MAJOR DEPRESSION Screening and Assessment

TREATING MENTAL HEALTH DISORDERS IN PRIMARY CARE

A toolkit designed to assist primary care physicians with finding resources within Behavioral Healthcare Options

Behavioral Healthcare Options, Inc.

BEHAVIORAL HEALTHCARE OPTIONS (BHO) Introduction...... Page 4 Initiating a Legal 2000 Mental Health Hold...... Page 4 ●● Professionals That May Initiate a Mental Hold for Emergency Admits ●● Commitment Standards Helpful Phone Numbers...... Page 5 Patient Medication Compliance...... Page 5 Practice Guidelines for Common Psychiatric Diagnosis...... Page 6 MAJOR DEPRESSION Screening and Assessment...... Page 7 Diagnosis...... Page 9 Treatment Planning...... Page 11 Medication...... Page 12 Follow-up...... Page 14

BIPOLAR DISORDER/TTREATING BIPLAR DISORDER IN PRIMARY CARE Screening and Assessment...... Page 16 Diagnosis...... Page 16 Treatment Planning...... Page 19 Medication...... Page 20 Follow-up...... Page 22

SUBSTANCE USE DISORDERS Screening and Assessment...... Page 24 Diagnosis...... Page 24 Intervention and Treatment...... Page 25

ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD) Screening and Assessment ...... Page 28 Diagnosis...... Page 28 Treatment Planning...... Page 30 Medication...... Page 30

[ 3 ] Treating Mental Health Disorders in Primary Care

INTRODUCTION

Established in 1991, Behavioral Healthcare Options (BHO) Inc., is a subsidiary of UnitedHealthcare. BHO is a leader in arranging specialized mental health, addiction treatment, employee assistance, and work-life services. We promote individualized problem-focused care in the least restrictive setting for our members to ensure proper treatment and minimal disruption to work and family activities. Our clients include self-insured employers, insurance carriers, third-party administrators, and union trusts. With a willingness to customize products and services, we enable our clients to provide the best benefits for their members and/or employees. The Life Connection (TLC) and our Employee Assistance Program (EAP) offer tools and resources to help employers and their employees resolve issues at work, and balance home and work life. Our innovative services, comprehensive training programs, and ongoing management support help our clients meet the ever-changing issues encountered in daily life. BHO has helped thousands of individuals meet life’s challenges through professional counseling, telephone consultations, and online resources. From emotional and personal conflict resolution, to mental health and substance abuse counseling, BHO understands the importance of finding the right solutions for a balanced and healthy life. BHO has created this educational toolkit for providers. It is composed of evidence-based information established from a systematic approach towards obtaining comprehensive research on mental health related conditions and Healthcare Effectiveness Data and Information Set (HEDIS) measures. It is the standard approach for BHO to utilize the best practices implied within the toolkit with direct guidance from the medical director and additional leadership involvement within BHO.

Initiating a Legal 2000 Mental Health Hold Professionals that May Initiate a Mental Health Hold for Emergency Admission ●● Law enforcement officers ●● Marriage and family therapists ●● Clinical professional counselor ●● Social worker ●● Registered nurse ●● Psychologist ●● Physician Commitment Standards ●● Danger to self – suicidal or self-mutilation ●● Danger to others ●● Grave disability – the inability to meet basic needs for food, shelter, safety, or medical care, resulting in the likelihood of death or disability in the next 30 days

This Nevada Statute allows for the emergency detention of mentally ill individuals. The definition of mental illness in the law does not include: ●● Substance intoxication withdrawal, or dependency ●● Mental retardation ●● Dementia ●● Seizure disorder

[ 4 ] Helpful Phone Numbers

BHO Main Line/Utilization Management: 702-364-1484 or 1-800-873-2246, TTY 711

BHO STAT Line: 1-855-442-4648 FOR INTERNAL STAFF USE ONLY – DO NOT DISTRIBUTE Answered live Monday through Friday, 8 a.m. – 5 p.m. PST. Used for: ●● Members in immediate crisis (need clinical support) ●● Securing immediate mental health or substance use outpatient appointments for identified at-risk patients ●● Doctor-to-doctor consults related to psychotropic medications

Provide patient with Behavioral Healthcare Options brochure - Your Mental Health

Patient Medication Compliance

Non-adherence with patient medication is a common barrier to the effective treatment for mental health patients. As a primary care provider, you can assist in reducing the risk of relapse for your patient by providing guidance on the importance of medication compliance. It is important to discuss any medication adherence issues during subsequent appointments.

Many mental health patients seek treatments or are put into the hospital as a result of a crisis in their lives. Follow-up appointments are an important tool for preventing future crisis. It is common to have a “flight into health” when the worst of the symptoms of a mental health problem pass; it becomes tempting for the patient to move on in hopes that the issues are behind them. Most mental health conditions today are very treatable, but success in treatment requires time and effort. If your patients have any problems or questions about their follow-up appointment, please call BHO STAT Line: toll-free at 1-855-442-4648.

[ 5 ] Treating Mental Health Disorders in Primary Care

 Practice Guidelines for Common Psychiatric Diagnosis As in the treatment of physical health conditions, evidence-based care for mental health disorders involves the following components: 1. Screening and assessment 2. Diagnosis 3. Treatment planning 4. Medication 5. Follow-up care Focused on these components, this toolkit will present information on four common mental health conditions. Also included will be references and links pertinent to the treatment of these disorders in primary care, as well as clinical pearls regarding care issues. Research indicates that practice guidelines and education about mental health disorders alone are of limited value in improving care. Collaborative care is a model of treatment that is demonstrated to greatly improve outcomes for mental health treatment in primary care.1,2,3 It builds on the strengths of a disease management approach while incorporating ideas common in mental health, such as a multidisciplinary approach and case management. Below is a stepped care framework model for major depression. It aims to match the needs of people with depression to the most appropriate services, depending on the characteristics of their illness, and their personal and social circumstances. Each step represents increased complexity of intervention, with higher steps assuming interventions in previous steps. Step 1: Screening and assessment Step 2: Treatment of mild depression in primary care Step 3: Treatment of moderate to severe depression in primary care Step 4: Treatment of depression by mental health specialist Step 5: Inpatient treatment for depression Screening tools are used to measure the severity of symptoms and to track the response to treatment. Results are treated as “mental health laboratory,” which is a method to track mental health conditions using the systems in place for tracking chronic medical conditions, such as hypertension and diabetes.

