An Overview of Psychiatric Disorders Commonly Seen in Primary
Care
Bambi A. Carkey DNP,PMHNP-BC,NPPClinical Assistant ProfessorSUNY
Upstate Medical UniversityCollege of NursingAn Overview of
Psychiatric Disorders Commonly Seen in Primary Care Depressive
DisordersAccording to the World Health Organization Major
Depression ranks among the most burdensome diseases in the
world.The lifetime prevalence of Major Depression in the U.S. is
reported to be between 16 % and 20%.Approximately 5% -10% of
primary care patients meet DSM-IV criteria for Major Depression and
3%-5% for Dysthymia.The prevalence of Major Depression is estimated
at 10%-20% in patients with medical illness, eg. heart disease and
diabetes.Depressive DisordersMajor Depression is a relapsing,
remitting illness.Following a first episode, the risk of recurrence
over a two year period is about 40%.After a second episode, the
risk of recurrence within five years is 75%.Between 10% and 30% of
patients treated for Major Depression will have an incomplete
recovery, with persistent symptoms or dysthymia.Initial
EvaluationPatients who present with depressive symptoms should be
evaluated by history, physical and labs ( CBC,CMP, thyroid studies,
and vitamin D level) to rule out secondary medical causes , such as
Thyroid Disease, Substance Abuse or Vitamin D
Insuffiency.Distinguish Unipolar vs. Bipolar Depression screen for
mood instability, agitation, episodic sleep dysregulation, periodic
impulsivity, and irritability. Initial Evaluation: R/O Bipolar
DODistractibilityIndiscretion or IrritabilityGrandiosityFlight of
IdeasActivity increaseSleep deficit ( decreased feeling of need for
sleep)Talkativeness (rapid, pressured speech) Initial Evaluation:
MDDSleep disorder (either increased or decreased, but most commonly
trouble staying asleepInterest deficit (anhedonia)Guilt (feelings
of worthlessness, hopelessness)Energy deficit
(anergia)Concentration deficitAppetite disorder (either increased
or decreased)Psychomotor retardation or agitationSuicidality
Initial EvaluationPotential for violence: historySuicidal
ideation: history of prior attempts, family history, recent
exposure, intent, plan, lethality, access to means, psychotic
symptoms (command hallucinations or severe anxiety), alcohol or
substance abuse Homicidal ideation notification Screening History
!!!Beck Depression InventoryHamilton Depression ScreenPatient
Health Questionnaire (PHQ-9)Mood Disorder Questionnaire
Referral: to ED or Out- Pt. Psyche Eval.Patients with severe
depression, evidenced by: suicidal ideation, in whom out patient
safety cannot be assuredPatients with significant weight loss, or
psychomotor retardation/agitationIntent to harm self or
othersDepressed patients who present with psychotic features eg.
delusions and/or hallucinationsDepressed patients with co-morbid
substance abuseInitial TreatmentAntidepressants : SSRIs (gold
standard), SNRIsAdjunctive Agents : Abilify, Cytomel,
StimulantsPsychotherapy : Cognitive Behavioral Therapy (CBT),
Generalized Anxiety DisordersLifetime prevalence of Generalized
Anxiety Disorder (GAD) in the U.S. is estimated at 5.1% - 11.9% GAD
is one of the most common disorders in primary care
settingsApproximately twice as common in women, and the most common
anxiety d/o among the elder populationHigh incidence of
co-morbidity social phobia, specific phobia, panic disorderGAD may
also be associated with substance abuse, post- traumatic stress
disorder (PTSD) and obsessive compulsive disorder (OCD) Generalized
Anxiety DisorderGAD is common among patients with medically
unexplained chronic painPatients with GAD and co-morbid MDD tend to
have a more severe and prolonged course of illnessGAD is considered
to be a chronic illness with fluctuations in symptoms over
timePatients with GAD can have a significant degree of functional
impairment Initial EvaluationHistory & physical exam when
indicatedSubstance abuse issuesMedical historyFamily historySocial
history including hx of trauma, stressful lifestyle
Initial Evaluation: GADMuscle tensionFatigueConcentration
difficultyRestlessness or feeling of impending
doomIrritabilitySleep disturbance specifically trouble getting to
sleepWorry, worry, worry!!!ScreeningBeck Anxiety InventoryThe
Hospital Anxiety and Depression Scale (HADS)Generalized Anxiety
Disorder seven-item scale (GAD-7)Penn State Worry Questionnaire
Initial TreatmentAnxiolytics Benzodiazepines ( effective, potential
for dependence, long term use may cause cognitive
deficitAntidepressants SSRIsCognitive Behavioral
TherapyEvidence-Based PracticeCo - MorbidityHigh degree of Patients
have a co-morbid Substance Abuse Disor5derSubstance Abuse
DisorderOften masked under the guise of anxiety and/or
depressionCharacterized by denial and minimizationLook at Family
HistoryInitial EvaluationHistoryLabs : BAC, UTOX, CBC, CMPCAGE
questionnaire - 4 questions, 2 or more positive answers indicate a
high probability of alcohol dependenceSummaryHistoryMental Status
exam / Physical ExamLab StudiesReferral
TreatmentQuestions???ReferencesBaldwin, D. (2013, March 28).
Generalized anxietydisorder: Epidemiology, pathogenesis, clinical
manifestations, course,assessment, and diagnosis. Retrieved from
UpToDate:
http://www.uptodate.com.libproxy2.upstate.edu/contents/generalize...Carlat,
D. J. (2005). The Psychiatric Interview. Philadelphia: Lippincott
Williams & Wilkins.Katon, W. &. (2013, March 21). Initial
Treatment of Depression in Adults. Retrieved from UpToDate:
www.uptodate.com.libproxy2.upstate.edu/contents/initial-trea...
