8/15/17. Managing Psychiatric Conditions in Primary Care Beyond the Basics. Speaker s Biography. Situation

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1 Managing Psychiatric Conditions in Primary Care Beyond the Basics Source: US National Library of Medicine, Images from the History of Medicine Luis Berrios, DNP, MHA, ANP, PMHNP Internal Medicine & Primary Care Director, Advanced Practice Providers Baptist Health System San Antonio, TX Speaker s Biography Integrated internal medicine, adult primary care, and psychiatry practice in San Antonio Clinical Director, Advanced Practice Providers for BHS San Antonio Air Force officer for over 17 years (currently reservist); Deputy Chief Nurse and Chief of Education and Training for over 120 nurses and medical technicians Guest lecturer for UTHSC San Antonio FNP students Education: DNP, Adult Health NP, University of Florida MSN, Adult NP and Psych NP, University of California San Francisco Board certified Adult NP and Psych/Mental Health NP Master s in Health Administration, Webster University Disclosures: None Situation Patients may be apprehensive about seeking treatment due to stigma of mental illness Often patients with psychiatric illnesses present first to primary care offices Many primary care practitioners uncomfortable with diagnosing psychiatric illnesses and prescribing psychotropics Too often patients with psychiatric conditions are misdiagnosed and improperly treated in primary care settings Despite being one of the leading causes of disability, non-psychiatric NP/PA/MD/DO programs provide minimal education on management of psychiatric Source: US National Library of Medicine, Images from the History of Medicine conditions Shortage of psychiatrists in communities, especially rural areas, and many not taking insurance 185 counties in Texas (3.1 million people) have no available psychiatrist

2 Brief Pathophysiology Review Key anatomical structures in psychiatry Cerebral Cortex: Speech, cognition, judgment, perception, and motor fx Limbic System: Emotions and memory Hypothalamus: Regulatory functions like appetite, hunger, thirst, libido, circadian rhythms, body temp, hormonal regulation Thalamus: Sensory relay station, regulates emotions, memory, and affective behaviors Blausen Gallery, 2014 Hippocampus: Regulates memory and converts short-term memory into long-term-memory Amygdala: Mediates mood, fear, emotion, aggression, connects sensory smell information with emotions Basal Ganglia: Modulates and stabilizes somatic motor activity; contains extrapyramidal motor system or nerve track; involuntary motor activities Brain Stem Midbrain:Ventral tegmental area and substantia nigra, dopamine synthesis; raphe nuclei, serotonin synthesis Pons: Locus ceruleus, norepinephrine synthesis Medulla: Autonomic control centers of internal body functions Cerebellum: Equilibrium Guess, K. (2008). Psychiatric-Mental Health Nurse Practitioner, 2nd Edition. ANCC. Brief Pathophysiology Review Neuropsychiatric system is a test tube comprised of various neurotransmitters: Monoamines Norepinephrine Dopamine Serotonin Amino acids Glutamate: Universal excitatory neurotransmitter Glutamate aminobutyric acid (GABA): Universal inhibitory neurotransmitter Acetylcholine: Cholinergic, associated with Alzheimer s Dz Glutamate = Bipolar disorder, psychosis Dopamine = Schizophrenia, bipolar disorder Acetylcholine = Alzheimer s, impaired memory Dopamine = Substance abuse, Parkinson s, depression Serotonin = Depression, OCD, schizophrenia Norepinephrine = Depression GABA = Anxiety disorders Guess, K. (2008). Psychiatric-Mental Health Nurse Practitioner, 2nd Edition. ANCC. General Concepts When assessing for use of psychotropics, take a look at big picture, avoid tunnel vision Is it just depression or depression with Anxiety spectrum and/or with Insomnia and/or with Attention deficit and/or with Mania or hypomania and/or with Psychosis and/or with Pregnancy and/or with Try to safely treat the most amount of symptoms with the least amount of medication Thorough evaluation of which psychotropics they have used in the past How effective, how long were they on it, what dosages, specific adverse reactions Use an organized approach 2

