Download Psychiatric Disorders in Primary Care

Mental Health Screening in
Primary Care
Valerie Dzubur EdD APRN FNP-BC
 All medical care flows through the relationship between
physician (provider) and patient, and the spoken word
is the most important tool
Eric Cassell
 Objectives:
 Identify & Rx
 Psychiatric disorders in Primary Care
 Discuss Co-morbidities
 Depressive Disorders
 Anxiety Disorders
 Suicidal Ideation
 Personality Disorders
 The difficult patient
 Somatoform Disorder
 Prevalence of mental illness (NIMH)
 22% of U.S. adults (~44 million persons) have a
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diagnosable mental disorder
The most common problem in primary care
4 of 10 disability are mental disorder
50 % of the time depressed persons will be treated by
primary care provider
80 % of Rx written by non-psychiatrist
Depressed persons use 50 – 75 % more health care
services than other chronic illnesses
Table 1: - The leading causes of years lived with disability, worldwide, 1990
Total
Per cent
(millions) of total
All causes
472.7
1. Unipolar major depression
50.8
10.7
2. Iron deficiency anaemia
22.0
4.7
3. Falls
22.0
4.6
4. Alcohol use
15.8
3.3
5.Chronic obstructive pulmonary disease 14.7
3.1
6. Bipolar disorder
14.1
3.0
7. Congenital anomalies
13.5
2.9
8. Osteoarthritis
13.3
2.8
9. Schizophrenia
12.1
2.6
10. Obsessive compulsive disorders
10.2
2.2
 Axis I
 Neurosis & Psychosis
 A clinical disorder that can be effectively relieved with
interventions
 Mood disorders
 Thought disorders
 Anxiety disorders
 Axis II
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Personality & Developmental Disorder
Long standing
Ingrained in the developmental process of childhood
May causes major life-long dysfunction in many
spheres of life
 Can be difficult to treat
 74% of Americans seeking help for depression
 Will go to a PC provider
 Not a mental health professional
 [Montano B: Journal of Clinical Psychiatry 1994]
 Clinical Tips
 Anxiety and Depression hold hands
 Future Focused Symptoms
 Consider Anxiety
 Past Focused Symptoms
 Consider Depression
 Clinical Tips
 Anxiety and Depression hold hands
 Future Focused Symptoms
 Consider Anxiety
 Past Focused Symptoms
 Consider Depression
 Treatments
 Have referral information in hand
 Use Medications early for
 Symptom and Mood Management
 Counseling helps people
 Understanding the cause & meaning
Meaning is not something you stumble
across, like the answer to a riddle or the
prize in a treasure hunt. Meaning is
something you build into your life. You
build it out of your own past, out of your
affections and loyalties…out of the things
you believe in, out of the things and
people you love, out of the values for
which you are willing to sacrifice
something” John Gardner
 Clinical Wisdom
 Medications Management
 A witches brew
Each persons treatment is individualized
Consider side effect profile
Personal Goals
Use different combinations of medications
Creating the recipe Making a stew
 People seen in a PC Setting
 5 - 10 % will have depression
 People in the hospital
 10 to 14%
 [National Institute of Mental Health, “Co-occurrence of Depression with Medical,
Psychiatric and Substance Abuse Disorders,”
http://www.nimh.nih.gov/depression/co_occur/abuse.htm.]
 There is a reciprocal relationship
 Between people who are depressed
 And the occurrence of major CV events
 People who are depressed are at risk for a
cardiovascular event
 People who have a cardiovascular event are at risk for
depression
 Heart Disease and Depression
 Depression
 occurs in
 40 to 65 % who have had an MI
 18 to 20 % who have CAD W/O MI
 After an MI
 A person with clinical depression
 Has a 3 - 4 X > chance of death
 Within the next six months.
[http://www.nimh.nih.gov/depression/co_occur/heart.htm.]
 Depression occurs in
 10 - 27 % of CVA survivor
 can last one year
 15 - 40% of CVA survivors
 experience some symptoms of depression within two
months after the stroke.
[http://www.nimh.nih.gov/depression/co_occur/stroke.htm]
 Reciprocal relationship
 Psychosocial risk factors
 Loss of social roles/independence after MI or CVA
contributes to depression.
 Depression may result in impaired adherence to
treatment and interfere with physical rehabilitation.
 Hypercortisolemia increases the risk of arteriosclerosis.
