Clinical topic: Depression/ADHD and other psychiatric dx in primary care

JustPlainBill

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So, after coming out of Urgent Care and stepping back into the world of Primary Care, I'm seeing a lot of psychiatric conditions (depression/ADHD mainly) that are requiring polypharmacy to control. The practice is using a lot of computer based screening/assessment tools which help sorts through some of the chaos ---

Here's the question -- does anyone have a good, practical resource for an FP who's just starting to manage this type of complaint -- I learned to be comfortable with Celexa in residency but it's not the be all/end all and I learn by reading --- and most of the ADHD went to peds and/or psych so I have no experience with it.
 

Doctor4Life1769

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For depression, I provide mind/body related handouts, exercise, and consider referral to psychology. If patient does not want referral, I see how they do with the handouts and exercise for a week or two, and then start low dose SSRI like celexa. If they seem more fatigued, then I consider fluoxetine as it is more stimulating. Otherwise if they are anxious in general, then paroxetine is a good one to consider. If they have pain related sequelae then I'll look into an SNRI. If they have issues with sleep and appetite, then mirtazepine is the medication I'd give.

If pregnant or breast feeding, sertraline is a good one to give. I know some will also look into escitalopram/citalopram.

As you know, most of these meds take 4 weeks or so for effect. Counsel on side effects, etc. Uptitrate accordingly.

ADHD - for pediatric population, look into the NICHQ Vanderbilt Scale. Give to the parent and have them give the school part to the teacher and have both parents and teacher fill out. Talk to the patient, figure out secondary cause (vision issues, hearing issues, learning disability) and consider next steps accordingly. Before starting a stimulant like ritalin get a family hx of cardiac issues, EKG and then start low dose ritalin or consider one of the non-stimulant based meds that are out there. CBT is first step, then add on medication.

For adults - get a detailed personal inventory, look at home/school/work performance, have family or significant other contribute if possible. Attain health history, social history, learning/vision/hearing issues, for teens also consider exploring secondary gain via academic performance. Meds seem more efficacious than CBT but combo is good.

Hopefully this helps. I wasn't clear on what exactly you wanted information on.
 
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JustPlainBill

JustPlainBill

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For depression, I provide mind/body related handouts, exercise, and consider referral to psychology. If patient does not want referral, I see how they do with the handouts and exercise for a week or two, and then start low dose SSRI like celexa. If they seem more fatigued, then I consider fluoxetine as it is more stimulating. Otherwise if they are anxious in general, then paroxetine is a good one to consider. If they have pain related sequelae then I'll look into an SNRI. If they have issues with sleep and appetite, then mirtazepine is the medication I'd give.

If pregnant or breast feeding, sertraline is a good one to give. I know some will also look into escitalopram/citalopram.

As you know, most of these meds take 4 weeks or so for effect. Counsel on side effects, etc. Uptitrate accordingly.

ADHD - for pediatric population, look into the NICHQ Vanderbilt Scale. Give to the parent and have them give the school part to the teacher and have both parents and teacher fill out. Talk to the patient, figure out secondary cause (vision issues, hearing issues, learning disability) and consider next steps accordingly. Before starting a stimulant like ritalin get a family hx of cardiac issues, EKG and then start low dose ritalin or consider one of the non-stimulant based meds that are out there. CBT is first step, then add on medication.

For adults - get a detailed personal inventory, look at home/school/work performance, have family or significant other contribute if possible. Attain health history, social history, learning/vision/hearing issues, for teens also consider exploring secondary gain via academic performance. Meds seem more efficacious than CBT but combo is good.

Hopefully this helps. I wasn't clear on what exactly you wanted information on.
Appreciate it -- I was actually looking for a decent text/clinical reference slanted toward FM ---
 

Crayola227

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Maybe AAFP articles?

