Assessing Adults with Mental Disorders in Primary Care

ANCC Contact Hours 2.0/ 1.0

Bonnie Davis, RN, DNS, APRN, BC

he literature highlights the and expanded community treatments prevalence of mental disor- have resulted in more people with men- T ders and physical comorbid- tal illness being treated in nonpsychi- ity.1-4 A mental disorder is a clinically atric settings such as primary care, significant behavioral or psychological prisons,and emergency rooms.11-13 His- syndrome associated with impairment torically, physical disorders and mental in one or more important area(s) of disorders have been treated in separate functioning, or with a significantly in- facilities.When they co-occur in the pri- creased risk of suffering death,pain,dis- mary care setting, a mental disorder ability,or an important loss of freedom.5 tends to get less attention, even though Among patients diagnosed with it may cause the greater disability.14,15 mental disorders, between 24% to 60% Recognition and treatment of men- have known physical disorders6 and tal disorders is more complex in non- There is a high prevalence of mental and many more have unrecognized and un- psychiatric settings than in psychiatric treated physical comorbidity. It is im- physical comorbidity. Increasingly, per- settings due to patient and clinician fac- 11 portant to screen for these as they can sons with mental disorders are seen in tors. Patients’ cognitive or interper- cause or worsen psychiatric symptoms sonal impairments may make them and, in some patients, increase suicidal nonpsychiatric settings where recogni- unwelcome. Elderly persons often so- attempts.1,6 Physical conditions such as tion of comorbidity is more complex. matize mental health symptoms and obesity, diabetes, dyslipidemia, and car- resist psychiatric etiologies and inter- This article notes the interactions be- diovascular disease may be induced or ventions. worsened by prescribed psychopharma- tween mental and physical disorders Some patients’ perceptual or cogni- cologic regimens and lifestyle patterns tive deficits prevent them from recog- and provides an assessment approach such as smoking.7-10 Persons with per- nizing or communicating their own sistent mental illness (disorders persist- to improve health outcomes for persons mental health symptoms or problems.9,10 ing over time with remissions and with mental illness who are seen in pri- Clinician obstacles to assessing recurrence of severe symptoms) form a health care of the persistently mentally disenfranchised group whose access to mary care. ill include poor communication between medical care has been limited, leading the primary care provider and the men- to greater mortality1,4 as demonstrated by statistics showing tal health clinician and primary care providers’ lack of skill. that individuals with schizophrenia have a life expectancy Additionally, some clinicians are uncomfortable with difficult 20% lower than the general population.6,7 behaviors in their patients.9,10 This article notes the interrela-

Illustration by Noma Bliss Managed care guidelines, psychiatric hospital closings, tions between mental and physical disorders and suggests an

www.tnpj.com The Nurse Practitioner • May 2004 19 Assessing Adults with Mental Disorders in Primary Care