 Depression is associated with increased heart rate
variability
 (interferes with parasympathetic function) and increases
the risk of arrhythmia.
 Depressed people have been shown to have increased
platelet activation
 (serotonergic mechanism).
 People with adult onset diabetes
 25% have depression.
 People with diabetic complication
 70% have depression [Lamberg L: JAMA 1996]
 People who tx for co-occurring depression
 An improvement in overall health
 Better compliance with medical care
 Better quality of life
 80% of people
 with depression can be treated
 Medication
 psychotherapy
 Combination of both
 Early diagnosis and tx reduces
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Patient discomfort
Morbidity
Cost
Suicide
 Prevalence 2.5 – 8% of the population
 Women affected twice as often as men
 20 % will have co-morbid substance abuse problems
 A symptom
 A Syndrome
 A Disorder
Symptom
Chest pain
Fatigue
% with Anxiety
33%
26%
28%
Headache
35%
Insomnia
31%
 Panic Disorder (+/agoraphobia)
 Post-traumatic Stress
Disorder
 Generalized Anxiety Disorder
 Social Phobia
 Obsessive-Compulsive
 Specific Phobia
Disorder
 Secondary to a Generalized
Medical Condition
 Substance-Induced
 Endocrine:
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Hyper/Hypo Thyroid
Pheochromocytoma
Hypoglycemia
Carcinoid syndrome
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Hypo-parathyroidism
Insulinoma
Cushing’s syndrome
Acute intermittent porphyria
 Respiratory
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COPD
Hypoxia from any cause
PE
Asthma
 Neurological Disorders
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Aura of migraine
Early dementia
Cerebral neoplasia
Delirium
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Partial complex seizures
Demyelinating disease
Post concussive disorder
Withdrawal from sedativehypnotics, caffeine, or
nicotine
 Manifested by unrealistic or excessive anxiety or worry
about two or more life circumstances that persists for 6
months or longer
 Symptoms
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Restlessness/nervousness
Fatigue
Concentration difficulties
Irritability
Tension
Sleep disturbances
 Treatment
 Patient Education – Life
style modification
 Avoid caffeine, nicotine,
alcohol, & other stimulants
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Increase exercise
Sleep hygiene
Stress management
acupressure/acupuncture,
reflexology
 Psycho Therapy – client
centered
 Behavior cognitive
therapy
 Support groups
 Complimentary medicine,
meditation, massage
 Occurs > in women than men
 Crosses all social
 Cultural & class lines
 The fears are life changing
 Symptoms include
 Palpitations
 Pounding heart
 Increase HR
 sweating
 trembling
 Chest pain
 Dizziness
 SOB
 Fear of dying
 Numbness
 Tingling
 Chills
 Hot flashes
 Nausea
 Vomiting
 Abdominal pain
 The key behavior changes…
 Avoid dating
 Fear they will never marry
 Avoid classes or jobs that require working in groups
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Decide not to go to college
Avoid employment opportunities
Work at a lower level than ability
Avoid public places
Stay at home more and more
Avoid anxiety producing events
 As social phobia worsens if begins to effect every
aspect of life and leads to
 Depression
 Substance Abuse
 Isolation
 Family disruption
 The patient’s fears direct the patients choices
 Limit their opportunities
 Spoiling their life
 As they adapt to accommodate the social phobia
 Treatment
 Medications
 SSRI
 Name the disorder
 people get relief by knowing they have a recognized &
treatable condition
 Patient education
 Act to rebuild self esteem
 Cognitive Behavior & Support Groups
 learn new coping skills
 Goal of treatment
 Focus on small gains over time
 Focus to improve or minimize
 symptoms
 Avoidance behaviors
 Panic Attacks or Episodes
 Effects 5 million Americans
 30% will have an isolated episode
 When the panic is recurrent
 With anticipatory anxiety
 Diagnosis = anxiety disorder
 Patients with panic disorder
 Discrete episodes of intense fear
 A sense of physical discomfort
 Episodes vary in frequency & severity
 Panic Episodes
 Sometimes described as a wave
 Happen for no apparent reason
 Last from 10–30 minutes
 Over time the anxiety becomes pathological…
 The person begins
 avoiding the situation where the attacks first occur
 As more and more attacks occur
 There are more and more situations to avoid
 Chest Pain
 Sweating
 Nausea
 Trembling
 GI Distress
 Shaking
 Shortness of breath
 Palpations
 Increased heart rate
 Feels like choking
 Diff. breathing
 Dizzy
 Fear of dying
 Light-headed
 Paresthesias
 De-realization
 Chills or
 Depersonalization
 Hot flashes
 Fear of losing
 Going crazy
 In the Worst Case
 The person becomes housebound
 Avoiding all possible situations
 That might bring on an attack
 50 % of the time
 People also suffer from depression
 SSRI & SSSRNIs
 Benzos (?)