Ditto what @Doctor4Life1769 said, but as he mentioned "activating" medications, one of the biggest mistakes I see in psych med Rx'ing is not doing a very pointed and thorough screen for bipolar tendencies. Family history for psych really counts for something, so I wouldn't skim over that part of history like I might for other complaints. Up to 1-3/10 patients presenting to primary care clinic for depression have bipolar disorder depending what study you read. Remember only 1 lifetime episode of hypomania/mania can garner the diagnosis of BPD 1 or 2 (or at least should make you wary), and even if episode is 2/2 medication in a patient, I would be very cautious and go low and slow w/ close follow up in those patients. Hypomania can also resemble ADHD and anxiety. Mixed episode, dyphoric mania or dysphoric hypomania, could all present looking like depression/anxiety/ADHD in whatever permutation you like. Please take the time to really consider BPD.

If suspicion is strong for BPD, I personally would not start those patients on any SSRI/SNRIs or other uppers. Some FPs will start mood stabilizing anticonvulsants (and not show enough respect to lamotrigine and SJS) or start antipsychotics themselves (check Qtc first for certain ones, others don't need it actually) and I don't know what to say about that, but *I* wouldn't ever start an SSRI/SNRI alone in a patient I thought might have BPD. Anything but mood stabilizers in BPD, certainly unopposed other classes of med, should go to psych if you ask me. You can justify starting some treatment of BPD while waiting to get in to psych probably, but sending home a BPD 1 OR 2 patient home with the other stuff is asking for trouble. Contrary to some beliefs I've heard, Celexa or Lexapro alone in BPD can also be a disaster.

It's also relevant for your "ADHD" cases to do a thorough BPD screen before handing out any "uppers".

Bipolar is just not something you want to miss when you Rx psych drugs, you can really **** some people up.

If you ever dabble in antipsychotic rx'ing, definitely be aware of not only s/s of TD but Parkinsonian sx, extrapyramidal sx. It's embarassing when people don't recognize difficulty swallowing, muscle spasm/stiffness/twitching (dystonia), "restless legs" or psychomotor agitation (akithisia), fatigue (bradykinesia) or constipation as medication SE. EPS sx predict a higher risk of TD while we're at it. Antipsychotics also mask TD sx, so more reason to beware EPS sx.

I don't know about varencicline but know that buproprion lowers the seizure threshold, and contraindicated in anorexic/bulimic/eating disorder not only for that reason but also suppresses appetite, so those folks often try to angle for that med, and also some of your ADHD meds too for weight loss.

A lot of patients don't know they need to knock off the weed for their depression/fatigue. Also consider hx of family psychotic illness and risk in pot-smokers or med MJ prescribing.

Patients don't often report hearing voices unless asked, that can be a sign of psychotic depression OR BPD, or even just run of the mill alcoholism. Isolated auditory hallucinations years after recovery from heavy alcoholism is possible.

So-called "rebound" anxiety in ex-heavy drinkers up to years after quitting is possible too.

As far as ADHD/depression, screen for sleep apnea or other sleep disorders too. Too many people forget about sleep hygeine, melatonin as options. Part of sleep hygeine can include sunrise simulators.

Blue light therapy not only for SAD but can also work for depression in general. Still use with care in those you might suspect bipolar but less likely to induce severe mania with light than meds, so it's a safer way to approach initial treatment of mild depression IMHO.

Another lifestyle issue is caffeine w/in 8 hrs of bedtime (has long half life). I know people that guzzle a whole pot before bed w/ no problems, and "ADHD" or "depression" I've cured just by having folks cut back on caffeine, or stop drinking it after 2-4 pm. People forget about soda in that equation too.

The latest psych research I read, and I think I saw an AAFP article on anxiety, supported that benzos are still first line and more effective for GAD than any of the other SSRIs in adults. Granted, I think most providers shy away from benzos and reach for SSRIs for anxiety for other reasons, and leave benzos for last or to the psychs, and I get it, I do. Just throwing the info out there.

Also, that social anxiety can be mistaken for GAD and vice versa, phobias and OCD, and while GAD and OCD can respond well to meds, they are less useful in social anxiety/phobias where therapy has the advantage over meds. For OCD/GAD med and therapy together are more effective than either alone, as with major depression.

Just my 2 cents on psych stuff I see missed/may be relevant to primary care considerations.