assessment approach to improve health During the intake interview, need for referral to more appropriate outcomes for persons with persistent services. Among those who commit observe the patient and col- mental illness who are seen in primary suicide, physical illness is a contribut- care. lect verbal, behavioral, and ing factor in 11% to 51% of cases, in- 6 physiologic data. Inquire about the his- creasing with the person’s age. Studies ■ Collecting Assessment Data indicate that 70% of people who com- To provide a comprehensive physical tory of the present physical illness, past mitted suicide had seen a primary care assessment of a patient with a mental medical and psychiatric illnesses in the provider within the previous 4 to 6 disorder, it is important to collect rele- weeks.18-20 Patients are not likely to vol- patient and patient’s family, surgeries, the vant data from multiple sources. The unteer suicidal intent, but the office approach described here begins with an patient’s developmental/social history, visit itself may be a call for help. An in- intake interview that incorporates data quiry such as, “How would you de- and present functioning. Explore all med- gleaned from observation and a Review scribe your predominant mood over of Systems (ROS), including past and ications the patient possesses—those the past 2 weeks?” may encourage the present subjective symptoms. Data currently and previously prescribed, as patient to discuss depression or suici- from previous health records, labora- dal ideation. Among a group of people tory findings, physical examination, well as their dosage schedules, along who survived serious suicide attempts, and collateral sources are also used. It with over-the-counter drugs, herbs, vita- 70% reported they had not been asked may be necessary to add follow-up ses- about their emotional state when they mins and recreational drugs. sions with the patient and (with the pa- saw their primary care provider.20 tient’s permission) family and other Sociodemographic risk factors for care providers in order to obtain a complete data base.6 suicide include being male, Caucasian or Native American, living alone, and having a chronic physical or mental disor- ■ Family Interview der.Among current mental disorders, affective disorders and Many psychiatric symptoms are beyond the awareness of the substance abuse pose greater risk.19,20 Suicide risk may be as- patient, but a family member who sees the patient regularly sessed by identifying feelings of hopelessness, past suicidal can give significant diagnostic clues not available to the health attempts, recent loss or rejection, level of external support, care provider.16 the seriousness of intent, the extent of planning, and the abil- During the intake interview, observe the patient and col- ity and means to carry out the plan.16 Hopelessness, little lect verbal, behavioral, and physiologic data. Inquire about external support, having an affective disorder, substance the history of the present physical illness, past medical and abuse, and specific planning are associated with greater sui- psychiatric illnesses in the patient and patient’s family, surg- cide risk (see Table:“Suicide Risk Assessment Questions”).20,21 eries, the patient’s developmental/social history, and present functioning. Explore all medications the patient possesses— those currently and previously prescribed, as well as their Suicide Risk Assessment Questions dosage schedules, along with over-the-counter drugs, herbs, 1. “Do you feel hopeless?” vitamins and recreational drugs. The patient’s presenting behavioral symptoms may be 2. “Have you tried to kill yourself in the past?” the result of prescribed and/or nonprescribed medications, herbs, or other substances.6 Research has shown that per- 3. “Has anyone in your family committed suicide?” sons with psychiatric disorders abuse drugs such as nico- 4. “Are you impulsive?” tine, caffeine, marijuana, hallucinogens, and cocaine more than the general population.10 Prescription drugs that com- 5. “Are you thinking about killing yourself now?” monly produce behavioral or emotionally related problem- 6. “Can you resist the impulse to do this?” atic symptoms include psychotropics, anticholinergics, steroids, antihistamines, antiarrhythmics, and beta-adren- 7. “Do you have a plan?” ergic blockers. Anxiolytics and hypnotics can produce con- fusion during withdrawal, especially in the elderly.17 8. “How would you kill yourself?” Inquire about the patients’ emotional state, particularly 9. “Do you have the means (pills, gun, etc) to kill depressive and suicidal thoughts. If the patient expresses sui- yourself?” cidal ideation, a brief assessment of lethality may indicate

