The Difficult Patient. Psychiatric Dilemmas in the Primary Care Setting. No Disclosures. Objectives 10/12/17. Erick K. Hung, MD

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1 Psychiatric Dilemmas in the Primary Care Setting No Disclosures Erick K. Hung, MD Associate Professor of Clinical Psychiatry University of California, San Francisco Objectives Describe approaches to the difficult patient in the primary care setting. Discuss common pitfalls in initiating antidepressants. Discuss strategies for effectively managing a patient who expresses suicide ideation. The Difficult Patient 1

2 Contributing Factors Contributing Factors 4 Difficult Behaviors The Clingers Personality Traits: Dependent Clinician Reaction: Aversion Practical Strategy: Set limits Groves (1978) Groves (1978) 2

3 The Demanders The Help-Rejecters Personality Traits: Narcissistic Clinician Reaction: Counter-attack Practical Strategy: Acknowledge demands and reframe Personality Traits: Histrionic Clinician Reaction: Despair Practical Strategy: Lower expectations and share doubts Groves (1978) Groves (1978) The Deniers Personality Traits: Mixed Clinician Reaction: Despair Practical Strategy: Lower expectations and let things go Common Antidepressant Pitfalls Groves (1978) 3

4 Start at a low dose! Sometimes you only get one chance to make a good impression Consider starting an antidepressant at half the starting dose sertraline 25 mg fluoxetine 10 mg citalopram 10 mg escitalopram 2.5 mg bupropion XL 150 mg STAR-D Trial for Depression STAR-D Trial (2006) STAR-D Trial (2006) Wait for at least 8 weeks Likelihood to Remission The likelihood for full remission of a major depressive episode with treatment at four treatment levels Level 1: 33% Level 2: 50% Level 3: 60% Level 4: 70% STAR-D Trial (2006) STAR-D Trial (2006) 4

5 STAR-D Take Home Points Clinicians and patients need to be patient for treatment response (i.e weeks) before trying another treatment strategy Patients with treatment-resistant depression can get well after multiple treatment strategies. The odds of beating depression diminish with every additional treatment strategy needed. Treat to remission (i.e. PHQ-9 score < 4) to minimize risk of episode relapse. Suicide STAR-D Trial (2006) Can We Intervene? Medical Setting Medical Setting within within 6 weeks 6 Weeks of of Suicide Attempt Suicide Attempt Can We Intervene? Medical Setting Medical within Setting 1 Week of Suicide Attempt within 1 week of Suicide Attempt No 30% No 35% Yes 70% 65% Yes Psych Services 1995, 46(5): Psych Services 1995, 46(5):

6 10/12/17 Suicide Suicide Attempt Aborted Suicide Attempt Suicidal Ideation Deliberate Self-Harm Suicide Suicide Suicide Attempt Self-inflicted death with evidence that the person intended to die. Aborted Suicide Attempt Suicidal Ideation Deliberate Self-Harm 6

7 Suicide Attempt Self-injurious behavior with a nonfatal outcome accompanied by evidence that the person intended to die. Suicide Suicide Attempt Aborted Suicide Attempt Suicidal Ideation Deliberate Self-Harm Aborted Suicide Attempt Potentially self-injurious behavior with a non-fatal outcome accompanied by evidence that the person intended to die but stopped before physical damage occurred. Suicide Suicide Attempt Aborted Suicide Attempt Suicidal Ideation Deliberate Self-Harm 7

8 Suicidal Ideation Thoughts of serving as the agent of one s own death. The seriousness may vary depending on the specificity of the plans and the degree of intent. Suicide Suicide Attempt Aborted Suicide Attempt Suicidal Ideation Deliberate Self-Harm Deliberate Self-Harm Willful self-inflicting of painful, destructive, or injurious acts without the intent to die. Suicide Statistics Fatal Nonfatal Characteristic No. % No. % All Self-Harm 30, , Cut/Pierce , Fall , Gunshot - - 3, Firearm 16, , BB/pellet gun Poisoning/Overdose 5, , Suffocation 6, , Other, specified 1, , Other, unspecified , National Center for Injury and Prevention and Control, U.S Data 8

