How to Treat Mental Illness in the Primary Care Setting

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Pediatric Overview

Depression

Post Partum Depression

Psychiatric and Medical Co-morbidity

Schizophrenia

Somatoform Disorders

Suicide

PEDIATRIC OVERVIEW

Psychiatric problems of youth in primary care: A review outcome monitoring of mental illness in children and adolescents has long been documented. So too has the fact that the vast majority of medical care given to children with psychiatric illness is by primary care clinicians, not child and adolescent psychiatrists. As specialty resources dwindle, or fail to keep pace with the complexities in the understanding of the etiology and treatments of psychiatric illnesses, primary care clinicians become the 'go to' people after brief exposure to specialty care or following episodic consultation. The goal of this paper is to discuss - by disease category - tools for detection and assessment, treatments, and issues in collaboration between primary care and specialty care. The advice given here is based in evidence based medicine, clinical best practices, and practice parameters as suggested by professional academies. Wisconsin Medical Journal Volume 103, Issue 6 - 2004

Achieving Remission in Depression: Managing Women and Men in the Primary Care Setting
Review the links between depression and gender, ethnicity, reproductive cycle, anxiety, and medical conditions such as cardiovascular disease and diabetes.
Medscape - 04/28/06

Using Care Managers Improves Depression Outcome in Seniors
There is mounting evidence that the IMPACT model for treating depression in seniors is clinically effective. Thanks to a grant from the John A. Hartford Foundation, a group of psychiatrists and primary care physicians came together in 1999 to develop a new model for treating depressed older Americans. They named the model "IMPACT" ("Improving Mood Promoting Access to Collaborative Care Treatment"). In essence, IMPACT would place a depression care manager (usually a nurse) in a primary care clinic to assist primary care physicians in the care of older depressed patients. The manager would work with the physicians to establish depression treatment plans for the patients. In addition, the manager would contact the patients every other week to see how they were doing. If they recovered from depression, a relapse-prevention plan would be put into effect, and the manager would follow them over the next few months to determine how well the plan was working. If they did not recover from depression, the manager would discuss their case with a consulting psychiatrist, and treatment would be adjusted accordingly. Psychiatric News - 04/07/06

The Macarthur Initiative on Depression and Primary Care at Dartmouth and Duke
Offers primary care providers tools for the recognition, diagnosis and treatment of clinical depression within the primary care setting. Their web site offers a free, downloadable depression toolkit that includes clinician memory aids and a patient questionnaire for the diagnostic purposes. It also includes patient handouts, treatment information including drug administration information and monitoring and follow-up tools. MacArthur Initiative www.depression-primarycare.org

Improving Care for Adolescents With Depression
An estimated 6% of adolescents have major depression, but few receive effective treatment in primary care settings. Asarnow and colleagues report results of a randomized trial that involved care managers to support primary care physicians in evaluating and managing adolescent depression and provided training and educational materials for the physicians to increase access to evidence-based treatments. Six months after randomization, patients in the intervention group reported fewer depressive symptoms and had greater access to mental health care, including psychotherapy, than usual care patients. Journal of the American Medical Association - 2005

DEPRESSION

Why Chronic Pain Can Lead to Depression Is Revealed
People who are in chronic pain may have high rates of depression and anxiety because areas of their brains that would normally be at rest are constantly active, a study in the Journal of Neuroscience indicates. "These findings suggest that the brain of a chronic pain patient is not simply a healthy brain processing pain information but rather it is altered by the persistent pain in a manner reminiscent of other neurological conditions associated with cognitive impairments," the researchers wrote. Reuters - 2/5/08

The Recognition and Treatment of Depression: A Review for the Primary Care Clinician
The signs and symptoms of major depression have been recognized since at least the eighth century BCE. For example, King Saul's bouts of severe depression and ultimate suicide are described in the Bible in the First Book of Samuel.^[1] In the fifth century BCE, Hippocrates described "melancholia" as despondency, insomnia, irritability, restlessness, and aversion to food. Indeed, the signs that we today recognize as indicative of significant depression -- guilt, low self-esteem, lack of pleasure, low energy, poor sleep, poor hygiene, and abnormal appetite -- have been recognized as such for millennia.^[2]Medscape - 09/30/05

Physical and Somatic Symptoms in the Diagnosis and Treatment of Depression: An Expert Interview With Maurizio Fava, MD
Editor's Note: The interplay of physical and somatic symptoms significantly complicates the diagnosis and treatment of patients with depression. As many as two thirds of depressed patients in primary care present with somatic symptoms, including general aches and pains, insomnia, and fatigue. These patients are difficult to diagnose and treat, feel a greater disease burden than those without somatic symptoms, and rely heavily on healthcare services. Patients who present with somatic complaints are 3 times more likely to be misdiagnosed compared with patients who have no physical complaints. On behalf of Medscape, Jennifer M. Covino, MPA, spoke with Maurizio Fava, MD, Professor of Psychiatry at the Harvard Medical School, Boston, Massachusetts, about the role of physical and somatic symptoms in the diagnosis and treatment of depression and approaches that may improve results. (Registration required-Medscape - 05/26/06