20 The Nurse Practitioner • Vol. 29, No. 5 www.tnpj.com Assessing Adults with Mental Disorders in Primary Care

■ Review of Systems Clinicians may have to cause blurred vision. Unusually frequent As with all patients, a ROS in patients blinking is associated with schizophre- work harder to discover with mental disorders notes the absence nia. Pupillary constriction suggests use or presence of symptoms in the major comorbid conditions, as of opioids and pupillary dilation may re- body systems, aids in developing dif- the patient with a mental illness may be sult from anticholinergic agents or hal- ferential diagnoses, and guides further lucinogens.6 Dilated pupils may also diagnostic and treatment choices.16,17 reluctant or unable to describe physi- result from overactivity of norepineph- Clinicians may have to work harder to cal problems. It has been noted that pa- rine, which occurs in anxiety.18 The discover comorbid conditions, as the symptoms constellation of rhinorrhea, tients suffering from schizophrenia are patient with a mental illness may be re- lacrimation, midriasis and yawning may luctant or unable to describe physical less sensitive to pain from myocardial indicate opiate withdrawal.18 Abnormal problems. It has been noted that pa- saccades (volitional eye movements) are infarction, fractures, and other serious tients suffering from schizophrenia are seen in some patients with schizophre- less sensitive to pain from myocardial conditions. Using a structured format nia, mood disorders, and drug induced 6 infarction, fractures, and other serious during each patient contact fosters com- states. One group of researchers reported conditions. Using a structured format that visual hallucinations and illusions 10 during each patient contact fosters prehensive assessment. were the psychiatric symptoms most in- comprehensive assessment.10 dicative of physical disorders such as alcohol withdrawal, temporal lobe epilepsy, and conditions ■ Neurological that impair visual acuity.6 During the interview, attend to the patient’s level of alert- Hearing-impaired individuals can be more vulnerable ness, responsiveness, and motor agitation or retardation. to delusional disorder than persons with normal hearing. Drowsiness or inattentiveness may be due to brain dysfunc- Perforation of the nasal septum with breathing difficulty can tion or drug overdose. Inquire about sleep patterns, because be caused by cocaine abuse. Perioral twitching may point to sleep pattern disturbance may herald the beginning or re- an early stage of antipsychotic-induced tardive dyskinesia.6 currence of a mental disorder.6 The patient’s gait and movements are telling. Ataxia ■ Respiratory System (awkwardness of posture or gait) may be caused by cerebel- Abnormal respiration may be affected by emotions. Psy- lar disorder or substance intoxication. Basal ganglia disor- chogenic hyperventilation is suggested if the patient’s ders may present with the rigidity,bradykinesia,and shuffling history includes apprehension, onset at rest, anxiety, de- gait of Parkinson’s disease, or the purposeless movements of personalization, palpitations, and numbness of the feet and Huntington’s disease or Sydenham’s chorea.6 Abnormal in- hands. Dyspnea caused by depression differs from that voluntary movements may result from the extrapyramidal caused by airway obstruction. In depression, dyspnea fluc- side effects of psychotropic drugs.18 tuates, coincides with mood, is most prominent upon in- Inquire about the presence, frequency, duration, char- spiration,and may be accompanied by vertigo,perspiration, acter, location, and severity of headaches. Headaches may palpitations, and paresthesias. In obstructive airway con- suggest etiologies as diverse as substance abuse, stress, brain ditions, the onset is often insidious, with the greatest diffi- tumor, head trauma, and subarachnoid hemorrhage. Multi- culty on expiration.6 infarct dementia, subdural hematoma, normal pressure hydrocephalus, tumors, and human immunodeficiency virus ■ Cardiovascular System all may produce dementia that must be differentiated from Cardiac complaints require differential diagnosis. Common Alzheimer’s disease and psychotic disorders. Ask about de- signs of anxiety include tachycardia, palpitations, and car- velopmental milestones, seizures, head trauma, any periods diac arrhythmias. Pheochromocytoma commonly produces of loss of consciousness, and substance abuse.6 symptoms mimicking anxiety. Mitral valve prolapse often coexists with panic attack. Because psychological stress can ■ Eye, Ear, Nose, and Mouth cause angina-like pain, a history of substernal pain should Reports of symptoms affecting the eye, ear, nose, and mouth be investigated. Recognizing and treating psychological risk provide information about risk factors, the need for med- factors for developing cardiac problems, such as anger, ication review, and future medication prescription. A his- trauma, or depression, and treating anxiety associated with tory of glaucoma is a contraindication for prescribing cardiac problems will contribute to a decline in patient mor- anticholinergic drugs. Certain psychotropic medications bidity and mortality.5,22

www.tnpj.com The Nurse Practitioner • May 2004 21 Assessing Adults with Mental Disorders in Primary Care

Summary of Review of Systems

System Sign, Symptom Possible Etiology/Differential Dx Iatrogenic Implications

Neurological Drowsiness, inattentiveness Brain dysfunction, drug overdose

Ataxia Cerebellar disorder, substance intoxifi- Lithium toxicity may mani- cation, normal pressure hydrocephalus fest with ataxia

