Psychiatric Assessment in Primary Care Aaron Short, MD, MPH1, 2 Ali Abbas Asghar-Ali, MD1, 2, 3 1Michael E. DeBakey Veterans Affairs Medical Center in Houston 2Baylor College of Medicine 3South Central Mental Illness Research, Education, Clinical Center Learning Objectives

• Outline the most common mental health symptoms in a primary care setting

• Distinguish between commonly occurring mental health illnesses in a primary care setting

• Make use of standardized questionnaires and clinical interview to assess for common mental health issues Number of Physical Symptoms and Association with Psychiatric Disorders Kroenke K, Spitzer R, William J, et al. Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment. Arch Fam Med. 1994;774-779.

No. of Symptoms No. of Patients Anxiety Mood Any Physical (n=1000) 0-1 215 2 (1) 5 (2) 16 (7) 2-3 225 17 (7) 27 (12) 50 (22) 4-5 191 25 (13) 27 (12) 67 (35) 6-8 230 68 (30) 100 (44) 140 (61) 9 or greater 139 66 (48) 84 (60) 113 (81) Somatoform (n=933) 0 654 68 (10) 107 (16) 162 (25)

1-2 143 42 (29) 60 (42) 74 (52) 3-5 87 35 (40) 40 (46) 77 (89) 6 or greater 49 27 (55) 34 (69) 46 (94) Prevalence of Mental Illness in Primary Care

• Approx. 20% of primary care patients had at least 1 anxiety disorder: • Generalized Anxiety Disorder • Panic Disorder • Social Anxiety Disorder • Posttraumatic Stress Disorder • 41% were not receiving treatment • Most common anxiety disorder category?

Kurt Kroenke, MD; Robert L. Spitzer, MD; Janet B.W. Williams, DSW; Patrick O. Monahan, PhD; Bernd Löwe, MD, PhD. Anxiety Disorders in Primary Care: Prevalence, Impairment, Comorbidity, and Detection. Ann Intern Med. 2007;146(5):317-325. Prevalence of Mental Illness in Primary Care

• 7% of all visits to primary care involve a prescription for an antidepressant (254 million prescriptions)

• 62% of all antidepressant prescriptions are written by primary care

http://www.npr.org/sections/health-shots/2011/08/06/138987152/antidepressant-use-climbs-as-primary-care-doctors-do-the-prescribing https://www.cdc.gov/nchs/images/databriefs/51-100/db76_fig5.png Impact of Mental Illness

• Unipolar depression is the third most important cause of disease burden worldwide: • First place in middle- and high-income countries • Eighth place in low-income countries • Anxiety disorder: • Estimated annual cost (in the 1990s): • $42.3 billion (primarily non-psychiatric medical treatment costs)

https://www.cdc.gov/mentalhealth/basics/burden.htm Impact of Mental Illness

• Bipolar disorder: • Inpatient hospitalisation rate: 39.1% compared to 4.5% for all other people with behavioral health care diagnoses • Schizophrenia: • Estimated cost of $6.85 billion (lost productivity, morbidity and mortality, healthcare and non-healthcare costs) • Dementia: • Estimated cost of $236 billion (nursing home, caregiver, hospitalisation, lost productivity)

https://www.cdc.gov/mentalhealth/basics/burden.htm http://www.alz.org/facts/overview.asp Impact of Mental Illness

• Suicide: • 10th leading cause of death • Over 44,000 American die by suicide each year • Costs the US $44 billion annually • 58% of simulated patients with Major Depressive Disorder and requesting antidepressant medications were NOT asked about suicide • 45% of people who died from suicide saw their PCP in the month before their death • Only 20% saw a mental health provider

https://afsp.org/about-suicide/suicide-statistics/ Anna K. McDowell, MD; Timothy W. Lineberry, MD; and J. Michael Bostwick, MD. Practical Suicide-Risk Management for the Busy Primary Care Physician. August 2011;86(8):792-800 Feldman, MD et al. Let’s Not Talk About It: Suicide Inquiry in Primary Care. Ann Fam Med September 1, 2007 vol. 5 no. 5 412-418 The Psychiatric Assessment

