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Dr. Jennifer Kennedy, MD, Psychiatrist VA
Dr. Mike Olson, Ph.D., Faculty SMFMR
Dan Blocker, MS, Doctoral Fellow
Objectives

 Review Integrated Care Team and Model
 Discuss common psychiatric themes/topics that
come up for primary care providers
 Review ITE Psychiatry and Behavioral Health
questions
Stages of Behavioral Health Integration

Coordinated
Co-located
Source: Agency for Healthcare Research and Quality, 2011.
Integrated
“Specialty Care”
“A lot to a little”
“Population-based Care”
“A little to a lot”
Stepped–Care Approach
Level I
Level II
Level III
Level IV
General Psychiatry Questions
• Categories/themes that came up from
resident’s questions
ITE Board Review
Question 1:
M141 Missed by 15
Which one of the following antidepressants can prolong the QT
interval and should be avoided with concomitant QT-prolonging
agents such as atypical antipsychotics?
A) Bupropion (Wellbutrin)
B) Citalopram (Celexa)
C) Mirtazapine (Remeron)
D) Sertraline (Zoloft)
E) Venlafaxine
Answer: B
M141 Missed by 15
B) Citalopram (Celexa)
Prolongation of the QT interval is an important medication adverse effect to
consider. This is particularly true in patients taking multiple medications,
because this effect can be additive and increases the risk of life-threatening
arrhythmias such as torsades de pointes. Among commonly used
antidepressants, citalopram and escitalopram may prolong the QT interval.
Other SSRIs, as well as bupropion, venlafaxine, and mirtazapine, do not have
this effect. Both tricyclic antidepressants and antipsychotics, commonly used in
patients also taking SSRIs, can cause QT prolongation, making their combined
use problematic.
Ref: Muench J, Hamer AM: Adverse effects of antipsychotic medications. Am Fam Physician 2010;81(5):617-622. 2) Price AL,
Marzani-Nissen GR: Bipolar disorders: A review. Am Fam Physician 2012;85(5):483-493. 3) Kovich H, DeJong A: Common questions
about the pharmacologic management of depression in adults. Am Fam Physician 2015;92(2):94-100.
Question 2:
M038 Missed by 14
A 42-year-old female visits your office. She has alcohol use disorder
and wants to quit drinking. She recently went through inpatient
detoxification and is attending Alcoholics Anonymous meetings and
counseling. She continues to have strong cravings and is fearful of a
relapse. Her medical history is notable for renal disease and
osteopenia.
Which one of the following would be most appropriate for this patient?
A) Acamprosate
B) Disulfiram (Antabuse)
C) Naltrexone (ReVia)
D) Bupropion (Wellbutrin)
Answer: C
M038 Missed by 14
C) Naltrexone (ReVia)
Medications are effective for alcohol use disorder and should
be offered in conjunction with psychosocial interventions. Oral
naltrexone is the most effective medication to prevent relapse.
Acamprosate is moderately effective but is contraindicated in
patients with renal disease. A recent meta-analysis indicated
that disulfiram is not effective for preventing relapse.
Bupropion is used for smoking cessation.
Ref: Jonas DE, Amick HR, Feltner C, et al: Pharmacotherapy for adults with alcohol use disorders in outpatient settings: A
systematic review and meta-analysis. JAMA 2014;311(18):1889-1900. 2) Centers for Disease Control and Prevention.
Fact sheets—Alcohol use and your health. 3) Hendry S, Mounsey A: PURLS: Consider these medications to help patients
stay sober. J Fam Pract 2015;64(4):238-240.
Question 3:
M224 missed by 9
A 44-year-old male complains of feeling tired and sad for the last few
months. He has a past medical history of obesity, diabetes mellitus with
painful peripheral neuropathy, and seizure disorder. He has also
noticed that he is not as interested in his usual hobbies and is eating
more than usual. You diagnose depression.
Which one of the following would be the most appropriate agent for
this patient, considering his comorbidities and symptoms?
A) Bupropion (Wellbutrin)
B) Citalopram (Celexa)
C) Duloxetine (Cymbalta)
D) Nortriptyline (Pamelor)
Answer: C
M224 missed by 9
C) Duloxetine (Cymbalta)
SSRIs and SNRIs are both effective in reducing depressive
symptoms, but SNRIs have been shown to be superior to SSRIs
for management of neuropathic pain (SOR A). Bupropion
would effectively treat the patient’s depression and could
cause weight loss, but it is contraindicated in patients with
seizure disorders (SOR A). Tricyclic antidepressants such as
nortriptyline could also help with the pain but might also
worsen the patient’s obesity and fatigue (SOR A).
