaborate?
Linda
Linda, 25 yo female, came to primary care
with concerns about feeling fatigued, having
difficulty concentrating, insomnia, and anxiety.
She has no hx of treatment for depression,
anxiety, or ADHD. She has been tx for irritable
bowel syndrome and asthma. She is
concerned that her performance review will not
be reflective of her abilities because she has
such trouble concentrating and fatigue.Your
learn she has a family hx of depression.
Linda
What history would be important to get from
her?
What would you assess for? What PE would
be important? What labs?
How would you treat on the initial visit?
What screening tools would be useful?
Common Presentations
in Primary Care
Depression, anxiety, insomnia, fatigue are
frequent complaints in primary care
Depression and anxiety frequently present as
somatic symptoms
Headaches, neck and back aches, insomnia,
little energy, are often symptoms presented
Hypothyroidism, anemia, adrenal fatigue,
vitamin B or D deficiencies need to be R/O
Assessment
Time spent taking a history is time well spent
First episode, family history, recent loss,
substance use, other medical conditions,
previous treatment successes and failures,
family history of response to medications
Use standardized screening tool for
depression as PHQ9 or Beck Depression
Inventory, and the GAD7 for anxiety
Assess for anxiety, depression, and insomnia
Ask about substance use
Dysthymia
Depressed mood for most of the day, for more
days than not, for at least 2 years(DSM-IV-TR)
Has not been without the symptoms for more
than 2 months at a time.
Presence of 2 or more of the following: poor
appetite or overeating, insomnia or
hypersomnia, low energy or fatigue, low selfesteem, poor concentration, difficulty making
decisions, feelings of hopelessness
Depression
FIVE OF THE FOLLOWING SYMPTOMS
DURING THE SAME 2 WEEK PERIOD AND
THIS MUST BE A CHANGE FROM
PREVIOUS FUNCTIONING
Depressed mood most of the day, nearly every
day
Little interest or pleasure in all or almost all
activities
One of the 2 symptoms above must be present
Depression Criteria
Significant weight loss or weight gain, change
in appetite
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or guilt
Depression Criteria Continued
Diminished ability to concentrate or
indecisiveness nearly every day
Recurrent thoughts of death, recurring suicidal
ideation w/wo plan or previous attempt
Symptoms not due to a medical condition,
substance use or withdrawal, or bereavement
Manic Episode
A distinct period of elevated, expansive or
irritable mood lasting at least 1 week with 3 or
more of the following present:
Inflated self-esteem, decreased need for sleep,
pressure to keep talking, flight of ideas,
distractibility, excessive involvement in
pleasurable activities that have high potential
for negative consequences, psychomotor
agitation.
Clinical Tips
Ask how these symptoms are affecting life
Ask about supplements, OTC medications,
and previous psychiatric medications
Realize this will take time, schedule another
visit
Clinical Tips
•
Develop a relationship with the patient
•
Explore losses, stressors, changes in family or
work situations
•
Assess support systems, e.g. friends, church
community
•
Ask about family history of depression, anxiety
or other mental health issues
Relevant Labs
To R/O a physical cause for depression,
anxiety, or insomnia
TSH, free T3, freeT4,
CBC, CMP
Vit B12, vit D,
Sleep study if long standing insomnia
Medication Management
Second generation antidepressants to treat
SSRIs(prozac, zoloft, celexa, lexapro),
SNRIs(effexor, cymbalta), NDRI(wellbutrin).
Avoid benzodiazepines except for short term
anxiety management; e.g. treat panic attacks
Trazodone preferred for insomnia over drugs
that are more likely to be addictive
Depression Treatment
Educate pt. about time for medication to take
effect, expected SE, timing of doses
SSRIs effective for anxiety and depression, but
benzodiazepines may be needed at first for
anxiety management, especially with panic
attacks
Will need to be on med for 9-12 months to treat
depression. A common mistake is to quit when
starts to feel better
Behavioral Changes
Set small, achievable goals, e.g., walk 15 min
every day, decrease use of caffeine, decrease
use of alcohol, call a friend, family member, do
one nice thing for self daily
Encourage therapy-Cognitive Behavioral Therapy
most effective
Consider a 12 step program
Use rating scales initially and at each visit to
evaluate progress
Follow Up
F/U 2-4 weeks after starting a medication
For moderate-severe depression, F/U in 1-2
weeks
Don’t change med for at least 3 mo. unless the
SE are not tolerated by patient
Can increase the dose after 1-2 weeks for
most
When stop medication, always best to taper
Anxiety Disorders
Generalized Anxiety Disorder
Excessive anxiety and worry, more days than
not, for at least 6 mo.
