Practical Psychiatry Tips for
Primary Care
Seth Wittner PA-C
Las Vegas, NV
DEPRESSION
Ask whether in the last two weeks patient has done something
they enjoyed.
Watched a movie? Fixed a favorite meal? A football game on
tv?
If the patient says NO, that’s a strong indicator of a depressed
patient.
If a particular antidepressant is likely to ever work for someone
(possibly with a high dosage required), there will be some
improvement in degree of the depression in first two weeks,
even with a low starting dosage.
Continue pt on that A/D if they get some relief in 1st 2 weeks,
otherwise switch.
One VERY IMPORTANT THING to delve into is whether …
… he or she could be BIPOLAR
This is very often OVERLOOKED.
An older person may no longer have long-lasting mood swings
even though she had them decades ago. You want to ask
about that, because an antidepressant could bring about a
manic episode.
WHEN YOU ASK
about mood swings (current or earlier in life)
EMPHASIZE that
it’s four days or longer of a steady mood you’re
asking about—with an “up” mood leading them to do things
they later realized were out of character. Things they later
regretted.
Symptoms of a Manic or Hypomanic episode include:
— buying lots of things they can’t afford (which sometimes get
returned the next day)
— looking for sexual partners in a reckless way
— speeding while driving
— doing other risky things, for example …
( examples of risky manic behavior:)
EXTREME SKIING
EXTREME SNOW-BOARDING
SLEDDING ON A MEDIUM-GRADE HILL
WITH BAD POTHOLES
If you ask about what was like when they CRASHED after
the
long episode of recklessness, they’re likely to know what
you
mean—if they are bipolar.
.
If the history suggests bipolar disorder (BPD), then start patient
on a mood stabilizer prior to starting an antidepressant or at
the same time.
(Mood stabilizers will be discussed on an upcoming slide.)
fluoxetine/Prozac — Least wt. gain among the SSRIs. If SWITCHING TO
another SSRI, stop Prozac (UNLESS pt takes > 20mg/day)…wait 4 to 7 days for
washout, then start the other SSRI at low dosage.) For Prozac > 20 mg/day, TAPER
off Prozac over two weeks first.
mirtazipine/Remeron — can also help with insomnia. But can also be sedating
during the day. Consider benefit and downside of better nightly sleep vs. fatigue,
over-sedation. Avoid in the elderly or obese. Causes wt. gain.
buproprion/Wellbutrin — Not very effective in my experience, but can help the
depressed pt. who is very fatigued or who has sexual dysfunction.
venlafaxine/Effexor is helpful for depression and social phobias.
amitriptyline/Elavil has anticholinergic properties and should be avoided in elderly pts.
paroxetine/Paxil is the best-studied with regard to OCD of the SSRIs. Shown to be useful.
Adjunctive Meds in depression: bupropion is often used.
Aripiprazole (Abilify) or (newer) brexpiprazole/Rexulti can be added. Ar
For a severely depressed pt with concurrent BPD or schizophrenia,
starting dosage of aripiprazole should be 10 mg or a little higher.
Pts without concurrent BPD or schizophrenia, dosage needs to be
lower, e.g. 2 to 5 mg.
Quetiapine can be quickly increased from 50 mg qhs to 100 mg on day #2,
to 150 mg on day #3.
Higher dosages can be used, even as high as 800 mg qhs or in divided do
Watch for abnormal movements such as tics,
jerks, dystonia, akathisia and DOCUMENT.
TALK THERAPY is very important. Should not be considered to be
optional. The more severe the depression, the more important talk
therapy is.
Remember the RISK of suicidal ideation that sometimes occurs
with SSRIs, SNRIs. The black box warning applies to
adolescents and young adults under the age of 25. The
thinking is that some people are severely depressed and would
attempt suicide if only they had the energy. The A/D improved
their energy to the point that they could obtain a weapon,
chose a site, write a note, etc, but only their energy improved,
not their depression.
BIPOLAR DISORDERS (BPD)
To repeat: bipolar disorders can arrive in sheep’s clothing, looking lik
simple depression. Ask about recent or remote long-lasting
mood swings when a patient presents with depression.
