Download Approaches to Diagnosis and Treatment of Common

Approaches to Diagnosis and
Treatment of Common
Psychiatric Problems in General
Medicine, and When to Refer
Patsy Hoyer, CFNP
October 27, 2010
• The Original Title: What To Do Until The
Psychiatrist Arrives
• The psychiatrist rarely arrives!
• Providers have to deal with a lot!
STATISTICS
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20% of general population, 25% office
1/3 adult problems begin in childhood
Anxiety most prevalent
Depression more elusive
Adult depression, 21 million
Adult depression 5-10% of practice
CDC Study
Postpartum Blues 80% , Depression 20%
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Adults with depression 16 % ADHD
Childhood ADHD 7%
ADHD Adults present a anx/dep
OCD, 50% have ADHD
10-12% Children ADHD have mood
disorder
• 1% true bipolar
• 4% spectrum conditions
• 1/1000 Schizophrenia
• Personality disorders may be as high as
10%-15%
• The take away: There is a lot of suffering
• Presentation may be obscuring of dx
• Often one or more co-morbid conditions
• Alcohol and drug abuse may be present
• Major variation in provider management
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Take time and fit it in
Suck it up, it is important to do
Psychcentral.com
Primary care sees patients over time
Follow-up is key
Refer suicidal
History is important!
• Current functioning
– Perceived issues/precipitating event
– Sleep
– Appetite
– Mood
– Functioning/work/school, family, relationships
– Recent drugs, alcohol, etc
– Suicidal ideation
– Specific other questions toward co-morbitities
Longitudinal History
• What were they like before, high school
the last several years
• Grades in school, jobs, troubles in job. law,
marriage
• Treatments in past
• ---Key in ADHD, mood disorders, mania,
previous suicide, etc
FAMILY Social and Genetic Hx
• Genetics is not a diagnosis, but it can give
a clue
• ANXIETY
– Higher doses of SSRI’s
– Inderal La may help instead of xanax
– Clonazepam—sometimes it is needed
• DEPRESSION
– STAR D-uses citalopram
• Most of us use by side effect
• New Recommendations
– buproprion
– remeron
• Cymbalta and Pristiq--niches
Irritability
• Anxiety—don’t disrupt
• Depressed---leave me alone
• Bipolar spectrum—intense, random
• Longitudinal and family hx helpful with this
• Atypicals
• Small doses, just might help
• Refractory anxiety, depression, family hx,
sleep
• Side effect issues, weight, metabolic
syndromes—need to discuss and monitor
• “Activation” not mania
Personality Disorders—how they
make you feel
• Proposed Classifications in DSM 5
• A—odd/eccentric-Odd ways of thinking—
what was that?
• C—anxious/fearful—down and depressed
• B—dramatic/emotional—suck the life out
of you
When do you refer?
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Diagnosis ?—Personality disorders
Treatment Plan not working
Not comfortable with the medicine
Therapy,life coaching, CBP, skills training
would help—most of the time!
• Refer with information about your
question.
• Refer with some history—esp of meds
used
• Refer with possible goals for therapy
• Refer with your question for testing—not
just “see a psychologist.”
Improve your skills
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Talk to colleagues
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