Ref: Kovich H, DeJong A: Common questions about the pharmacologic management of depression in adults. Am Fam Physician
2015;92(2):94-100.
Question 4:
M165 missed by 8
A 24-year-old female sees you for follow-up of her chronic abdominal
pain. You have diagnosed her with somatization disorder. You have
scheduled regular, frequent visits and she has been in counseling for a
few months. She still has significant anxiety about her symptoms and
you would like to start her on a medication.
Which one of the following medications would be most appropriate for
this patient?
A) Amitriptyline
B) Aripiprazole (Abilify)
C) Bupropion (Wellbutrin)
D) Carbamazepine (Tegretol)
E) Lamotrigine (Lamictal)
Answer: A
M165 missed by 8
A) Amitriptyline
Somatic disorders usually require a multifaceted approach to treatment. It is
important to schedule regular visits at short intervals to establish a
collaborative relationship with the patient. It is also important to limit
diagnostic testing and reassure the patient that serious diseases have already
been ruled out, and to screen for other mental illnesses. Referral for counseling
using cognitive-behavioral therapy and mindfulness-based therapies is also
effective. SSRIs and tricyclic antidepressants have been found to be the most
effective pharmacotherapy (SOR B) for somatic symptom disorders.
Amitripityline is the most studied tricyclic antidepressant, and trials have shown
that it has a greater likelihood of success compared to SSRIs. Other
antidepressants, anticonvulsants, and antipsychotic medications are ineffective
and should be avoided (SOR B).
Ref: Kurlansik SL, Maffei MS: Somatic symptom disorder. Am Fam Physician 2016;93(1):49-54.
Question 5:
M066 missed by 6
A 45-year-old male reports being held up at gunpoint while on
vacation 3 months ago. Since that time he has had intrusive memories of
the event, as well as nightmares. Further questioning reveals that he has
been having dissociative reaction flashbacks and meets the criteria for
posttraumatic stress disorder.
Which one of the following is the most appropriate pharmacotherapy
for this patient?
A) Clonazepam (Klonopin)
B) Clonidine (Catapres)
C) Mirtazapine (Remeron)
D) Sertraline (Zoloft)
E) Risperidone (Risperdal)
Answer: D
M066 missed by 6
D) Sertraline (Zoloft)
The dissociative reactions (flashbacks) in this patient are consistent with the diagnosis of
posttraumatic stress disorder (PTSD). The first-line medications for this disorder are
SSRIs and SNRIs. Paroxetine and sertraline have FDA approval for PTSD. Other
antidepressants such as mirtazapine would be second-line therapy. The effectiveness of
central "2-agonists such as clonidine are unknown, and even though benzodiazepines
might help with hyperarousal symptoms, they can worsen other symptoms. Atypical
antipsychotics such as risperidone are not recommended.
Ref: Warner CH, Warner CM, Appenzeller GN, Hoge CW: Identifying and managing posttraumatic stress disorder. Am Fam
Physician 2013;88(12):827-834.
Question 6:
M122 missed by 6
The preferred method for diagnosing psychogenic nonepileptic
seizures (pseudoseizures) is
A) inducing seizures by suggestion
B) postictal prolactin levels
C) EEG monitoring
D) video-electroencephalography (vEEG) monitoring
E) MRI of the brain
Answer: D
M122 missed by 6
D) video-electroencephalography (vEEG) monitoring
Inpatient video-electroencephalography (vEEG) monitoring is the preferred test for the diagnosis
of psychogenic nonepileptic seizures (PNES), and is considered the gold standard (SOR B). VideoEEG monitoring combines extended EEG monitoring with time-locked video acquisition that allows
for analysis of clinical and electrographic features during a captured event. Many other types of
evidence have been used, including the presence or absence of self-injury and incontinence, the
ability to induce seizures by suggestion, psychologic tests, and ambulatory EEG. While useful in
some cases, these alternatives have been found to be insufficient for the diagnosis of PNES.
Elevated postictal prolactin levels (at least two times the upper limit of normal) have been used to
differentiate generalized and complex partial seizures from PNES but are not reliable (SOR B).
