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Mood Disorders in Primary Care

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Mood Disorders in Primary Care Mood Disorders in Primary Care KATHLEEN TERRY, DO MPH PSYCHIATRY PGY2 OPSO ANNUAL PRIMARY CARE CONFERENCE 1 5 SEPTEMBER 2 0 1 7 Objectives Understand the prevalence of common mood disorders and their presentation in primary care settings Increase diagnostic and treatment knowledge, including criteria, available screening tools, and medication & therapy approaches Recognize that effective treatment is a team effort, and increase knowledge of systemic structures and legal avenues supporting that Outline EPIDEMIOLOGY CLASSIFICATION & DIAGNOSTIC CRITERIA TREATMENT APPROACHES True or false? A majority of patients with undiagnosed bipolar disorder present initially with bipolar- defining hypomanic or manic symptoms. True or false? A majority of patients False. with undiagnosed bipolar disorder present Depression and its initially with bipolar- related symptoms are the defining hypomanic or most common manic symptoms. presenting complaints, and may precede manic episodes by years. Epidemiology Major depressive episode 6.7% 12-month prevalence among adults 18+ (1 in 15) 12.5% 12-month prevalence in adolescents ages 12-17 (1 in 8) lifetime prevalence: 11.7% in females, 5.6% in males Bipolar spectrum diagnosis 2.6% 12-month prevalence among adults (1 in 39) 3.9% lifetime prevalence (1 in 26) Mood disorders are associated with high utilization of care Inpatient psychiatric hospitalization (39% annually in bipolar) High co-occurrence of somatic complaints Management of pharmacotherapy side effect profiles Among the most expensive conditions nationally, substantially related to indirect costs of lost productivity in addition to the financial costs of care 26% of anxiety and/or depression-related presentations to PCP meet bipolar qualifications Depressive episodes often precede mania or hypomania, and may cause greater cumulative disease burden Bipolar disorder has highest suicide rate among major psychiatric illnesses Retrospectively, 55% of bipolar patients who have taken antidepressants can be seen to precipitate mania/hypomania Primary care providers prescribe the majority of antidepressants nationwide Classification of Mood Disorders MAJOR DEPRESSIVE DISORDER DISRUPTIVE MOOD DYSREGULATION DISORDER PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA) PREMENSTRUAL DYSPHORIC DISORDER BIPOLAR I DISORDER BIPOLAR II DISORDER CYCLOTHYMIC DISORDER Major Depressive Episode 2+ weeks of >5 concurrent symptoms: Depressed mood Anhedonia Unintentional weight loss, or change (+/-) in appetite Insomnia / hypersomnia Psychomotor agitation or slowing Fatigue / loss of energy Worthlessness or excessive / inappropriate guilty feelings Indecision / decreased concentration Recurrent thoughts of death, or suicidal ideation "SIG E CAPS” Major Depressive Disorder Criteria met for major depressive episode Clinically significant distress/functional impairment Not attributable to substance or medical condition Not explained by a psychotic or delusional disorder No history of manic or hypomanic episodes Exclusive of substance use or medical conditions Bipolar Disorder Bipolar I disorder REQUIRES history of manic episode Hypomanic and major depressive episodes frequently occur, however not required for diagnosis Bipolar II disorder characterized by hypomania Bipolar Disorder Mania: Abnormally elevated or irritable mood and increased energy, persisting > 1 week 3+ other symptoms (4+ if mood ‘only’ irritable) Grandiosity / increased self esteem Decreased need for sleep Increased talkativeness / pressured speech Racing thoughts / flight of ideas Increased goal-directed activity or psychomotor agitation Distractibility Increased recklessness / risk taking (financial, physical, sexual, etc) “DIG FAST” Bipolar Disorder Mania MARKED disturbance in day-to-day functioning Notable impairment: requires hospitalization, psychosis, etc Not due to substance use Caveat for symptoms emerging during antidepressant treatment Hypomania Same characteristic symptoms Shorter duration (4+ consecutive days) Change in function is not impairing Not due to substance use True or false? There are validated screenings tools which are sensitive and specific for bipolar-spectrum disorders, and easy to use in an outpatient setting. True or false? There are validated True. screenings tools which are sensitive and specific The Mood Disorder for bipolar-spectrum Questionnaire (MDQ), Hypomania Checklist (HCL- disorders, and easy to 32), and Bipolar Spectrum use in an outpatient Diagnostic Scale (BSDS) are setting. brief, validated screening tools which can be used by primary care and specialists. “Secondary” Mood Disorders