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Approaches to Diagnosis and Treatment of Common Psychiatric Problems in General Medicine, and When to Refer Patsy Hoyer, CFNP October 27, 2010
• The Original Title: What To Do Until The Psychiatrist Arrives • The psychiatrist rarely arrives!
• Providers have to deal with a lot!
STATISTICS • • 20% of general population, 25% office 1/3 adult problems begin in childhood Anxiety most prevalent Depression more elusive Adult depression, 21 million Adult depression 5 -10% of practice CDC Study Postpartum Blues 80% , Depression 20%
• • • Adults with depression 16 % ADHD Childhood ADHD 7% ADHD Adults present a anx/dep OCD, 50% have ADHD 10 -12% Children ADHD have mood disorder • 1% true bipolar • 4% spectrum conditions
• 1/1000 Schizophrenia • Personality disorders may be as high as 10%-15% • The take away: There is a lot of suffering
• Presentation may be obscuring of dx • Often one or more co-morbid conditions • Alcohol and drug abuse may be present
• Major variation in provider management
• • • Take time and fit it in Suck it up, it is important to do Psychcentral. com Primary care sees patients over time Follow-up is key Refer suicidal
History is important! • Current functioning – Perceived issues/precipitating event – Sleep – Appetite – Mood – Functioning/work/school, family, relationships – Recent drugs, alcohol, etc – Suicidal ideation – Specific other questions toward co-morbitities
Longitudinal History • What were they like before, high school the last several years • Grades in school, jobs, troubles in job. law, marriage • Treatments in past • ---Key in ADHD, mood disorders, mania, previous suicide, etc
FAMILY Social and Genetic Hx • Genetics is not a diagnosis, but it can give a clue
• ANXIETY – Higher doses of SSRI’s – Inderal La may help instead of xanax – Clonazepam—sometimes it is needed • DEPRESSION – STAR D-uses citalopram • Most of us use by side effect • New Recommendations
– buproprion – remeron • Cymbalta and Pristiq--niches
Irritability • Anxiety—don’t disrupt • Depressed---leave me alone • Bipolar spectrum—intense, random • Longitudinal and family hx helpful with this
• Atypicals • Small doses, just might help • Refractory anxiety, depression, family hx, sleep • Side effect issues, weight, metabolic syndromes—need to discuss and monitor • “Activation” not mania
Personality Disorders—how they make you feel • Proposed Classifications in DSM 5 • A—odd/eccentric-Odd ways of thinking— what was that? • C—anxious/fearful—down and depressed • B—dramatic/emotional—suck the life out of you
When do you refer? • • Diagnosis ? —Personality disorders Treatment Plan not working Not comfortable with the medicine Therapy, life coaching, CBP, skills training would help—most of the time!
• Refer with information about your question. • Refer with some history—esp of meds used • Refer with possible goals for therapy • Refer with your question for testing—not just “see a psychologist. ”
Improve your skills • • Talk to colleagues Subscribe to Current Psychiatry Buy Primary “Care Psychiatry” Let Lafayette Medical Education know what topics you would like next year