9/7/15. The Onus is on You: Managing Psychiatric Conditions in Primary Care. Speaker s Biography. Situation. Situation. Typical Management Flowchart

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1 The Onus is on You: Managing Psychiatric Conditions in Primary Care Speaker s Biography Integrated internal medicine, adult primary care, and psychiatry practice in San Antonio Director, Non-physician practitioners for BHS San Antonio Clinical preceptor for UTHSC San Antonio NP students Air Force officer for over 15 years (currently reservist), Chief of Nursing Education for over 40 nurses and medical technicians, and internal medicine nurse practitioner Luis Berrios, DNP, MHA, ANP, PMHNP Internal Medicine & Primary Care Director, Non-Physician Practitioners Baptist Health System San Antonio, TX 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 MHA, 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 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 Situation Typical Management Flowchart Patient with Psych Illness Acute Illness Sub-Acute Illness Presents to ER Presents to PCP Stabilized & Outpatient 72-Hour Hold* Sent to PCP or Psychiatry Outpatient Psychiatry In-Patient Psych In-Patient Psych 72-Hour Hold* Patients Lost in the System Managed by PCP * Generally placed by psychiatrist or police officer 1

2 Situation Typical Management Flowchart Situation Patient Decompensates Patient with Psych Illness Acute Illness Presents to ER Sub-Acute Illness Presents to PCP Psychosocial Stressor, Meds Ineffective, or Patient Stops Meds Presents to ER, PCP, or Psychiatrist Stabilized & 72-Hour Hold* Managed by PCP 72-Hour Hold* Sent Back to PCP In-Patient Psych Stable In-Patient Psych Stable on Medication Regimen and/or Therapy Managed by PCP or Psychiatrist Patients Lost in the System * Generally placed by psychiatrist or police officer 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 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. Guess, K. (2008). Psychiatric-Mental Health Nurse Practitioner, 2nd Edition. ANCC. 2

3 Case Study 1 A 27 year old patient presents to your clinic to establish care. Insomnia, fatigue, feeling depressed Are you already thinking: Refer to Psych? Case Study 1 A 27 year old female patient presents to your clinic to establish care Insomnia, fatigue, feeling depressed HPI: Depressed mood nearly every day since teenager but has never sought treatment. Unable to sleep most nights, generally no interest in activities/hobbies, at times feels worthless no one would miss me if I was gone, no energy/fatigue nearly every day, difficult concentrating/reading and with basic tasks, irritable and easily agitated, and at times has passive suicidal ideations (SI), no specific plan, but wished she didn t wake up in the morning. No specific stressor or cause of depression. No hx of abuse. Feels safe at home. Lives with mother, positive support system. No access to weapons. She denies any mania*, auditory hallucinations (AH), visual hallucinations (VH), or homicidal ideations (HI). PMH: No prior diagnoses GYN Hx: LMP 4 days ago, regular, mood not affected by menses, not sexually active but wants to be Social Hx: Self medicating with marijuana 3x/week, occasional ETOH, doesn t smoke cigarettes, single and unemployed FHx: Mother and MGM all had mood issues Allergies: NKDA * Important to define mania to patient Depression (Unipolar) Depressed mood or anhedonia >2 weeks, impact on quality of life, significant change from baseline SIGECAPS, 5+ of these Sleep (loss of or hyper) Interests (loss of) Guilt/worthlessness (feelings of) Energy (increase or decrease) Concentration (loss of) Appetite (increase or decrease) Psychomotor agitation/irritability or retardation Suicidal ideations Assess hx of depression, past treatments, medications Assess family hx of depression, bipolar d/o or other mood d/o Assess stressors/threatsà does pt feel safe at home? Assess protective factorsà who/what makes pt feel safe? Assess thyroid dysfunction, vitamin D deficiency, anemia, B-vitamin deficiency MUST rule out bipolar disorderà Mania, insomnia, irritability, racing thoughts, hypersexual, impulsivity, AH/VH, family hx MUST assess SI, HI; access to weapons; safety Are SI/HI passive, active with plan? Guns, rifles, swords? Do you feel safe at home? American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. 5 th ed. 1. e.g., Sathyanarayana Rao, T.S., et al. (2008). Understanding nutrition, depression, and mental illnesses. Indian Journal of Psychiatry. 50,