Did the pt do things that they realized soon after were reckless or
just not like them. This is very important. It helps distinguish between
(Bipolar disorder, continued)
At least 3 of the following symptoms must also be present:
• Grandiosity
• Diminished need for sleep
• Excessive talking or pressured speech
• Racing thoughts or flight of ideas
• Clear evidence of distractibility
•Increased level of goal-focused activity at home, at work, or sexually
•Excessive pleasurable activities, often with painful consequences.
]
CLUES that someone presenting with depression may be bipolar.
Acute onset of a mood change
* * Psychotic symptoms
* *family h/o bipolar disorders
* early onset (during the pt’s teens)
*
*
If you believe the patient has a bipolar d/o, do not start
an antidepressant without also having a mood stabilizer
onboard. An antidepressant could cause a hypomanic
or manic episode.
Some patients with bipolar II will request to simply continue
their antidepressant instead of starting or continuing a
mood stabilizer, because they actually prefer their mood
swings to be more severe.
Lithium is cheap and effective but some patients can’t
tolerate it, mostly due to tremors, nausea, vomiting or
diarrhea.
Lithium is better at preventing MANIA than depression. It’s
also less effective in FREQUENT MOOD SWINGS/Rapid
Cycling - 4 or more episodes a year.
LAMICTAL is a first line option in BIPOLAR DEPRESSION. It’s
also used for MAINTENANCE or acute bipolar mania.
The most important adverse event w/ Lamictal is a RED RASH.
This can become life-threatening (as Stevens-Johnson
Syndrome.) Pt must promptly D/C Lamictal if a red rash
develops (other than an insect bite, etc.)
Other mood stabilizers include Lamictal, Depakote (which was
better tolerated than Lithium in some studies) and Topamax.
Topamax can cause weight LOSS, but it can also cause
KIDNEY STONES. Emphasize need to drink enough fluids.
BIPOLAR patients often need antipsychotics
such as quetiapine/Seroquel;
risperidone/Risperdal; ziprasidone (GEODON)
The main problems are WEIGHT gain — which can
be
shockingly quick and severe — and drowsiness.
Of the antidepressants, ziprasidone is the least likely
to
cause weight gain.
Antipsychotics can lead to, or worsen diabetes.
Haloperiodol/Haldol is a good choice when DM is an
issue.
DON’T FORGET AN IM ANTI-PSYCHOTIC FOR PTS WITH
POOR ADHERENCE TO MEDS.
ONCE A MONTH. CONVENIENT.
I OFTEN CHOOSE INVEGA SUSTENNA. BUT IT’S VERY
EXPENSIVE.
HALDOL IS INEXPENSIVE.
YOU WILL NEED A PRIOR AUTH. SOME INSURANCE
COMPANIES REQUIRE YOU TO CONTACT THE SAME DEPT
THAT APPROVES DME, ETC. ASK.
ANTI-PSYCHOTICS HELP A PERSON TO NOT ACT IMPULSIVELY.
They can be lifesavers for someone with suicidal ideation.
People already ON an antipsychotic can also take an
additional dose of what they’re on if they start having
hallucinations or to become manic.
ADHD:
One good question to ask when ruling this in or out is:
Do your friends and family often think (or have they often said) that you’
not listening to them?
Some people will find it easier to think about what others have said — e
as restless and themselves as being easily distracted.
A very bright child with ADHD may be able to
power through school and get good grades (with extra study, etc.)
Good grades do not automatically rule out ADD or ADHD.
ADHD has high priority when it comes to which dx to treat first in
pts with multiple psychiatric dxs. If someone with
ADD or ADHD is depressed, treat the ADD/ADHD first….unless
they are suicidal.
In that case, do not delay treating the depression.
When treating a young child, say six or eight years old, for
ADHD, it’s important to start off with very low dosages of
meds like Clonidine, which helps with hyperactivity and sleep,
or ProCentra (dextroamphetamine) which comes in liquid
form only, 5mg/5 mL.
Clonidine 0.1mg tabs can broken (with the fingers, not a pill
splitter) into quarters, with 1/4 tab given TID to 4x/day. A half
tablet may be needed once or twice per day.
Parents need to give the child with ADHD advance notice
when taking him away from a favorite activity like a video
game or a tv show.