3 History Before starting evaluation try to establish rapport Then explore: When did symptoms first start? (adolescence, as an adult, after traumatic experience, as long as they can remember ) History of psychiatric hospitalizations or ER visits History of suicide attempts History of illicit drug use or ETOH abuse History of physical, mental or sexual abuse Family history of mood disorders or substance addiction/abuse Medical history (specifically insomnia, chronic headaches, thyroid dysfunction, vitamin deficiencies, hormone deficiencies, chronic pain) On opioids or other pain medications including SNRIs and Tricyclics? On any supplements? (St John s Wort, Ginkgo Biloba, etc) Current stressors or life events contributing to symptoms Mental Status Exam As you are collecting history evaluate for the following: Presentation (Calm, cooperative, restless, excitable ) Eye contact (Appropriate, intense, avoidant ) Grooming (Appropriate, careless, eccentric ) Speech (Appropriate, rapid, slow ) Affect (Appropriate, restricted, blunted, excitable, tearful, labile ) Thought process (Logical, fragmented, tangential, circumstantial ) Thought content (Psychoses, delusions ) Insight (Stable, fair, poor ) Judgment (Stable, fair, poor ) Concentration (Stable, fair, poor ) Memory (Short term, long term; stable, fair, poor ) Can be assessed in just a few minutes but can help guide diagnosis and medication regimen Decision Time Therapy Vs Psychotropics Vs Both 3

4 Depression Medications Activating Neutral Sedating SSRIs Fluoxetine (Prozac) Vilazodone 1 Vortioxetine 1 Sertraline Citalopram Escitalopram (Viibryd) (B/Trintellix) (Zoloft) (Celexa) (Lexapro) Paroxetine (Paxil) SNRIs Venlafaxine 7 (Effexor) Duloxetine 7 (Cymbalta) Desvenlafaxine 7 (Pristiq) TCAs Amitriptyline 2 (Elavil) Buproprion Other 6,7 Mirtazepine 3 (Wellbutrin) Trazodone 4 (Remeron) Symptoms Anhedonia Loss of Energy Difficulty Concentrating Feelings of Guilt Loss of Appetite Excessive Worrying Anxiety Insomnia Dosing Morning 5 Morning or Evening Evening 5 Notes: 1. Vilazodone and vortioxetine are SSRI-like drugs 2. Amitriptyline should be avoided in pts at high risk for suicide, hx of cardiac conditions 3. Mirtazepine has notable increase in appetite 4. Trazodone is mostly used for sleep but does have antidepressant effects 5. Dosing for some antidepressants is BID (eg, Effexor, Wellbutrin) 6. Wellbutrin is neutral on weight gain and sexual side effects, in some pts may worsen anxiety 7. Avoid in those with a hx of seizures Bipolar Disorder Medications Activating Neutral Sedating Antidepressants (AD) Fluoxetine Vilazodone Paroxetine SSRIs 1 Vortioxetine 1 Sertraline Citalopram Escitalopram (Prozac) (Viibryd) (B/Trintellix) (Zoloft) (Celexa) (Lexapro) (Paxil) SNRIs Venlafaxine Duloxetine Desvenlafaxine (Effexor) (Cymbalta) (Pristiq) Amitriptyline TCAs 1 (Elavil) Buproprion 1 Mirtazepine 2 Other AD (Wellbutrin) (Remeron) Trazodone 2 Mood Stabilizers (MS) Atypical Anti- Psychotics AEDs Other MS Aripiprazole (Abilify) Quetiapine Ziprasidone (Seroquel) (Geodon) Divalproex Lamotrigine 3 Oxcarbazepine 3 Carbamazepine 3 sodium (Lamictal) (Trileptal) (Tegretol) (Depakote) Lithium 3 Olanzapine (Zyprexa) Dosing Morning 4 Morning or Evening 4 Evening 4 Notes: 1. Avoid in patients with Bipolar Disorder 2. Not a first line agent, use with caution 3. Caution with starting if no experience with these meds 4. For once daily dosing; AED, antipsychotics, and some antidepressants may require BID dosing Anxiety Medications Activating Neutral Sedating SSRIs Fluoxetine (Prozac) Vilazodone 1 Vortioxetine 1 Sertraline Citalopram Escitalopram (Viibryd) (B/Trintellix) (Zoloft) (Celexa) (Lexapro) Paroxetine (Paxil) SNRIs Venlafaxine 2 (Effexor) Duloxetine 2 (Cymbalta) Desvenlafaxine 1, 2 (Pristiq) TCAs Amitriptyline 1, 3 (Elavil) Other Buproprion 1, 2 (Wellbutrin) Mirtazepine 1 (Remeron) Trazodone 1 Non-Benzo Anxiolytics Buspirone (Buspar) Propranalol Hydroxyzine (Atarax, Vistaril) Benzos Alprazolam (Xanax) Clonazepam (Klonopin) Diazepam (Valium) Lorazepam (Ativan) Dosing Morning 4 Morning or Evening 4 Evening 4 Notes: 1. Not specifically indicated for anxiety disorders 4. For once daily dosing; anxiolytics and some antidepressants may require BID or TID dosing 2. SNRIs, buproprion can increase anxiety d/t effects on adrenergic receptors 3. Amitriptyline should be avoided in pts at high risk for suicide, hx of cardiac conditions 4