 Client Centered counseling
 Cognitive Behavior Therapy
 Support Groups
 Patients Education
Medication Choices
 Reoccurring obsessions and or compulsions that are
severe enough to be time consuming ( > 1 hours per
day)
 These behaviors cause significant distress or
impairment
 The person may recognize that the obsession or
compulsion is excessive or unreasonable but they can
not resist
 4 th most common anxiety disorder, can begin at any
age, 50 % of the time begins in childhoods
 At first the person can not finish anything than as things
get worse the person can not start anything
 Obsessions
 Compulsions
 Recurrent, persistent
 Repetitive behaviors with
thoughts, images,
impulses, etc.
 Intrusive, inappropriate
 Marked anxiety/distress
 Not excessive real-life
worries
 Attempts to
ignore/suppress
driven quality
 Rigidly applied rules
 Aimed at reducing
distress or preventing a
dreaded event or outcome
but are unrealistic or
excessive
 Left untreated symptoms will worsen leading to
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Loss of employment
Isolation
Depression
Divorce or other family disruption
 Medications are the mainstay
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Name the disorder
SSRI - high doses
Behavior focused therapy
Patient Education
 Not a moral/character failing
 Relief from a sense of shame
 Goal
 gradual improvement over time as the person begins to
be able to let go of unwanted thoughts
 You may not see any improvement from medication for 4
- 6 months
 Acute Traumatic Stress
 Symptoms < 3 months
 Post Traumatic Stress
 Symptoms > 3 months
 Delayed Onset
 Symptoms can occur 6 mos - 30 yrs
 Delayed Onset
 The Kindling Effect
 The process in which repeated sub-threshold stimulation of a
neuron eventually generates an action potential
 The Origin is Trauma
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Child Abuse
Beatings
Sexual assault
Serious accident
Incurring a significant injury
Sudden unexpected death
Captivity
War
 Exposure to a traumatic event in which both of the
following were present:
 Events involved threat of
 actual death of self or other
 serious injury of self or other
 Disintegration of the integrity of self/others
 Response involves
 intense fear
 helplessness
 horror
 Persistent re-experiencing of trauma
 (1 or more)
 Recurrent, intrusive images, thoughts, perception
 Distressing dreams, flashbacks, illusions, hallucinations
 Intense psychological & physical distress in response to
symbolic internal or external cues
 Persistent avoidance & numbing
 3 or more
 Avoidance of thoughts & feelings
 Avoidance of activities, places or persons associated with or
triggering recall of trauma
 Inability to recall important aspects of trauma
 Disassociation from time or place
 Persistent avoidance & numbing
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 3 or more
Diminished interest or participation
Feeling detached or estranged from others
Restricted affect
Sense of a foreshortened future
 Persistent arousal
 2 or >
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Sleep disturbance
Irritability or outbursts of anger
Unstable mood
Difficulty concentrating
Hyper-vigilance
Exaggerated startle response
 Treatment
 The first principle of recovery is empowerment of the
survivor
 A person must be the author and arbiter of recovery.
