MENTAL HEALTH IN THE COMMUNITY: A PERSPECTIVE ON THE SELF-ASSESSMENT MODULE (SAM)

Educational Objectives

The goal of this program is to improve the diagnosis and management of mental health disorders. After hearing and assimilating this program, the clinician will be better able to:

1. Use screening tests and obtain an adequate history to diagnose specific mental health disorders.

2. Distinguish acute stress reactions from chronic anxiety disorders, based on history.

3. Recommend pharmacotherapy and cognitive behavioral therapy in the management of anxiety disorders, major depressive disorders, and other mental health disorders.

4. Recognize the risk factors for depression in pregnancy.

5. Assess the risks for suicide, especially in older adults.

Summary

Generalized anxiety disorder (GAD): most common of 5 standard anxiety disorders defined in Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition); other anxiety disorders are panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), and agoraphobia; disorders often mixed (eg, patient with GAD may have panic attacks), and overlaps seen in treatment and management; short screening tests include GAD 7-item scale; screen for depression (coexists in many patients); some treatments of anxiety and depression overlap or similar; patients with GAD often self-medicate with alcohol or other drugs (elicited by history); questions can distinguish acute stress reactions from chronic anxiety disorders; acute stress reactions last <1 mo and often triggered by events (eg, motor vehicle accident); less severe adjustment or stress reactions may mimic major anxiety disorders; persistence of stress reaction may develop into PTSD; treatment — cognitive-behavioral therapy (CBT); long-term therapy with selective serotonin reuptake inhibitors (SSRIs) or combination of antidepressants beneficial; short-term benzodiazepine therapy beneficial in controlling symptoms and reasonable in early stages of treatment for patient extremely distressed by symptoms; nonpharmacologic treatment (eg, yoga) may help

Panic disorder: panic attacks may occur in all anxiety disorders; to make diagnosis, must exclude substance abuse, comorbid medical (eg, thyroid disease) or psychiatric condition (eg, bipolar disorder in manic phase), and other anxiety disorders; often present to emergency department (ED) with chest pain and physiologic symptoms (eg, sweating, palpitations); difficult to rule out in older patient due to risk for cardiac disease; treatment — combination therapy, as with GAD; pharmacotherapy and CBT beneficial; early pharmacotherapy advantageous

Posttraumatic stress disorder: multiple triggers (eg, motor vehicle accident, death in family); symptoms must be present for significant period to make diagnosis; often unrecognized in primary care; SSRIs not highly effective; combination therapy often used; prognosis not as good as in other anxiety disorders; more difficult to treat compared to other disorders; treatment — combination of pharmacotherapy and psychotherapy (usually CBT); some efficacy seen with eye movement therapy

Obsessive-compulsive disorder: more responsive to therapy; variety of SSRIs used; clomipramine (Anafranil) often combined with other medications and CBT; outcomes better with combination therapy (pharmacotherapy and psychotherapy); better prognosis

Major Depressive Disorders (MDDs)

Screening and epidemiology: United States Preventive Services Task Force — recommends screening for adults and adolescents if treatment available; screening not recommended for ages 7 to 11 yr (not validated); questionnaires — short ones as effective as long ones for screening and mostly used in primary care; include Center for Epidemiologic Studies Depression Scale, Edinburgh Postnatal Depression Scale, Beck Depression Inventory, and Zung Self-Rating Depression Scale; some available in Spanish; older adults — geriatric depression and pseudodementia sometimes used interchangeably; older patients with depression may present with dementia-like symptoms (eg, forgetfulness, carelessness about daily habits, inattentiveness); patient with depression but not demented tends to magnify loss; patient developing dementia attempts to cover up symptoms or problems; depressed patients have higher risk of developing dementia; depression common after myocardial infarction and other chronic diseases; risk factors — past depression; pregnancy; recent traumatic events; not caused by use of β-blockers