Women at Greater Risk From Post-MI Depression
Researchers speculate on the reasons for the surprising finding that there are higher rates of depression among women aged 45 to 49 who suffer heart attacks than among older women. Most physicians know to screen those who survive a heart attack for symptoms of depression because the psychiatric disorder can contribute to further cardiac trouble. However, new research indicates that younger women may benefit most from such screening, because they are the most vulnerable to depression following a heart attack. Psychiatric News - 06/02/06

Family Medicine and Primary Care: Working Toward the 3 "Rs" for Managing Depression
Explore practical ways for primary care providers to recognize and manage patients with depression, including the appropriate use of screening instruments, medications, and referrals. Medscape - 02/23/05

It Takes a Team: Effective Management of Depression
Recognize and diagnose depression and learn when to use a collaborative team approach in treating depressed patients. Medscape - 02/23/06

Are the SSRIs and Atypical Antidepressants Safe and Effective for Children and Adolescents?
Current evidence supports the conclusions of the UK drug regulator in warning against the use of all the newer antidepressants except fluoxetine in this age group, and alternative therapies should be sought in the first instance. Caution is needed in interpreting drug company sponsored trials given the evidence of selective reporting and publication bias. Combining fluoxetine with a psychological treatment such as cognitive-behavioural therapy is also worth considering. Medscape - 02/23/05

POST PARTUM DEPRESSION

Postpartum Depression: Identification, Screening, and Treatment
Depression during the postpartum period is a significant public health concern, affecting 8%-15% of women and resulting in considerable morbidity for women, and their infants and families. Risk, prevalence, and distinguishing features of postpartum mood disorders are provided. Anxiety and depression frequently co-occur, suggesting symptoms of anxiety should also be attended to when screening for postpartum depression. Recommendations include the use of a brief, valid screening instrument as a routine clinical practice and the unique role of the obstetrician/gynecologist, pediatrician, and family practice physician in identification and referral. A summary of evidence-based treatment options for postpartum depression, along with current information about psychotropic medication, is provided to assist in risk-benefit analyses and decision making with patients. Wisconsin Medical Journal Volume 103, Issue 6 - 2004

PSYCHIATRIC AND MEDICAL CO-MORBIDITY

Better Poststroke Outcome Follows Antidepressant Use
Early detection and appropriate treatment of poststroke depressionare essential factors in improving patients' poststroke outcomes.Antidepressant medications can effectively treat post-strokedepression (PSD), potentially leading to improvement in outcomesand decreases in overall health care services utilization bypatients, a pair of new studies indicates.After an acute stroke, the first of the two studies found, healthcare utilization was significantly higher among patients withPSD than in patients who had strokes but did not have PSD. Thestudy, funded by the Department of Veterans Affairs (VA), appearedin the November 2006, Stroke. Psychiatric News - 01/05/07

Comorbid Depression, Chronic Pain, and Disability in Primary Care
Comorbid conditions are the norm rather than the exception among patients with major depressive disorder (MDD). Findings from the World Health Organization Collaborative and the National Comorbidity Studies revealed that a substantial majority of patients with MDD also met criteria for at least one or more concurrent psychiatric disorders. There is also growing evidence that MDD and chronic pain frequently coexist. Psychosomatic Medicine - 9/29/2005

Depression and Stroke: Cause or Consequence?
Depression after stroke is common. Although different opinions exist about the definition, diagnosis, and measurement of outcomes related to depression after stroke, there is little debate about the prevalence of depression symptoms and their impact on stroke survivors and their families. Depression after stroke has long been recognized as a common condition with many negative effects in the poststroke period, but more recently depression has also been identified as an independent stroke risk factor. Given that there are at least 500,000 new ischemic strokes yearly in the United States, a conservative estimate is that 150,000 U.S. stroke survivors develop poststroke depression each year. Because effective treatments exist but are likely underutilized for depression, this is an important example of an evidence-practice gap to which increased efforts to improve care should be made. Such efforts would likely improve not only patient symptoms but may also decrease stroke risk, influence stroke functional recovery, decrease mortality, and reduce poststroke health care utilization. This article provides an overview of depression diagnosis in stroke, reviews the epidemiology of poststroke depression and its associated morbidity and mortality, and reviews existing evidence on the treatment and prevention of poststroke depression. (Membership required) Medscape - 02/15/06