As far as resources, I know there's online stuff that makes picking out a starting meds for major depression, GAD, mild OCD, ADHD, taking into account SE effect profiles for the individual patient and age, fairly easy, but the key is proper diagnosis to begin with and appropriate lifestyle modifications (eg fatigue from caffeine and sleep apnea leading to depression is not likely to benefit much from SSRI)

I'd have to google to find these guides, but I hope this helps somewhat.
 
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Doctor4Life1769

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Appreciate it -- I was actually looking for a decent text/clinical reference slanted toward FM ---
Check out the AFP articles. They're solid.
 
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styphon

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For depression, I provide mind/body related handouts, exercise, and consider referral to psychology. If patient does not want referral, I see how they do with the handouts and exercise for a week or two, and then start low dose SSRI like celexa. If they seem more fatigued, then I consider fluoxetine as it is more stimulating. Otherwise if they are anxious in general, then paroxetine is a good one to consider. If they have pain related sequelae then I'll look into an SNRI. If they have issues with sleep and appetite, then mirtazepine is the medication I'd give.

If pregnant or breast feeding, sertraline is a good one to give. I know some will also look into escitalopram/citalopram.
Other sources to consider: Uptodate has great articles, as does the Family Medicine Audio Digest.

I start with an SNRI, like effexor (as there is a comparison study weight cost/efficacy/and side effect profile and effexor came out top), and see them in 2-4 weeks to see if there is any response, if not I will titrate up. I may do a second titration at 6-8 weeks if no or little response. After 2 months with no response, I will go to another SNRI/SSRI. If people have trouble with sleep in addition to depression, I will add trazodone or melatonin. If someone has fatigue/"atypical" depression instead of prozac as above, I will give welbutrin - the most stimulating of all the antidepressants (avoid in patients with seizures or heavy drinkers or someone you think is bipolar). Prozac is great for someone who often forgets doses as it has a longer half life. There is even a "weekly" prozac.

I would be very hesitant to use an antidepressant outside of Zoloft in pregnancy, as it is the most studied.
 
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Ericslv

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Don't forget other factors that can cause depression. thyroid, hormone levels, anemia and even autoimmune disorders due to the fatigue and difficulty with sleep. Sleep disorders come to mind as well.
 
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Crayola227

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And I wish people remembered how nasty the Paxil w/d can be, no joke. That and with the SNRIs. Wellbutrin, Celexa, Effexor, can all leave you feeling really nasty if you're even hours late on dosing, or miss a dose.

Just good to keep in mind to let patients know some of those drugs they need to keep on top of or yuck.

And it was news to me recently that Paxil has risk of upper GI bleed and contraindicated if using ASA for cardioprotection.

All reasons I guess it seems to be falling out of favor.

Bonus points for using melatonin and trazodone with those more activating meds! You want your depressed patients more awake during the day but still getting sleep at night.
 
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Doctor4Life1769

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Number of my patients tell me melatonin was ineffective and led to "weird" side effects
 

Doctor4Life1769

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I actually have began using this website since a lot of my pts would prefer not to be on anti-depressants

http://www.fammed.wisc.edu/integrative/modules

Check it out, it's only further enhanced my DPR since it appears the trend (at least in my patient population - and it's a residency clinic, perhaps it's just my patients?) may be away from pharma meds and more towards a holistic approach involving root cause analysis and behavioral/diet/lifestyle modifications.
 
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Crayola227

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Number of my patients tell me melatonin was ineffective and led to "weird" side effects
I get that from them too sometimes.

A psych schooled me and I school patients on the fact that it can work paradoxically, more is not better, especially past 3 mg. At that point you're usually better off with something else.

And for some patients, especially depressed patients, it can make depression worse although that's not common.

Thanks for the website.

Young patients can use benadryl for sleep, personally, I find it ruins my sleep and I'd rather be up all night than use Benadryl for misery sleep. I have mixed feelings on having patients use it, because they either get accustomed to it, start OD'ing on it at home, or obviously they get to an age where you wish someone had never got them on it, but that's true of a lot of meds your 80 year olds are taking, I'm not saying that's what one in focused on in someone young but it crosses my mind whenever I'm getting someone accustomed to a pill for a basic body function like sleep.

