CONCORD INTERNAL MEDICINE MENTAL HEALTH PROTOCOL

Transcription

1 CONCORD INTERNAL MEDICINE MENTAL HEALTH PROTOCOL Douglas G. Kelling, Jr., MD Carla Gismondi-Eagan, MD, FACP George C. Monroe III, MD Revised April 8, 2012 The information contained in this protocol should never be used as a substitute for clinical judgment. The clinician and the patient need to develop an individual treatment plan that is tailored to the specific needs and circumstances of the patient.

2 Mental Health Protocol Table of Contents Page(s) Section I: Depression Pathway Clinical Pathway 1-11 PHQ-9 Screening Tool Bipolar Questionnaire 14 Section II: Anxiety Spectrum Disorders Clinical Considerations Pathway 15 GAD Screening Tool 16 Anxiety Treatment Pathway OCD Screening Tool Section III: Adult ADHD Adult ADHD Self Report Scale Symptoms Checklist 23

3 1 Depression Pathway All patients are screened with two questions: 1. Have you lost interest in things you used to enjoy? 2. Have you been feeling depressed, sad, blue or down in the dumps? Patient answers yes to one or both questions Evaluate severity with PHQ-9 Score Pages 12 & 13 PHQ-9 Score < 5 Not clinically depressed PHQ-9 Score > 5 Continue Medical Treatment PHQ-9 Question 9 indicates patient at risk for suicide Repeat depression screen yearly or as medically indicated Page 11

4 2 Depression Pathway PHQ Score > 5 Screen for Bipolar Disorder Page 14 Screen Positive Screen Negative Refer for second opinion regarding diagnosis of Bipolar Disorder Page 3 Second opinion agrees with diagnosis of Bipolar Disorder Second opinion does not agree with diagnosis of Bipolar Disorder Treat Bipolar Disorder Page 3

5 3 Depression Pathway No evidence of Bipolar Disorder Screen for Psychosis Screen for Obsessive Compulsive Disorder Pages 20, 21 & 22 One or more screens positive All screens negative Psychiatrist Screen for alcohol/substance abuse Screen for anxiety Pages 15 & 16 Screen Positive Screen Negative Screen Positive Treat alcohol/substance abuse Treat depression Page 4

6 4 Depression Pathway Treatment Offer referral to Psychiatrist/psychologist especially if PHQ-9 Score >20 Select antidepressant and initiate medication PHQ-9 Score > 20? No Yes In 2 weeks, 4 weeks, and 6 weeks re-evaluate, patient s status In 1 week re-evaluate patient s status including PHQ-9 Score* Week 6-assess patient s response by re-administering PHQ-9 Score PHQ-9 Score < 5 PHQ-9 Score less than initial PDQ-9 Score No improvement of PHQ-9 Score Worsening of PHQ-9 Score Page 9 Page 5 Page 8 Consider referral to psychiatry

7 5 Depression Pathway PHQ-9 Score Improved by > 5 points Improved by 4 points or less PHQ-9 Score < 10 PHQ-9 Score >10 Re-evaluate patient in 6 weeks with PHQ-9 Score In 2 weeks re-evaluate patient with PHQ-9 Score Page 6 PHQ-9 Score < 5 PHQ-9 Score 5-9 PHQ-9 Score >10 PHQ-9 Score < 5 PHQ-9 Score 5-9 PHQ-9 Score > 10 Page 9 Re-evaluate in 4 weeks with PHQ-9 score psychiatrist See Page 9 Re-evaluate in 4 weeks with PHQ-9 score PHQ-9 Score < 5 PHQ-9 Score 5-9 PHQ-9 Score >10 Page 9 psychiatrist Re-evaluate in 4 weeks with PHQ-9 score PHQ-9 Score < 5 PHQ-9 Score 5-9 PHQ-9 Score > 10 Page 9 Page 7 psychiatrist