 Restoration of control
 Treatment
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Client Center Counseling
Cognitive Behavior Therapy
Disclosure therapy
Support Groups
Complimentary Medicine < stress
Patient Education
 Recovery unfolds in a spiral
 First central task of therapy
 Safety
 Second task of therapy
 Remembrance and mourning
 Third task of therapy
 Reconnection with ordinary life
 Pharmacotherapy
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Mood Stabilizer
Anti-anxiety Rx with caution
Sedative hypnotics Rx with caution
Buspirone (BuSpar)
Antidepressants
 At least 4 of the
following present for at
least 2 weeks
 Low mood
 Anhedonia
 Poor concentration
 Low energy
 Guilt or worthlessness
 Pessimism or
hopelessness
 Sleep disturbance
 Agitation or retardation
 Appetite disturbance
 Loss of libido
 Suicidal ideation
SALSA
Sleep disturbance
Anhedonia
Low Self esteem
Appetite decreased
97% sensitivity
94% selectivity
(Brody, Arch Int Med, 1998)
 SIG-E-CAPS
 Energy decreased
 Depressed Mood Plus:
 Concentration difficulties
 Sleep decreased
 Appetite disturbance or
 Interest decreased in
 Psychomotor
activities (Anhedonia)
 Guilt or worthlessness
(Not a major criteria)
weight loss
retardation/agitation
 SSRI
 SSRNI
 TCA
 Mood Stabilizer
 Sleeping Meds
 Anti-psychotics
 Atypical
 More than One Rx
 Avoid the use of TCAs with co-morbid CV
 “Dirty”- non-selective with many side effects
 Altered cardiac conduction increases risk of arrhythmia.
(Class I anti-arrhythmic effect)
 Orthostatic hypotension (alpha-adrenergic)
 Exacerbation of hypertension (noradrenergic)
 Clomipramine (Anafranil)
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Class TCA
Starting does 25 – 50 mgs
Dosage Range 100 – 250 mgs
Approved of OCD
 Selective Serotonin Reuptake Inhibitors
 2D6 inhibitors
 Citalopram, Sertraline, Fluoxetine, Paroxetine, Escitalopram
 Weight gain, sleep disturbance, sexual dysfunction, may
reduce platelet aggregation.
 Clinical Tip:
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They will all work
Think about the side effects
Consider Escitalopram for crying
They all cause sexual dysfunction
Consider a lower dose
Drug Holidays
Check Akathisia
Avoid in bi-polar can cause mania
 Fluvoxamine (Luvox)
 Class SSRI
 Starting dose 25 – 50 mgs
 Dosage Range 100 – 300 mgs
 Approved for OCD SAD depression
 Careful management of interactions
 Paroxetine (Paxil)
 Starting dose 10 – 20 mgs
 Dosage Range 40 – 60 mgs
 Approved for PD OCD SAD depression
 Sertraline (Zoloft)
 Starting dose 25 mgs
 Dosage Range 50 – 200 mgs
 Approved for PD OCD (adults children) PTSD
depression
 Fluozetine (Prozac)
 Starting Dose 10 – 20 mgs
 Dosage Range 20 – 80 mgs
 Approved for OCD anxiety depression
 Venlafaxine - Effexor 37.5 - 150 mgs
 May exacerbate HNT
 Take at the same time each day, don’t miss a dose
Taper to discontinue or use prozac
 Cymbalta - Duloxetine HCL 20 - 60 mgs
 May exacerbate HNT
 If diabetic monitor glucose
 Buspar
 Class azapirones
 Starting dose 15 mgs
 Dose Range 15 – 60 mgs
 Therapeutic Response 3 – 6 weeks
 Beta Blockers
 Inderal 10 – 20 mgs TID or QID
 Metoprolol 25 – 50 mgs BID
 Atenolol 50 – 100 mgs QD
 Careful history and assessment of B/P, HR, Lungs,
History of CHF, arrhythmia, COPD, Asthma
 Bupropion (Wellbutrin) 150 - 300 mgs
 Reduce seizure threshold dose related
 Activating, smoking cessation
 Use for couch potatoes and grazers
 A potentially fatal toxic encephalitis
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Confusion
Agitation
Rigidity
Hyper-reflexia
Fever
Hyperthermia
 Usually a drug interaction that raises the blood level of
serotonin
 Needs hospitalization for support
 Check medication profile for drug interactions
 Any selective 5HT receptor antagonist for example Zofran
 Mirtazipine (Remeron) 15, 30, 40 mgs
 Causes weight gain
 Good for sleep
 Good for nausea
 Trazadone 50 -300 mgs
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Good for sleep
Good for alcoholics - not addictive
Priapism
Avoid with an acute MI
Urinary Retention
 Annual suicide rate (U.S.) =
11.2/100,000
 9th leading cause of death
 Socio-demographics
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Elderly (men>70 years)
Unmarried
Native American or Caucasian
Male (white men = 70% of U.S. suicides)
Living alone
Increasing rates among adolescents
 Recent stressors
 Health, Financial
 Marital, Family
 Legal, Occupational
 Psychiatric disorder
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Depression
Anxiety (panic)
Schizophrenia
Bipolar Disorder
 Personality disorder
 Alcohol/drug use
 Command Hallucinations
 Previous attempts
 Family history
 Ask about suicidal ideation
 Check for risk factors
 Listen to comments about suicide
 If the patient discusses
 Putting affairs in order
 Care of pets
 Other cues and clues
 If patient responds positively
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Do you have a plan
How would do this
Are there means available
Have you rehearsed or practiced
How strong is your intent
Do you tend to be impulsive
Can you resist the impulse
 Suicide Contract
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Dependent on the strength of relationship
Agreement to call provider
Use support system, resources, suicide prevention
Inform family, significant other, close friend
Close follow-up
Referral to mental health provider
If unable to contract or at imminent risk refer for
emergency psychiatric assessment.