Even my patients addicted to OD'ing on benadryl for sleep seem better off than the folks trying to get off Ambien.

Most psychs I know will use benzos over Ambien for sleep, and while I hate using benzos for anxiety (aside from what I posted above, obviously my feelings on practice can run counter to EBM) if it's just for sleep I gotta say I'm more supportive of low dose benzo for sleep over Ambien.

At the end of the day, I find myself trying melatonin as a first line sleep pharm if that's the route I've gotta go.

I'll check out that site tho. I love staying UTD on non-kooky alternatives for mood/sleep.

Latest stuff I saw on fish oil for depression/BPD was not encouraging I'm sad to say.
 

Ericslv

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And I wish people remembered how nasty the Paxil w/d can be, no joke. That and with the SNRIs. Wellbutrin, Celexa, Effexor, can all leave you feeling really nasty if you're even hours late on dosing, or miss a dose.

Just good to keep in mind to let patients know some of those drugs they need to keep on top of or yuck.

And it was news to me recently that Paxil has risk of upper GI bleed and contraindicated if using ASA for cardioprotection.

All reasons I guess it seems to be falling out of favor.

Bonus points for using melatonin and trazodone with those more activating meds! You want your depressed patients more awake during the day but still getting sleep at night.
SSRI's also increase the risk of seizures.
 
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Ericslv

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Number of my patients tell me melatonin was ineffective and led to "weird" side effects

Melatonin in high doses (especially if you start at a high dose) can give patients very vivid dreams and sometimes nightmares at the start. Go low and raise it slow.
 
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Crayola227

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Melatonin in high doses (especially if you start at a high dose) can give patients very vivid dreams and sometimes nightmares at the start. Go low and raise it slow.
Huh, I knew paradoxical action of it, but not the nightmare thing.

Funny, I just started re-taking melatonin myself this week and I noticed nightmares!! I just figured because I was sleeping better/differently that was the case. Almost any med that improves/changes sleep can lead to an emergence of more memorable dreams than before.

But unlike many patients, I'm not immediately looking to ascribe any odd changes or nose itch as a med SE (of course in patients I'm always trying to keep vigilant about known SE that hint at the serious or particularly bothersome).

I felt like melatonin made me more depressed before (but I had insomnia AND sleeping 12 hrs a day from depression, so I suppose it was 50/50 whether the melatonin was going to help or make worse) and further research indicated to me that it could do that, which is why I mentioned that fairly uncommon SE.

In any case, it's good to know about the nightmare thing. I'm noticing that they are getting less nightmare-ish (the first few featured rape and being cannibalized, last night's was a mere kidnapping and I made it back home safe and sound and there were rainbows and sunshine). So like I always tell patients, any med is going to have trade offs (I'm having sleep benefit but having nightmares) and sometimes you have to give a drug time for effects to settle out. I'm hopeful the dream business is going to tame down a bit.

In any case, thanks for the tidbit on melatonin! I love to collect little tidbits on mood/sleep/psych drugs, it makes such a difference to patients subjectively.

I find when I give them advice they can really feel subjectively (like improved sleep) they tend to trust me more about stuff they can't (BP management).

Psych primary care can be so rewarding. Or frustrating. More often rewarding if you can get improvement with the little tweaks.
 

Doctor4Life1769

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Melatonin in high doses (especially if you start at a high dose) can give patients very vivid dreams and sometimes nightmares at the start. Go low and raise it slow.
I always tell them to start at the lowest dose possible.
 
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Crayola227

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Right. I tell them not to go past 3 mg or it might oddly start causing insomnia. Paradoxical effect. If I don't, then I'm not surprised when later they told me it wasn't working, and they "slowly" hit a ceiling dose of 15 mg total, whereupon life got weird and they started doing other stuff.

