Mental Health Kristina Jones M.D Clinic Assistant Professor of Medicine Center for Diagnostic Medicine

Why is recognizing mental health conditions is so important in primary care? How many of you feel comfortable diagnosing and treating mental health condition?

Depression Majority of patient with depression actually come to primary doctor office not to psychiatrist. Majority of psychotropic medications are prescribed by primary care doctors nationwide.

How to recognize depression in your practice. It really is not about diagnostic criteria it is about your clinical judgment. A lot of patient with depression have physical symptoms like fatigue, low energy, weight gain or loss. Patient may just complain of low energy, insomnia, problem in interpersonal relationship, problem at work and so on.

DSMV V criteria Depressed mood most of the day, almost every day, indicated by your own subjective report or by the report of others. This mood might be characterized by sadness, emptiness, or hopelessness. 2. Markedly diminished interest or pleasure in all or almost all activities most of the day nearly every day. 3. Significant weight loss when not dieting or weight gain. 4. Inability to sleep or oversleeping nearly every day. 5. Psychomotor agitation or retardation nearly every day. 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day. 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day. 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning C. The episode is not due to the effects of a substance or to a medical condition D. The occurrence is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders E. There has never been a manic episode or a hypomanic episode

Important screening tool PHQ 2 During the last month, have you often been bothered by feeling down, depressed, or hopeless? During the last month, have you often been bothered by having little interest or pleasure in doing things?

PHQ 9 Valid instrument to assess severity of depression. Questions are about the level of interest in doing things, sleep problem , energy levels, eating habits, self-perception, ability to concentrate, speed of functioning and thoughts of suicide. Responses range from “0” (Not at all) to “3” (nearly every day). The 10th question that clinic sometime ask is about difficulty with functioning due to condition.

SSRI ( fluoxetine, sertraline, citalopram ..) Treatment of Depression SSRI ( fluoxetine, sertraline, citalopram ..) SNRI( duloxetine, desvenlafaxine, venlafaxine…) Atypical antidepressant ( bupropion , mitrazapine…) Serotonin modulators( trazodone, vilazodone…) Trycyclic andidepresants( amytriptyline,clomipramine…) MAO inhibitor( Phenelzine, selegiline transdelmal patch)

Drug Anticholinergic Drowsiness Insomnia/agitation Orthostatic hypotension QTc prolongation* Gastrointestinal toxicity Weight gain Sexual dysfunction Selective serotonin reuptake inhibitors (SSRIs)¶ Citalopram 1+ 1+Δ 1+ (all SSRIs: see¶) 3+ Escitalopram Fluoxetine 2+ Fluvoxamine 0 to 1+ Paroxetine 4+ Sertraline 2+◊

Side effect of SNRI Compared to SSRI cause less weight gain. Do not cause QTC prolongation. Do not cause sexual dysfunction.

Side effect of antidepressants Atypical antidepressants do not cause weight gain or sexual dysfunction. Mirtazapine causes weight gain and sedation. Indicated for patient with insomnia who do no respond to trazadone or another medication.

Side effect of antidepressant Serotonin modulators do not cause weight gain and sexual dysfunction. Tricyclic antidepressants cause anticholinergic side effects. MAO inhibitors cause anticholinergic side effects.

Treatment resistant depression Send to psychiatry? Try different medication? Treat depression properly?

Common mistakes of depression treatment Starting SSRI at low dose and keeping patient on that dose forever. No follow up in 2-3 weeks to assess patient and adjust medication. Misdiagnosing bipolar disorder as depression and treating with SSRI only. No psychotherapy. No suicide risk assessment. Referral to psychiatry that takes 8 month.

How to not make those mistakes Start SSRI. Follow up 2-3 weeks ( patient should feel better). If not feeling better increase the dose. Titrate to maximum dose ( Do not be afraid). Augment with psychotherapy. If that medication not working try different SSRI. You can try up to 3 SSRI. Same algorithm. If no response try SNRI. Follow same algorithm.

What is next? If monotherapy does not work SSRI and trazodone. SSRI and buspar. SSRI and mirtazapine. No SSRI and another SSRI due to serotonin syndrome. No SSRI and SNRI due to serotonin syndrome. No SSRI and MAO due to hypertensive crisis.

Anxiety Disorder GAD-7 has seven items, which measure severity of various signs of GAD according to reported response categories with assigned points . Assessment is indicated by the total score, which made up by adding together the scores for the scale all seven items GAD-7 is a sensitive self-administrated test to assess generalized anxiety disorder. Not at all (0 points) Several days (1 point) More than half the days (2 points) Nearly every day (3 points)

Anxiety Disorders Generalized Anxiety Disorder Phobias Agoraphobia Social anxiety disorder Post traumatic stress disorder OCD Very common comorbidity with depression.

DSMV V criteria Excessive anxiety and worry ,occurring more days than not for at least six months, about a number of events or activities (such as work or school performance). The individual finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months): Restlessness or feeling keyed up or on edge Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition (eg, hyperthyroidism). The disturbance is not better explained by another mental disorder.

Treatment of anxiety Same as depression SSRI SNRI Atypical antidepressant Serotonine modulator

Common mistakes when treating anxiety Not recognizing coexisting anxiety disorders. Not referring to psychotherapy. Same mistake with medications as with depression treatment. No augmentation therapy.

Remember hypomania or mania with depression. Bipolar Disorder Remember hypomania or mania with depression. Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least four consecutive days and present most of the day, nearly every day. Plus 3 or 4( if mood irritable) of the following 1) Inflated self-esteem or grandiosity. 2) Decreased need for sleep 3) More talkative than usual or pressure to keep talking. 4) Flight of ideas or subjective experience that thoughts are racing. 5) Distractibility 6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. 7) Excessive involvement in activities that have a high potential for painful C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance

Treatment of bipolar disorder Assess patient for suicide risk. Does patient need hospitalization? Is patient danger to other? If patient is suicidal or homicidal involuntary admission to psychiatric unit. Remember suicidal patients need to be sent to ER. There is chapter 573 for emergency detention.

Treatment of Bipolar Disorder Lithium ( old medication , side effects). Anticonvulsants ( depakote,topamax,lamictal). Antipsychotic medications ( ziprazidone, olanzapine). Referral to psychiatry for Bipolar 1.

Most common mistakes Not screening patients with depression for bipolar disorder. Starting SSRI for bipolar patient. Not assessing suicide risk. Referring to psychiatrist without any urine toxicology screen. Diagnosing schizophrenia in bipolar patient .

Things to remember Patient with psychiatric condition come to primary doctor’s office not to a psychiatrist. We need to be able to at least start patient on treatment and titrate medication correctly. We need to work in collaboration with psychotherapist and psychiatrist treating complicated mental health conditions like bipolar 1 , schizoaffective disorder and schizophrenia. We need to know when to refer.