Download Mental Health in the Primary Care Setting

Mental Health in the
Primary Care Setting
Kimberly R SIRK MSN,CNS,APRN,PMHNP-BC
Patients Verses Psychiatric Nurse Practitioners
Q. What's the difference between the Psych NP and the patients admitted to an
inpatient psychiatric hospital?
A. The patients eventually get better and go home!
Emoticons for Psychiatric Med Management
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stable. cont prozac 40mg. f/u 3 mos.
reduce prozac to 20mg. f/u 1mo.
d/c prozac. add lithium 300 tid. check TSH, creatinine, lithium level. f/u
add depakote. check valproic acid level, Liver Panel, CBC. f/u 1wk.
stable. cont prozac 40 mg. f/u 1mo.
increase prozac to 60mg. f/u 2wk.
add wellbutrin SR 150mg. f/u 1wk.
call 911. send to ER. check for OD.
check breathalyzer. refer to AA.
weekly tox screen. refer to AA/NA.
add haldol 2mg bid.
d/c ambien.
d/c elavil. use hard candies.
d/c haldol. add clozapine. AIMS exam. vitamin E 800 iu bid.
reduce haldol. add cogentin to reduce sialorrhea.
establish boundaries. do not schedule at end of day.
see with chaperone only.
US Mental Health Stats
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42.5 million (18%) have suffered from any kind of mental illness
19.7 million (8.46%) had a substance abuse problem
8.8 million (3.77%) have had serious suicidal ideation
In 2012 8.1 million Americans with menlt health illness were uninsured
Only 41.4 % of those with mental illness reported receiving treatment
1 in 4 adults
1 in 5 children
1 out of five American take psychotropic medicaitons.
Melville,N.”US Menlal Health Services Ranked by State”13Jan2015 <www.Medscape.com>
Mental Health Treated in Primary Care Stats
• In 2010 at least 20% of all visits to primary care had mental health
related issues according to the National Ambulatory Medical care
survery. www.cdc.gov/nchs/ahcd.htm.
• In 2009 the American Academy of Pediatrics published a statement
urging primary care providers to be more active in treating mental
health conditions. They estimated that 1/3 of US children with
mental health conditions are being treated in Primary Care.
Kelly,J.“PCPs Care for a Third of Kids With Mental Health Conditions” Medscape,12Oct.2015. www.Medscape.com/view
article/852605.
It is estimated that 11%-36% of all patients treated in Primary Care
actually have criteria for a mental health diagnosis.
In a national survey of mental health disorders it showed that 52% of
patients over a 12 month period sought treatment in primary care.
“Mental Health Care Services by Family Physicians”. www.aafp.org/about/policies
WHY is there such a high number of patients
seen in primary care for Mental Health Illness
• Shortage in Mental health providers- It is estimated that there is 1
mental health provider per every 790 people according to a report
by Mental HealthAmerica.www.Medscape.com/viewarticle/837003
• Lack of insurance coverage for mental health
• Mental Health Stigma
The Dilemma: to treat or not to treat
• One physician stated
• “This winter Ill see more patients with seasonal affective disorder
than the flu and the tissues in my exam room will dry tears more
that they muffle sneezes”
• She expressed the concern about treating so many mental health
conditions and stated “I lack the time and training to diagnose and
manage psychiatric disorders”
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Koven,S. “Should Mental Health Be A Primary Care Doctors Job?”, The New Yorker, 21Oct.2013. <www,newyorker.com>11April2016.
Reasons to Treat
• If patient are not treated in primary care many patients suffering from
mental health issues will go without being treated at all.
• Increasing demand and decreasing number of providers
• Psychiatric disorders effect the patients physical health.
• A patient that has an undiagnosed or untreated Mental helath condition is at
risk for suicide.
• Patients are resistant to seeing a mental health provider or they do not
perceive the need.
• Presence of a mental health condition leads to poorer health outcomes,
increased mortality, consequences to society and a lower quality of life for
your patient.