And they should try to establish a daily routine, so the
child knows what’s next.
People who get started on Adderall or Ritalin or another
stimulant and get aggressive and out of control of their anger
may need a mood stabilizer.
A patient with PTSD needs one on one talk therapy, and it
should be with an experienced therapist, not only an intern.
An intern can be part of the team, but someone experienced
should be overseeing the therapy.
PTSD is not easy to treat, and there is no medication that is
very effective even though meds can help.
Someone who re-experiences traumatic events can easily
have nightmares that keep them awake. One med that can
help with
nightmares is prazosin. Assuming a normotensive patient, you
could start them on 2mg QHS. It’s worth a try.
A study of PTSD in Maine Army reservists conducted by a
psychologist at the COMMUNITY COUNSELING CENTER in
Portland (343 Forest Avenue, Portland, Maine 04101 Phone:
(207) 874-1030) showed that only 15% of Maine reservists with
PTSD were getting talk therapy for it. But 32% said they would
get such help if they were offered it.
Medical treatment is not the most effective approach for
PTSD, but the strongest evidence is for paroxetine, fluoxetine,
and venlafaxine (an SNRI).
SCHIZOPHRENIA
This is a chronic disorder that usually begins before age
25
in males, 35 in females.
I’ve seen patients who were top students in
college before suddenly experiencing schizophrenic
symptoms.
Not every schizophrenic has auditory or visual hallucinations.
Some lie about it. Get input from a family member when
possible. Some have only delusions and disorganized speech
plus the negative symptoms.
Schizophrenia is usually treated with anti-psychotic meds. Ask
whether the voices (if they’re hearing them) are saying violent
things—telling them to hurt themselves or others. The patient
may need IM administration of an anti- psychotic. These
injectable meds are very expensive, but you can impress upon
the insurance company/prior auth people that they can save a
lot by avoiding frequent hospital admissions.
Do the voices tell the patient to hurt him/herself or others?
If the pt is already on an antipsychotic, then having him or her
take an extra dose of Ability or Risperdal or whatever they take
may be enough to turn things around.
Writing for Risperdal or Seroquel simply for insomnia is not a
good idea. These are powerful meds with potentially
dangerous side effects and some other solution to insomnia
should be found.
INTERMITTENT EXPLOSIVE DISORDER
— a diagnosis for both children and adults.
You could ask about the whole list of DSM V criteria, but when parents
get into a back and forth conversation about how the child does one
thing or another, you won’t have time to cover everything on the list.
You may want to just get a sense of whether the child — or adult — is
blowing up at people to a degree that is high above
the upper limit of normal and is making their life difficult
\
Talk therapy is important, but I have seen many cases in
which it was not enough. Medication was needed as well.
Mood stabilizers are first line and they usually work well. I will
typically try lithium first or adults and oxcarbazepine (Trileptal)
for children.
If a patient with ADD or ADHD shows signs of IED, remember
that treating the attention deficit is the higher priority. It’s easy
for someone to get angry when there is constant criticism
stemming from
distractability or disorganization — or from academic
difficulties.
AUTISTIC SPECTRUM DISORDER
One physical sign that suggest autism is STIMMING.
The person engages is repetitive movements that are self-stimulating.
YOUTUBE has some good videos. Just search for STIMMING.
There’s one of a seven-year-old boy who gently pats or slaps himself on the back of his
head.
Another good diagnostic clue that someone may be autistic is
the inability to use body English (or body French or body
whatever-the-native-language-is) for expressive purposes with
language. And similarly, the inability to understand body
English used by others.
What we can medically treat in ASD are the symptoms.
Guanfacine (generic for Intuniv) is well tolerated and
effective for hyperactivity and inattention.
Guanfacine is helpful with hyperactivity, oppositional behavior
and insomnia. It is less sedating than clonidine and may
be better tolerated.
PLEASE CHECK OUT “TRUE TALES FROM A PHYSICIAN AS
Mood stabilizers are first line for IED and they usually work
well.
I will typically try lithium first after making sure that the
patient is not diametrically opposed to having blood drawn.
Taper off, D/C or minimize dosage of any meds that may be
making patient irritable (e.g. Adderall)