1. Thielke, S., M.D., M.P.H., M.A., Integrating Mental Health and Primary Care, Primary Care: Clinics in Office Practice 2007; 34: 571-592. 2. Major Depression in Adults in Primary Care, Institute for Clinical Systems Improvement (ICSI), icsi.org 3. Moussari, S., M.D., Decrements in Health- World Health Organization, Lancet 2007; 370: 851-58.

[ 6 ] Major Depression

1. Screening and Assessment A common illness with an enormous impact on health and productivity. ●● Mood disorders are very common with a lifetime prevalence of approximately 20%,6 and they also cause significant dysfunction. ●● Depression produces a greater disease burden than angina, arthritis, asthma, or diabetes according to the World Health Organization.7 ●● 80% of depressed patients seek treatment, most commonly in primary care where 70-80% of the antidepressant prescriptions are written. Less than 20% of those patients receive appropriate care.1 ●● 80% of depressed patients in primary care have a co-morbid medical condition. In particular, patients with the following medical conditions should be screened for depression:4 Cardiovascular disorders Stroke Diabetes Chronic pain Substance abuse

Risk Factors Presentations Associated with Major Depression

●● Family history ●● Multiple medical visits ●● Recent loss or trauma ●● Multiple unexplained symptoms ●● Major life changes ●● Relationship or work dysfunction ●● Domestic abuse or violence ●● Fatigue, pain or other somatic complaints ●● Irritable bowel syndrome

Screening Tools BHO recommends the use of the PHQ-9, as it is: ●● Well validated for use in primary care across a wide age range ●● In the public domain and is available in other languages ●● Useful as a measure of severity and for monitoring the patient’s progress and response to treatment over time

[ 7 ] Treating Mental Health Disorders in Primary Care

Sample - Patient Health Questionnaire (PHQ-9) Sample Questions the days Not at all Several days Several More than half of More Nearly every day Nearly every 1. Do you have little interest or pleasure in doing things? 0 1 2 3 2. Do you feel down, depressed or hopeless? 0 1 2 3 3. Do you have trouble falling or staying asleep or are you 0 1 2 3 sleeping too much? 4. Do you feel tired or have little energy? 0 1 2 3 5. Do you have a poor appetite or are you overeating? 0 1 2 3 6. Do you feel bad about yourself – or that you are a failure or 0 1 2 3 have let yourself or your family down? 7. Do you have trouble concentrating on things, such as 0 1 2 3 reading or watching television? 8. Are you moving or speaking slowly and other people have 0 1 2 3 noticed? Or are you so fidgety or restless that you have been moving around a lot more than usual? 9. Have you had thoughts that you would be better off dead 0 1 2 3 or of hurting yourself in some way?

Add columns _____ + _____+ _____ Health care professional: for interpretation of total please refer to accompanying scoring card. Total ______If you have checked off any problems, how difficult have these Not difficult at all problems been for you to do your work, take care of things at Somewhat difficult home, or get along with other people? Very difficult Extremely difficult PHQ-9 is adapted from PRIME-MD TODAY®, developed by Drs. Robert L. Spitzer, Janet B. W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. Use of the PHQ-9 may only be made in accordance with the Terms of Use available at http://www.pfizer.com. Copyright ©1999 Pfizer, Inc. All rights reserved. PRIME-MD TODAY is a trademark of Pfizer, Inc. If you find that the PHQ-9 does not meet your needs, please contact BHO for additional resources.

[ 8 ] 2. Diagnosis DSM 5 Criteria – Major Depressive Episode:12 A. Five (or more) of the following symptoms have been present during the same two week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. NOTE: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless), or observation made by others (e.g., appears tearful). (NOTE: In children and adolescents, can be irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (NOTE: In children, consider failure to make expected weight gain.) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 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 (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 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. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or to another medical condition. NOTE: Criteria A-C represent a major depressive episode. NOTE: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss. D. The occurrence of the major depressive episode 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. NOTE: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance- induced or are attributable to the physiological effects of another medical condition.

[ 9 ] Treating Mental Health Disorders in Primary Care

Differential Diagnosis It is very important to ask about symptoms of bipolar illness. ●● Bipolar Disorder: The treatment is very different for unipolar vs. bipolar depression - treating Bipolar Disorder with antidepressants can actually worsen the patient’s symptoms. Ask about distinct periods of elevated, expansive, or irritable mood, during which there has been grandiosity, a decreased need for sleep, pressure to talk, racing thoughts, distractibility, increased activity, or risk taking behavior. ●● Mood disorders due to a general medical condition: e.g., multiple sclerosis, stroke, hypothyroidism. ●● Substance-induced mood disorders: The mood problems occur only with the use of or withdrawal from a substance. ●● Dementia: Typically has a premorbid history of a gradual cognitive decline, versus a more abrupt decline in function with the onset of a depression. ●● Attention Deficit/Hyperactivity Disorder: The distractibility is usually accompanied by irritability rather than sadness and lack of interest. ●● Bereavement: Differentiated by the duration and intensity of symptoms as well as the level of functional impairment. Depression in Adults: Diagnosis and Treatment Guideline Prepare your practice: Implement systems for accurate diagnosis, treatment and follow-up. Tip 1: Implement staff assisted patient self-management and care coordination (possible by phone). Tip 2: Compile information on psychiatry and mental health consultation and referral options. Tip 3: Identify resources to address treatment barriers. Tip 4: Monitor symptoms with the Patient Health Questionnaire (PHQ-9);

Severity Rating (Based on PHQ-9 Score) PHQ-9 Score Provisional Diagnosis Treatment Recommendations

5-9 Minimal symptoms Support, educate to call if worse; return in one month 10-14 Major Depression, mild Evidence-based psychotherapy equally effective as Minor impairment in function antidepressant 15-19 Major Depression, moderate Evidence based psychotherapy and/or antidepressant Impairment in functioning between mild and severe >20 Major Depression, severe Antidepressant and psychotherapy (esp. if not Marked impairment in functioning improved on monotherapy)