Treatment: antidepressants — more effective than placebo in treating MDD, but not in minor episodes of depression; beneficial in ≈50% of patients; for minor episodes of depression, should not overvalue medications (CBT or supportive psychotherapy beneficial); no single antidepressant more effective than another, including tricyclic antidepressants; long-term response rates with older antidepressants (eg, nortriptyline, amitriptyline) about same as with newer SSRIs (better tolerated); explain to patients that some time required to see effects of medication; augmenting medications (for, eg, sleep, anxiety) early in course of treatment beneficial; CBT — effective, but has slower response; better than medications for preventing relapse (occurs in >50% of patients with major depressive episode); combination therapy best; duration — continue medications for ≥6 mo if patient compliant and tolerates medications; consider lifelong therapy if patient has >2 relapses and therapy effective; serotonin syndrome possible if SSRI discontinued, and more likely to occur if SSRI given for >3 mo and in higher doses; more on CBT — family physicians with special training can effectively use CBT, but referral generally recommended; CBT shorter in duration and has faster response than other more traditional types of psychotherapy; other therapies — augmentation therapy when initial treatment unable to result in full response includes increasing dose, switching medications, and adding atypical antipsychotics; music therapy and exercise not proven effective for MDD; if no response to treatment seen, consider wrong diagnosis; bipolar disorder — often misdiagnosed as major depression; poor response to typical antidepressants; substance abuse may trigger changes often misinterpreted as depression

Depression in pregnancy: risk factors include maternal anxiety, unintended pregnancy, domestic violence, and Medicaid population; careful assessment needed before starting medication; avoid unnecessary medication; risk for occurrence greater than risk from medication; avoid paroxetine; risks low with sertraline (Zoloft) and fluoxetine (eg, Prozac, Rapiflux, Sarafem); risk for relapse higher if medications stopped in pregnancy; risks similar for postpartum depression

Seasonal affective disorder: occurs primarily in women during winter months in northern latitudes; patients may also have bipolar disorder; has common genetic connection with attention-deficit/hyperactivity disorder; light therapy effective; responds to standard treatments for depression; therapy can precipitate mania

Bipolar disorder: peak age of onset in late teens for both sexes; two-thirds of patients have multiple episodes of major depression or some variable form of mania; bipolar I disorder characterized by manic episodes, while highs and lows occur in bipolar II disorder; delay in diagnosis often due to initial depression; 40% to 50% of patients have problems with substance abuse; treatment — mood stabilizing drug (eg, lithium, valproic acid) first; atypical antipsychotics beneficial but not all approved by Food and Drug Administration as treatment for bipolar disorder; augmentation required in some patients for episodes of depression or anxiety; psychotherapy not highly effective but often included in treatment plan

Suicide risks: 50% of older adults who successfully commit suicide have seen physician within past month; heavy alcohol intake and previous suicide attempts key risk factors; some truth to old belief that women attempt suicide more with less success, while men more successful in suicide attempts, especially in younger age groups; should not be afraid to ask patient directly whether contemplating suicide (does not increase risk); contracts with patients to avoid attempting suicide found not beneficial

Alcoholism

Diagnosis: CAGE (have you ever felt you needed to cut down on drinking? have people annoyed you by criticizing your drinking? have you ever felt guilty about drinking? have you ever felt you needed a drink first thing in the morning [eye-opener] to steady your nerves or get rid of a hangover?) questionnaire may not be best tool for screening; single-question screening gaining popularity; ask how often individual has had 5 drinks/day in last 3 mo or how many times in last 6 mo individual has had 5 drinks/day (4 drinks/day for women; 5 drinks/day for men); positive answer to either question indicates positive screen; be aware of physiologic clues (eg, poor control of blood pressure, low platelet count, macrocytosis); alcoholism accompanies other mental health disorders (eg, bipolar disorder, personality disorder)

Treatment: Clinical Institute Withdrawal Assessment used to monitor amount of benzodiazepines given during detoxification; use lorazepam rather than long-acting agents in patients with liver disease who undergo detoxification in hospital; naltrexone and acamprosate (Campral) — fairly effective and improve recovery in patients who have undergone short course of detoxification; nausea side effect of naltrexone; diarrhea side effect of acamprosate; proven to prevent relapse; course of treatment ≈12 wk after detoxification; Alcoholics Anonymous — still mainstay of treatment; indicated for long-term management of alcoholism and combined substance abuse

Other Disorders

Attention-deficit/hyperactivity disorder: screening not recommended at this time; presence of symptoms at school and at home needed for diagnosis; period of watchful waiting with diagnosis acceptable before treatment; avoid pressure from school to medicate; elimination diets for food additives and coloring not beneficial

Autism spectrum disorders: characteristics of autistic child — unusual or no reaction to sensory stimuli; lack of interest in peers; refusal to share; screening tests not highly accurate and do not rule out diagnosis if negative; diagnosis becoming more complicated; average age of diagnosis 4 to 5 yr; early behavioral interventions result in better outcome, depending on severity of condition