 When treating a patient for depression
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The risk for suicide may increase
In the early phase of treatment
As the patient’s energy levels lifts.
The patient simply develops enough
New energy to carry out a plan
 Manic Episode:
A.elevated, expansive, or irritable mood,
lasting at least 1 week
B.three (or more) of the following
symptoms
C.inflated self-esteem or grandiosity
D.decreased need for sleep
E.Hyper-verbal or pressured speech
Bi-Polar
A. insomnia or hypersomnia
B. psychomotor agitation or retardation
C. flight of ideas or racing thoughts
D. distractibility
E. increase in goal-directed activity at work or
psychomotor agitation
F. excessive involvement in pleasurable activities that
have a high potential for painful consequences
 25% suicide attempt
 w/o treatment 15% successful attempt
 Recurrent illness 80-90%
 Repeat events-progressive deterioration
 Untreated 9 year < in life expectancy
 14 year < in productivity
 Treatment > 6.5 - 10 yrs
 Bipolar I=periods of mania +/- depression
 Bipolar II=periods of depression/hypomania
 Mixed states=periods of mania & depression
 Rapid Cycling = 4 episodes in 12 mos
 More common in bipolar II
 Lithium
 Anticonvulsants
 Atypical antipsychotics
 Traditional antipsychotics
 Antidepressants
 Lamictal 12.5 - 200 mgs bid
 Stop for any rash (life threatening)
 Raise dose q 2 weeks 25 mgs
 Trileptal 150 - 600 mgs bid
 Small dose in am
 Larger dose in pm
 Mood Stabilizer
 May use a higher dose
 When one medication is not enough
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Mood instability at the end of the day
Break through symptoms
Nothing works
Stopped working
Medication failure
New symptoms
 Add a mood stabilizer
 Depakote 125 - 1500 mgs bid
 blood level, Liver Function
 Lithium 300 - 600 bid
 blood levels, narrow therapeutic range
 Lamictal 12.5 - 200 mgs bid
 Add a mood stabilizer
 Topomax 25 - 100 mgs bid  may cause glaucoma, expensive
 Trileptal 1200 - 1500 mgs bid
 Tegretol 100 - 1200 mgs bid
 blood levels, interactions
 Zyprexa 2.5 - 5 mgs bid
 Weight gain diabetes
 Add an antipsychotic
 Navane 5 mgs bid
 Trilafon 2 - 8 mgs bid
 Abilify 5 - 20 mgs qd
 Add an antipsychotic
 Seroquel 25 mgs bid
 Risperdal .25 - .5 mgs bid
 Geodon 40 mg - 60 mgs bid
 Titrate the dose up according to the patient’s mood q 1
- 2 weeks
 Need a lower dose as adjunctive
 When stable consider QD dosing
 Change to HS is sleepy
 Change to am if activated
 If suddenly can’t sleep change dose earlier in the
evening
 Taper one medication
 Start new medication low & slow
 Increase dose every 3 - 4 days
 Use Prozac 20 mgs for self taper off of SSRI
 Listen to your patient
 As the Provider you may experience:
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You’re working hard but getting no where
4 or more problems vaguely or unrelated
Everything has been tried – nothing worked
Consider the diagnosis of Personality Disorder
 15% or more of patients (Hahn et al J Gen Intern Med, 1996)
 Overly dependent,
 “clinging”
 Demanding
 “entitled” “manipulative,
 unwilling to accept recommendations
 “self destructive” (Groves, NEJM, 1976)
 Consider personality disorder
 Characterized by chronic
 Rigid maladaptive behaviors
 Persons with personality disorders
 may appear odd or eccentric
 cluster A
 dramatic, emotional, or erratic
 cluster B
 anxious and fearful
 cluster C
 Personality disorders
 frequently co-occur with other psychiatric & substance
use disorders
 depressed, emotionally labile, & prone to suicidal ideation
 High users of medical and psychiatric services
 Severe disorders require
 referral to mental health services.