[ 10 ] 3. Treatment Planning As with most mental health conditions, the approach to depression treatment should include a combination of psychosocial interventions and medication tailored to fit the unique needs of each patient. Plan Treatment Shared Decision Making ●● Tailor treatment to individual patient ●● Provide education on diagnosis ●● Review treatment options (based on symptom severity) ●● Discuss treatment barriers, family/work responsibilities, insurance, transportation ●● Negotiate treatment plan ●● Set timeline; response, side effects and treatment duration ●● Educate on importance of adherence ●● Develop safety plan for suicidal ideation Additional Considerations ●● Current or planned pregnancy: psychotherapy preferred if symptoms are tolerable ●● Start medication at lower dose if anxious or elderly ●● Cultural factors that influence treatment choice ●● SNRI or tricyclic for chronic pain ●● Level of functioning/activities of daily living ●● Complementary/alternative medicine ●● Discuss safety with the patient ●● Need for emergency services ●● Psychiatry referral, including ECT evaluation Consider Referral or Consult ●● Suicidal patient ●● Bipolar disorder ●● Co-occurring substance abuse ●● Psychotic features ●● Multiple medications Role of Psychotherapy4 ●● Effective in treatment of mild to moderate depression, and as an adjunct in the treatment of severe depression. ●● Shown to help reduce relapse rates. ●● Evidence-based treatments include cognitive/behavioral therapy, interpersonal psychotherapy, problem solving therapy, and short-term psychodynamic psychotherapy. If Receiving Therapy Alone ●● Onset of effectiveness is more gradual ●● Discuss and share PHQ-9 with therapist When and How to Refer to Psychotherapy

Provide patient with Behavioral Healthcare Options brochure - Psychotherapy

[ 11 ] Treating Mental Health Disorders in Primary Care

4. Medication Key issues for effective medication treatment: ●● Patient education improves compliance and outcomes. ●● Side effects often occur early in treatment, but tend to fade over time. ●● Dosage adjustments or trial of another medication are often necessary to achieve remission and to limit side effects. ●● There may be benefit after two weeks, but the full benefit often takes longer. The patient and family should watch for the emergence of irritability and agitation, or suicidal ideation and report these to the provider immediately. Medication Algorithms Treatment Algorithms Examples: ●● Institute for Clinical Systems Improvement (ICSI)4 – “The mission of our collaboration is to champion the cause of health care quality and to accelerate improvement in the value of the health care we deliver to the populations we serve. ICSI’s vision is to be a collaboration that is deemed essential by its members for their improvement of health care and deemed essential by our community as a trusted voice for quality in health care.”14 icsi.org ●● STAR*D9,10 — The NIMH-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study was conducted to determine the effectiveness of different treatments for people with major depression who have not responded to initial treatment with an antidepressant. This is the largest and longest study ever conducted to evaluate depression treatment. nimh.nih.gov ●● TMAP11,15 – The Texas Medication Algorithm Project is a decision-tree medical algorithm, the design of which was based on the expert opinions of mental health specialists. It has provided and rolled out a set of psychiatric management guidelines for doctors treating certain mental disorders within Texas’ publicly-funded mental health care system, along with manuals relating to each of them. The algorithms commence after diagnosis and cover pharmacological treatment.nami.org Highlights of Medication Algorithm Studies ●● After six weeks of treatment, if the patient has less than a 25% response to medication at therapeutic dose, first reevaluate the diagnosis (e.g., rule out bipolar disorder or substance abuse). Next, consider switching medication. Note that failure of a medication in a particular class does not rule out benefit from another medication in the same class. Also, consider adding a second medication. ●● There is little likelihood of additional benefit in switching to a third medication after the failure of two monotherapies. ●● For treatment resistance or partial response, consider augmentation: second antidepressant, addition of an atypical antipsychotic (especially Abilify), lithium carbonate, or thyroid (T3). ●● Medication trials should last 8-12 weeks (unless side effects are an issue), with the dose increased every two to three weeks to the maximum (or until the emergence of side effects). ●● Maintenance therapy should continue at the same dose that produced remission. Considerations for Medication Selection ●● Cost ●● Formulary ●● Responsiveness to prior treatment ●● Responsiveness in a first degree relative ●● Complementary/alternative medicine

[ 12 ] Clinical Pearls ●● The goal of treatment should be full remission of symptoms, and relapse prevention. ●● Approximately 50% of patients will have a recurrence of symptoms within two to three years after one episode of depression. After three episodes, the relapse rate goes up to 90%.4 ●● There are a wide range of treatments available, so most patients should eventually reach remission and return to previous levels of social and occupational function. ●● Longer trials of drug therapy (12 weeks) can yield improved response rates. ●● Patients should be carefully educated about the time lag that can occur for antidepressants to become effective. Commonly Prescribed Antidepressant Medications Selective Serotonin Reuptake Inhibitors (SSRIs) ●● Citalopram (Celexa®) - widely used and well tolerated. FDA now advises to no longer use doses > 40mg because of concerns regarding QTc prolongation. ●● Escitalopram (Lexapro®) - fewer side effects and drug interactions than Celexa. ●● Fluoxetine (Prozac®) - may provide extra benefit to energy and concentration. Long half-life, so less issue with withdrawal. More likely to have drug interactions. ●● Paroxetine (Paxil®) - mildly anticholinergic so may be calming, but this effect also increases possibility of side effects. Short half-life increases withdrawal issues. ●● Sertraline (Zoloft®) - may also have a dopamine effect, so may have extra benefit for motivation and psychotic symptoms. Frequent GI side effects. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) ●● Venlafaxine (Effexor®) - extended release versions decrease side effects secondary to rapid absorption of immediate release form. Has both serotonin and norepinephrine effect, but this is only true at higher doses. Must titrate dose to limit side effects. May cause hypertension. ●● Desvenlafaxine (Pristiq®) - active metabolite of venlafaxine. Has proportionately more norepinephrine effect and less drug interaction. ●● Duloxetine (Cymbalta®) - also has benefit in pain syndromes. ●● Levomilnacipran (Fetzima®) - potent noradrenergic action may lead to higher incidence of sweating and urinary hesitancy, but it may also help better relieve chronic pain. Serotonin Partial Agonist/Reuptake Inhibitor (SPARI) ●● Vilazodone (Viibryd®) - does have a unique mechanism of action, and has a relative lack of sexual side-effects and weight gain. Serotonin Antagonist/Reuptake Inhibitor (SARI) ●● Trazadone (Desyrel®) - often not tolerated at a therapeutic antidepressant dose secondary to excess sedation, but is used as a non-addictive treatment for insomnia or an adjunct to treat anxiety. Can cause priapism. Norepinephrine-Dopamine Reuptake Inhibitor (NDRI): ●● Bupropion (Wellbutrin®) - norepinephrine and dopamine activity. Used also for smoking cessation and to reduce other drug craving. Lowers seizure threshold at higher doses. Avoid in patients with an eating disorder or a seizure disorder. Alpha-2 Antagonist ●● Mirtazapine (Remeron®) - unique mechanism of action, including some serotonin receptor blockade, so less sexual side effects and GI upset. Is sedating (especially at low doses), but patient may become tolerant to the sedation at higher doses. More risk of weight gain.