Eating disorders: bulimia nervosa — lifetime incidence in women 1.5%; many patients have other mental health diagnoses; more serious disorder with worse prognosis than anorexia nervosa (responds better to treatment); screening for eating disorder best done at school level for younger patients; treatment — difficult; SSRIs and CBT used

Insomnia: chronic insomnia defined as lasting >1 mo; many cases of acute insomnia triggered by medical conditions; learn sleep hygiene recommendations; be aware of short- and long-term risks of sleep medications; little evidence that diphenhydramine (eg, Benadryl, Genahist, Hydramine) beneficial; advise patients to take sleep medication in short-term bursts to avoid daytime somnolence and amnesia

Personality disorders: complex diagnostics, with different types often overlapping; borderline personality disorder — most common diagnosis; characterized by affective instability (mood swings), disturbed relationships, dependency, and self-injury; some benefits seen with medications and psychotherapy, but treatment difficult; relationships of patients with their physicians and others often become difficult

Drug Abuse

Opiate abuse in chronic nonterminal pain: clues in history include frequent mood swings, heavy cigarette smoking, and history of legal problems; ask patients directly about use and misuse; screening tests available; urine drug testing of questionable value; most standard routine initial drug screens problematic and often unable to detect oxycodone and methadone (able to detect heroin, methamphetamine, and marijuana); often necessary to order specific tests for specific drugs; switching and varying opiates not proven to avoid misuse; prescription opiates more commonly abused than heroin

Treatment for opiate abuse: methadone and buprenorphine treatment programs — methadone treatment programs beneficial but availability problematic; buprenorphine treatment programs can improve outcomes if run properly by physicians with special training and certification; not contraindicated in pregnant women; CBT beneficial

Illicit drug abuse in young people: in adolescents, marijuana use still more common than prescription drug misuse (second most common); prescription drug abuse — exceeds abuse of heroin, cocaine, and methamphetamine (“speed”) in adolescents; prescription drugs often obtained from other individuals; accounts for more ED visits than illegal drugs

Models of treatment: family physicians have primary role in collaborating and integrating with others to provide treatment for mental health disorders; clinical assessment and use of valid screening tools recommended; documentation of baseline symptom severity and monitoring patients after starting treatment; use of nurses and other health professionals for outreach to patients; use of other mental health professionals when needed

Readings

Bulloch A et al: Alcohol consumption and major depression in the general population: the critical importance of dependence. Depress Anxiety, 2012 Dec;29(12):1058-64; Bunevicius A et al: Screening for anxiety disorders in patients with coronary artery disease. Health Qual Life Outcomes, 2013 Mar 11;11:37; Calleo JS et al: Treating late-life generalized anxiety disorder in primary care: an effectiveness pilot study. J Nerv Ment Dis, 2013 May;201(5):414-20; Chaudron LH: Complex challenges in treating depression during pregnancy. Am J Psychiatry, 2013 Jan 1;170(1):12-20; Grigoriadis S et al: Achieving the balance: treating depressed pregnant women with antidepressants. J Clin Psychiatry, 2013 Apr;74(4):375-6; Harries C: The real cost of eating disorders. Community Pract, 2012 Oct;85(10):14-6; Lagerberg TV et al: Treatment delay and excessive substance use in bipolar disorder. J Nerv Ment Dis, 2010 Sep;198(9):628-33; Lord S, Marsch L: Emerging trends and innovations in the identification and management of drug use among adolescents and young adults. Adolesc Med State Art Rev, 2011 Dec;22(3):649-69, xiv; Reeves GM et al: Improvement in depression scores after 1 hour of light therapy treatment in patients with seasonal affective disorder. J Nerv Ment Dis, 2012 Jan;200(1):51-5; Rice JB et al: A model to identify patients at risk for prescription opioid abuse, dependence, and misuse. Pain Med, 2012 Sep;13(9):1162-73; Van Ameringen M et al: Panic attacks in generalized anxiety disorder. J Nerv Ment Dis, 2013 Jan;201(1):52-5; White C, Byrt R: Understanding and caring for people with personality disorders. Ment Health Today, 2013 Jan-Feb:23-7.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Bonanno and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Bonanno was recorded at the 39th Annual Maurice Goldenhar Family Medicine Update, held March 20-22, 2013, in Stony Brook, NY, and sponsored by the Department of Family Medicine, State University of New York School of Medicine at Stony Brook. For information on upcoming CME activities by this sponsor, please visit http://medicine.stonybrookmedicine.edu/cme/courses. The Audio-Digest Foundation thanks Dr. Bonanno and the State University of New York School of Medicine at Stony Brook for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

FP613401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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