Emotional symptoms
effect the mental and
physical and visa versa.
We cannot separate one
from the other. We must
assess and treat the
whole patient for the
best results. Social and
spiritual aspects of a
patients life should also
be considered.
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Reasons to Treat
• Appropriate treatment leads to increased productivity, better parents,
better students, improved medical outcomes and increased
independence for the elderly.
• It is recommended by multiple health care organizations including the
Surgeons General office, Institute of Medicine, New Freedom
Commission.
• Not all mental health conditions are complex.
• Conserves specialized resources for more complex patients that need
them most. Many times new patients have to wait 1-2 months to get an
appointment or provider adjust their schedules to see patients that need
to be seen right away.
When to consider referring to a mental
health provider.
• Delayed referral may impair recovery and overall outcomes.
• There are no formal guidelines.
• When a patient is not treated properly or has tried multiple
medications that were either not appropriate or tried at a sub
therapeutic level it seems to lead to hopelessness and a distrust of
psychotropic medications in general.
• Always try to refer patient with mental health issues to a therapist
and /or a support group.(AA,Alanon,grief support,Celebrate
Revcovery) Most patients will have greater outcomes they receive
medication management and therapeutic intervention.
You should probably refer a patient if:
• the patient seems to have a more complex condition or has multiple
psychiatric diagnosis such as depression, anxiety and/or substance
abuse. Many patients have 2 or more diagnosis.
• you do not have adequate desire, time, knowledge or resources to
adequately treat them or you are unsure of the diagnosis.
• the patient states that they have already tried multiple psychotropic
medications or if you have tried several medication and they do not
seem to be helping or they are having side effects.
• you have prescribed up to your comfort or knowledge level.
• the patient expresses suicidal or homicidal ideations.
• The patient is having psychotic symptoms.
• it seems to be a chronic long term condition. That will require long
term care.
Mental Health Treatment Overview
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Common Myths about Mental Health.
Mental Status Examination
Most common diagnosis: signs and symptoms and diangnosti criteria.
Most common psychotropic medications, prescribing tips and guidelines.
Serious potential conditions associated with psychotropic medications.
Other potential treatments.
Myths about Mental Health
• Patients with mental health issues are usually violent. The truth is most
patients with mental health issues are not violent.
• Mental Illness is a character flaw that they will grow out of or pull
themselves out of. The truth is that most mental health conditions are brain
disease that may not get any better without proper treatment.
• People with mental illness are incapable of making rational decisions. Most
patient with mental health issues are functioning very well and able to
make decisions and care for themselves just fine.
• Psychiatric medications make people become like zombie. The truth is that
proper medication management should not make a person feel like a zombie
but should help them to function more efficiently and have increased ability
to concentrate. If the medication has negative side effects it should be
adjusted or changed.
Making a Diagnosis
Mental status Examination
• General behavior-compliant,polite,hostile,intoxicated
• Appearance-welldressed,disheveled,hygiene
• Level of consciousness-alert, oriented,lethargic
• Attitude, speech-volume,tone,rate
• Psychomotor activity-normal,hpyo or hyperactive,tremors,pacing
• Mood and affect-angry,sad,anxious,labile
• Thought process and content-clear,intact or
delusional,hallucinations
• Insight and judgement-are they aware of how they are acting,
blaming others
beyondtheborderlinepersonality.files.wordpress.com/2011/05/dsm-v.jpg
Making a Diagnosis
• Patient History-History of trauma or abuse, may include screening tools(PHQ9,Mood
disorder questionnaire, ADHD screening), history of manic episode, substance
abuse.
• Family History of mental health issues very important. Genetic information is very
important.
• Social support-who do they live with, were do they work
• Current stressors-marital,legal or financial issues
• Current symptoms-open ended questions, “what's going on currently that you need
some help with?", "How have you been feeling lately”
• Rule out medical causes for symptoms. Labs-CBC,CMP,Ha1c,vit D, vit B12,iron TSH,
Thyroid antibodies to check for hashimotos.
