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

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

3. 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.

4. 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.

5. 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

6. 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?

7. 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.

8. 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)

9. 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+◊

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

11. 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.

12. 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.

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

14. 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.

15. 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.

16. 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.

17. 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)

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

19. 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.

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

21. 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.

22. 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

23. 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.

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

25. 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 .

26. 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.