 Treatment includes
 psychotherapy
 medication for depression
 Self-awareness:
acknowledge frustration
 Verbalize concerns
 Allow more time
 Schedule regular f/u visits
 Set limits
 Cultivate participation &
 Monitor for “burn-out”
 Seek consultation
partnership
 Developed in the 1980’s by Dr. Linehan
 Emphasis
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Acceptance that encourages change
Firmness with flexibility
Nurturance with benevolent demands
Non-re-enforcement of self destructive behaviors
Patient completes behavior change analysis
 Developed out of research on suicidal behavior
 Combines Western and Eastern points of view
 Radical acceptance
 Self Responsibility for change
 Physical complaints
 can not be completely or adequately explained by a
 general medical condition
 substance abuse
 mental disorder
 Symptoms must be
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Clinically significant
Cause distress
Functional impairment
Symptoms are not intentional
 Disorders Include
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Somatization Disorder
Undifferentiated somatoform disorder
Conversion disorder
Pain disorder
Hypochondriasis
Body Dysmorphic Disorder
Somatoform disorder
See hand out
 There are no specific Dx or Rx
 Standard medical evaluation
 assess for treatable cause
 Considerations
 History of sexual/physical abuse
 Consider Hypochondriasis
 Use primary care management principles
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Scheduling regular brief visits
Avoid many tests and subspecialty referrals
Avoid disputing the realty of the complaint
Use symptom management
Give reassurance
Listen
Be flexible
 Consider Cognitive Behavior Therapy
 Utilize complementary and alternative medicine
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intervention
Aim for function not disability
Time management
Reassurance
Avoid saying nothing is wrong
 Reassurance can include
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Legitimize the suffering
Explain symptoms without tests
Symptoms are non-progressive
Expect gradual improvement
 Consider
 neurological symptom
 consider conversion disorder
 Unexplained pain
 Consider pain disorder
 Multiple Unexplained symptoms
 undifferentiated somatoform disorder
 somatization disorder
 If suspect symptoms are intentionally feigned
 Malingering or Factitious Disorder
 To note in the record
 unexplained medical complaint
 Why
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Respectful
Accepts The Client
Encourages Self Responsibility
Mobilizes Inner Resources
 Motivation is a key to change
 Motivation is multidimensional
 Motivation is a dynamic and fluctuating state
 Motivation is interactive
 The clinician’s style influences the client’s motivation
 In contrast with confrontational/denial
 A label is not necessary
 Focus on personal choice (does not force disease model
 Elicits client’s concerns instead of telling the client what
to be concerned about
 Resistance is seen as interpersonal, influenced by the
therapist/NP
 Resistance is met with reflection, not argument
 As the interviewer you want to
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Develop Discrepancy
Avoid Argument
Roll with Resistance
Express Empathy
Support Self Efficacy
Used along with the stages of change model can be a
very effective method to support people with making
changes in their lives
 Strategies of motivational interviewing might include
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Focus on the person’s strengths
Respect their autonomy and decisions
Individualize/patient centered treatment
Avoid labels - they are dehumanizing
Develop a therapeutic relationship
Focus on early interventions or less intensive treatments
 Is a therapeutic style or way of interacting with people
 that facilitates an exploration of stage-specific
motivational conflicts that can that hinder future
progress
 Successful motivational interviewing includes being
able to
 Express empathy through reflective listening
 Communicate respect and acceptance of the person and
their feelings
 Establish a nonjudgmental, collaborative relationship
 Be supportive a knowledgeable consultant
 Compliment rather than denigrate
 Listen rather than tell
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Gently persuade with understanding
Develop discrepancy
Between the person’s goals/values & behavior
Support people to recognize the discrepancies
Between where they are and where they hope to be.
 Tip Treatment Improvement Protocol
 U.S Department of Health and Human Services National
Clearinghouse for Alcohol and Drug Information
 DHHS Publication No. (SMA ) 02-3629
 1-800-729-6686
 1-301-468-2600