My favorite was my patient who would drink an entire bottle of Tylenol PM or whatever OTC cold medicine that was lacking tylenol, a couple shots of Jack Daniels in some chamomile tea, up to 15 tablets of OTC Benadryl, in addition to 15 mg of melatonin, all combined. I was able to convince them to cut all that **** out, stop drinking caffeine after 2 pm, cut down to 0 benadryl for a week, and then only use up to 5 mg melatonin going low and slow (big person), and add back only 2 tablets max of the benadryl PRN, and take a 1-2 week holiday from benadryl when that much stopped being effective (they mostly liked drugging themselves to sleep, I had to come up with an "off" button for them in the form of some pharmacology, harm reduction model). I had them use a blue-light decreasing app on their phone and other electronics when the sun went down (there was no way they were giving up right-before-bed texting). I had them get light-blocking curtains for their bedroom too. They still added some booze of course but switched to red wine, and since they were getting more sleep benefit from the other stuff they were relying on/using less alcohol overall.

This was someone without good drug coverage, and even if they had good coverage, their liberal self-prescribing for sleep bordering on OD made me hesistant to give them anything Rx.

I'm proud to say voila - sleep issues cured. I get a lot of success with the above techniques on anyone. It's so easy to reach for a pill (passive therapy), and like anyone, I love passive therapies, but passive can be as passive as light-blocking curtains or drinking non-caffeinated insert-American-deadly-sweet-beverage-of-choice. I certainly don't expect my patients to exercise to help them sleep (puh-leease), but curtains are pretty easy.

While we're talking about lifestyle mod, I had a patient lose 100 lbs just replacing their typical 4 L of regular pepsi a day with diet. Maybe the aspartame or whatever sweetener is going to kill them some other way, but when someone's 300 lbs if that's all they do to lose 100 lb of it I'm not going to complain. I remember they were so inspired by the weight loss, while they didn't give up their beloved pepsi they actually added some salad lettuce to their diet.

I taught one of my IVDU some basic sterile technique and cut down on their abscess number and hospitalizations dramatically. Using bottled water to shoot up over whatever from a tap. Some alcohol wipes, using sterile gauze from Bimart rather than regular cotton balls for filtering. Convinced them to stop licking their needles because the amount of drug lost at the tip from getting the air out wasn't going to make a difference to their high, but was way more likely to get them a nasty abscess. Only reusing their own needles that had been used in this manner if they couldn't get more. They often still can't keep from sharing needles because they often share from the same spoon or they only have one needle between the two of them or don't want to lose the small amount that you lose using two needles not one. People are typically expected to share some product in a drug deal, and unfortunately not everyone keeps their own needle with them.

A little off topic, but yeah I'll take what I can get for improving wellness. Those tiny adjustments in how my patients are killing themselves tends to help mood too. Changing the world one diet pepsi and alcohol wipe and OTC melatonin at a time.

My problem with a lot of the lifestyle mod stuff we give people is it's often not easy enough, or it wants people to give up too many of their pleasurable bad habits.

Any more tips from anyone on ADHD? I can't say I've figured out any good tricks for that one.
 

Ericslv

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Huh, I knew paradoxical action of it, but not the nightmare thing.

Funny, I just started re-taking melatonin myself this week and I noticed nightmares!! I just figured because I was sleeping better/differently that was the case. Almost any med that improves/changes sleep can lead to an emergence of more memorable dreams than before.

But unlike many patients, I'm not immediately looking to ascribe any odd changes or nose itch as a med SE (of course in patients I'm always trying to keep vigilant about known SE that hint at the serious or particularly bothersome).

I felt like melatonin made me more depressed before (but I had insomnia AND sleeping 12 hrs a day from depression, so I suppose it was 50/50 whether the melatonin was going to help or make worse) and further research indicated to me that it could do that, which is why I mentioned that fairly uncommon SE.

In any case, it's good to know about the nightmare thing. I'm noticing that they are getting less nightmare-ish (the first few featured rape and being cannibalized, last night's was a mere kidnapping and I made it back home safe and sound and there were rainbows and sunshine). So like I always tell patients, any med is going to have trade offs (I'm having sleep benefit but having nightmares) and sometimes you have to give a drug time for effects to settle out. I'm hopeful the dream business is going to tame down a bit.

In any case, thanks for the tidbit on melatonin! I love to collect little tidbits on mood/sleep/psych drugs, it makes such a difference to patients subjectively.

I find when I give them advice they can really feel subjectively (like improved sleep) they tend to trust me more about stuff they can't (BP management).