• Offer open ended questions: • Tell me more… • You mentioned that you get really nervous sometimes, could you describe that to me? • Reflect and empathise: • The voices have been a lot worse since your mother’s death anniversary. It sounds like it has been an awful two weeks for you. • Pay attention to body language – theirs and yours The Psychiatric Assessment

• Be prepared to ask the “difficult questions”: • Have you had thoughts of wanting to kill yourself? • Be aware of commonly occurring, concerning psychiatric symptom clusters: • Depressive episode • Mania • Generalized Anxiety Disorder • PTSD • Psychotic episode • Cognitive impairment • Never forget influences of substances and general medical conditions Overlapping, Commonly Occurring Symptoms

• Irritability • Depressive episode • Anxiety • Mania • “Hearing voices” • Generalized Anxiety Disorder • “Racing thoughts” • PTSD • Difficulty sleeping • Psychotic episode • Suicidality • Cognitive impairment

The Mental Status Exam

• Appearance • Thought process • Behaviour/Attitude • Thought content (suicidality, • Motor homicidality, delusions) • Speech • Perceptions (hallucinations) • • Mood Judgement and Insight • • Affect Cognition

Hallucination or Delusion

• I need my gun to get rid of the people who’ve moved into our guest bedroom. Nobody gave them permission! • I can hear my neighbours talking about killing me. • I can feel ants biting me • I haven’t been eating because it isn’t safe. I don’t know who, but someone is adding poison to it. • Those aren’t lines on the wallpaper, there’s worms crawling around! Delusions, Hallucinations, and Illusions

• Delusion: Fixed, false belief • Hallucination: Experience of a stimulus in the absence of one

• Illusion: Misinterpretation of a stimulus Homicidality

• Suggested clinical approach: • Planning • Friendly • Access to Means • Frank • Protective factors: • Firm • What most holds you back from • Ask the question: acting on your plan? • When someone feels as upset as you do, they may have thoughts • Past experiences about hurting the person what has upset or hurt them. Have you had • Future expectations such thoughts?

Assessing Client Dangerousness To Self and Others: Stratified Risk Management Approaches;. Greg Merrill, LCSW. September 18, 2013 Psychiatric Assessments Scales What are psychiatric assessment scales? How are assessment tools

A variety of questionnaires, interviews, checklists, useful in psychiatric outcome assessments and other instruments that are practice? available to inform practice, research, and • Useful for monitoring Veterans administration. over time by providing more consistent information compared to clinical interview alone • Administration and payors want standardized assessments to justify the need for services or assess quality of care • Can be used to study Utility of Assessment Tools

• Patient Centered Care • Team-based care: Information can be shared between providers for increased collaboration • Population-Based Care • Track changes over time, based on region and other demographics; helpful for research efforts • Measurement-Based Treatment to Target • Track treatment goals and outcomes, as specific to individual Veterans • Evidence-Based Care • Treatments follow indications based on evidence Screening and Assessment Tools as

ü Screening for conditions üMaking a diagnosis ü Measuring severity ü Tracking change in symptoms ü General functioning üStandardized tracking Depressive Disorders

• Patient Health Questionnaire (PHQ2 or PHQ9) • Beck Depression Inventory (BDI-II) • Geriatric Depression Scale (GDS) • Hamilton Rating Scale for Depression (HAM-D) Patient Health Questionnaire (PHQ) 2 or 9 Item Depression Screener • PHQ2 • Ultra-brief; assessment for depressed mood and a loss of interest in pleasure or in routine activities is the focus • Positive response to either question indicates further testing is required • Good diagnostic sensitivity but poor specificity • First two questions from PHQ9 • PHQ9 • Both sensitive and specific for diagnoses • Commonly used in primary care settings

Beck Depression Inventory-II (BDI-II)

• Focus on the behavioral and cognitive dimensions of depression • Used to measure intervention outcomes in clinical trials for depression • Can be used as a screen for major depression • Self report

Geriatric Depression Scale (GDS)

• Description • Increases accuracy of detecting depressive symptoms in older adults; is a self-report questionnaire; recommend the 15 question version (GDS-s); staff or self administered • Administration Time • ~ 2 minutes • Materials Needed • Test, and pen/pencil • Scoring • Most studies using validity testing use a cut-off score of 5 or 6 as suggestive of an active depressive process Anxiety