Rigidity, bradykinesia, shuffling gait Parkinson’s disease

Purposeless movements Huntington or Sydenham’s disease

Abnormal involuntary movements of Extrapyramidal s.e. of psy- mouth, feet and legs, fingers chotropic drugs

Headache Tumor, head trauma, subarachnoid hemorrhage, stress

Cognitive abnormalities Multi-infarct dementia, Alzheimer’s disease, HIV, or psychosis, head trauma, substance abuse

Hallucinations Temporal lobe epilepsy, psychosis, substance abuse

Sleep pattern disturbance Environmental factors, little Depression, psychosis exercise, pain, shift work, obstructive sleep apnea

Hypersomnia or insomnia Depression, psychosis S.E. of drugs

Motor agitation or retardation Psychosis or depression Effects of drugs or illicit substance

Eyes, Ears, Nose History of glaucoma Avoid exposure to and Mouth anticholinergics drugs

Blurred vision Refractive error Possible s.e. psychotropic drugs

Pupillary constriction or dilation Use of opioids, anticholinergics or hallucinogens

Unusually frequent blinking, saccades May be associated with schizophrenia

Deafness More vulnerable to delusions

Breathing problem associated with nasal Cocaine use septum perforation

Perioral twitching, tongue thrusting Early stage tardive dyskinesia, s.e. of psychotropic drugs

Clustered rhinorrhea, lacrimation, midriasis Opiate withdrawal and yawning (+ dysphoria, nausea, vomiting)

Respiratory Dyspnea with onset at rest, anxiety, Psychogenic hyperventilation palpations, numbness of feet and hands

Dyspnea fluctuates with mood, is most Dyspnea associated with depression prominent upon inspiration, accompanied by vertigo, perspiration, palpitations, paresthesias

Dyspnea with insidious onset, greatest Obstructive airway condition difficulty upon expiration continued on page 24

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Assessing Adults with Mental Disorders in Primary Care

Summary of Review of Systems (continued)

System Sign, Symptom Possible Etiology/Differential Dx Iatrogenic Implications

Cardiovascular Tachycardia, palpitations, cardiac Anxiety, mitral valve prolapse, Failure to treat anxiety mor- arrhythmias, substernal pain Pheochromocytoma, cardiac disease bidity with cardiac disease

Gastrointestinal Up or down in appetite and weight Depression, eating disorder

Nausea, vomiting, diarrhea Infection, inflammation, drugs, anxiety Lithium toxicity may mani- fest with diarrhea

Maladaptive eating patterns, purging, Anorexia, bulimia, binge eating laxative abuse

Obesity, hyperlipidemia, hyperglycemia Sedentary life style, excessive caloric S.E. of psychotropic drugs intake

Ascites, signs of poor nutrition Chronic alcohol use

Integumentary Spider nevi over face, neck, chest Chronic alcohol use

Cool dry skin, coarse hair, loss of lateral Hypothyroidism 1 ⁄3 eyebrows, brittle nails

Thinning scalp hair, eye lashes Excessive hair pulling In psychiatric patients exposed to valproic acid, buspirone

Alopecia Chemotherapy, baldness

Severe bullous rash Stevens-Johnson syndrome R/T exposure to lamotriginc

Nonsurgical scars: cigarette burn, lacerations Victimization or self mutilation

Needle tracking Intravenous drug abuse

Hormonal Irregular menses, dysmenorrhea Uterine pathology, mood disturbance

Amenorrhea Anorexia nervosa, extreme stress, pseudocyesis

Mood, cognitive changes following Postpartum depression or postpartum pregnancy, abortion psychosis

Gynecomastia, impotence in males, Antipsychotic induced hy- amenorrhea perprolactinemia

Galactorrhea and osteoporosisin women

Marked weight gain associated with Metabolic syndrome Induced by antipsychotic diabetes, dyslipedemia e.g. clozapine, olanzapine