[ 13 ] Treating Mental Health Disorders in Primary Care

Multimodal Agent ●● Vortioxetine (Brintellix®) – unique multimodal mechanism of action may benefit patients who have failed other antidepressants. May have more ability to restore cognitive function. Expensive. 5. Follow-up4,5,10 ●● Relapse prevention should be the central focus of follow-up. ●● Proactive follow-up contacts in person or on the phone significantly improve outcomes. The screening tool is used to monitor any benefit, and the severity of any remaining symptoms. As dictated by the severity of symptoms at follow-up, the patient may need to move to another level of intervention (stepped care). ●● Duration of treatment and frequency of contacts: Acute phase: Treatment prior to remission of symptoms. (Usually six to12 weeks). Full remission is defined as a two month period with no depression symptoms. Follow-up contact by the second week, and then at least every four to eight weeks as indicated. Continuation phase: Begins after remission (four to nine months). Monitor for signs of relapse (most common in the first six months). Contact every two to three months. Maintenance phase: (One to several years.) For patients with three or more episodes of depression. Also consider when additional risk factors for recurrence are present: family history of depression, early age of onset, ongoing stressors, co-occurring disorders. Monitor and Adjust Treatment - Monitor Side Effects Goal of treatment is complete remission. First follow-up contact at one to two weeks, then every four to eight weeks (consider telephone contact in some cases). Perform ongoing suicide risk assessment; risk may increase during early treatment phase. If starting dose was low, consider up-titration at initial check-in. Acute Phase (month 1-4) Response PHQ-9* Score after 4-6 weeks Treatment Plan

Responsive Drop >5 points from baseline No treatment change needed. Follow-up again after an additional 4 weeks. Partially responsive Drop 2-4 points from baseline Often warrants increase in dose. Possible no change needed.

Non-responsive Drop 1 point or no change or increase ●● Consider starting antidepressant if receiving therapy alone ●● Increase dose ●● Switch medications ●● Augmentation (Lithium, thyroid, stimulant, 2nd gen anti- antipsychotic, 2nd antidepressant) ●● Review psychological counseling options and preferences ●● Informal or formal psychiatric consultation (ECT an option in some cases) Continuation Phase (months 4-9) ●● Begins after symptom resolution ●● Monitor for signs of relapse ●● Continue medications full strength ●● Generally, use same antidepressant dose as in ●● Contact every two to three months (telephone Acute Phase appropriate in some cases)

[ 14 ] Maintenance Phase for Recurrent Depression (nine months and over) Goal is to prevent relapse. ●● For patients with history of three or more episodes of major depression or chronic major depression ●● Also consider for patients with additional risk factors for recurrence (family history, early age onset, ongoing psychological stressors, co-occurring disorders) ●● May need to maintain for one to several years ●● Use PHQ-9 for ongoing monitoring Tapering Antidepressant Medication ●● Taper over several weeks ●● Educate patient and family regarding possible withdrawal symptoms and the early signs and symptoms of relapse ●● Flu-like symptoms common ●● With SSRI and SNRI may also experience anxiety/agitation, sweats, paresthesias ●● Diphenhydramine may help with anticholinergic withdrawal symptoms

Provide patient with Behavioral Healthcare Options brochure - Taking Your Medication

Depression References: 1. Young, A., M.D., The Quality of Care for Depression and Anxiety Disorders in the U.S., Archives of General Psychiatry 2001; 58(1): 55-61. 2. Depression in Adults: Diagnosis and Treatment Guideline. HealthTeamWorks.org 3. Thielke, S., M.D., M.P.H., M.A., Integrating Mental Health and Primary Care, Primary Care: Clinics in Office Practice 2007; 34: 571-592. 4. Major Depression in Adults in Primary Care, Institute for Clinical Systems Improvement (ICSI), icsi.org 5. Unutzer, J, M.D., JAMA 2002; 288(22): 2836-45. 6. Kessler, R., Ph.D., Lifetime Prevalence and Age of Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication, Archives of General Psychiatry 2005; 62(6): 593-602. 7. Moussari, S., M.D., Decrements in Health-World Health Organization, Lancet 2007; 370: 851-58. 8. Merikangas, K., M.D., The Impact of Comorbidity of Mental and Physical Conditions on Role Disability in the U.S. Adult Household Population, Archives in General Psychiatry 2007; 64(10): 1180-88. 9. Rush, J., M.D., Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report, American Journal of Psychiatry 2006; 163(11): 1905-17. 10. Cain, R., M.D., Navigating the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study: Practical Outcomes and Implications for Depression Treatment in Primary Care, Primary Care: Clinics in Office Practice 2007; 34: 505-19. 11. Texas Medication Algorithm Project Procedure Manual 12. The diagnosis for a major depressive episode is based on the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. 13. nami.org 14. nimh.nih.gov/trials/practical/stard/index.shtml 15. Rosenberg, Mark MD, Ph.D. CEO, BHM Healthcare Solutions, Mind Body Advancements in the Treatment of Depression

[ 15 ] Treating Mental Health Disorders in Primary Care

Bipolar Disorder Treating Bipolar Disorder in Primary Care ●● Patients most commonly present in the depressed phase (for most patients, depression significantly dominates the course of eth illness), so anyone being treated for depression should be asked about symptoms of hypomania, mania, or mixed states. ●● The pharmacotherapy for bipolar disorder (vs. unipolar depression) is very different. Antidepressant monotherapy for bipolar disorder is typically ineffective, at best, and can lead to a worsening of symptoms, including an increased risk for suicide. ●● Patients often do not report hypomania when presenting for help with depression as they may not connect the two, or they are reluctant to lose their energized episodes. ●● Patients who present a danger to themselves or others, or patients with severe symptoms (especially psychosis) requiring immediate stabilization should be referred for psychiatric hospitalization. Patients with bipolar disorder that can appropriately be treated in the primary care setting include: New presentation of mood problems with mild to moderate symptoms and functional impairment Patient is stable on a medication regimen with a confirmed diagnosis of bipolar disorder Patient previously stable with new onset of mild to moderate symptoms Initiating treatment while awaiting transition to a psychiatrist Patients who are nonresponsive to or tolerant to antidepressants and so may be in the “bipolar spectrum” At a minimum, assess for any bipolar symptoms before starting antidepressants for a depressive episode 1. Screening and Assessment N.B. - screening tools are not intended to replace clinical judgment ●● Mood Disorder Questionnaire (MDQ) - validated screening instrument. Can also be completed by parents to screen adolescents. ●● Bipolar Spectrum Diagnostic Scale (BSDS) - Patients are asked to review descriptions of typical experiences of mood swings, and identify those that they have experienced. It is available free online.2 2. Diagnosis Bipolar I: A mood disorder in which patients have experienced one or more episodes that meet the criteria for a manic episode. Episodes of major depression are not required for the diagnosis, but most patients will experience both mania and depression with this illness. This disorder is less common than the type II disorder, with a lifetime prevalence of <1%. Bipolar II: A mood disorder in which patients experience at least one hypomanic episode as well a past or current episode of major depression. For most patients, depression is the predominant mood problem. This disorder is much more common than the type I disorder with a lifetime prevalence as high as 6 to 8% in various studies. DSM 5 Criteria – Manic Episode12 A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

[ 16 ] B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent as noticeable change from usual behavior. 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only three hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli as reported or observed) 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non goal-directed activity) 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition NOTE: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy), but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis. NOTE: Criteria A-D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder. DSM 5 Criteria – Hypomanic Episode12 A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only three hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli as reported or observed) 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 consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) 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.