Psych primary care can be so rewarding. Or frustrating. More often rewarding if you can get improvement with the little tweaks.

Well since we are talking about sleep and anxiety and things that can calm them other than ssri's then we should include BHRT. Progesterone an hour before bedtime will improve sleep and anxiety. Not synthetic.

Testosterone in men and women has a calming effect overall. So it can calm someone overall. If your thinking what about roid rage. It's does not happen unless they get synthetic anabolics or get really really high doses. Testosterone should only be given to those who are low. Men with T. below 400 and in women they seem to be low after 35 or 40 years old. Oddly enough many women start to get their insomnia and anxiety/depression at about the same age.
 

Doctor4Life1769

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I've never prescribed testosterone. We aren't allowed. I'm assuming start low go slow.
I plan to look into hormones when out in practice.
I prescribed prn ambien to a patient and that was looked upon with a gasp.
 

VA Hopeful Dr

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I've never prescribed testosterone. We aren't allowed. I'm assuming start low go slow.
I plan to look into hormones when out in practice.
I prescribed prn ambien to a patient and that was looked upon with a gasp.
If you're going to do testosterone (and I'm not a big fan), make sure you do the proper work up. Just because a guy in his 30s thinks he "has low T" doesn't make it so.
 

Doctor4Life1769

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If you're going to do testosterone (and I'm not a big fan), make sure you do the proper work up. Just because a guy in his 30s thinks he "has low T" doesn't make it so.
I agree.
I don't know if I will actually prescribe it or not, but it is something I wish to be more knowledgeable about.
I do order an initial AM T, and if normal I counsel accordingly and look at other likely causes. If it is low, I re-check it. I've never had a patient with low T and even if I did, I'm not allowed to prescribe testosterone anyways and so I refer to urology and let them handle it.
 
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mark v

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I do tons of psych and find it pretty rewarding. Much more so than managing diabetes or HTN. Let's be honest, most of your patients couldn't care less about their A1C or anything else that truly requires any sort of lifestyle modification. They won't hug your neck for finally getting their LDL under 100 but to "give someone their life back" is a pretty good feeling.

Getting an accurate time scale of symptoms is paramount. It tells a lot. You're 45 and the depressive sx and sleep problems just started a couple weeks ago, out of the blue with NO recent stressors or life events.... Not buying it. After further questioning, you'll quickly discover that "I've had sleep problems since high school, mom had an alcohol problem, dad left when I was a baby and my brother struggles with substance abuse." "I just can't shut my mind off at night." "come to think of it, a doc did put me on Zoloft in the past but I really didn't like the way it made me feel." Come to find out that this patient will also describe their mood as "all over the place"," they struggle with their personal relationships and often times have have been told they talk to fast, loud or too much. Oh yeah, they've got a ring on every finger (i call this a positive ring sign) and way too much makeup on. Bipolar disorder until proven otherwise.

By far, the most useful thing you can do to improve your psychiatry is to ditch the laptop at the door. Be nonjudgmental, especially with the substance abuse issues. Find an accurate assessment of when things truly began and then go from there. Establish early on what meds they've been on in the past and was any of it truly helpful. That alone can turn 30 minute encounter in to 10. You loved Effexor, still had a sex life, slept well and didn't get fat? See you back in 6 weeks for follow up. Don't sleep at night, extreme mood lability, "mind won't shut down," anxiety, ADD, OCD and I can hardly,GE a word in. Here's 50 of Seroquel, see you in 2 weeks.
 

Ericslv

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I've never prescribed testosterone. We aren't allowed. I'm assuming start low go slow.
I plan to look into hormones when out in practice.
I prescribed prn ambien to a patient and that was looked upon with a gasp.
There are many high quality CME events that will help you learn how to properly treat patients with hormone issues. I agree that you should wait until you are done with residency to look into them. I believe you will enjoy the perspective they will bring into your practice.