Genitourinary Urinary retention Benign prostatic hypertrophy Maybe induced by antipsychotic or tricyclic antidepressant

Priapism Exposure to trazodone

Rash, pustules, pain, drysuria, discharge Sexually transmitted disease

Incontinence Abdominal organ prolapse, dementia

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■ Gastrointestinal System Depression may cause certain psychiatric drugs (e.g. valproic The gastrointestinal system is the acid (Depakote) and buspirone (BuS- changes in appetite and be source of problems of both iatrogenic par). A severe bullous rash of Stevens- and psychologic origins. The practi- accompanied by weight Johnson syndrome might be caused by 6 tioner should assess appetite, eating gain or loss. Weight loss may be caused exposure to lamotrigine (Lamictal). patterns, avoidance of food, dysphagia, Cigarette burn-patterned laceration xerostomia (dry mouth from salivary by anorexia nervosa, stimulant abuse, scars,or other nonsurgical types of scars gland dysfunction), vomiting, diarrhea, dementia, or infectious conditions. Con- may indicate a history of self-mutila- constipation, laxative use, and weight. tion or victimization. Ask,“What is this stipation can be caused by opiates and Primary illnesses related to maladaptive from?” If you suspect self-mutilation, eating patterns include anorexia ner- by psychotropic drugs with anticholin- the patient should be referred to an ap- vosa, bulimia nervosa, and binge eating propriate mental health specialist. If you ergic properties. Lithium toxicity may disorder. Laxative abuse and induced suspect victimization, you must follow vomiting are seen in bulimia.6 Incorpo- be manifested with diarrhea. Food avoid- the appropriate steps in reporting and 26 rate the following questions to identify ance may be associated with phobia or following up your suspicions. women with eating disorders: “Are you satisfied with your eating patterns?”and an obsessive ritual. ■ Genitourinary System “Do you ever eat in secret?” If screen- Exposure to certain drugs results in ing data is positive, follow up with a full medical workup.25 some genitourinary problems. Many antipsychotics and tri- Research demonstrates a higher prevalence of obesity cyclic antidepressants cause urinary retention and, less com- among those who are mentally ill than the general popula- monly, prostate hypertrophy. The antidepressant trazodone tion due to a frequent sedentary life style and side effects of (Desyrel) is associated with priapism, which requires imme- psychotropic medications. Psychiatric inpatients who un- diate drug cessation and referral for possible surgical inter- derstand the need for weight reducing practices may find vention. Inquire about incontinence, sexual activity, and behavioral change difficult because of their limited ability history of sexually transmitted disease.6 to make dietary choices within a hospital setting.24 At spaced intervals, plan to encourage weight reduction with these ■ Hormonal Systems obese patients. A menstrual history should include the age of menarche Depression may cause changes in appetite and be ac- and menopause, regularity, irregular bleeding, dysmenor- companied by weight gain or loss.Weight loss may be caused rhea, amenorrhea, and any associated treatments. Note by anorexia nervosa, stimulant abuse, dementia, or infec- premenstrual mood changes such as irritability, depres- tious conditions. Constipation can be caused by opiates and sion, and dysphoria. Amenorrhea occurs in anorexia ner- by psychotropic drugs with anticholinergic properties.6 vosa, extreme stress, and pseudocyesis (false pregnancy). Lithium toxicity may be manifested with diarrhea.18 Food Note significant mood changes associated with abortion avoidance may be associated with phobia or an obsessive rit- and pregnancies. Referral to a mental health clinician may ual. Among the elderly, dysphagia and xerostomia may im- be indicated.6 pair eating and,combined with exposure to tardive dyskinesia Antipsychotic-induced hyperprolactinemia may result inducing antipsychotics, may cause choking.16 One group of in gynecomastia and impotence in men, and amenorrhea, researchers found the incidence of irritable bowel syndrome galactorrhea, and osteoporosis in women. Marked weight higher in patients with schizophrenia than the control group, gain is associated with increases in diabetes, cholesterol, and although patients with schizophrenia seldom reported the triglycerides, especially among patients taking clozapine symptoms.10 (Clozaril) and olanzapine (Zyprexa).6,7,10