4 Psychiatric Exam: Affect: Blunted, flat? Sensorium: Alert to person, place, time, situation? Thought process: Organized, logical, disorganized? Thought content: Hallucinations, delusions? Speech/rate: Regular, slowed, rapid? Insight: Intact, fair, poor? Judgment: Intact, fair, poor? Short/Long Term Memory: Intact, fair, poor? Eye contact: Appropriate, minimal, avoidant? Body posture: Relaxed, guarded, restless? Grooming: Appropriate, careless or disheveled? Neuro/MSK: Abnormal body movements, lethargic? Skin: Picking lesions, superficial cuts, bruising? You can collect a significant amount of information by just observing Activating Neutral Sedating Fluoxetine Vilazodone 1 Vortioxetine 1 Citalopram Escitalopram Sertraline Paroxetine SSRIs (Prozac) (Viibryd) (Brintellix) (Celexa) (Lexapro) (Zoloft) (Paxil) Venlafaxine SNRIs 7 Duloxetine 7 Desvenlafaxine 7 (Effexor) (Cymbalta) (Pristiq) Amitriptyline 2 TCAs (Elavil) Buproprion 6,7 Mirtazepine Other 3 (Wellbutrin) Trazodone 4 (Remeron) Anhedonia Feelings of Guilt Excessive Worrying Insomnia Symptoms Difficulty Concentrating Loss of Appetite Anxiety Loss of Energy Dosing Morning 5 Morning or Evening Evening 5 Notes: 5. Dosing for some antidepressants is BID (eg, Effexor, Wellbutrin) 1. Vilazodone and vortioxetine are SSRI-like drugs 6. Wellbutrin is neutral on weight gain and sexual side effects, in some pts 2. Amitriptyline should be avoided in pts at high risk for suicide, hx of cardiac conditions may worsen anxiety 3. Mirtazepine has notable increase in appetite 7. Avoid in those with a hx of seizures 4. Trazodone is mostly used for sleep but does have antidepressant effects My initial go-to drugs Population/Symptoms Medication Dosages Adolescents (16+ for me) 1 Younger adult population (18-40) 1 Depression with anhedonia Depression with anxiety or insomnia Depression with headaches or chronic pain Prozac Lexapro Wellbutrin Lexapro Prozac Prozac Wellbutrin Lexapro Zoloft Elavil Cymbalta 10-60mg QAM 5-20mg QHS 150mg-300mg XL QAM 10-20mg QHS 20-80mg QAM 20-80mg QAM 100mg SR, 150mg XL, 300mg XL QAM 10-20mg QHS mg QHS mg QHS mg QAM Medication side effect profile, in general: N/V/D HA Dizziness Dry mouth Urinary retention Constipation Somnolence Weight gain Loss of libido Orthostasis Hyponatremia Seizures Mania Serotonin syndrome (agitation, restlessness, confusion, tachycardia, HTN, dilated pupils, muscle rigidity, diaphoresis, shivering, HA, fever, dysrhythmias, seizures) 1. Need to assess for pregnancy Although most antidepressants are pregnancy class C, SSRIs (except paroxetine) are generally used. Minimal concern for congenital malformations, pulmonary hypertension, poor neonatal adaptation syndrome, and premature delivery. E.g., Yonkers, K. A., et al. (2009). The management of depression during pregnancy General Hospital Psychiatry; Grigoriadis, S., et al. (2014). Prenatal exposure to antidepressants British Medical Journal. Image 4