Essential to rule out substance-related (including prescribed medications) and medical etiologies for patient presentation before determining a psychiatric diagnosis. Thyroid disorder (hyper- or hypo-) Adrenal disorder (hyper- or hypo-) Stimulant use Sedative/hypnotic use or withdrawal Alcohol use or withdrawal Cannabis use or withdrawal Seizures Screening for Mood Disorders SBIRT / PHQ-2 PHQ-9 Screening, Brief Intervention, & Referral to Treatment Patient Health Questionnaire Mood Disorder Questionnaire (MDQ) Hypomania Checklist (HCL-32) Bipolar Spectrum Diagnostic Scale (BSDS) Mood Disorder Questionnaire 5 multi-part “Yes/No” questions Focus on manic symptoms Hypomania Checklist 8 questions ranking symptoms qualitatively Focus on degree of impairment, differentiate hypomania from mania Bipolar Spectrum Diagnostic Scale 19 statements with self- assessment of how accurately they describe the patient Portrays manic, depressive, and interim symptoms Who to screen? A variety of approaches Every person, every visit Every person, prompted at regular intervals In response to symptoms depression, anxiety, fatigue, restlessness, insomnia, difficulties with concentration Selected population based on high-risk service use patterns visit frequency, substance use, sexually/intravenously transmitted infections Screening tool can’t help you if you don’t use it Approach to Treatment MEDICATIONS PSYCHOTHERAPY WHEN TO INVOLVE OTHER PLAYERS True or false? In certain circumstances, a health care provider may discuss a patient’s mental health and treatment with family or friends without the patient’s consent. True or false? In certain circumstances, True. a health care provider may discuss a patient’s The Susanna Black mental health and Gabay Act (ORS 192.567) treatment with family or permits disclosures in friends without the order to reduce risk of patient’s consent. harm without a patient’s consent in certain circumstances. Medications Antidepressants SSRIs SNRIs TCAs MAOIs Mood stabilizers Lithium Anticonvulsants Antipsychotics typical/first-generation atypical / second-generation Challenges in Primary Care Medication management is hard Balancing efficacy, side effects, contraindications, other medical conditions Off-label uses National surveys reflect that most PCPs are uncomfortable with pharmacotherapy around bipolar disorder Optimal treatment is recovery-focused, involving the patient and key stakeholders team approach Treatment Team Patient Primary care provider Mental Health specialist/liason Medical-home-based psychologist Psychiatric prescriber (primary vs consult) Therapist Patient’s family Others: school counselors, pastoral/spiritual care, substance use programs, etc Psychotherapy Cognitive behavioral therapy (CBT) Dialectic behavioral therapy (DBT) Insight-oriented therapy / psychodynamic therapy Substance abuse treatment Trauma-focused Gabay Act – PHI Disclosure without ROI Disclosure may be made to family/friend without patient’s informed consent IF: Disclosure is to someone close to patient, and PHI disclosed is relevant to their involvement in the patient’s care Patient unavailable/unable to consent and provider deems it in patient’s best interest, or, patient doesn’t object to disclosure Provider makes good-faith disclosure to prevent/lessen a threat to safety of any person or the public, and disclosure made only to someone who can act to reduce the threat PHI disclosed may include diagnosis, treatments, risk factors, safety planning/contingencies, community resources Obligated to disclose minimum necessary PHI No civil liabilities for providers acting in good faith Summary Screen widely Familiarize yourself with the personnel/resources available in your health system or community Consider how your clinic team can serve this population and what needs remain front office/back office training including MHSs/LCSWs/psychologists in the clinic Refer when needed; be prepared to take on prescribing role for stable patients on maintenance If patient’s safety is a concern, share it. References DSM-5 https://www.oregonlaws.org/ors/192.567 Stahl’s https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3225131/pdf/icns_8_10 _10.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492519/pdf/nihms409 636.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902189/ https://www.cdc.gov/mentalhealth/basics/burden.htm https://www.nimh.nih.gov/health/statistics/prevalence/major- depression-among-adults.shtml https://www.nimh.nih.gov/health/statistics/prevalence/bipolar-disorder- among-adults.shtml https://www.nimh.nih.gov/health/statistics/prevalence/major- depression-among-adolescents.shtml http://www.medscape.com/viewarticle/490521 https://www.ncbi.nlm.nih.gov/books/NBK84656/.
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