Depression is an interesting topic because it can be caused by so many things. I'm not huge fan of handing out SSRI's right away. Always test and always talk to the patient about what is going on in their life. I'm a strong advocate of counseling. I imagine if this was 2008 and I had patients walk in for depression because they lost their jobs or careers etc. They weren't depressed a week ago or a month ago before that event. So will SSRI's especially long term be the best option or will some quality counseling and guidance be the best option. Or perhaps a short course of SSRI with counseling at the same time.

We can fix the chemical imbalance short term and work on fixing the problems and the negative thoughts that cause it. The example above is different from the person who just can't get out of a rut is always depressed and has been for several years. Their chemical imbalance may not have a fix other than medications.

It's tough to do this in primary care environment because short visits and seeing 25 - 30 patients a day makes it hard to really focus on these issues.
 

Doctor4Life1769

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There are many high quality CME events that will help you learn how to properly treat patients with hormone issues. I agree that you should wait until you are done with residency to look into them. I believe you will enjoy the perspective they will bring into your practice.

Depression is an interesting topic because it can be caused by so many things. I'm not huge fan of handing out SSRI's right away. Always test and always talk to the patient about what is going on in their life. I'm a strong advocate of counseling. I imagine if this was 2008 and I had patients walk in for depression because they lost their jobs or careers etc. They weren't depressed a week ago or a month ago before that event. So will SSRI's especially long term be the best option or will some quality counseling and guidance be the best option. Or perhaps a short course of SSRI with counseling at the same time.

We can fix the chemical imbalance short term and work on fixing the problems and the negative thoughts that cause it. The example above is different from the person who just can't get out of a rut is always depressed and has been for several years. Their chemical imbalance may not have a fix other than medications.

It's tough to do this in primary care environment because short visits and seeing 25 - 30 patients a day makes it hard to really focus on these issues.
Thanks
I agree it is difficult to do with 15 min visits or less.
This is why I feel the current system is broken.
 
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Crayola227

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I do tons of psych and find it pretty rewarding. Much more so than managing diabetes or HTN. Let's be honest, most of your patients couldn't care less about their A1C or anything else that truly requires any sort of lifestyle modification. They won't hug your neck for finally getting their LDL under 100 but to "give someone their life back" is a pretty good feeling.
Yeah.

Getting an accurate time scale of symptoms is paramount. It tells a lot. You're 45 and the depressive sx and sleep problems just started a couple weeks ago, out of the blue with NO recent stressors or life events.... Not buying it. After further questioning, you'll quickly discover that "I've had sleep problems since high school, mom had an alcohol problem, dad left when I was a baby and my brother struggles with substance abuse." "I just can't shut my mind off at night." "come to think of it, a doc did put me on Zoloft in the past but I really didn't like the way it made me feel." Come to find out that this patient will also describe their mood as "all over the place"," they struggle with their personal relationships and often times have have been told they talk to fast, loud or too much. Oh yeah, they've got a ring on every finger (i call this a positive ring sign) and way too much makeup on. Bipolar disorder until proven otherwise.
Maybe. Could be borderline. I'd be careful to use the DSM 4 or 5 criteria pretty closely to distinguish either. Unless it's very obviously a manic episode right in front of you. First psych related visit doesn't have to walk out with a dx or Rx. Knee jerk dx of BPD or any axis 2 can really follow a patient around in the worst kind of way so I'd just tread lightly.

I'd want to be sure we had the rapport for me to think I'm getting the truth on substance abuse. Do a psych screen, TSH, drug panel. I might see them back a few times to chat more to get more history. In psych they do 30-60 min initial history, may send home questionnaires for friends/family, have them return with spouse/SO or parent, and maybe a couple more visits to get more of a feel, if the depression isn't too bad and it's not full-blown mania. Main difference between hypomania and mania is severity of symptoms, and functional status is key. If no big issues at work, with friends/family, dangerously impulsive behavior, otherwise status quo, I could take some time before an Rx. Try to get them into therapy which they will need if borderline or BPD. Therapist notes can offer more enlightenment (I'm assuming here that getting to psych anytime soon is a pipedream as it often is).