Depression Questionnaire May Change Treatment Plan
A phase 3 trial involving 1763 patients with depression from 17 psychiatric centers has found that asking patients to fill out a short questionnaire caused their psychiatrists to change their treatment decisions 40% of the time. Moreover, 93% of psychiatrists said that the questionnaire was helpful in their practice. The 1-page, 9-item Patient Health Questionnaire (PHQ-9) is based on criteria for major depression and dysthymic disorder from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Originally designed for primary care physicians, the PHQ-9 is free for clinical use and available from the Web site of the MacArthur Initiative on Depression and Primary Care. Medscape - 10/6/06

Only Incident Depressive Episodes After Myocardial Infarction Are Associated With New Cardiovascular Events
The effects of depression after myocardial infarction (MI) on cardiovascular prognosis are poorly understood. Post-MI depression is associated with a 2 to 2.5 times increased risk of cardiovascular events, but in most studies that tested for the confounding effects of MI severity, the effects of depression reduced of disappeared. Journal of the American Collegeof Cardiology - 06/2/06

MH Issues Get Short Shrift By Primary Care Docs
Analyzing 7,100 hours of videotape of primary care physicians talking with their patients shows far-from-optimum interactions on mental health issues.
Psychiatric News - 11/3/06

Increased Suicide Rate in Children and Teens Found: Better understanding of mental disorders & treatments fails to translate into better outcomes for children with the disorders
A statement by David Shern, P.h.D., President and CEO of Mental Health America. Pediatrics today published "Annual Summary of Vital Statistics: 2005," which measured death rates in youth. While the death rates for youth did not change significantly between 2003 and 2004, deaths attributed for suicide increased significantly between 2003 and 2004. For youth aged 14-19 the suicide rate increased by 11% from 7.3 per 100,000 to 8.3 per 100,000 children and adolescents. Download the full statement here.

Mental Illness Mortality, Morbidity Get Medicaid Officials' Attention
New approaches to mental health care in Medicaid programs couldreceive greater federal funding if state officials are moresuccessful in their efforts to track cost savings from "collaborativecare."State and federal Medicaid officials expressed growing alarmat the high rates of comorbidity and early death among beneficiarieswith mental illness, as they outlined new efforts to addressmental disorders among the general Medicaid population.
American Psychiatric Association - 12/15/06

Biopsychosocial Care of Heart Patients: Are We Practicing What We Preach?
The need for attention to the mental health component of healing.
Families, Systems & Health Volume 24, Number 5, 400-403 - 2005

Psychiatric Comorbidity in Epilepsy and End Stage Renal Disease
Many chronic serious medical conditions are associated with increased psychiatric comorbidity. Two such conditions are epilepsy and chronic renal failure. While specialists are often involved in the care of these patients, well-established primary care remains an important part of their treatment. When psychiatric conditions arise, primary care providers will often be the first to see these disorders. These can be very complicated patients, and coordination of care between primary care physicians, specialists, and other health care providers is essential. Recognition, treatment initiation, and referral when needed are reviewed in this article. Wisconsin Medical Journal Volume 103, Issue 6 - 2004

Managing medical and psychiatric comorbidities
The task of assessing and treating patients with combined medical and psychiatric problems can seem daunting, especially as patients become older, acquire chronic conditions, encounter acute illnesses, and take increasing numbers of medications. Add intercurrent social stressors as well as personality issues that affect how patients cope and this task can seem bewildering. But there has been significant progress made over the past few years in better appreciating how such factors may interact. Representative examples, which will be the focus of this article, include advances in the understanding of how vascular disease or diabetes and depression or cognitive impairment may interact and exacerbate each other. (For two other examples, epilepsy and end-stage renal disease, see the article by Bresnehan elsewhere in this issue.) In addition, evidence is emerging of how adequate treatment of depression may improve outcomes in vascular disease or diabetes, and vice versa. These significant advances in research at the interface of medicine and psychiatry are a source of valuable guidance. Wisconsin Medical Journal Volume 103, Issue 6 - 2004.