8 6 Depression Pathway Improved by 4 points or less PHQ-9 Score > 10 PHQ-9 Score < 10 Increase antidepressant Consider increasing antidepressant Re-evaluate patient in 2 weeks with PHQ-9 Score Re-evaluate patient in 6 weeks with PHQ-9 Score PHQ-9 Score < 10 PHQ-9 Score > 10 PHQ-9 score < 5 PHQ-9 Score 5-10 PHQ-9 Score > 10 Re-evaluate patient in 4 weeks with PHQ-9 score PHQ-9 Score improved PHQ-9 Score same See Page 7 PHQ-9 Score worse psychiatry Page 9 psychiatry PHQ-9 Score < 5 PHQ-9 Score 5-10 PHQ-9 Score > 10 Re-evaluate in 4 weeks with PHQ-9 score Page 9 psychiatry PHQ-9 Score < 5 PHQ-9 Score 5-9 PHQ-9 Score > 10 Page 9 Page 7 psychiatrist

9 7 Depression Pathway PHQ-9 Score 5-9 Consider: 1. Maximize dose antidepressant patient already on (See Page 8) or 2. Switching to another antidepressant (See Page 8) or 3. Adding a second antidepressant from another class (See Page 8) or 4. Referral to psychiatry

10 8 Depression Pathway Maximize dose antidepressant, select alternative antidepressant, or add second antidepressant or refer to psychiatrist Re-evaluate patient, 2 weeks, 4 weeks and 6 weeks after initiation of medication Week 6 Assess response by re-administering PHQ-9 Score PHQ-9 Score < 5 Current PHQ-9 Score less than initial PHQ-9 Score but > 5 No improvement or worsening of PHQ-9 Score Page 9 Psychiatrist

11 9 Depression Pathway PHQ-9 Score < 5 For first episode of depression Continue maintenance therapy for total 6-9 months then consider tapering off medication over several weeks For second episode of depression Page 10 For third or higher episode of depression Continue maintenance treatment indefinitely

12 10 Depression Pathway Second episode depression Does patient have Family history of bipolar disorder History of recurrence within 1 year after previously effective medication was discontinued A family history of recurrent major depression Early onset (before age 20) of the first episode Both episodes were severe, sudden or life threatening in the past three years No Yes Continue maintenance therapy for total 6-9 months then consider tapering off medication over several weeks Continue maintenance treatment indefinitely

13 11 Depression Pathway Assessment of suicide risk No specific plans or intent to commit suicide and have no history of active suicide behavior Low Risk Current thoughts Immediate referral to mental health personnel in ER page 2

14 12 Depression Screening Patient Name: DOB: Date: Over the last 2 weeks how often have you been bothered by any of the following problems? Several More than Nearly every Questions Not at all days half the days day Complete Questions 1-9 Initially then at all Critical Decision Points (CDPs) Little interest or pleasure in doing things 2. Feeling down, depressed or hopeless 3. Trouble falling/staying asleep, sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed. Or the oppositebeing so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or hurting yourself in some way. (if positive, complete the Suicide Risk Assessment) #Symptoms x 0 = x 1 = x 2 = x 3 = Per Category = Grief Reaction Screening YES NO 1. Did your most recent period of feeling depressed or sad begin after someone close to you died? 2. If so, did the death occur more than 2 months ago? If NO to first question, or if YES to both questions, treat the patient for depression