9 Suicide Statistics Fatal Nonfatal Characteristic No. % No. % All Self-Harm 30, , Cut/Pierce , Fall , Gunshot - - 3, Firearm 16, , BB/pellet gun Poisoning/Overdose 5, , Suffocation 6, , Other, specified 1, , Other, unspecified , Estimating Risk National Center for Injury and Prevention and Control, U.S Data Estimating risk is more than just SI 9

10 Suicide Statistics Annual Incidence per 100,000 Suicide Completion 10.7 Suicide Attempts 260 Suicidal Ideation 4,000 The rarity of the suicidal event makes it impossible to predict behavior. National Center for Injury and Prevention and Control, U.S Data Risk Factors Past Present Future Although an understanding of risk factors allows the clinician to recognize individuals at relatively increased risk, it does not allow for prediction. Previous suicide attempts Previous self harm Sexual or physical abuse Neglect Medical History Family history Psychiatric conditions Substance use Suicidal ideation (plans, intent, and behavior) Acute psychosocial stressors (family discord, interpersonal losses, financial difficulties) Hopelessness Reasons for living Plans for the future Cultural and religious views about suicide Presence of external supports Likelihood of exposure to ongoing stressors Quality of therapeutic relationship Quality of problem-solving skills Psychiatric history Impulsivity Access to weapons such as firearms Substance use history Employment status Personality traits Living situation Past responses to stress Capacity for reality-testing 10

11 Framework #1 Framework #2 Risk Factors Risk Factors Past Present Future Static Modifiable Protective Factors Protective Factors Am J Psychiatry 160:11, November 2003 Supplement Am J Psychiatry 160:11, November 2003 Supplement The Method The Method Risk Factors Estimated Risk Estimated Risk Intervention Past attempt Low Low Low SI/intent/plan Intoxication Active symptoms Moderate Moderate Moderate Access to weapons Future-orientation High High High 11

12 Acute vs. Chronic Talk is Cheap Acute Chronic Time of Evaluation hours Months to Years Patient (Behavior > Words) Medical Records Health Care Providers Friends and Family Roommates Interventions When in doubt, consult with your colleagues 12

13 13

14 The Next Level Responding to +SI Responses to SI I understand that you are suffering. I will promise to help you to the best of my ability. I will not abandon you. You suffering is temporary. You are blinded by suffering. Many people have been in your situation, have survived, and are living happily. When this crisis is over, you will be stronger. What has stopped you from killing yourself? I understand you wish to die. What do you think these thoughts represent? 14

15 Approach Strategies I m suicidal I m NOT suicidal The Next Level High Risk No-Brainer Patient Inconsistent Patient Moving Beyond +SI Low Risk Gamey Patient Stable Patient Conditional Patient Interview Techniques Inconsistent Patient 15

16 I feel fine now. It was all a misunderstanding. Can I go home now? Behavioral Incident Obtain collateral information Normalization Symptom Amplification 16

17 Denial of the Specific Gamey Patient If I really wanted to kill myself, I wouldn t tell you! Conditional Patient Clarify your role and force the issue 17

18 References If you don t admit me (or give me pain meds, or find me housing, or...), I will kill myself! Separate condition from suicidal ideation Groves, JE. Taking Care of the Hateful Patient. NEJM 1978; 298(16): Trivedi MH et al. Evaluation of Outcomes with Citalopram for Depression Using Measurement-Based Care in STAR-D. Am J Psychiatry 2006; 163: Gaynes BN et al. The STAR-D Study: Treating Depression in the Real World. Cleveland Clinic Journal of Medicine 2008; 75(1) Shea SC. The Practical Art of Suicide Assessment Questions? 18

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