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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.

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Patsy Hoyer, CFNP October 27, 2010

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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


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