[ 17 ] Treating Mental Health Disorders in Primary Care

F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication other treatment) NOTE: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diasthesis. NOTE: Criteria A-F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. 12 DSM 5 Criteria – Major Depressive Episode: A. Five (or more) of the following symptoms have been present during the same two week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. NOTE: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless), or observation made by others (e.g., appears tearful). (NOTE: In children and adolescents, can be irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (NOTE: In children, consider failure to make expected weight gain.) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 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 (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 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. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or to another medical condition. NOTE: Criteria A-C represent a major depressive episode. NOTE: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the contest of loss.

[ 18 ] Differential Diagnosis ●● Major depression: Symptoms of irritability can occur in both major depression and bipolar illness ●● Anxiety disorders: Anxious ruminations may be mistaken for the racing thoughts of bipolar illness ●● Substance-induced mood disorders: get substance use history; consider drug screen when suspicion is high ●● Attention deficit/hyperactivity disorder: early onset, is chronic rather than episodic, no elevated or expansive mood ●● General medical conditions: Degenerative neurological conditions – e.g., Parkinson’s disease, Huntington’s disease Cerebrovascular and cardiovascular disease Endocrine conditions Autoimmune conditions Viral infections Certain cancers 3. Treatment Planning ●● The key to successful treatment is proper diagnosis and collaboration with the patient and family. ●● The data suggest that up to 70% of patients with bipolar disorder experience delays in proper diagnosis, with 30% of patients waiting for 10 years or longer. ●● Involve the family for collateral history of symptoms and to help spot signs of future mood swings. Impaired insight is a common issue with bipolar disorder. Family reports of hypomanic symptoms are twice as likely as from the patient.4 ●● Involve the patient in shared decision making.5 Does the patient understand the diagnosis and have any motivation for treatment? What particular concerns does the patient have (e.g., costs, risks, stigma, side effects)? What other issues may effect treatment? For example, family/work problems, substance abuse or medical problems. Treatment Guidelines: 1. Systematic Treatment Enhancement Program for bipolar disorder (STEP-BD) - NIMH algorithm for Bipolar Disorder (2007) 2. VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (2010) 3. Canadian Network for Mood and Anxiety Treatments (CANMAT) and the International Society for Bipolar Disorders (ISBD) collaboration update (2009) 4. Texas Medication Algorithm Project (2005) 5. Practice Parameters for Assessment and Treatment of Children and Adolescents with Bipolar Disorder - practice guideline from the American Academy of Child and Adolescent Psychiatry (2007)

[ 19 ] Treating Mental Health Disorders in Primary Care

4. Medication There is no clinical evidence to support the efficacy or safety of antidepressant monotherapy in bipolar disorder. ●● Polypharmacy is common. The medications currently considered mood stabilizers are often limited to being either antimanic or antidepressant. Also, side effects can lead to the need to use lower doses of multiple medications instead of a higher dose of a single agent. Brief Summary of Current Mood Stabilizers2 Lithium carbonate - well-studied, and therapeutic range for blood levels established. Effective especially in type I patients. Thought to have anti-suicidal benefit (but it is very dangerous in overdose). Very inexpensive. Lamotragine (Lamictal™) - more strongly antidepressant rather than antimanic, so particularly helpful for type II patients. Relatively free of side effects, but must titrate slowly to avoid increased risk of life threatening rash. Valproate (Depakote®) - well studied and the therapeutic range for blood levels established. Is more strongly antimanic. May be particularly helpful with rapid cycling or mixed states. Carbamazepine (Tegretol®) - also helpful with rapid cycles. Relatively high rates of side effects. Oxcarbazepine (Trileptal), active metabolite of Tegretol, reduces side effects, but it also seems to be less effective. Second generation antipsychotics - vary in benefit. More expensive. Concerns regarding weight gain and metabolic syndrome, as well as extrapyramidal symptoms. Olanzapine (Zyprexa®) - relatively rapid response for even severe symptoms, but has significant weight gain risk. Quetiapine (Seroquel®) - sedating, good for anxiety, agitation, and sleep symptoms. Also has significant concerns regarding weight gain. Risperidone (Risperdal®) - increased rate of EPS. Aripiprazole (Abilify®) - strong antimanic effect and possible antidepressant effect. Less metabolic issues and is expensive. Ziprasidone (Geodon®) - less concern with metabolic issues, but appears to be less effective and is expensive. Lurasidone - FDA approved for bipolar depression. Appears to be less likely to cause weight gain. Does not cause QTc prolongation. Asenapine - May be effective in bipolar depression, but no FDA indication. Must be taken sublingual, which may lead to compliance. Cariprazine - Approved for acute mania or mixed episodes. May have a higher rate of extrapyramidal side-effects. Brexpiprazole - Not approved for bipolar disorder. May have a higher rate of weight gain. Other Treatments: Topiramate (Topomax®) - questions of efficacy. May counteract weight gain from other agents. Verapamil - beneficial in some patients. Used in patients who fail first line treatments. Clozapine (Clozaril®) - effective for refractory symptoms, but has the risk of bone marrow suppression. Benzodiazapines - are antimanic and antianxiety. Used as adjuncts (should be avoided in patients with co-occurring chemical dependency issues). Omega 3 fatty acids - mild mood stabilizing properties.