5 Key Points: Did I mention rule out Bipolar Disorder? Start low and go slow Advise pts of side effects profile and that it will take at least 3-4 weeks for symptoms to start improving Recommend f/u at 4 weeks (or earlier), titrate up as appropriate q 2-4 weeks Ensure correct diagnosis MDD Dysthymia (chronic MDD) Mood disorder NOS Document on SI, HI, mania or psychosis Role of psychotherapy Most common type is cognitive behavioral therapy (CBT) Help pinpoint problems contributing to depression Identify negative/distorted thinking patterns Explore learned thoughts and behaviors contributing to mood Help regain sense of control Coach, support and coordinate resources/care Research shows CBT/therapy effective in improving symptoms of depression Combination of psychotropics AND therapy can be more efficacious e.g.: Keller MB, McCullough JP, Klein DN, Arnow B, Dunner DL, Gelenberg AJ, et al. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression [published correction appears in N Engl J Med 2001;345:232]. N Engl J Med. 2000;342: Khan A, Faucett J, Lichtenberg P, Kirsch I, Brown WA (2012) A Systematic Review of Comparative Efficacy of Treatments and Controls for Depression. PLoS ONE 7(7): e doi: /journal.pone Case Study 1 Case Study 1 A 27 year old female patient presents to your clinic to establish care Insomnia, fatigue, feeling depressed HPI: Depressed mood nearly every day since teenager but has never sought treatment. Unable to sleep most nights, generally no interest in activities/hobbies, at times feels worthless no one would miss me if I was gone, no energy/fatigue nearly every day, difficult concentrating/reading and with basic tasks, irritable and easily agitated, and at times has passive suicidal ideations, no specific plan, but wished she didn t wake up in the morning. No specific stressor or cause of depression. No hx of abuse. Feels safe at home. Lives with mother, positive support system. No access to weapons. She denies any mania*, AH, VH, or HI. PMH: No prior diagnoses GYN Hx: LMP 4 days ago, regular, mood not affected by menses, not sexually active but wants to be Social Hx: Self medicating with marijuana 3x/week, occasional ETOH, doesn t smoke cigarettes, single and unemployed FHx: Mother and MGM all had mood issues Allergies: NKDA Key Points Objective: VS: Stable Weight: 68kg Psych: Fatigued-appearing female in NAD, minimal eye contact, mildly restless and guarded, speech mildly slowed but comprehensible, thoughts organized and linear, insight fair to stable, judgment fair to stable Neuro: No dystonia or EPS Skin: No cutting or picking lesions or other lesions or bruising What s your A/P? * Important to define mania to patient 5

6 Case Study 1 1. Based on this information, what would be her initial diagnosis? A. Bipolar I Disorder B. Mood Disorder NOS C. Major Depressive Disorder 2. Based on her symptoms, what initial medication would you start? A. Sertraline 50mg PO QHS B. Paroxetine 10mg PO QHS C. Fluoxetine 20mg PO daily in AM D. Bupropion 150mg XL PO daily in AM 3. What other treatment options would you order? A. Referral to psychotherapist/psychologist/counselor B. Electroconvulsive therapy C. Referral to psychiatry Case Study 1 1. MDD: Bupropion 150mg XL one capsule PO daily Hydroxyzine 25mg one to two capsules PO QHS PRN for sleep Provided education on marijuana cessation, pt signed contract and consents to periodic UDS Referral for psychotherapy/cbt CBC, CMP, TSH, Vitamin D total 25-hydroxy, Vitamin B12, Folate UDS at f/u appt F/u 1 month or earlier PRN Discussed plan with pt including meds and side effect profile and pt consents to plan of care Pt contracts for safety and verbalized understanding of who to call if symptoms worsen, local crisis center information provided RTC if symptoms worsen or go to nearest ER 2. Substance abuse (Marijuana): As above. 4. Which diagnostics would you order? A. Vitamin D, Vitamin B12, Folate, TSH, CBC, CMP B. CBC and CMP only C. CT head with contrast and urinalysis D. CT head with contrast only Case Study 2 A 35 year old male patient presents to your clinic to establish care Bipolar symptoms acting up HPI: Hx of Bipolar I disorder diagnosed 10 years ago after manic episode where he stayed up for 3 days straight and then binge drank ETOH, attempted to shoot himself in the head with a shotgun but didn t go through with it. He called 911. Has been on several mood stabilizers and antipsychotics, can t remember names, stopped taking all medications 1 year ago. Presents today with difficulty sleeping for the past 2 months, difficulty keeping up with thoughts, very irritable short temper, hypersexual, has been making many spontaneous purchases and is broke. At times feels very anxious but not every day. Has been able to go to work as a construction worker but is having a hard time focusing. Is drinking ETOH every night and taking Ambien he borrowed from a friend to try to sleep. Denies any AH, VH but sometimes he thinks someone is calling his name, doesn t recognize voice. Denies any depressed mood, SI or HI. PMH: HLP, not taking meds; Chronic back pain, on PRN hydrocodone/acet and ibuprofen Social Hx: Six-pack of beer QHS, 1 ppd cigarettes x 20 years, denies illicit drugs, has live-in GF who has her own issues FHx: Mother and paternal uncle with Bipolar disorder Allergies: Lithium What about that bipolar disorder you keep talking about? Looking for hypomania or mania or history of these Mania: Distinct period of abnormality and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). During mood disturbance, 3 or more of these to a significant degree Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Flight of ideas or racing thoughts Distractibility Psychomotor agitation or hypersexual or other goal-directed activities Engaging in high-risk activities Not caused by drugs/stimulants or other conditions American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. 5 th ed. 6