■ Integumentary System ■ Diagnostic Tests Nutritional deficits associated with alcoholism may result in Order routine laboratory tests to screen for concurrent dis- spider nevi over chest, face, and neck. Depression may be ease, illicit drug use, pregnancy for women with child bear- mimicked or worsened by hypothyroidism, and present with ing potential, and to establish baseline values of functions cool dry skin, coarse hair, loss of lateral third of eyebrows, that will be monitored. Such laboratory tests include com- brittle nails, and alopecia.25 Thinning scalp hair or eye lashes plete blood count, electrolytes, blood sugar, renal, liver and may be caused by trichotillomania (excessive hair pulling). thyroid function, urine drug screen, blood alcohol level, and Alopecia may be reported by psychiatric patients exposed to pregnancy test if appropriate. Neuroimaging is the most ef-

www.tnpj.com The Nurse Practitioner • May 2004 25 Assessing Adults with Mental Disorders in Primary Care

ficient means for detecting or ruling out Evaluation through history, mental state. Using a calm, matter of major neurological pathologies, but is fact manner with a running account of physical examination and not indicated routinely. Many psychi- what is being done allays anxiety. Lin- atric patients smoke excessively, so an laboratory findings leads gering over one aspect of the examina- evaluation of pulmonary and cardiac to diagnosis. When symptoms are iden- tion may arouse the patient’s concern. status may be indicated. Ordering lab- Beginning with familiar procedures oratory tests is guided by the clinical tified, the clinician must determine if such as measuring weight and vital signs presentation and risk factors. Tests they are real or delusional, and if the eti- may be helpful.6 should be ordered judiciously, but not The physical examination should be ology is psychogenic, physiological, or avoided because of costs.6,17 customized based on the patient’s be- iatrogenic. In making a differential di- havior, the ROS, and patient and family ■ Physical Examination history. Assessment of the neurological agnosis, physiological etiologies should A physical examination for persons system is particularly important,because with a mental disorder may require in- be considered first. disorders in the brain may cause psychi- creased sensitivity to patient response. atric symptoms. For patients with per- The examination may evoke adverse reactions in patients sistent mental illness, it is important to note neurological who have a history of rape or sexual abuse, as well as pa- findings that are commonly associated with psychiatric dis- tients who are delusional. Occasionally it is wise to defer or orders and/or psychotropic medications such as posturing, reschedule the physical examination because of the patient’s asterixis, dyskinesia, tremor, paresthesia, subtle dysarthria, and gait disturbance.6

Conditions Associated with Psychosis ■ Differential Diagnosis Evaluation through history, physical examination and lab- Addison’s disease Multiple sclerosis oratory findings leads to diagnosis. When symptoms are CNS infections Myxedema identified, the clinician must determine if they are real or CNS neoplasms Pancreatitis delusional, and if the etiology is psychogenic, physiological, CNS trauma Pellagra or iatrogenic.10 In making a differential diagnosis, physio- Cushing’s disease Lupus logical etiologies should be considered first. The Diagnostic Delirium Syphilis (untreated) and Statistical Manual of Mental Disorders-Fourth Edition, Dementias Temporal lobe epilepsy describes general medical conditions in which there is a Folic acid deficiency Thyrotoxicosis known physiological link between a medical condition and