Anxiety/worry associated with 3 of these 6
symptoms:
Difficulty concentrating, mind going blank
Irritability
Anxiety Symptoms
Being easily fatigued
Restlessness, feeling keyed up
Muscle tension
Sleep disturbances
Irritability
These symptoms cause clinically significant
distress or impairment
Panic Disorder
Recurrent unexpected panic attacks:
palpitations, sweating, trembling, shaking,
sensation of shortness of breath, feeling of
choking, chest pain, nausea, dizzy, light
headed, fear of losing control, going crazy or
dying, paresthesias, chills or hot flushes
concern about having another attack, and a
change in behavior related to attacks
Anxiety Treatment
SSRIs first line for both anxiety and depression
Prozac, zoloft, celexa, lexapro
Benzodiazepines are useful for tx panic
attacks and until the SSRI begins to work but
carry risk of dependence, overdose, and
accidents; falls in elderly
Trazodone 50 mg effective for sleep
Cognitive behavioral therapy effective and
highly recommended
Behavioral Techniques
Exercise, deep breathing, progressive
relaxation
Establish a “winding down routine” in evening,
create a boundary between work/school and
bedtime
Reduce or eliminate caffeine, alcohol,
marijuana, other substances
Tracking Response to Treatment
Patient Health Questionnaire 9, Generalized
Anxiety Disorder 7, available in English and
Spanish
These help to assess for specific symptoms
and evaluate response to treatment
Use at initial visit and every subsequent visit to
assess response to tx and document
Always ask about thoughts of self harm
Adolescent Depression
Prevalence of MDD estimated at 0.4%-8.3% of
adolescents, female to male 2:1Familial
vulnerability
Patients with high genetic risk more
susceptible to negative life events and
environmental stressors
Risk factors include: increased family conflict,
death of a parent, divorce, physical or sexual
abuse/neglect,lack of supportive relationships
Adolescent Depression
Diagnosis made according to criteria
previously listed
Must have depressed or irritable mood and
anhedonia for 2 weeks or longer, and at least 5
symptoms listed from DSM-IV
Screening tools: Adolescent PHQ9 or Beck
Depression Inventory
Screening for suicidal ideation, plans, means
Adolescent Depression
Screen for substance use/abuse
Major risk factors for suicide are : previous
attempt, substance use and presence of another
psychiatric diagnosis, e.g. bipolar or personality
disorder
Family hx of suicide or suicide of someone
known to pt. increase risk.
Ask about available means, firearms in the home,
alcohol, substance abuse by family members
Adolescent Depression
Explore physical causes with PE and labs
CBC, CMP, TSH, T3,T4, Epstein -Barr,
pregnancy test
Pt. needs to feel provider is taking symptoms
seriously and working in partnership
Schedule another visit within 1 week
Explore support systems, family, teachers,
therapists
Treatment of Adolescent Depression
SSRIs used with knowledge of black box
warning for increased risk of suicide
Prozac and Lexapro are FDA approved for tx
of adolescent depression; Zoloft and Celexa
are also used
Start low(Prozac 10mg qD, Lexapro 10mg qD)
and increase dose in 1-2 weeks if necessary
Closely monitor behavior and response
Treatment of Adolescent Depression
Usually stay on med for 1 year
Common mistake is to stop med when feels
better; educate about this
Limit alcohol intake, educate about this
Involve family, caregivers, significant others
Psychosocial Treatment
CBT and Interpersonal therapy
CBT is based on premise that thoughts
influence feelings which influence behavior
Is concrete, focused on identifying errors in
thinking, challenging them, and creating more
accurate thinking.