7 Mania Mania Hypomania Euthymia Hypomania Euthymia Major Depression Bipolar I Disorder Bipolar II Disorder Major Depression Bipolar I Disorder Bipolar II Disorder Key Points: Utilization of multiple resources common Adherence to medications can be a problem, pick medications with once a day dosing or with longer half lives Higher risk for suicide, use caution when selecting medications Start low and go slow Will likely require frequent follow-ups initially Consider referral to psychiatry after starting basic drug regimen (if available) Sometimes misdiagnosed as ADHD Mood Stabilizers (MS) Antidepressants (AD) Activating Neutral Sedating Fluoxetine Vilazodone Vortioxetine Citalopram Escitalopram Sertraline Paroxetine SSRIs (Prozac) (Viibryd) (Brintellix) (Celexa) (Lexapro) (Zoloft) (Paxil) SNRIs Venlafaxine Duloxetine Desvenlafaxine (Effexor) (Cymbalta) (Pristiq) Amitriptyline TCAs 1 (Elavil) Buproprion Mirtazepine 2 Other AD (Wellbutrin) (Remeron) Trazodone 2 Atypical Anti- Aripiprazole Quetiapine Ziprasidone Olanzapine Psychotics (Abilify) (Seroquel) (Geodon) (Zyprexa) Divalproex AEDs sodium Carbamazepine Oxcarbazepine Lamotrigine (Depakote) (Tegretol) (Trileptal) (Lamictal) Other MS Lithium 3 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. Avoid starting lithium unless experience with prescribing 4. For once daily dosing; AED, antipsychotics, and some antidepressants may require BID dosing 7

8 If you suspect pt has a history of Bipolar Disorder And they present with depression Avoid starting antidepressants unless also starting a mood stabilizer If unsure, pick quetiapine (Seroquel) which can be used as monotherapy 1, or a more sedating antidepressant like trazodone or sedating SSRIs in HS (avoid Prozac, Wellbutrin, SNRIs 2 ) and provide education on S/S of mania And they present with hypomania or mania Consider quetiapine (Seroquel) or aripiprazole (Abilify), especially if with psychoses Consider lamotrigine if hypomania (Bipolar II) Consider divalproex sodium (Depakote) 3 in acute mania where person is in control and doesn t need emergency detention (ED) Consider ED if patient has severely disorganized thoughts, labile, no control of faculties, very poor insight and judgment, and/or appears to be a threat to self or others (call 911, police officer can place pt on ED and be transferred to ER) My initial go-to drugs (mania/hypomania) Population/Symptoms Medication Dosages General mania/hypomania Quetiapine (Seroquel) Aripiprazole (Abilify) Lamotrigine (Lamictal) 1 Younger females (18-40) 2 Abilify (Preg Class C) 3 Lamictal (Preg Class C) Obese patients With hallucinations/psychosis Mania with need for quick response Abilify Ziprasidone (Geodon) 3 Lamictal Seroquel Abilify Depakote (divalproex sodium) mg QHS 5-30mg QAM Titration to mg 5-30mg QAM Titration to mg 5-30mg QAM 40-80mg QHS Titration to mg mg QHS 10-30mg QHS 500-1,00mg ER QHS 1. Thase et al. (2013). Quetiapine XR monotherapy in major depressive disorder International Clinical Psychopharmacology. 2. All antidepressants can trigger mania 3. Divalproex sodium indicated for acute mania; eg, Cipriani et al. (2013). Valproic acid, valproate, and divalproex in the maintenance treatment of bipolar disorder. Cochrane Database of Systematic Reviews. 1. Lamotrigine titration: 25mg QHS x 14 days then 50mg QHS x 14 days then 100mg QHS 2. Need to assess for pregnancy 3. Musil, R., et al. (2014). Weight gain and antipsychotics: a drug safety review. Expert Opinion in Drug Safety. PMID Image Medication side effect profile, in general: Somnolence Weight gain N/V/D Dizziness HA Dry mouth Constipation Orthostasis Hypotension QT prolongation EPS/TD/Dystonia/Akathesias Leukopenia/Neutropenia Hyperglycemia Neuroleptic malignant syndrome (high fever, diaphoresis, unstable BP, stupor, muscular rigidity, autonomic dysfunction) History, physical exam, and lab monitoring With use of antipsychotics and AED Baseline CBC, CMP, EKG In 1-3 months recheck CBC, CMP, EKG; if stable consider every 6-12 months Looking for: Leukopenia, neutropenia Hyperglycemia Elevated transaminases Electrolyte imbalances, Na and K Prolonged QT-c Recommend monitoring lipids Increased risk for metabolic syndrome with antipsychotics With every visit assess for orthostasis, syncope, weight gain and other common side effects On PE, assess for dystonia/eps and sedation 8