[ 20 ] ECT - the rate of effectiveness is higher than any of the medications, but benefits do not last, so patient will require medication for maintenance treatment (or maintenance ECT). Used especially in cases of severe suicidal ideation or manic agitation where rapid symptom relief is an important safety consideration. Psychotherapy - several psychotherapies have been shown to improve outcomes in the treatment of mood disorders versus medication alone.6 Can be particularly important for bipolar disorder given the severity of impairment associated with the illness, and the limited efficacy of medications alone. Sample of evidence-based psychotherapies for bipolar disorder: Cognitive Behavioral Therapy - challenges negative thoughts and dysfunctional beliefs of the patient. Family Focused Therapy - encourages patient and family to develop a common understanding of the illness and its management. Interpersonal and Social Rhythm Therapy - focuses on social rhythms (sleep/wake cycle, social routines) and identifies potential disruptions to their stability. Clinical Pearls The rate of bipolar disorder among patients presenting with depression is thought to be as high as 20-30%.4 Suicidal behavior is substantially more likely in bipolar disorder vs. MDD.8 Treatment of unipolar depression versus the depressed phase of bipolar disorder differs greatly. In bipolar disorder, antidepressants are either ineffective or they can actually worsen symptoms. Mania vs. Hypomania Similar symptoms, but in hypomania, the change in social and occupational functioning does not lead to marked impairment as in mania. Clinical Features of Bipolar Spectrum The concept of a bipolar spectrum along with “soft signs” of bipolar illness is gaining acceptance.7 Especially important to consider in patients who have “treatment resistant” depression. ●● Family history of bipolar disorder in first degree relative ●● A history of antidepressant-induced mania or hypomania ●● Hyperthymic personality ●● > 3 recurrences of major depressive episodes ●● Brief major depressive episodes (average < 3 months) ●● Atypical depressive features (increased appetite and sleep) ●● History of a major depressive episode with psychosis ●● Onset of major depressive episodes prior to age 25 ●● Postpartum depression ●● Antidepressant tolerance ●● Lack of response to > 3 antidepressant trials

[ 21 ] Treating Mental Health Disorders in Primary Care

5. Follow-up ●● Mental health laboratories:4 Monitor mental health symptoms with screening tools and use them as the “lab values,” so that the patients are plugged into the same systems used for management of chronic diseases like diabetes or hypertension. ●● Stepped care:4 The treatment plan is created using evidenced-based guidelines, and is then modified as the patient meets or does not meet treatment goals. Medication Monitoring9 Initial Laboratory Work-Up: Screen for common comorbid conditions and for selection of medications based on their side effect profiles. Body mass index, blood pressure, CBC, electrolytes, BUN/creatinine, liver function tests, fasting glucose, fasting lipid profile, pregnancy test. Lithium Carbonate: Baseline: TSH, calcium, two blood levels to establish dose. Maintenance levels at 3-6 months or after dose change (or as symptoms indicate); kidney function at 3-6 months; Ca, TSH, and weight after six months, then annually. Valproate: Baseline: two levels to establish therapeutic dose. Maintenance: weight, CBC, LFT’s, and inquire regarding menstrual changes at three months for the first year, then yearly. Carbamazepine: Baseline: two levels to establish therapeutic dose (separated by four weeks). Maintenance: monthly CBC, LFT’s, EUC’s for three months, then annually. Review oral contraceptive efficacy. Remind patient to withhold medication and seek follow-up within 24 hours of emergence of dermatological eruptions. Lamotrigine: No maintenance labs, remind patient to withhold medication and seek follow-up within 24 hours of emergence of dermatological eruptions. Atypical Antipsychotics: Maintenance: weight monthly for three months, then every three months. Blood pressure and fasting glucose at three months for one year, then annually. Fasting lipid profile at three months, then annually. EKG (QTc prolongation), and prolactin levels when indicated.

Provide patient with Behavioral Healthcare Options brochure - Taking Your Medication

[ 22 ] Bipolar Disorder References: 1. Hirschfeld, Robert, M.A., M.D., et. al. Development and Validation of a Screening Instrument for Bipolar Spectrum Disorder: The Mood Disorder Questionnaire; American Journal of Psychiatry 2000; 157(11): 1873-5. 2. PsychoEducation.org - website with information regarding the diagnosis and treatment of Bipolar Disorder for physicians and patients. 3. Hirschfeld, Robert, M.A., M.D., et. al. Perceptions and Impact of Bipolar Disorder: How far have we really come? Results of the National Depression and Manic-Depression Association 2000 survey of individuals with Bipolar Disorder; Journal of Clinical Psychiatry 2003; 64(2): 161-74. 4. Muzina, David, M.D. Bipolar Spectrum Disorder: Differential Diagnosis and Treatment; Primary Care: Clinics in Office Practice 2007; 34(3): 521-50. 5. Thielke, Stephen, M.A., M.D. Integrating Mental Health and Primary Care; Primary Care: Clinics in Office Practice 2007; 34(3): 571-92. 6. Miklowitz, David J., et. al. Psychosocial Treatments for Bipolar Depression: A 1 year randomized trial from the Systematic Treatment Enhancement Program; Archives of General Psychiatry 2007; 64(4): 419-26 7. Ghaemi, S. N., M.D., et. al. Bipolar Spectrum Disorder: A pilot study; Psychopathology 2004; 37(5): 222-26. 8. Rihmer, Z., M.D., Ph.D., et. al. Bipolar II Disorder and Suicidal Behavior; Psychiatric Clinics of North America 1999; 22(3): 667-73. 9. The International Society for Bipolar Disorders (ISBD) Consensus Guidelines for the Safety Monitoring of Bipolar Disorder Treatments; Bipolar Disorders 2009; 11: 559-95. 10 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. 11. National Alliance on Mental Illness: nami.org/Template.cfm?Section=Bipolar1&Template=/ContentManagement/ ContentDisplay.cfm&ContentID=130758. 12. The diagnosis for a Hypomanic and Manic Episodes are based on the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2013.

[ 23 ] Treating Mental Health Disorders in Primary Care

Substance Use Disorders

●● Prevalence - 90% of adults and nearly as many adolescents have used alcohol, but most never develop problems related to its use. ●● Screening efforts should be directed at finding cases of problem use and abuse.1 ●● Approximately 2.5% of people older than 12 years have used psychotherapeutic medications (pain killers, sedatives, and stimulants) for nonmedical purposes in the last month, and the numbers appear to be increasing.2 ●● There were 63,600 drug overdose deaths in the U.S. in 2016, which is nearly a 4-fold increase from 1999. In 2016, Nevada’s rate of drug overdose death was 21.7 per 100,000 population, well over the national average. 1. Screening and Assessment Use a 2 step screen to improve sensitivity and specificity.1,3 Brief screening: alcohol - how many drinks per week, > 14 is a positive screen for men and > 7 is positive for women. When was the last time you had four or more drinks in one day (women, men > 65 yrs.), or five or more drinks in one day (men < 65 yrs.)? A positive screen is in the past three months. In the past year, have you experimented with an illegal drug or a prescription drug for nonmedical reasons? “Yes” is a positive screen.