While prolactin levels are often elevated after an epileptic seizure, they do not always rise, and
the timing of measurement is crucial, making this a less sensitive test than was previously believed.
Other serum markers have also been used to help distinguish PNES from epileptic seizures,
including creatine phosphokinase, cortisol, WBC counts, lactate dehydrogenase, pCO2, and
neuron-specific enolase. These also are not reliable, as threshold levels for abnormality, sensitivity,
and specificity have not been determined. MRI is not reliable because abnormal brain MRIs have
been documented in as many as one-third of patients with PNES. In addition, patients with
epileptic seizures often have normal brain MRIs.
Ref: Alsaadi TM, Marquez AV: Psychogenic nonepileptic seizures. Am Fam Physician 2005;72(5):849-856. 2) Ropper AH, Samuels MA, Klein JP: Adams and Victor’s Principles
of Neurology, ed 10. McGraw-Hill, 2014, p 332. 3) Goldman L, Schafer AI (eds): Goldman’s Cecil Medicine, ed 25. Elsevier Saunders, 2016, p 2403.
Question 7:
M218 missed by 4
A 19-year-old female high school student is brought to your office by a friend who is
concerned about the patient cutting herself on the wrists. The patient denies that she
was trying to kill herself, and states that she did this because she “just got so angry” at
her boyfriend when she caught him sending a text message to another woman. She
denies having a depressed mood or anhedonia, and blames her fluctuating mood on
everyone who “keeps deserting her,” making her feel like she’s “nothing.” She admits
that she has difficulty controlling her anger. Her sleep quality and pattern appear
normal, as does her appetite. She denies hallucinations or delusions. The wounds on her
wrists appear superficial and there is evidence of previous cutting behavior on her
forearms. Her vital signs are stable.
Which one of the following would be most beneficial for this patient?
A) Clonazepam (Klonopin)
B) Fluoxetine (Prozac)
C) Quetiapine (Seroquel)
D) Inpatient psychiatric admission
E) Psychotherapy
Answer: E
M218 missed by 4
E) Psychotherapy
This patient displays most of the criteria for borderline personality disorder. This is a maladaptive
personality type that is present from a young age, with a strong genetic predisposition. It is estimated to
be present in 1% of the general population and involves equal numbers of men and women; women seek
care more often, however, leading to a disproportionate number of women being identified by medical
providers. Borderline personality disorder is defined by high emotional lability, intense anger, unstable
relationships, frantic efforts to avoid a feeling of abandonment, and an internal sense of emptiness.
Nearly every patient with this disorder engages in self-injurious behavior (cutting, suicidal gestures and
attempts), and about 1 in 10 patients eventually succeeds in committing suicide. However, 90% of
patients improve despite having made numerous suicide threats. Suicidal gestures and attempts peak
when patients are in their early 20s, but completed suicide is most common after age 30 and usually
occurs in patients who fail to recover after many attempts at treatment. In contrast, suicidal actions such
as impulsive overdoses or superficial cutting, most often seen in younger patients, do not usually carry a
high short-term risk, and serve to communicate distress. Inpatient hospitalization may be an appropriate
treatment option if the person is experiencing extreme difficulties in living and daily functioning, and
pharmacotherapy may offer a mild degree of symptom relief. While these modalities have a role in
certain patients, psychotherapy is considered the mainstay of therapy, especially in a relatively stable
patient such as the one described.
Ref: Dean L, Falsetti SA: Treating patients with borderline personality disorder in the medical office. Am Fam Physician 2013;88(2):140-141.
Question 8:
M181 missed by 2
A 43-year-old male presents to your office for an urgent visit because he has a feeling that he is
being followed and is fearful for his life. He tells you someone is listening to his cell phone
conversations and has stolen files from his laptop, and he has observed “shadowy figures”
watching him. He reports that the police have done nothing to protect him, and he has considered
hiring a private investigator. He reports that he has been living out of his car for the past month.
Upon further questioning the patient admits that he lost his job as an accountant a year ago and is
estranged from his family. His overall appearance is unkempt and his speech is pressured and
rapid. His heart rate is 88 beats/min, blood pressure 138/80 mm Hg, and temperature 37.0°C
(98.6°F).
In ruling out medical causes for his psychosis, which one of the following would be most useful?