SCHIZOPHRENIA

What primary care physicians need to know about people with schizophrenia
Schizophrenia is an illness that attacks people as they first move into adolescence and adulthood, just at the time when they are starting their dreams of what they want their lives to be. It is a disorder that comes with a surprisingly high risk of mortality, from both suicide and medical illness. Even among health professionals, there are many misconceptions about schizophrenia, including the belief that there is invariably a downhill course to the illness. Actually, schizophrenia is an episodic illness, often with ups and downs, and a surprisingly large number of people affected by it are able to live independently, work at jobs they like, and have social relationships that are satisfying. Living with schizophrenia is never easy, but many people with this illness are able to live more complete and normal lives than is commonly believed.
Wisconsin Medical Journal Volume 103, Issue 6 - 2004

SOMATOFORM DISORDERS

Medically Unexplained Symptoms and the Concept of Somatization
Somatization, the physical expression of psychological distress, is a prevalent and important problem. It is seen in a wide variety of clinical settings and represents a significant evaluation and management dilemma. The burden to the patient-coupled with the consequential economic and social costs-can be substantial. As a result, the identification and appropriate management of these patients and their often-challenging symptoms is imperative. The following review attempts to summarize the significant body of work committed to the concept of somatization in the medical, surgical, and psychiatric literature. Articles were found through a Medline Search. Wisconsin Medical Journal Volume 103, Issue 6 - 2004

SUICIDE

Suicide: A Focus On Primary Care
The judgment of the primary care physician is critical in preventing suicide since most mental health care is provided by a primary care doctor. This article will briefly discuss the epidemiology of suicide, then turn to the pragmatic assessment of suicide in the primary care office and treatment issues in patients with elevated suicide risk. Special attention is paid to the risk of suicide with antidepressants because of the recent publicity and the concerns many practitioners have expressed. Wisconsin Medical Journal Volume 103, Issue 6 - 2004

Post-traumatic Stress Disorder Following Traumatic Injuries in Adults
The residuals of traumatic injuries from home or workplace accidents, automobile accidents, physical assault, or other unintentional human error can affect victims both physically and psychologically. Symptoms of post-traumatic stress disorder (PTSD) are common among survivors of accidents and nonsexual assaults and can impede recovery. Early identification of PTSD and timely referrals to mental health providers can greatly reduce medical expenses, disability payments, lost wages, lost work productivity, and direct mental health costs. A physician-screening tool to identify PTSD is outlined in this article and can be completed in a few minutes. Implementation of this screening following traumatic injuries can promote early diagnosis of possible psychological complications and facilitate referral to appropriate mental health professionals. Wisconsin Medical Journal Volume 103, Issue 6 - 2004

Post-traumatic Stress Disorder Within a Primary Care Setting: Effectively and Sensitively Responding to Sexual Trauma Survivors

It is estimated that 1 in 4 females and 1 in 6 males have experienced sexual assault or abuse before the age of 18.1 While the response to such experiences vary, a significant number of survivors will develop post-traumatic stress disorder or another mental illness. Post-traumatic responses can persist for years and may impact a patient's experience of medical care. Unfortunately, consistent inquiry around sexually traumatic experiences is not implemented in primary care settings. As a result, patients may feel retraumatized while receiving care or their mental health symptoms may be misdiagnosed, resulting in inappropriate treatment or referrals. Screening for sexual trauma and gaining an understanding of how to respond empathically to post-traumatic responses enable primary care physicians to provide sensitive and effective care to trauma survivors.
Wisconsin Medical Journal Volume 103, Issue 6 - 2004

PTSD and the Practitioner

Part of the art of medicine, like in Goldilocks and the Three Bears, is getting it "just right" when it comes to under-diagnosing or over-diagnosing conditions-providing false negatives or false positives-on day-to-day practice. This is especially important, but problematical, when a new diagnosis appears on the scene because, in my experience, such new conditions often either continue to be unrecognized by some practitioners, or are over-recognized by others. Post-traumatic Stress Disorder (PTSD) is one such relative newcomer to "official" diagnoses. PTSD first appeared officially coded as such in DSM-III in 1980, although it had been known by various names before that: "soldiers heart," "shell shock," "traumatic neurosis," or "Gross Stress Reaction," to name several.
Wisconsin Medical Journal Volume 103, Issue 6 - 2004

Post-traumatic Stress Disorder: Early Recognition and Intervention in the Emergency Department

Post-traumatic stress disorder (PTSD) has become an increasingly recognized condition in society, with significant and far-reaching consequences to the affected individual as well as those close to them. In this issue of the Wisconsin Medical Journal, Lee et al explore the awareness of and procedures for evaluation of PTSD risk in emergency departments (EDs) for victims of trauma. The study evaluates the awareness of the disorder and brings to light how under-appreciated the disorder actually is and how much more there is yet to learn about it. The importance of allied health professionals such as social workers, pastoral care, psychologists, and others in the total care of these patients is emphasized. Equally important is the awareness that effective and consistent risk recognition and intervention is best achieved with on-site professionals. These professionals see situations in the ED as they evolve, recognizing at-risk patients, as well as family members, and intervening with assistance and linkage to follow-up and treatment. Only by early recognition can we effectively reduce the incidence of this disorder. Wisconsin Medical Journal Volume 103, Issue 6 - 2004