COMMON MISTAKES MADE IN PRIMARY CARE WHEN TREATING PSYCHIATRIC PATIENTS BY SONNY CLINE M.A.,M.DIV.,PA-C NOT ASKING This is a common problem for many reasons: The provider does not feel comfortable managing psych problems. The provider perceives he/she does not have time for a discussion about psych issues. The provider is focused on physical problems and does not think about a psychological source of the presenting symptoms.
HOW TO FIX IT Become familiar with at least the basics of identifying and treating 3 disorders, anxiety, depression, Bipolar. Learn preset questions that you have memorized that narrow the problem quickly. Reassure the patient that this is important and you want to make sure they are properly treated. Schedule them back in a short time period (1 2 weeks initially) and put them in your schedule where you know you will have some leeway (for me that is the end of the day). Be comfortable with a small number of medications in each category that you can use as go to meds. NOT ASKING ABOUT MANIA This is often missed because most Bipolar patients will only come in for help when they are depressed. Bipolar depression is typically worse than unipolar depression and therefore will be easy to become the main focus. Bipolar patients will often not offer any information about being manic unless asked (sometimes several times as they like being manic as opposed to depressed). This is critically important because it changes your choice of medications.
HOW TO FIX IT When talking to a patient who presents with depression ALWAYS ask about mania and document it clearly. If mania has been present in the past make sure they have something on board (antipsychotic or mood stabilizer) to prevent a complete flip to mania. DOSING DRUGS TO LOW This tends to happen mostly because providers are fearful of what could happen if they keep raising the dose. Providers are not familiar with the medications and their indications and may worry about off label use.
HOW TO FIX IT Remember these basic guidelines: If you are treating anxiety, SSRI s are the standard of care, start low and go slow but drive the dose high. If treating someone with high anxiety or OCD you will likely need to max the dose, Example: Zoloft 50 mg 1/2 qd x 7 days then 1 qd x 7 days, then 1 and 1/2 qd x 7 days then 100 mg 1 qd x 7 days then 1 and 1/2 qd x 7 days then 2 qd If you are treating depression, you can start higher but don t need to drive the dose as high and can go quicker, Example: Zoloft 50 mg 1 qd x 7 days then 100 mg qd Always tell the patient if they have relief of symptoms at lower doses they can stop there and not feel the need to keep titrating HOW TO FIX IT II If you are treating Bipolar one of my favorite go to meds is Lamictal. This drug has a good antidepressant effect, but does offer some protection against mania. People tend to steer away from this drug due to fears of SJS, but we have learned that by titrating this drug slowly this significantly lowers the risk of SJS occurring. Example: Lamictal 25 mg 1 qd x 14 days, then 25 mg 2 qd x 14 days, then 100 mg 1 qd x 14 days then 150 mg 1 qd. The therapeutic window is typically between 100 mg and 300 mg If they are off the medication for more than 5 days the re titrate NOT KNOWING SOME SIDE EFFECTS OF PSYCH MEDS EXAMPLES: AKATHISIA LITHIUM TOXICITY NMS SEROTONIN SYNDROME MENTAL NUMBNESS FROM SSRI AGRANULOCYTOSIS
Akathisia: Described often as anxiety, or internal restlessness Lithium Toxicity: Nausea, vomiting, diarrhea, muscle weakness, tremor, confusion, ringing in the ears. NMS: High fever, irregular pulse, tachycardia, tachypnea, muscle rigidity, altered mental status, autonomic instability, BP high then low Serotonin Syndrome: Agitation, confusion, rapid heart rate, dilated pupils, heavy sweating, twitching Mental Numbness from SSRI: Not depressed, not happy, really not caring about much or mentally engaged Agranulocytosis: A severe leukopenia, check ANC NOT ASSESSING FOR COMORBID ANXIETY WHEN SOMEONE COMES IN FOR DEPRESSION This typically happens because the provider will focus on the chief complaint which is usually depression. Patients will often not talk about anxiety especially male patients. Patients will not recognize anxiety and write it off as normal stress or just silly fears. HOW TO FIX IT Simply ask a few screening questions for anxiety Do you ever feel anxious, how often? Scale of 1 10 (1 = no anxiety, 10 = freaking out) Do you ever avoid activities, places or people due to anxiety? Have you ever had a panic attack? (did it lead to an ER visit)
NOT SETTING APPROPRIATE EXPECTATIONS FOR PATIENTS WHEN STARTING PSYCH MEDS This typically happens because the provider is focused on getting this done and moving on to the next patient. Let s be honest it is a time drain to educate patients but it saves time and provides better care in the end. HOW TO FIX IT Trying to find the right psychiatric medication can be like trying on jeans. Two hurdles; side effects and efficacy. Just because your friend did fabulous on Drug X does not mean you will have a good response to the same drug. (unless the friend is a genetic relative then maybe) STAY OFF THE INTERNET!!!!!
NOT TAKING A GOOD FAMILY HISTORY A couple of quick questions: HOW TO FIX IT Ask about mom, dad, brothers and sisters. Does anyone have a mental illness or ever been treated for mental illness? Does anyone have a substance abuse problem? Has anyone ever committed suicide or attempted to do so? If you have time, then include grandparents. Lastly if one or more family members has the same diagnosis and is on a drug that is working use that drug first. ATTRIBUTING ALL PROBLEMS TO MENTAL ILLNESS Yes mental health patients can actually have physical problems. Listen to them and evaluate their complaints just as you would any other patient. Brain tumor patient