A) The PHQ-9 questionnaire
B) Urine toxicology
C) MRI of the brain
D) HIV antibody testing
E) A serum calcium level
Answer: B
M181 missed by 2
B) Urine toxicology
Illicit substance use is the most common medical cause or secondary cause of
acute psychosis. Conditions diagnosed by brain imaging, blood chemistry, and
HIV tests (intracranial mass, paraneoplastic syndrome, and HIV infection,
respectively) are less common medical causes of acute psychosis. Major
depression with psychosis would be considered a psychiatric or primary cause
of psychosis.
Ref: Griswold KS, Del Regno PA, Berger RC: Recognition and differential diagnosis of psychosis in primary care. Am Fam Physician
2015;91(12):856-863.
Question 9:
M231 missed by 2
An 18-year-old male comes to your office because of the recent onset of
recurrent, unpredictable episodes of palpitations, sweating, dyspnea,
gastrointestinal distress, dizziness, and paresthesias. He says he is always
concerned about when the next attack will occur. His physical
examination is unremarkable except for moderate obesity. Laboratory
findings, including a CBC, blood chemistry profile, and TSH level, reveal
no abnormalities.
The most likely diagnosis is
A) mitral valve prolapse
B) paroxysmal supraventricular tachycardia
C) pheochromocytoma
D) generalized anxiety disorder
E) panic disorder
Answer: E
M231 missed by 2
E) panic disorder
Panic disorder typically presents in late adolescence or early adulthood with
unpredictable episodes of palpitations, sweating, gastrointestinal distress,
dizziness, and paresthesias. The attacks are sporadic and last 10–60 minutes.
Generalized anxiety disorder is more common, and common symptoms include
restlessness, fatigue, muscle tension, irritability, difficulty concentrating, and
sleep disturbance. Pheochromocytoma is associated with headache and
hypertension, and usually occurs in thin patients. Paroxysmal supraventricular
tachycardia is usually not associated with gastrointestinal distress or
paresthesias. While mitral valve prolapse can be associated with anxiety and
panic disorder, the physical examination would not be normal.
Ref: Kasper DL, Fauci AS, Hauser SL, et al (eds): Harrison’s Principles of Internal Medicine, ed 19. McGraw-Hill, 2015, pp 27082709.
Question 10:
M119 missed by 1
During a routine health maintenance visit, a 24-year-old female admits that she is not
feeling well due to being overwhelmed with stress. She feels she has always worried
more than most people, but recent troubles at home and at work have made things
much worse. She says she is irritable with people around her, has trouble focusing at
work, and feels fatigued late in the day. Despite her fatigue, she has difficulty falling
asleep at night. The patient denies anhedonia, suicidal thoughts, or a persistently
depressed mood. She limits her caffeine intake, does not smoke or drink alcohol, and is
not using any illicit drugs.
In addition to psychotherapy, which one of the following medications is recommended
for this patient?
A) Alprazolam extended release (Xanax XR)
B) Clonazepam (Klonopin)
C) Gabapentin (Neurontin)
D) Quetiapine (Seroquel)
E) Sertraline (Zoloft)
Answer: E
M119 missed by 1
E) Sertraline (Zoloft)
This patient’s symptoms are consistent with the DSM-5 criteria for generalized
anxiety disorder. First-line treatments for this condition are SSRIs, SNRIs, and
tricyclic antidepressants. Quetiapine and gabapentin are considered secondline medications for anxiety if control cannot be obtained with more traditional
agents. Benzodiazepines such as alprazolam and clonazepam are sometimes
necessary for short-term control of anxiety symptoms but are generally
discouraged due to sedating side effects, the potential for abuse or diversion,
and gradual tolerance.
Ref: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 5. American Psychiatric
Association, 2013, pp 189-264. 2) Combs H, Markman J: Anxiety disorders in primary care. Med Clin North Am
2014;98(5):1007-1023. 3) Locke AB, Kirst N, Shultz CG: Diagnosis and management of generalized anxiety disorder
and panic disorder in adults. Am Fam Physician 2015;91(9):617-624.
Question 11:
M031 missed by 1
Which one of the following is effective in preventing seizures
associated with alcohol withdrawal syndrome?