By far, the most useful thing you can do to improve your psychiatry is to ditch the laptop at the door. Be nonjudgmental, especially with the substance abuse issues. Find an accurate assessment of when things truly began and then go from there. Establish early on what meds they've been on in the past and was any of it truly helpful. That alone can turn 30 minute encounter in to 10. You loved Effexor, still had a sex life, slept well and didn't get fat? See you back in 6 weeks for follow up. Don't sleep at night, extreme mood lability, "mind won't shut down," anxiety, ADD, OCD and I can hardly,GE a word in. Here's 50 of Seroquel, see you in 2 weeks.
I agree on ditching the laptop. Getting a 30 min visit down to 10 min before sending home with Seroquel? Hmmm.

Extreme caution should be made to sort out BPD before giving out psych drugs that aren't mood stabilizers, but what you're describing could be borderline (mood lability) and its often-accompanying flair for the dramatic.

Seroquel could be an OK first choice to buy you time to sort more out or get in to psych, but it really isn't the most benevolent drug. It is one of the best for acute treatment of manic phase, and better than other atypicals for BPD depression (harder than mania or other types of depression to treat, the bane of many BPD sufferers).

They will likely sleep 10-14 hours starting out on that, or be in a brain fog, difficulty driving a few days, and can gain 5-10 lbs in those two weeks. NMS is rare but definitely should warn the patient what to watch, maybe have a f/u call in that time.

Once they get accostomed to Seroquel, which can take weeks, it may be problematic to wean to another drug. Weaning to another drug should be something to aim for. (Little known SE that is not uncommon can be protracted withdrawal vomiting, this is because Seroquel has powerful histaminergic blocking effects, leading to upregulation of histamine receptors to compensate (the reason it give patients "munchies" and drowsiness, which decrease with time and acclimatization), stopping then leaves the upregulated receptors relatively unopposed, which can lead to classic signs of histaminergic excess: vomiting, diarrhea, even skin reaction.)

Using Seroquel initally isn't wrong, but I have to say the goal should usually be to get patients controlled with valproic acid (more effective in preventing relapse in this list) or lamotrigine (best SE profile, aside from risk of SJS, need to be careful and stress caution in patient, I heavily researched this, there are easy guidelines on starting, once up to dosage patient can miss up to 2 days due to long half life, but after two days needs to start all the way over in uptitrating, usually takes at least 6 weeks to get to maintenance dose of at least 300 mg, can go higher as SEs and effectiveness allow, no need for checking levels in BPD. There's a lot more I could write on the skin rash vs, SJS thing, most providers stop at first sign of *any* skin issue, only a derm or psych with a lot of exeperience looking at acute lesion can know if fairly common skin rxn to drug vs SJS, so for safety rule of thumb is stop if any skin sx). Lamotrigine is usually well tolerated, FDA approved for BPD, but has less mood stabilizing effects in that it can prevemt relapse to mania, but not as good as other agents, and not for acute management of mania.

There's your mainstay lithium but in primary care, the need for monitoring, and SE profile compared to anticonvulsants, I wouldn't be the one to start with that drug. It's still considered your most effective agent, but more and more providers are wanting to use anticonvulsants if they can get away with it because of SE.

I've seen so many PCPs throw atypicals Seroquel or Zyprexa at patients and call it a day. Those drugs are nasty and will do nasty things longterm. Goal should always be short-term with those drugs in BPD and see if another mood stabilizer will do the trick. Aripiprazole and Latuda have better SE profiles as far as weight and cognitive/fatigue, but can be activating so not a first choice in a hypomanic/manic. Still risk for metabolic syndrome, elevated lipids, and DM (still a risk independent of weight!).

All the atypicals have risk of EPS, and TD. The risk of TD is admittedly better than the typicals, but has been downplayed greatly by drug companies and these drugs just haven't been used long enough to really know. Obviously risk of TD is not the first issue in acute management of BPD, but when all my neurology rotations were unbelievably punctuated by patients with depression, questionable BPD, being put on atypicals by PCP, left that way for years, with no psych monitoring, presenting with what could be permanent neurologic SEs, I feel pretty passionate about more care with atypicals.
 
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clausewitz2

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Note also that Seroquel has significant abuse potential and is is quite valuable on the street. If there is any concern for diversion it is probably not a good first choice. Obviously has its place, but it is not strictly benign.
 
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