9 Case Study 2 A 35 year old male patient presents to your clinic to establish care Bipolar symptoms acting up HPI: Hx of Bipolar I disorder diagnosed 10 years ago after manic episode where he stayed up for 3 days straight and then binge drank ETOH, attempted to shoot himself in the head with a shotgun but didn t go through with it. He called 911. Has been on several mood stabilizers and antipsychotics, can t remember names, stopped taking all medications 1 year ago. Presents today with difficulty sleeping for the past 2 months, difficulty keeping up with thoughts, very irritable short temper, hypersexual, has been making many spontaneous purchases and is broke. At times feels very anxious but not every day. Has been able to go to work as a construction worker but is having a hard time focusing. Is drinking ETOH every night and taking Ambien he borrowed from a friend to try to sleep. Denies any AH, VH but sometimes he thinks someone is calling his name, doesn t recognize voice. Denies any depressed mood, SI or HI. PMH: HLP, not taking meds; Chronic back pain, on PRN hydrocodone/acet and ibuprofen Social Hx: Six-pack of beer QHS, 1 ppd cigarettes x 20 years, denies illicit drugs, has live-in GF who has her own issues FHx: Mother and paternal uncle with Bipolar disorder Allergies: Lithium Ready to tackle this patient? Key Points Case Study 2 Objective: Vitals: Stable. Weight: 70kg Psych: Restless but cooperative, thoughts mostly organized/linear but at times tangential, speech is mildly rapid but comprehensible, eye contact is stable, grooming is stable, judgment is fair to stable, insight is fair. Neuro: No dystonia or EPS Skin: No cutting lesions, abrasions, burns, bruising What s your A/P? Case Study 2 1. Based on this information, what would be his initial diagnosis? A. Bipolar I Disorder, most recent manic B. Bipolar II Disorder, most recent manic C. Bipolar II Disorder, most recent depressed 2. Based on his symptoms, what initial medication(s), if any, would you start? A. Divalproex sodium (Depakote) 500mg ER QHS B. Fluoxetine (Prozac) 20mg QAM C. Quetiapine 50mg QHS D. Lithium 300mg QHS 3. What other treatment options would you order? A. Referral to psychotherapist/psychologist/counselor B. Electroconvulsive therapy C. Referral to psychiatry 4. Which diagnostics, if any, would you order? A. TSH, CBC, CMP, EKG B. UDS C. CT head with contrast and UDS D. A and B only Case Study 2 1. Bipolar 1 D/O, most recent hypomanic: Seroquel 50mg PO QHS Hydroxyzine (Vistaril) 25mg 1-2 caps po Q8 hours PRN for anxiety/sleep Referral to psychotherapy/cbt Check UDS and EKG in clinic (if available) CBC, CMP, TSH, lipid panel Education provided on not using prescription drugs not prescribed to him Pt denies any SI or HI and feels in control, F/u 2 weeks or earlier PRN Discussed plan with pt including meds and side effect profile and pt consents to plan of care Pt contracts for safety and verbalized understanding of where to call if symptoms worsen, local crisis center information provided RTC if symptoms worsen or go to nearest ER (If psychiatry referral available consider referral) 2. ETOH dependence: Education provided on ETOH cessation, plan of care developed, verbalized understanding 9