A) Carbamazepine (Tegretol)
B) Chlordiazepoxide
C) Clonidine (Catapres)
D) Gabapentin (Neurontin)
E) Phenytoin
Answer: B
M031 missed by 1
B) Chlordiazepoxide
Benzodiazepines, such as chlordiazepoxide, can prevent
alcohol withdrawal seizures. Anticonvulsants such as
carbamazepine, gabapentin, and phenytoin have less
abuse potential than benzodiazepines but do not prevent
seizures. Clonidine, an "-adrenergic agonist, reduces the
adrenergic symptoms associated with withdrawal but does
not prevent seizures.
Ref: Muncie HL Jr, Yasinian Y, Oge L: Outpatient management of alcohol withdrawal syndrome. Am Fam Physician
2013;88(9):589-595.
Question 12:
M121 missed by 0
Which one of the following is most likely to improve
outcomes in schizophrenia?
A) Combining antipsychotic medication with psychosocial
treatment
B) Prescribing two second-generation antipsychotic
medications together in small dosages
C) Initial treatment in the outpatient rather than inpatient
setting
D) Using only one first-generation, or typical, antipsychotic
medication combined with an antidepressant medication
Answer: A
M121 missed by 0
A) Combining antipsychotic medication with psychosocial treatment
The combination of antipsychotic medication and psychosocial
treatments, including cognitive-behavioral therapy, family therapy, and
social skills training, is associated with the best outcomes in patients with
schizophrenia (SOR B). Antipsychotic medications should not be
combined. Hospitalization, especially for the first episode of
schizophrenia, is also recommended for the best outcome (SOR C).
Antidepressant medication will treat depression associated with
schizophrenia but will not necessarily improve the symptoms of
schizophrenia.
Ref: Holder SH, Wayhs A: Schizophrenia. Am Fam Physician 2014;90(11):775-782.
Question 13:
M173 missed by 0
A 19-year-old female college student is referred to you by her dentist
for a medical evaluation related to dental problems. The patient states
that she feels well and exercises at least 2–3 hours every day. On
examination her teeth are stained and there are enamel erosions. She
has nontender enlargement of both parotid glands. The remainder of
the examination is normal.
Which one of the following is associated with these findings?
A) Bacterial parotitis
B) Bulimia nervosa
C) Cat scratch disease
D) Mononucleosis
E) Mumps
Answer: B
M173 missed by 0
B) Bulimia nervosa
Bulimia nervosa is an eating disorder associated with recurrent
binge eating and induced vomiting. There is also a history of
excessive physical activity in many cases. Because of vomiting,
the teeth are stained and there is destruction of the enamel
from stomach acid. Parotid swelling is also noted frequently.
With mumps and bacterial parotitis the patient feels sick and
parotid glands are tender. Cat scratch disease and
mononucleosis affect lymph glands.
Ref: Harrington BC, Jimerson M, Haxton C, Jimerson DC: Initial evaluation, diagnosis, and treatment of anorexia nervosa
and bulimia nervosa. Am Fam Physician 2015;91(1):46-52.
Question 14:
M178 missed by 0
In an adult patient with significant depression and no
other health problems, which one of the following is
the best initial choice for pharmacotherapy?
A) Amitriptyline
B) Duloxetine (Cymbalta)
C) Fluoxetine (Prozac)
D) Mirtazapine (Remeron)
E) Trazodone (Oleptro)
Answer: C
M178 missed by 0
C) Fluoxetine (Prozac)
Depression can be treated with counseling and/or medication. The choice of medication
depends on many factors including side effects, dosing schedule, cost, patient
preference, and comorbidities. In a patient with significant depression and no
comorbidities, a second-generation SSRI should be the initial medication choice.
Fluoxetine is the only SSRI choice listed. Duloxetine is an SNRI that may lead to
sweating, tachycardia, urinary retention, and elevation of blood pressure. It is indicated
if the patient has fibromyalgia. Trazodone is associated with somnolence, orthostatic
hypotension, and priapism. It may be used in low doses as an adjuvant in patients with
insomnia. Mirtazapine can cause sedation, weight gain, increased appetite, dry mouth,
dizziness, and constipation. It is helpful for patients with significant insomnia and loss of
appetite. Amitriptyline is a tricyclic antidepressant and has significant anticholinergic
side effects. It is also associated with conduction abnormalities that can lead to
arrhythmias.
Ref: Drugs for psychiatric disorders. Treat Guidel Med Lett 2013;11(130):53-64. 2) Kovich H, DeJong A:
Common questions about the pharmacologic management of depression in adults. Am Fam Physician
2015;92(2):94-100.