REMEMBER: Standard drink = 12 oz. beer 1 1/2 oz. of 80 proof liquor 5 oz. wine The U.S. Preventative Services Task Force recommends that alcohol and drug brief screen occur yearly (and more frequently based on psychosocial stressors or adolescents), and that tobacco use is asked at every visit. Positive Screens Should Get Further Screening: ●● Patients with a positive brief screen should receive further screening/assessment using a validated screening tool. Scoring instructions are on each tool. AUDIT (Adult alcohol use) - detects at risk and problem drinking5 CAGE - brief questionnaire for when practitioner suspects alcohol dependency5 DAST-10© (Adult drug use6) CRAFFT - alcohol and drug abuse screen for adolescents7,10 2. Diagnosis8 Below are the criteria from the DSM 5 for a substance use disorder. The diagnosis should name the substance of concern, e.g., alcohol use disorder, opioid use disorder, etc. The use of the concepts of abuse and dependence are no longer used in the current criteria. Instead, the criteria refer to a use disorder with a range of severity from mild to severe, based on the number of criteria met. A. A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Substance is often in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control substance use. 3. A great deal of time is spent in activities necessary to obtain substance or recover from its effects. 4. Craving, or a strong desire or urge to use the substance.

[ 24 ] 5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home. 6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of substance. 7. Important social, occupational, or recreational activities are given up or reduced because of substance use. 8. Recurrent substance use in situations in which it is physically hazardous. 9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the substance to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of the substance. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for the substance. b. The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. 3. Intervention and Treatment There is extensive evidence of the important impact on patient health behavior when primary physicians engage in discussions ranging from diet and exercise to the problematic use of alcohol. Regarding substance use in particular, there are various models for approaching the issues in primary care, for example, SBIRT which is widely used as supported by SAMHSA and the Institute of Medicine.4 Central to any effective approach to substance use disorders (SUDs) in primary care is a discussion of the concerns between the patient and physician. Discomfort with the topic or time constraints cause some physicians to make referrals for SUD evaluation without speaking directly to the patient. These patients rarely follow through. When the physician engages the patient on the subject, it is far more likely to lead to a reduction of substance use or compliance with referrals for further evaluation and treatment. For patients who do require SUD treatment, BHO will provide referrals based on the severity, duration, prior treatment history, potential for acute withdrawal, and other factors. The continuum of care for SUDs includes: ●● Inpatient (for acute detoxification or other imminent safety risks) ●● Residential care (for patients with on-going imminent safety risks) ●● Partial hospital and intensive outpatient programs (for patients who require a higher level of structure than regular outpatient treatment) ●● Outpatient individual and group sessions ●● Community supports (such as AA or other 12 step groups) Each patient’s treatment plan should be individualized and specific to current clinical needs. Program driven models, e.g., the fixed 30 day rehabilitation, lead to very high recidivism rates. Treatment should be patient centered and involve the least restrictive level of care. Patients and their families often encounter very attractive advertising from out-of-area treatment facilities that assert the need for the patient to be out of the environment that led to the addiction. There is no evidence base for this thinking. In fact, the most effective treatment is community based, which also allows regular participation in treatment by the patient’s family and other supports.

[ 25 ] Treating Mental Health Disorders in Primary Care

Special considerations regarding opioid use disorders: Much of the current crisis regarding opioid addiction and overdose death is a result of iatrogenic opioid dependence. Primary prevention is obviously the best solution, and opioid prescribing practices are being increasingly scrutinized. Patients who are inappropriately receiving opioids for pain do not automatically have an opioid use disorder. Most patients take these drugs as prescribed without any misuse. Depending on the dose and duration of use, these patients are commonly tolerant (i.e., they require higher doses to achieve the same effect), and dependent (i.e., they will develop symptoms of acute withdrawal syndrome with abrupt cessation of the drug). These patients are specifically excluded from the diagnosis of an opioid use disorder and should be carefully tapered off the drugs as appropriate while also receiving alternative modalities for pain treatment. For patients who do have an opioid use disorder, treatment needs to be individualized, taking into account multiple factors such as psychosocial supports and possible comorbid physical and mental health issues. Many treatment programs only support an abstinence based approach. However, relapse rates after acute opioid withdrawal can be as high as 90%. In addition, accidental overdose deaths commonly happen in patients who have recently detoxified, and so have lost their prior tolerance for the drugs. Medication assisted treatment (i.e., the use of buprenorphine, methadone, and naltrexone) is a safer and more effective approach for many patients. Why Screen for Alcohol and Drug Use? Brief motivational conversations with patients can promote significant, lasting reduction in risky use of alcohol and other drugs. Nearly 30% of adult Americans engage in unhealthy use of alcohol and/or other drugs, yet very few are identified or participate in a conversation that could prevent injury, disease or more severe use disorders.9 Local Support Groups Alcoholics Anonymous aa.org Las Vegas Intergroup Main: 702-598-1888 Narcotics Anonymous na.org 24 Hour Help Line Phone: 1-888-495-3222 lvcentraloffice.org Oficina Central Hispana Main: 702-387-8744 Paso 12* 702-362-5360 Other Helpful Websites al-anon.alateen.org nar-anon.com

[ 26 ] Substance Abuse References: 1. Freedy, J., M.D., Ph.D., Alcohol Screening and Case Finding: Screening Tools, Clinical Clues, and Making the Diagnosis, Primary Care: Clinics in Office Practice (2011); 38(1): 91-103. 2. Manubay, J., M.D., Prescription Drug Abuse: Epidemiology, Regulatory Issues, Chronic Pain Management with Narcotic Analgesics, Primary Care: Clinics in Office Practice (2011); 38(1): 71-90. 3. HealthTeamWorks substance abuse practice guidelines - healthteamworks.org 4. Substance Abuse and Mental Health Services Administration (SAMHSA) - samhsa.gov 5. Botelho, R., M.D., Brief Interventions for Alcohol Misuse, Primary Care: Clinics in Office Practice (2011); 38(1): 105-123. 6. Skinner, H., Ph.D., The Drug Abuse Screening Test, Addictive Behavior (1982); 7(4): 363-71. 7. The Center for Adolescent Substance Abuse Research [email protected]. 8. The diagnosis for Substance Abuse and Substance Dependence is based on the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. 9. “Helping Patients Who Drink Too Much: A Clinician’s Guide,” U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. Updated 2005. niaaa.nih.gov/guide 10. “The CRAFFT Screening Tool”, The Center for Adolescent Substance Abuse Research (CeASAR) (Children’s Hospital Boston), Last updated 2009, ceasar-boston.org/CRAFFT/index.php, retrieved 21 November 2010.