Modified from Hahn, Reist, and Albers Psychiatry, a current clinical psychiatric symptoms, such as seizures and psychosis or strategies medical book 2003-2004. Cushing’s syndrome and depression.5 Researchers have noted that the most common general medical conditions that cause psychiatric symptoms are from the cardiovascular, en- 6 Conditions Associated with Depression docrine, immune, and neurological systems (see Tables: “Conditions Associated with Psychosis”and “Conditions As- AIDS Menopause sociated with Depression”). Anorexia Multiple sclerosis ■ Alcoholism Postpartum status Conclusion Anemia Rheumatoid arthritis The health needs of the population with physical and Asthma Stroke mental comorbid conditions are not adequately met. The Cocaine use Syphilis goal of reducing morbidity and mortality among persons with mental and physical comorbidity can be addressed Cushing’s disease Obesity by NPs who are vigilant assessors. Obstacles to assess- Heart disease Lupus ment of persons with comorbid disorders can be dimin- Hypothyroidism Uremia ished by: 1) developing greater awareness of their needs, Insomnia Ulcerative colitis 2) increasing sensitivity to their responses, 3) accommo- Malignancies dating their behaviors, 4) forming therapeutic alliances Modified from Hahn, Reist, and Albers Psychiatry, a current clinical with them, and 5) partnering with formal and informal strategies medical book 2003-2004. care providers.

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DISCLOSURE ment provided primary care patient with major depression. Arch of Fam The author has disclosed that she has no significant relationship or financial in- Med 2000;9:150-154. terest in any commercial companies that pertain to this education activity. 15. Scharer K, Boyd M, Williams CA: Blending specialist and practitioner roles in psychiatric nursing: Experiences of graduates. J Amer Psych Nurs Assoc REFERENCES 2003;9(4):136-144. 1. Geffken GR, Ward HE, Stabb JP: Psychiatric morbidity in endocrine disor- 16. Boyd MA: Psychiatric nursing contemporary practice, 2nd edition. Philadel- ders. Psychiatr Clin North Am 1998;21(2):473-489. phia: Lippincott. 2002. 2. Felker B, Yazel JJ, Short, D: Mortality and medical comorbidity among psy- 17. Andreasen NC, Black DW: Introductory textbook of psychiatry, 2nd Ed. chiatric patients: A review. Psy Serv 1996;47:1356-1363. Washington DC: American Psychiatric Publishing, Inc., 2001. 3. Takesita J, Masaki K, Ahmed I, et al: Are depressive symptoms a risk factor 18. Stahl SM: Essential psychopharmacology. New York, New York: Cambridge for mortality in elderly Japanese American men? The Honolulu-Asia Aging Press, 2000. Study. Am J Psychiatry 2002;159:1127-1132. 19. Hirschfield AMA, Russell JM: Assessment and treatment of suicidal patients. 4. Harris E, Barraclough B: Excess mortality in mental disorder. Br J Psychiatry N Engl J Med 1997;337:910-915. 1999;173:11-53. 20. Hall RCW, Platt DE: Suicide risk assessment : A review of risk factors for sui- 5. American Psychiatric Association: Diagnostic and statistical manual of men- cide in 100 patients who made severe suicide attempts. Psychosomatics 1999; tal disorder-Text revision, 4th Ed. Washington DC, 2000. 40:18-27. 6. Kaplan HI, Sadock BJ: Synopsis of psychiatry: Behavioral sciences/clinical psy- 21. Fenton WS, McGlashan TH, Victor BJ: Symptoms, subtype, and suicidality chiatry, 9th edition. Baltimore, MD: Lippincott Williams and Wilkins, 2002. in patients with schizophrenia spectrum disorders. Am J Psychiatry 1997; 154:2,199-204. 7. Bailey KP: Choosing between atypical antipsychotics: Weighing the risks and benefits. Arch Psych Nrsg 2002;16(3):[Suppl 1], S2-S11. 22. Cowan MJ, Pike KC, Budyzynski HK: Psychosocial therapy reduced the risk of cardiovascular at two years after out of hospital sudden cardiac arrest. 8. Casey DE: Atypical antipsychotics: Enhancing healthy outcomes: Arch Psych Nursg Res 2001;50,68-76. Nrsg, 2002; 16,(3)[Suppl 1]S12-S19. 23. Freund K, Graham SM, Lesky LG: Detection of bulimia in a primary care 9. Hodges B, Inch C, Silver I: Improving the psychiatric knowledge, skills and setting. J Gen Int Med 1993;8:236. attitudes of primary care physicians, 1950-2000: A review. Am J Psychiatry 2001;158:1579-1586. 24. Meyer JH: Awareness of obesity and weight among chronically mentally ill in-patients: A pilot study. An Cl Psych 2002;14(1):34-45. 10. Dixon L, Fischer PJ, Lehman A: The association of medical comorbidity in schizophrenia with poor physical and mental health. J Nerv Ment Dis 1999; 25. Dunphy LM, Winland-Brown JE: Primary care: The art and science of ad- 187: 496-502. vance practice nursing. Philadelphia: FA Davis,2000;903. 11. Goldman LS: Medical illness in patients with schizophrenia. J Clin Psychia- 26. Gallop K: Failure of the capacity for self-soothing in women who have a his- try 1999;60[Suppl 21], 10-15. tory of abuse and self-harm. J Amer Psych Nrs Assoc 2002;8(1):20-26. 12. National Rural Health Assoc; Mental health in rural America: The scope of 27. Hahn RK, Reist C, Albers LJ: Psychiatry -A current clinical strategies med- mental health issues in rural America, 2002. Found at http://www.nrharural. ical book. 2003-2004 Laguna Hills CA: Clinical Strategies Publishing. org/dc/issuespapers. 13. Talley S: Improving outcomes: Clinical and educational challenges for psy- ABOUT THE AUTHOR chiatric nurses. Arch Psych Nrsg 2002;16(3):520-526. Bonnie Davis is an Associate Professor at the University of Mississippi School of 14. Rost K, Nutting P,Smith J, et al: The role of competing demands in the treat- Nursing, Jackson, Miss.