5 Disclaimer The following prescribing approaches are tools to assist in clinical decision-making. NPs must use their clinical judgment in determining appropriate medication regimens specific to their patients needs. (In other words don t say Dr. Berrios told me to prescribe this) Prescribing Approaches: Unipolar Depression Initial Approach Depression with Loss of Energy Depression with Anxiety Depression with Loss of Concentration Depression with Chronic Pain Fluoxetine (Prozac) Sertraline (Zoloft) Bupropion (Wellbutrin) Bupropion (Wellbutrin) Escitalopram (Lexapro) Amitriptyline (Elavil)* Fluoxetine (Prozac) Vilazodone (Viibryd) Wait at least 3-4 weeks to assess response to medication Ensure there are no drug-drug interactions with patient s other medications * Avoid in those with SI or history of suicide attempts Prescribing Approaches: Unipolar Depression Secondary Approach Switch to Different Drug Class (Same or Other) SSRI + Bupropion SSRI + Adjunct SNRI + Adjunct For Example Fluoxetine to Sertraline Venlafaxine to Duloxetine Escitalopram + Bupropion Fluoxetine to Duloxetine For Example Sertraline + Bupropion Citalopram + Bupropion Vilazodone + Bupropion Caution with Fluoxetine + Bupropion Avoid Paroxetine, Vortioxetine Avoid two drugs in same class (eg SSRI + SSRI) Avoid Amitriptyline + Quetiapine or Aripiprazole Mirtazapine + Aripiprazole Trazodone + Aripiprazole For Example Sertraline + Aripiprazole Escitalopram + Aripiprazole Citalopram + Aripiprazole Paroxetine + Quetiapine Fluoxetine + Quetiapine Vortioxetine + Quetiapine Escitalopram + Quetiapine Caution with Fluoxetine or Paroxetine with Aripiprazole Avoid Citalopram with Quetiapine For Example Duloxetine + Quetiapine Venlafaxine + Quetiapine Caution with SNRIs and Aripiprazole Avoid SNRIs and Bupropion 5

6 Prescribing Approaches: Unipolar Depression Tertiary Approach Consult With or Refer to Psychiatrist/Psych NP Prescribing Approaches: Bipolar Disorder Initial Approach Mostly Mania Mostly Depression Mixed Mania and Depression Bipolar II Hypomania and Depression Aripiprazole (Abilify) Quetiapine (Seroquel) Lithium* Oxcarbazepine (Trileptal)* Note: Start low and go slow (titrating up) Avoid: Bupropion in Bipolar Disorder Sertraline + Aripiprazole or Quetiapine Fluoxetine + Quetiapine Sertraline + Aripiprazole or Quetiapine Escitalopram + Escitalopram + Aripiprazole or Quetiapine Aripiprazole or Quetiapine Fluoxetine + Quetiapine Sertraline + Aripiprazole or Quetiapine Fluoxetine + Quetiapine Escitalopram + Aripiprazole or Quetiapine Fluoxetine + Lamotrigine* Escitalopram + Lamotrigine* * Caution with starting these if limited or no experience Prescribing Approaches: Bipolar Disorder Secondary Approach Switch to Different Drug(s) And/ Consult With or Refer to Psychiatrist or Psych NP 6