15 13 PHQ-9 SCREENING AND DIAGNOSIS Patient Health Questionnaire (PHQ-9) Form Symptoms & Impairment 1-4 symptoms (not including questions 1 or 2), + functional impairment 2-4 symptoms including question 1 or 2, + functional impairment > 5 symptoms including question 1 or 2, + functional impairment > symptoms including question 1 or 2, + functional impairment PHQ-9 Severity Provisional Diagnosis <10 Mild or minimal Depressive Symptoms Moderate Depressive Symptoms (Minor Depression)* Moderate Severe Major Depression > 20 Severe Major Depression *If symptoms present for > 2 years, chronic depression, or functional impairment is severe, remission with watchful waiting is unlikely. IMMEDIATE active treatment is indicated for Minor Depression. Three (3) Phases of Depression Treatment** Acute Phase aims at minimizing depressive symptoms typically first 3-4 months of therapy Continuation Phase tries to prevent return of symptoms in the current episode 4-12 months (repeat PHQ-9 Q 4-6 months). Maintenance Phase tries to prevent return of symptoms within 2 years months Medication Therapy is recommended for at least 90 months after return to well state **REFERRAL or co-management with mental health specialty clinician if the patient is: High Suicidal Risk Bipolar Disorder Inadequate Treatment Response Complex Psychosocial Needs Other Active Mental Disorder The MacArther Initiative on Depression and Primary Care at Dartmouth & Duke, Version 9.0-January 2004.

16 14 The Bipolar Disorder Questionnaire Name DOB Instructions: Please answer each question as best you can: 1. Has there ever been a period of time when you were not your usual self and YES NO you felt so good or so hyper that other people thought you were not your normal Self or you were so hyper that you got into trouble? you were so irritable that you shouted at people or started fights or arguments? you felt much more self-confident than usual? you got much less sleep than usual and found you didn t really miss it? you were more talkative or spoke much faster than usual? thoughts raced through your head or you couldn t slow your mind down? you were easily distracted by things around you that you had trouble concentrating or staying on track? you had more energy than usual? you were much more active or did many more things than usual? you were much more social or outgoing than usual, for example, you Telephoned friends in the middle of the night? you were much more interested in sex than usual? you did things that were unusual for you or that other people might have thought were excessive, foolish or risky? spending money got you or your family into trouble? 2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? 3. How much of a problem did any of these cause you like being able to work; having family, money or legal troubles; getting into arguments or fights? Please circle ONE response only: No problem Minor problem Moderate problem Serious problem 4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles,) had manic-depressive illness or bipolar disorder)? 5. Has a health professional ever told you that you have manic-depressive or bipolar disorder? This instrument is designed for screening purposes only and is not to be used as a diagnostic tool.

17 15 Generalized Anxiety Disorder (GAD) Screen Over the last 2 weeks, how often have you been bothered by the following problems? Not Several More than Nearly at all days half the every days day Feeling nervous, anxious or on edge Not being able to stop or control worrying Worrying too much about different things Having trouble relaxing Being so restless that it is hard to sit still Becoming easily annoyed or irritable Feeling afraid as if something awful might happen Total Score Add Columns + + Scoring 0-4 No to minimal anxiety 5-9 Mild anxiety Moderate anxiety Severe anxiety

18 16 Anxiety Spectrum: Clinical Considerations Spectrum of anxiety; worry; fear; avoidance; repetitive, intrusive, inappropriate thoughts or actions; or unexplained general medical complaint. Consider the role of a general medical condition or substance use and whether the anxiety is better accounted for by another mental disorder No Presenting symptom is fear, avoidance, or anxious anticipation about one or more specific situations No Presenting worry or anxiety is related to recurrent and persistent thoughts (obsessions) and/or ritualistic behaviors or recurrent mental acts (compulsions) No Pervasive symptoms of anxiety and worry are associated with a variety of events or situations and have persisted for at least 6 months Presenting symptom is recurrent Panic Attacks No Presenting symptoms include fear of separation No Presenting symptoms are related to reexperiencing highly traumatic events No No Symptoms are in response to a specific, psychosocial stressor If clinically significant anxiety is present but the No criteria are not met for any of the previously described disorders If the clinician has No determined that a disorder is not present but wishes to note the presence of symptoms Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Anxiety Disorder Due to a General Medical Conditions ( and specify substance or condition) Alcohol Induced Anxiety Disorder ( and specify substance or condition) Substance-Induced (including medication) Anxiety Disorder ( and specify substance or condition) Other mental disorders (consider urine drug screen) Panic Disorder With (300.21) or Without (300.01) Agoraphobia Panic Attacks occurring within the context of other Anxiety Disorders (e.g., Social Phobia, Specific Phobia, Posttraumatic Stress Disorder, Obsessive-Compulsive Disorder) Social Phobia (avoidance of social situations in which the person may be exposed to scrutiny) (300.23) Specific Phobia (avoidance of a specific object or situation) (300.29) Panic Disorder With Agoraphobia (avoidance of situations in which escape may be difficult in the event of having a Panic Attack) Agoraphobia Without History of Panic Disorder (avoidance of a situation in which escape may be difficult in the event of developing panic-like symptoms) (300.22) Consider Separation Anxiety Disorder (309.21) Consider Obsessive-Compulsive Disorder (300.3) (see tool) Posttraumatic Stress Disorder (if symptoms persist at least 4 weeks) (309.81) Acute Stress Disorder (if symptoms persist for less than 4 weeks) (308.3) Consider Generalized Anxiety Disorder (300.2) ( see tool) Adjustment Disorder with Anxiety (309.24) or Adjustments Disorder with Mixed Anxiety and Depressed Mood (309.28) Consider Anxiety Disorder Not Otherwise Specified (300.00) Consider Anxiety (799.2)