CE Test Assessing Adults with Mental Disorders in Primary Care

Instructions: Provider Accreditation: • Read the article beginning on page 19. This Continuing Nursing Education (CNE) activity for 2.0 contact hours •Take the test, recording your answers in the test answers and 1.0 pharmacology contact hour is provided by Lippincott Williams section (Section B) of the CE enrollment form. Each question & Wilkins, which is accredited as a provider of continuing education in has only one correct answer. nursing by the American Nurses Credentialing Center’s Commission on • Complete registration information (Section A) and course Accreditation and by the American Association of Critical-Care Nurses evaluation (Section C). (AACN 11696, CERP Category A). This activity is also provider approved • Mail completed test with registration fee to: Lippincott by the California Board of Registered Nursing, Provider Number CEP Williams & Wilkins, CE Group, 333 7th Avenue, 20th Floor, 11749 for 2.0 contact hours and 1.0 pharmacology contact hour. LWW is New York, NY 10001. also an approved provider of CNE in Alabama, Florida, and Iowa and • Within 3 to 4 weeks after your CE enrollment form is holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA received, you will be notified of your test results. #75. All of its home study activities are classified for Texas nursing con- • If you pass, you will receive a certificate of earned contact tinuing education requirements as Type I. hours and an answer key. If you fail, you have the option of taking the test again at no additional cost. Your certificate is valid in all states. This means that your certificate of • A passing score for this test is 11 correct answers. earned contact hours is valid no matter where you live. • Need CE STAT? Visit http://www.nursingcenter.com for immediate results, other CE activities, and your personal- Payment and Discounts: ized CE planner tool. • The registration fee for this test is $14.95. • No Internet access? Call 1-800-933-6525 for other rush ser- • If you take two or more tests in any nursing journal published by vice options. LWW and send in your CE enrollment forms together, you may deduct • Questions? Contact Lippincott Williams & Wilkins: 646-674- $0.75 from the price of each test. 6617 or 646-674-6621. • We offer special discounts for as few as six tests and institutional bulk discounts for multiple tests. Call 1-800-933-6525 for more informa- Registration Deadline: May 31, 2006 tion.