7 Prescribing Approaches: Anxiety Initial Approach Intermittent/ Situational Hydroxyzine Buspirone (Buspar) Clonazepam (Klonopin) Lorazepam (Ativan) Avoid Alprazolam Persistent/ GAD Sertraline (Zoloft) Escitalopram (Lexapro) Bupropion (Wellbutrin)* Buspirone (Buspar) Severe with Panic Attacks Sertraline (Zoloft) Escitalopram (Lexapro) Plus Hydroxyzine Lorazepam or Clonazepam for Short-Term Use as Deemed Appropriate * Avoid in those with panic attacks Prescribing Approaches: Anxiety Secondary Approach SSRI or SNRI (Switch to Different Drug and/or Augment) + Buspirone or Gabapentin + PRN Clonazepam or Lorazepam For example: Sertraline 150mg + Buspirone 10mg BID +Clonazepam 0.5mg BID PRN Sertraline 200mg + Gabapentin 100mg BID + Clonazepam 0.5mg BID PRN Prescribing Approaches: Anxiety Tertiary Approach Consult With or Refer to Psychiatrist/Psych NP 7

8 Prescribing Approaches: Pregnancy Unipolar Depression Bipolar Disorder Anxiety Spectrum Sertraline (Zoloft) Other SSRIs except Paroxetine (Paxil) Bupropion (Wellbutrin) SNRIs Ensure patient understands limited human data and there is always some risk Weigh risk vs benefit and always try to pick med(s) with safest profile(s) Encourage patient to discuss medication regimen with obstetrician Lurasidone (Latuda) Olanzapine (Zyprexa) Sertraline (Zoloft) Buspirone (Buspar) Other SSRIs except Paroxetine (Paxil) Bupropion (Wellbutrin) SNRIs Caution with: Hydroxyzine Contraindicated: Benzodiazepines Prescribing Approaches: Weaning/Changing Meds In theory Med 1 Med 2 Plasma Concentration Time (Days) Prescribing Approaches: Weaning/Changing Meds Reality Med 1 Med 2 Plasma Concentration Time 4-6 weeks For Example Sertraline to Duloxetine Decrease Sertraline from 150mg to 100mg x 1 week then 50mg x 1 week then D/C Start Duloxetine at 30mg x 1 week then 60mg daily Fluoxetine to Wellbutrin Decrease Fluoxetine from 80mg to 40mg x 1 week then 20mg x 1 week then D/C Start Bupropion 150mg XL x 1 week then 300mg daily Some meds like venlafaxine require longer weaning due to short half life 8

9 Prescribing Approaches Important Point Remember to Treat the Underlying Condition Not Put a Band-aid On It Apply Your Knowledge Case Studies Summary With increasing shortages in psychiatry professionals, the onus will be on primary care providers to manage psychiatric conditions Just like managing DM and OCPs, managing psychotropics is an art that can be learned Always involve the patient in the plan of care and possible side effects Start low and go slow, especially in elderly population Avoid jumping from one medication to the other, educate pts on timeframe needed to assess improvement (~4 wks) Avoid blanket referrals to psychiatry without attempting to initially manage them As primary care providers you are in a great position to manage depression, anxiety, and even bipolar disorder in conjunction with other chronic medical problems Source: US National Library of Medicine, Images from the History of Medicine 9

10 References American Psychiatric Association Practice guideline for the treatment of patients with major depressive disorder (2010) Practice guideline for the treatment of patients with bipolar disorder (2002) Practice guideline for the treatment of patients with acute stress disorder and PTSD (2004) rderptsd.pdf Practice guideline for the psychiatric evaluation of adults (2006) s.pdf Questions? Source: US National Library of Medicine, Images from the History of Medicine 10