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PIPC® Psychiatry In Primary Care
MOOD DISORDERS
Robert K. Schneider, MD
Departments of Psychiatry, Internal Medicine
and Family Practice
The Medical College of Virginia at
the Virginia Commonwealth University
Richmond, Virginia
PIPC® Goals
• Effectively recognize, diagnose and
treat mental illness in primary care
• Bring the psychiatry skills and
knowledge base of the primary care
physician on par with other medical
specialty knowledge bases
Outline
• PIPC 1
– Introduction
– PIPC Interview
®
– MAPS-O
– Mood Disorders
– Suicide
®
Outline
• PIPC 2
– Anxiety Disorders
• PIPC 3
– Neurotransmitters
– The 3 Phases and the 5Rs
– Medications
– Cases and Discussion
“de facto mental health system”
Regier,1978
• 54% of people with mental illness who
seek treatment are exclusively seen in
the “general medical sector”
• 25% of patients in primary care setting
have a diagnosable mental illness
Why Now?
• Great scientific evidence
– Genetic basis for disease
• Twin studies and Human Genome Project
– Neuroscience Research
• CT to MRI to PET to SPECT scanning
• Neurotransmitter basic science
• Somatic Therapies
– Psychiatric Medication Explosion (“SSRI
Surge”)
• Economic pressures (Managed Care)
PIPC Interview
®
PIPC Interview
• Organized by “organ system” approach
– Hypothesis driven interview
• Makes psychiatric knowledge assessable
• Demonstrates holes in knowledge base for
PCP
• Creates a foundation for evidence to be
applied
Data Gathering:
Hypothesis Driven Interview
• Notice cues from patient
–pattern recognition
• Develop differential diagnosis
• Collect target symptoms
• Ask further questions to rule in or rule
out
Example: Chest Pain
• Target symptoms
– Chest pain, Shortness of Breath
• Differential diagnosis
– Cardiac (ischemic, valvular, cardiomyopathy)
– GI (esophageal spasm, PUD)
– Pulmonary (COPD, pleuresy, pneumonia)
– Musculoskeletal (intercostal spasm, rib fx)
• Further questions
– Age, onset, associated symptoms, etc…..
Example: Depression
• Target symptoms:
– Poor sleep, fatigue, isolation (no enjoyment)
• Differential diagnosis:
– Major Depression (single episode vs recurrent)
– Dysthymia (2 year history)
– Bipolar (mania/hypomania)
– Substance induced mood disorder (mood
during periods on abstinence)
• Further questions:
– Age, onset, associated symptoms, etc…
Screening Strategies vs.
Case Finding Strategies
• High false positives if everyone screened
• Practicing physicians think using casefinding strategies
• High comorbidity
• Different tools:
– Interviewing questions
– Diagnostic checklists
– Disease specific scales
How can a primary care doc
make a reasonable psychiatric
differential diagnosis?
• Language:
– Symptoms
– Diagnostic categories
• DSM-IV:
– 6484 signs, symptoms, inclusion criteria
– 405 diagnoses
– 18 diagnostic categories
• DSM-IV PC starts the process but is inefficient
and “psychiatric”
HELLO
DATA GATHERING
NEGOTIATION
D
A
T
A
CUES
HYPOTHESES (MAPSO©)
G
A
T
H
E
R
I
N
G
CASE FINDING QUESTIONS
DIAGNOSTIC CRITERIA (DSM-IV)
Comorbidities (ROS)
DIAGNOSIS
N
E
G
O
T
I
A
T
I
O
N
TREATMENTS
PATIENT PREFERENCE
E
PD
AU
TC
IA
ET
N I
TO
N
DIAGNOSIS & TREATMENT CHOICE
MAPS-O
®
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
–“Organic”
–Other Psych
MAPS-O®
• Most prevalent disorders in primary care
• Proven treatments available
• If “other” psychiatric disorder is diagnosed
(somatization, personality disorders),
• Then successful treatment requires
diagnosing one of these categories first
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
Major Depression, Dysthymia,
Bipolar Disorder
MAPS-O®
Mood Disorders
Anxiety Disorders
GAD, Panic Disorder, PTSD,
OCD, Phobias (Social/Specific)
Psychotic Disorders
Substance Abuse
Other
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
Schizophrenia, Schizoaffective
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
Alcohol, Cocaine, Nicotine,
Other Psychoactive Substances
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
“Organic”:
Stroke, Dementia, HIV, TBI
Other Psych:
Personality Disorders, ADHD,
Somatization,Eating Disorders
MOOD DISORDERS
Mood Disorders
• Major Depression
– Single episode
– Recurrent
• Dysthymia
• “Double” Depression
• Bipolar Disorder
– Mania
– Hypomania
• Psychotic Depression
EPISODE OF DEPRESSION
RECOVERY OR
REMISSION
NORMAL MOOD
DEPRESSION
TIME
6 - 24 months
5-1
Stahl S M, Essential
Psychopharmacology (2000)
Mood Disorders –
Major Depression
5 or more of the 9 symptoms
at least 2 weeks (everyday, all day)
–Depressed mood
–Anhedonia
–Worthless/Guilt
–Death/Suicidal
–Appetite
–Sleep
–Fatigue
–Concentration
–Psychomotor
Major Depression –
Questions:
• How is your mood?