• There is no definite test to make a diagnosis. Must use clinical skills based on the
information obtained from your assessment.
• Assess substance use or abuse in every patient.
Pathophysiology of Mental Illness
Mental illness is a diagnosable disease of the brain that effects a persons
feelings, thinking and behavior. It is disease that is psychobiological in
nature and is influenced by genetics, biology and environment.
There is are three major neurotransmitters(chemical messengers) that
can produce mental illness when they become imbalanced.
Most psychotropic medications either increase or block the effects of
these neurotransmitters in the brain and are synthetic versions of
chemicals found in the body.
Pathophysiology of most mental illness
Dopamine
reward,pleasure,obsession
Movement disorders
Serotonin
Depression,sleep,appetite,libido,
anxiety
Norepinephrine
Concentration,fatigue,similar
to adrenalin,memory recall
Depression
Depression, ADHD SX,
Depressive symptoms
Parkinsons,EPS
decreased cognition
fatigue, ADHD sx.
Mania
Schizophrenia,Mania
Anxiety
serotonin syndrome
Insomnia
Neurotransmitters(chemical messengers) transmit information from nerve to
nerve across the synapse. They are released at the presynaptic nerve ending and
attach to receptors. Medications can either inhibit or stimulate neurotransmitters
in the postsynaptic cleft.
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Common Psychiatric Diagnosis and Treatments
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Major Depression:
Diagnosis and Treatment
Depression is a common and treatable illness. It is not
just being down. For a diagnosis a patient must have at
least 5 symptoms for at least 2 weeks and can not be
explained by substance abuse, grief or a medical reasons.
Does this patient really have depression or is it something else? Screen
carefully because several other disorders may present as depression.
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Bipolar Disorder: Diagnosis and Treatment
• Bipolar disorder is a chronic and complex mental illness characterized by
periods of mania or hypomania alternating with periods of depression.
• The worlds 6th leading cause of disability.
• %25-%50 of bipolar patients attempt suicide and about %15 complete
suicide.
• Average of 8 year delay between the first presentation and diagnosis.
• Up to %30 of patient presenting with depression or anxiety actually have
Bipolar Disorder.
• Misdiagnosis can lead to ineffective treatment or adverse treatment
outcomes.
Mccarron,R.,Xiong,G.&Bourgeois,J.(2009). Lippincotts Primary Care Psychiatry. Baltimore,MD: Lippincott,Williams & Wilkins.
Bipolar Disorder
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•Bipolar I Disorder— defined by manic
episodes that last at least 7 days, or by
manic symptoms that are so severe that the
person needs immediate hospital care.
Usually, depressive episodes occur as well,
typically lasting at least 2 weeks. Episodes
of depression with mixed features (having
depression and manic symptoms at the
same time) are also possible.
•Bipolar II Disorder— defined by a pattern
of depressive episodes and hypomanic
episodes, but not the full-blown manic
episodes described above.
A Bipolar patient
spends that
Majority of their
time having
predominantly
depressive
symptoms.
32% in Bipolar I
50% in bipolar II
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Anxiety Disorder
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Severe anxiety is a medical disorder
that requires treatment
It is not a weakness or a personality
problem.
Anxiety is a mental and physical
response to a fearful or threatening
situation.
Normal response experienced by
everyone.
Severe anxiety is believed to be a
dysfunction of serotonin or
norepinephrine.
Common Symptoms of Anxiety
Psychological
Physical
• Tension
• Trembling
• Worry
• Sweating
• Panic
• Heart pounding
• Feelings of unreality
• Diziness
• Fear of going crazy
• Light Headed
• Fear of dying
• Muscle tension
• Fear of losing control
• Nausea
• Breathlessness
• Numbness
• Stomach pains
• Tingling sensation
• The symptoms of anxiety
interfere with work social or
family.
• The fears are out of proportion
to the situation’
• Start to avoid situations.
• GAD-free floating anxiety, no
specific trigger, ruminating
and chronic worrying.