• Beck Anxiety Inventory (BAI) • Clinical Administered PTSD scale • Hamilton Anxiety Rating Scale (HAM-A) • Panic Disorder Severity Scale • Yale-Brown Obsessive-Compulsive scale Beck Anxiety Inventory (BAI)

• 21-question multiple-choice self report inventory that is used for measuring the severity of anxiety • Cognitive and Somatic subdomains • May not differentiate anxiety from depression Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) • The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 has a variety of purposes, including: • Screening individuals for PTSD • Monitoring symptom change during and after treatment • The gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS-5). • When necessary, the PCL-5 can be scored to provide a provisional PTSD diagnosis.

http://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp Substance Use Disorder Scales

• CAGE

• AUDIT-C

• AUDIT CAGE

1. Cut down • score of 1 = more follow up 2. Annoyed • score of 2 = suggests alcohol 3. Guilt problem 4. Eye opener

Although a good screening for alcohol use disorder, doesn't identify early problematic drinking AUDIT-C

• Scored on a scale of 0-12 (scores of 0 reflect no alcohol use)

• A score of 4 or more is considered positive in men 3 in women

• The higher the AUDIT-C score, the more likely it is that the patient's drinking is affecting a Veteran’s health and safety

http://www.integration.samhsa.gov/images/res/tool_auditc.pdf http://www.alcohol.org.nz/sites/default/files/documents/AUDIT-C%20tool.pdf The Alcohol Use Disorders Identification Test (AUDIT)

• Developed by World Health Organization in ‘82 as screening tool to identify at risk drinkers • Used to detect alcohol problems experienced within the last year, primarily identifying preliminary signs of mild dependence and/or hazardous drinking. • Has been shown to be applicable across ethnic and gender groups • Contains 10 multiple choice questions on quantity and frequency of alcohol consumption, drinking behavior and alcohol related problems or reactions • A score of more than 8 indicates a problem with alcohol Assessment Tools for Cognitive Disorders

• Cognition: • Mini Mental State Exam (MMSE) • Montreal Cognitive Assessment (MoCA) • Mini-Cog • Saint Louis University Mental Status Exam (SLUMS) • Confusion Assessment Method (CAM; delirium) • Functional Status: • Functional Assessment Staging (FAST; Activities of Daily Living) • Lawton Instrumental Activities of Daily Living Brief Cognitive Tools: Montreal Cognitive Assessment (MoCA) • Neurocognitive Domains Tested • Orientation, memory, attention, executive function, language, and perceptual-motor function • Administration Time • ~ 10 minutes • Materials Needed • Printed test, administration instructions, timer, and pen • Scoring • Highest score is 30; cut-off score indicating impairment is 26; sensitive to mild cognitive impairment. • Multiple versions/languages available Brief Cognitive Tools: Mini-Cog • Neurocognitive Domains Tested • Memory, executive function, and perceptual-motor function • Two items only: • Three-item recall and pre-drawn clock—drawing test. • Administration Time • ~ 3 minutes • Relatively uninfluenced by level of education or language variations • Materials Needed • Paper and pen/pencil • Scoring • Scored as either “positive” or ”negative” screen for dementia The Lawton Instrumental Activities of Daily Living Scale (IADL)

• Most useful for identifying how a person is • Eight domains: functioning at the present time and for identifying improvement or deterioration • Ability to use telephone over time • Shopping • Food preparation • Score ranges from 0 (low function, • Housekeeping dependent) to 8 (high function, independent). • Laundry • Mode of transportation • Responsibility for own medications • Ability to handle finances Functional Assessment Staging

Functional scale designed to evaluate moderate-severe stages of dementia when the MMSE/MoCA no longer can reflect changes in a meaningful clinical way

• Stage 1: No difficulties, objectively • Stage 4: Mild dementia or subjectively • Stage 5: Moderate dementia • Stage 2: Very mild memory loss • Stage 6: Severe dementia • Stage 3: Early dementia • Stage 7: Further progression of severe dementia

http://geriatrics.uthscsa.edu/tools/FAST.pdf