• Have you been feeling sad, blue or
depressed?
• Have you lost interest in or do you get less
pleasure from the things you used to enjoy?
• Has there been any change in your
appetite? (5% weight change in 1 month)
• How have you been sleeping?
Major Depression –
Questions:
• Have you been more fidgety?
• Have you felt slowed down, like you were
moving in slow motion or stuck in mud?
• How has your energy level been?
• How have you been feeling about yourself?
• Have you been blaming yourself for things?
• Have you had problems thinking or
concentrating?
NORMAL
MOOD
DYSTHYMIA
DEPRESSION
2+ years
5-7
Stahl S M, Essential
Psychopharmacology (2000)
Mood Disorders –
Dysthymia
• Depressed mood for most of the day,
for more days than not, for at least two
years.
–No episodes of major depression
during the last 2 years
–Symptoms have not gone away for
more than 2 months at a time
–Depressed plus 2 symptoms
Dysthymia –
Questions:
• Same as major depression
• Longitudinal course and symptoms
density is the focus of questions
DOUBLE DEPRESSION
NORMAL
MOOD
DYSTHYMIA
2+ years
5-8
DEPRESSION
PARTIAL RECOVERY
6 - 24 months
Stahl S M, Essential
Psychopharmacology (2000)
Mood Disorders –
Mania and Hypomania
Mania
Distinct period of abnormally and
persistently elevated, expansive or
irritable mood, lasting at least one week.
Hypomania
Like mania but less and lasts throughout
at least 4 days. Clearly different from the
usual nondepressed mood.
MANIA
MIXED EPISODE
HYPOMANIA
NORMAL
MOOD
DEPRESSION
5-5
Stahl S M, Essential
Psychopharmacology (2000)
Mania and HypomaniaQuestions:
• Have there been times lasting at least a
few days when you felt the opposite of
depressed, that is when you were very
cheerful or high and felt different than
your normal self?
• Did you feel hyper, or like you were high
on drugs, even though you hadn’t taken
anything?
• Did anyone notice there was something
different?
Mania and HypomaniaQuestions:
•
•
•
•
•
How long did it last?
What was your self-esteem like?
During this time did you sleep?
Were you more talkative than usual?
Did it feel like your thoughts were going
very fast and racing through your mind?
• Were you easily distracted?
• Were you more active than usual?
SUICIDE
Suicide
• More common in all psychiatric diagnoses;
not just depression
• Dispel myths:
talking about it probably makes it less
likely to happen
• Symptom as well as outcome
• High risk groups (men, older, past history)
• Assess prohibitions to suicide
Suicide - Questions:
• When things have gotten really bad • Have you had increased thoughts about
death and dying?
• Have you thought about hurting yourself?
• Have you ever acted on those thoughts?
• Do you have access to those means?
• What keeps you from doing this?
CASE
39 year old woman
• Intermittently depressed since age 28
• Treated with fluoxetine and sertraline in
the past with success.
• Three weeks ago depression returned
(SI, fatigue, poor sleep, poor appetite)
• On call doctor restarted her fluoxetine
2 weeks later
• Suicidal ideation gone
• BUT
– Not sleeping
– More irritable
– Has increased psychomotor now
Differential Dx,
Cues, and Questions
• Differential Dx
– Mania
– Overstimulation from medications
– Substance abuse
– Worsening depression