10 Case Study 3 A 55 year old female patient presents to your clinic to establish care Trouble sleeping, feels anxious all the time HPI: For several years she s felt very anxious, every day, wakes up feeling on edge and nervous. Two years ago she was held up at gun-point and struck in the head and her car was stolen. Since then she s had nightmares around 3 times a week, avoids crowds, is very apprehensive being around men, at times afraid to leave house. Prior to the event, she had a history of anxiety but its much worse. Intermittent chest tightness and palpitations when anxiety is high. She was prescribed propranolol and hydroxyzine PRN by previous PCP and weren t effective. Was also prescribed zolpidem PRN and she didn t tolerate it. Denies depressed mood but states I m certainly not happy. Denies mania, AH, VH, SI or HI. PMH: HTN on lisinopril, HLP on simvastatin GYN Hx: Hysterectomy 20 years ago Social Hx: Married, stable relationship; she s a retired school teacher; has been drinking a glass of wine every night to calm her nerves; drinks 3-4 cups of coffee in the AM; denies smoking or illicit drugs FHx: Mother had the nerves Allergies: NKDA Review: Anxiety Anxiety Differentiate between normal anxiety and clinical anxiety Affects daily activities and difficult to control, with at least 3 characteristics: Insomnia Restlessness, on edge Difficulty concentrating Fatigue Muscle tension Irritability For Dx of GAD, symptoms for at least 6 months with above criteria Rule out unipolar depression, bipolar depression, psychosis or other condition Further eval for PTSD, OCD, and other anxiety-spectrum disorders * Important to define mania to patient American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. 5 th ed. Review: Anxiety Avoid benzos as first line agent, even if past history of use, band-aid Identify and treat underlying issue Insomnia Stressors Thyroid dysfunction, adrenal disorders Excessive use of caffeine or other stimulants/drugs Is this chronic or new condition? If chronic what have they tried in the past? Are they drug seeking? PCP-shopping? Review: Anxiety Activating Neutral Sedating Fluoxetine Vilazodone 1 Vortioxetine 1 Citalopram 1 Escitalopram Sertraline Paroxetine SSRIs (Prozac) (Viibryd) (Brintellix) (Celexa) (Lexapro) (Zoloft) (Paxil) SNRIs Venlafaxine 2 Duloxetine 2 Desvenlafaxine 1, 2 (Effexor) (Cymbalta) (Pristiq) Amitriptyline 1, 3 TCAs (Elavil) Buproprion 1, 2 Other Mirtazepine 1 (Wellbutrin) Trazodone 1 (Remeron) Non-Benzo Buspirone Propranalol Hydroxyzine Anxiolytics (Buspar) (Atarax, Vistaril) Alprazolam Clonazepam Diazepam Lorazepam Benzos (Xanax) (Klonopin) (Valium) (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 10

11 Review: Anxiety Key Points: Did I mention avoid benzos? Treat underlying causes Insomnia--educate on sleep hygiene; melatonin, hydroxyzine, trazodone or other agents Cognitive behavioral therapy for stressors/management Caffeine reduction, cessation of stimulants Depression Rule out bipolar disorder Individualize based on pt s age, symptoms, existing medication regimen, health & psychosocial status Benzos appropriate in significant GAD, panic disorder, PTSD, agoraphobia Start with clonazepam, less abuse potential Avoid long acting benzos in elderly (>65) and frail population Alprazolam for moderate to severe cases of PTSD, panic disorder, agoraphobia (quick onset) F/u in 2-4 weeks, ensure proper diagnosis Case Study 3 A 55 year old female patient presents to your clinic to establish Trouble sleeping, feels anxious all the time HPI: For several years she s felt very anxious, every day, wakes up feeling on edge and nervous. Two years ago she was held up at gun-point and struck in the head and her car was stolen. Since then she s had nightmares around 3 times a week, avoids crowds, is very apprehensive being around men, at times afraid to leave house. Prior to the event, she had a history of anxiety but its much worse. Intermittent chest tightness and palpitations when anxiety is high. She was prescribed propranolol and hydroxyzine PRN by previous PCP and weren t effective. Was also prescribed zolpidem PRN and she didn t tolerate it. Denies depressed mood but states I m certainly not happy. Denies mania, AH, VH, SI or HI. PMH: HTN on lisinopril, HLP on simvastatin GYN Hx: Hysterectomy 20 years ago Social Hx: Married, stable relationship; she s a retired school teacher; has been drinking a glass of wine every night to calm her nerves; drinks 3-4 cups of coffee in the AM; denies smoking or illicit drugs FHx: Mother had the nerves Allergies: NKDA Key Points * Important to define mania to patient Case Study 3 Objective: VS: P: 105 BP: 150/90 Psych: Restless in chair, scratching her arms and hands, guarded, minimal eye contact, speech is regular rate/rhythm, well groomed, thoughts organized/linear but brief, judgment is good, insight is fair. Neuro: No dystonia or EPS, no tremors Skin: Multiple skin lesions around hands and arms c/w picking Case Study 3 1. Based on this information, what would be her initial diagnosis? A. Anxiety B. Generalized Anxiety Disorder (GAD) C. PTSD D. GAD and PTSD 2. Based on her symptoms, what initial medication(s), if any, would you start? A. Venlafaxine (Effexor) 75mg BID and lorazepam 0.5mg PO TID PRN B. Escitalopram 10mg PO QHS and clonazepam 0.25mg BID PRN C. Hydroxyzine 25-50mg PO TID PRN D. Alprazolam 0.5mg PO TID PRN What s your A/P? 3. What other treatment options would you order? A. Referral to psychotherapist/psychologist/counselor B. Electroconvulsive therapy C. Referral to psychiatry 4. Which diagnostics, if any, would you order? A.TSH, CBC, CMP B. UDS C. CT head with contrast and UDS D. A and B only 11