Requires a sound therapeutic alliance and
teaches pt. to be own therapist
Interpersonal Therapy
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Interpersonal Therapy - focus on relationships
and conflicts and one’s own role in them
Treating Adolescent Depression
Refer to a mental health specialist if pt. doesn’t
respond to pharmacologic tx, exhibits signs of
manic behavior, has suicidal or homicidal
ideation, substance abuse.
Keep lines of communication open between
primary care and specialist
ADHD
Pattern of behavior- inattention or impulsivity
present over at least 6 months to a degree that
is maladaptive or inappropriate for
developmental level
Inattention includes carelessness, difficulty
sustaining attention in activities, not listening,
no follow through, disorganization, avoidance
of tasks that require sustained mental effort,
loss of important items, easily distracted,
forgetful
ADHD
Hyperactive/Impulsive criteria includes
squirms, fidgets, unable to stay seated,
runs/climbs excessively, can’t play or work
quietly, on the go, feeling “driven by a motor,”
excessive talking, blurts out answers, can’t
wait for turn, intrudes and interrupts
ADHD
Can use short form(Adult ADHD-RS-IV) in
primary care that needs to be administered by
provider; takes 30-40 min.
More extensive evaluation, neuropsych testing,
provided by psychologists, psychiatrists is
preferable
Often not covered by insurance plans
Need an assessment before prescribing a med
R/O medical cause; assess anxiety, depression
ADHD Treatment
Ritalin immediate release, sustained
release(Ritalin SR), or long acting(Concerta),
Adderall immediate release or AdderallXR,
Vyvanse
Affects dopamine and norepinephrine in several
areas of the brain
Monitor for insomnia, hypertension, tachycardia,
do EKG if any preexisting cardiac diagnosis or
symptoms
Monitor BP, tachycardia, do EKG prior to starting
with any preexisting cardiac problem
ADHD treatment
30 day supply at a time unless pt. is well
established on med and known to you
For established pt. , can pick up script at office
for 2 intervening months and return q 3 mo.
All are schedule II drugs with high abuse
potential
When to Refer
Active suicidal thoughts, previous suicide
attempt
Suspected drug use or abuse
Instability, difficult to manage in primary care
Multiple medications or high doses, usually not
given in primary care
case study
Gloria, 58, comes to primary care as a new pt.
to the practice. She has DM Type2,
hyperlipidemia, , HTN, depression and obesity.
She has recently separated from a long term
marriage in which her spouse was consistently
verbally abusive. She wants to get back on
track with her own health after doing little selfcare while so preoccupied with her situation.
Social supports include an adult daughter and
a sister. Finances are strained.
case study
Meds she brought in: GlucophageXR 1000mg
BID, Lisinopril 10mg, Crestor 10mg, Klonopin
1 mg BID.
What would be important to do on this first
visit?
Labs? Medications? Other tests?
Referral Sources
Make your own list of mental health providers in
your community
If has insurance for behavioral health tx, access
list of participating providers from company
website and review with pt.
Can get reimbursement for an out of network
provider at a lower rate of reimbursement
Local county may have some limited services,
most often for pts. on Medicaid or Medicare
Clinical trials, NIH, NIMH
References
American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorder. 4th ed..
Washington, DC, 2000.
Hamrin V, Antenucci M, Magorno, M. Evaluation
and management of pediatric and adolescent
depression. Nurse Practitioner, 2012;37(3), 22-29.
Krautner R, Cook,S. Pharmacogenetics and the
pharmacological management of depression.
Nurse Practitioner. 2011; 36(10), 15-21.
References
•
MacArthur Initiative on Depression in Primary
Care. www.depression-primarycare.org
O’Brien P, Flemming, L. Recognizing anxiety
disorders. Nurse Practitioner. 2012;37(10) 35-42.
Qaseem A, Snow V, Denberg T, Forciea, MA
Owens D. Using second generation
antidepressants to treat depressive disorders: A
clinical practice guideline from the american
college of physicians. Annals of Internal
Medicine. 2008; 149(10)725-734.
References
Krautner R, Cook,S. Pharmacogenetics and
the Pharmacological Management of
Depression. Nurse Practitioner. 2011;
36(10), 15-21.
Stahl S. Essential Psychopharmacology:
The Prescriber’s Guide. 2nd ed. Cambridge
University Press, 2009.