• Panic Disorder – characterized
by frequent panic attacks.
PTSD is no longer an anxiety disorder in
the DSM5
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ADHD
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Psychopharmacology for Common Psychiatric Disorders
Antidepressants
SSRI – Selective Serotonin
Reuptake Inhibitors
SNRI – Serotonin Norepinephrine
Reuptake Inhibitor
Prozac,Zoloft Celexa,Lexapro ,Paxil,Luvox Effexor,Pristiq,Cymbalta,Fetzima
Block the reuptake of serotonin
First line of treatment for depression and
anxiety
Main side effects – transient mausea,vomiting
or diarrhea due to serotonin receptor in the
gut usually last 7-14 days,sexual dysfunction,
sleep disturbance,fatigue
,headache,drymouth,constipation.
Block the reuptake of serotonin and
norepinephrine
Also have anticholinergic side effects
Main side effects – transient mausea,vomiting
or diarrhea due to serotonin receptor in the
gut usually last 7-14 days,sexual dysfunction,
sleep disturbance,fatigue ,headache,dry mout
constipation.
• Tricyclic Antidepressants
• Other antidepressants
• Amitryptyline,imipramine,Nortripytyline
• Trazodone mostly used for a sleep
aide.
• Doxepin
• Mainly used for sleep due to highly sedation
• Imipramine is used for eneurses due to side
effect of urinary retention.
• Remeron increases serotonin and
norepinephrine,used as a sleep
aid and a appetite stimulant.
• Brintellix newer medications that
works very well for depression
and cognitive functioning.
DNRI – Dopamine, Norepinephrine
Reuptake Inhibitor
• Wellbutrin comes in 3 forms
• IR,SR,XL
• Used to treat depression,ADHD,smoking
cessation
• Side effects- insomnia,dizziness,dry mouth,
constipation.
• Contraindicated with seizure disorder
Benzodiazepines
Used to treat acute anxiety
Use Benzos for a short time if possible
Use with caution due to addictive potential
Use caution with older patients
Educate patient prior to first use about
highly addictive properties and physical
dependence.
• Rarely use with pts. Under the age of 18
and only if absolutely necessary with pt.
age 18-21.
• So addictive because they WORK.
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Other options for anxiety
• Buspar-partial agonist for
serotonin
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Non addictive
Acute effects 30-60- minutes
Longer term effects 2-4 weeks
Vistaril-25 mg po bid prn, may
or may not make pt to tired.
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Xanax
Librium
Klonopin
Valium
Ativan
½ life
12-15
5-30
30-40
20-80
10-20
peak
1-2
1-4
1-4
0.5-2
2-4
Mood Stabilizers
1st line of treatment for Mania
Lithium – monitor lithium levels -.6-1.2
Watch for lithium toxicity NVD,tremors
confusion lethargy, possible seizure and
death.
• Increase risk-elderly,renal disease,volume
depletion or salt restriction.
• Depakote- do not use in woman of child
bearing years
• Lamictal– start at 25 mg and go up slowly
to avoid Stevens Johnson rash and
education pt that they must stop if they
develop a rash.
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• Second generations antipsychotics
• Used to treat bipolar disorder and
adjunct for depression.
• Monitor for metabolic syndrome
• May be used for agitation
General guidelines
• Most meds take about 3-4 weeks to see significant improvement in
mood.
• Increase antidepressant to therapeutic dose frequently (every 2-4
weeks) if not seeing results.
• If no improvement after and adequate trial of medication about 6 weeks
of more cross titrate to another medication in the same class.
• If SSRI are not effective try a medication in a different class.
• If first agent somewhat but not fully effective augment with another
medication from another class.(Abilify,Buspar,Wellbutrin)
• Vitamins and Omega 3 can be helpful
• Other options for treatment TMS
Monitor pt for adverse reactions, serotonin syndrome, Malignant
neuroleptic syndrome,EPS, Sodium Depletion.
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Changes in the DSM-5
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