[ 27 ] Treating Mental Health Disorders in Primary Care

Attention Deficit/Hyperactivity Disorder ●● Incidence: Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common neurobehavioral disorder of childhood. Multiple studies suggest a 7-8% incidence of ADHD among children, and the majority will continue to meet the criteria for the disorder into their teen years. Most of these patients will have some symptoms and persistent impairment of their function as adults.1,3 ●● Comorbidities: Over one half of children may have a co-occurring Oppositional Defiant Disorder, and may go on to develop Conduct Disorder and substance abuse disorders. Anxiety and mood disorders are also common, with mood disorders becoming more frequent in adulthood.1 1. Screening and Assessment Ask about the presence of symptoms from the three diagnostic domains: inattention, impulsivity, and hyperactivity, as well as the level of impairment from these symptoms. Formal Screening Tools Include: ●● ADHD Rating Scale 5 - 18 item scale using the DSM 5 criteria. Can be used for children, adolescents, and adults. ●● Conners Parent Rating Scale ●● Conner Wells Adolescent Self-Report Scale ●● Conners Adult Attention-Deficit Rating Scale Evaluation: ●● The full evaluation of children and adolescents should consist of interviews with the patient and parents, information regarding school or daycare function (screens completed by teachers and academic records), screening for possible comorbid psychiatric conditions, and a review of the patient’s medical, social, and family histories.3 ●● The adult evaluation focuses on current symptoms, childhood and academic histories, possible comorbid conditions, work and marital function, and family history. Approximately 50% of adults with ADHD will have a child with the disorder.2 2. Diagnosis DSM 5 Criteria - Attention Deficit/Hyperactivity Disorder4 A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2): 1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: NOTE: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).

[ 28 ] e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). 2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: NOTE: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. a. Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) d. Often unable to play or engage in leisure activities quietly. e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). f. Often talks excessively. g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation). h. Often has difficulty waiting his or her turn (e.g., while waiting in line). i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing). B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

[ 29 ] Treating Mental Health Disorders in Primary Care

3. Treatment Planning The treatment plan should include some combination of medication and/or psychosocial intervention. Several studies show that medication, overall, is more effective than psychotherapy. Behavioral therapy is effective and may be appropriate as the sole treatment in cases with mild symptoms and minimal impairment, disagreement among the parents and/or the teachers regarding the diagnosis, or if parents reject medication therapy. Interpersonal therapies and play therapies have been shown to be ineffective.3 Psychosocial interventions are also appropriate when there is a suboptimal response to medication, there are comorbid mental health issues, or to deal with significant stressors. 4. Medication The medications listed below are specifically FDA approved for ADHD. There are also several agents that are regularly used off label that have shown some effectiveness for this indication. Stimulant medications FDA approved for ADHD: Drug Brand name duration of action Amphetamine (D) Dexedrine 3-6 hrs. Dexedrine spansules up to 8 hrs. Amphetamine (D,L) Adderall 3-6 hrs. Adderall XR up to 8 hrs. Lisdexamphetamine Vyvanse 10-12 hrs. Methylphenidate (D) Focalin 2-4 hrs. Focalin XR 4-8 hrs. Methylphenidate (D,L) Concerta up to 12 hrs. Metadate CD up to 8 hrs. Ritalin 2-4 hrs. Ritalin LA up to 8 hrs. Daytrana (transdermal) up to 9 hrs. Non-Stimulant medications FDA approved for ADHD: Drug Brand name Class Atomoxetine Strattera Selective norepinephrine reuptake inhibitor Clonidine Kapvay Central alpha 2 agonist Guanfacine Intuniv Central alpha 2A agonist Duration of Treatment Patients who have been symptom-free for one year should be asked if they feel that their medication still provides a benefit (e.g., does their concentration persist even with missed doses or drug holidays). Treatment should continue as long as there are symptoms that are causing an impairment of function. Clinical Pearls As ADHD symptoms improve for children and adolescents, then academic performance should also improve. If there is no significant improvement after one to two months despite decreased ADHD symptoms, then consider testing for a learning disorder.1 Symptoms that arise suddenly and without previous history suggest other conditions or psychosocial stressors (e.g., mood or neurological problems, substance abuse, physical or sexual abuse).3 Patients with comorbid manic symptoms should have their mania treated first with a mood stabilizer prior to medication for ADHD.1 Up to 75% of patients respond to stimulants with a very large effect size (vs. placebo). Both types of amphetamines are equally efficacious, but a significant number of patients will respond to just one class, so trying both types improves the response rate.1 Doses can be titrated every one to three weeks to remission of symptoms, the maximum recommended dose, or the occurrence of side effects.

[ 30 ] Long acting forms are more convenient, and can allow the patient a smoother response with fewer periods of loss of benefit as a dose begins to wear off. They also improve compliance as well as confidentiality (i.e., a student doesn’t need to go to the school nurse for doses during the day). However, long acting forms are more likely to interfere with sleep or evening appetite. Patients can start with the long acting forms and do not need to be titrated using the short acting drugs. The short acting drugs are appropriate for small children. Treatment response can be objectively measured by repeating the rating scales by the patient, parent, and teacher. Atomoxetine can take as long as six weeks for full effect. It may be particularly helpful for comorbid anxiety, but it is not effective as an antidepressant. Consider it as a first line treatment for patients with substance abuse issues, or a tic disorder. There is a small chance for it to cause the onset of suicidal ideation (see black box warning); this should be discussed with the patient and parents.

Attention Deficit/Hyperactivity Disorder References: 1. Pliszka, S., M.D., et. al., Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder, Journal of the American Academy of Child and Adolescent Psychiatry (2007); 46(7): 894-921. 2. Adler, L., M.D., Diagnosis and Evaluation of Adults With Attention-Deficit/Hyperactivity Disorder, Psychiatric Clinics of North America (2004); 27(2):187-203. 3. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents, Pediatrics (2011); 128(5): 1007-1022. 4. The diagnosis for Attention Deficit/Hyperactivity Disorder (ADHD) is based on the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.

[ 31 ] Tiene derecho a recibir ayuda e información en su idioma sin costo. Para solicitar un intérprete, llame al número de teléfono gratuito para miembros que se encuentra en su tarjeta de identificación del plan o los documentos de su plan.

bhoptions.com

58NVBHO17542 PD1808 (05/18)