12 Case Study 3 Assessment: 1. PTSD 2. GAD Case Study 4 A 27 year old female patient presents to your clinic for f/u Difficulty sleeping Plan: Escitalopram 10mg one tab PO QHS Clonazepam 0.25mg one tab PO BID PRN for anxiety After detailed discussion including SE profile, pt consents to plan of care Educated on limiting caffeine and gradual reduction in ETOH F/u in 2 weeks RTC if symptoms worsen or go to nearest ER Referral to psychotherapy/counselor HPI: Existing Bipolar I patient, generally well controlled symptoms on quetiapine (Seroquel) 100mg QHS and fluoxetine (Prozac) 40mg daily. Brought by her husband today with difficulty sleeping x 1 week, has not slept in 3 days, with racing thoughts, increased paranoia, delusions of persecution the FBI is trying to kill me! Maybe I should just do it for them! She is very restless and difficult to follow her thought process. PMH/Meds: Hypothyroidism on 100mcg daily, Ortho Cyclen OCP daily Social Hx: Married, stable relationship; she works as an accountant; non-smoker; no illicit drugs; occasional ETOH FHx: Hx of depression in mother Allergies: NKDA Case Study 4 A 27 year old female patient presents to your clinic for f/u Difficulty sleeping HPI: Existing Bipolar I patient, generally well controlled symptoms on quetiapine (Seroquel) 100mg QHS and fluoxetine (Prozac) 40mg daily. Brought by her husband today with difficulty sleeping x 1 week, has not slept in 3 days, with racing thoughts, increased paranoia, delusions of persecution the FBI is trying to kill me! Maybe I should just do it for them! She is very restless and difficult to follow her thought process. PMH/Meds: Hypothyroidism on 100mcg daily, Ortho Cyclen OCP daily Social Hx: Married, stable relationship; she works as an accountant; non-smoker; no illicit drugs; occasional ETOH FHx: Hx of depression in mother Allergies: NKDA Key Points Case Study 4 Objective: VS: Pt did not allow Psych: Restless in chair, covering her ears, shouting at the staff and her husband, thoughts disorganized, speech is fast and loud, intense eye contact, grooming is careless; judgment is poor; insight is poor; appears to be having AH; unable to answer simple questions. Neuro: No dystonia or EPS, no tremors Skin: Multiple abrasions to wrists What s your A/P? 12

13 Case Study 4 1. Based on this information, what would be her diagnosis? A. PTSD with flashbacks B. Generalized Anxiety Disorder (GAD) C. Acute anxiety with a panic attack D. Bipolar I disorder, most recent episode manic, decompensated 2. Based on her symptoms, what initial medication(s), if any, would you start? A. None, call 911 for emergency detention and further psych evaluation B. Divalproex sodium in HS and lorazepam C. Lithium in HS and clonazepam D. Seroquel in HS and alprazolam Case Study 4 1. Bipolar I D/O, most recent manic with psychosis and delusions, decompensated Pt not in control of faculties, danger to self and others 911 called for emergency detention, ED placed by police officer Transferred to ER via EMS, no acute physical distress BMC ER called and case discussed with physician Summary Questions? 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 13