19 17 Anxiety Pathway Generalized Anxiety Disorder Treatment Consider referral to psychiatrist, especially if GAD screen score > 15 Consider referral for counseling, Employee Assistance Program (EAP) or other talk/cognitive therapy resource Select SSRI and initiate medicine GAD score > 15 No Yes Clinically reevaluate in 4 weeks and administer GAD screen Clinically reevaluate in 2 weeks GAD < 5 GAD score less than initial but >5 No improvement in GAD score Worsening of GAD score Page 18 Page 19 Change class of antianxiety medicine Change class of anti-anxiety medicine & consider referral to psychiatry Reevaluate in 4 weeks GAD < 5 GAD score less than initial but >5 No improvement or worse Page 19 Psychiatry

20 18 Anxiety Pathway GAD Score <5 For first episode of anxiety Continue Maintenance therapy for 6-9 months then taper off medication for several weeks For second or higher episode of anxiety Continue maintenance treatment indefinitely

21 19 Anxiety Pathway Maximize does of SSRI, select alternative, add augmenting agent (i.e., Trazadone, low dose Welbutrin, Mirtazipine, long acting Benzodiazepine) Again consider referral for counseling Reassess patient 4-6 weeks after above change Page 18 GAD score <5 Current GAD score less than initial/improving but >5 Consider increasing dose, augmenting or referral (psych and/or counseling) GAD score no improvement or worse Psychiatrist Reevaluate in 4-6 weeks GAD score <5 GAD score less than last but >5 GAD score no improvement or worse

22 20 Side 1 Name: Date: ZOHAR-FINEBERG OBSESSIVE COMPULSIVE SCREEN (Z-FOCS) ThThese questions questions are are designed designed to screen to screen for the for presence the presence of obsessive compuls of obsessivecompulsive ive Yes No disorder. Please disorder. tick the response Please tick you the think response is correct. you think is correct. Yes No 1. Do you wash or clean a lot? 2. Do you check things a lot? 3. Is there any thought that keeps bothering you that you would like to get rid of but can t? 4. Do your daily activities take a long time to finish? 5. Are you concerned about orderliness or symmetry? If you answered yes to any of the above questions, please turn over page and complete side 2

23 21 Obsessive Compulsive Disorder Questionnaire Concord Internal Medicine Side 2 Rate the average amount of time spent on each item during the past week. Obsession Scale Obsession is a focus an idea, feeling or thought. These may be unreasonable or disturbing. Examples include (but are not limited to): excessive cleanliness, thoughts of violence, thoughts of injuring yourself or others, and mental images of upsetting events. Remember: Obsessions are thoughts or ideas, not actions. Time spent on obsession Interference with daily living/activities Distress directly from obsessions Resistance to obsessions Control over obsessions Total None 0 1 hours a day 1 3 hours a day 3 8 hours a day More than 8 hours a day Compulsion Scale Total of all columns Compulsion is an urge to repeatedly do something in a specific pattern, for example: touching, counting, arranging, in an attempt to relieve anxiety resulting from obsessive thoughts. Remember: compulsions are actions, not thoughts or ideas. Time spent on compulsive activity Interference with daily living or activities Distress directly from compulsive behaviors Resistance to compulsive behaviors Control over compulsive behaviors Total None 0 1 hours a day 1 3 hours a day 3 8 hours a day More than 8 hours a day Staff Use Only Enter Y BOCS Total Total of all columns

24 22 Obsessive Compulsive Disorder Questionnaire Staff Worksheet Patient Name: DOB: Obsession Scale Total Compulsive Scale Total Total Score Severity Scale Score Diagnosis 0-7 Subclinical 8-15 Mild Moderate Severe Extreme Obsessive Compulsive Disorder Questionnaire Staff Worksheet Patient Name: DOB: Obsession Scale Total Compulsive Scale Total Total Score Severity Scale Score Diagnosis 0-7 Subclinical 8-15 Mild Moderate Severe Extreme

25 Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist Patient Name Today s Date Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today s appointment. Never Rarely Sometimes Often Very Often 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? 3. How often do you have problems remembering appointments or obligations? 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? 6. How often do you feel overly active and compelled to do things, like you were driven by a motor? Part A 7. How often do you make careless mistakes when you have to work on a boring or difficult project? 8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? 9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? 10. How often do you misplace or have difficulty finding things at home or at work? 11. How often are you distracted by activity or noise around you? 12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? 13. How often do you feel restless or fidgety? 14. How often do you have difficulty unwinding and relaxing when you have time to yourself? 15. How often do you find yourself talking too much when you are in social situations? 16. When you re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? 17. How often do you have difficulty waiting your turn in situations when turn taking is required? 18. How often do you interrupt others when they are busy? Part B

26 Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist Instructions The questions on the back page are designed to stimulate dialogue between you and your patients and to help confirm if they may be suffering from the symptoms of attention-deficit/hyperactivity disorder (ADHD). Description: The Symptom Checklist is an instrument consisting of the eighteen DSM-IV-TR criteria. Six of the eighteen questions were found to be the most predictive of symptoms consistent with ADHD. These six questions are the basis for the ASRS v1.1 Screener and are also Part A of the Symptom Checklist. Part B of the Symptom Checklist contains the remaining twelve questions. Instructions: Symptoms 1. Ask the patient to complete both Part A and Part B of the Symptom Checklist by marking an X in the box that most closely represents the frequency of occurrence of each of the symptoms. 2. Score Part A. If four or more marks appear in the darkly shaded boxes within Part A then the patient has symptoms highly consistent with ADHD in adults and further investigation is warranted. 3. The frequency scores on Part B provide additional cues and can serve as further probes into the patient s symptoms. Pay particular attention to marks appearing in the dark shaded boxes. The frequency-based response is more sensitive with certain questions. No total score or diagnostic likelihood is utilized for the twelve questions. It has been found that the six questions in Part A are the most predictive of the disorder and are best for use as a screening instrument. Impairments 1. Review the entire Symptom Checklist with your patients and evaluate the level of impairment associated with the symptom. 2. Consider work/school, social and family settings. 3. Symptom frequency is often associated with symptom severity, therefore the Symptom Checklist may also aid in the assessment of impairments. If your patients have frequent symptoms, you may want to ask them to describe how these problems have affected the ability to work, take care of things at home, or get along with other people such as their spouse/significant other. History 1. Assess the presence of these symptoms or similar symptoms in childhood. Adults who have ADHD need not have been formally diagnosed in childhood. In evaluating a patient s history, look for evidence of early-appearing and long-standing problems with attention or self-control. Some significant symptoms should have been present in childhood, but full symptomology is not necessary.