Depression management in GIM primary care?

[futureapppsy2]

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I'm a psychologist but have a mentor who's an IM attending (primarily research-focused but has worked as a preceptor and attending in both outpatient GIM and in-patient hospital medicine throughout her career). She's of the strong opinion that if internists don't feel comfortable diagnosing and managing MDD for at least a couple of medication trials, they shouldn't be practicing primary care. Thoughts?

 

[DrMetal]

I'm a psychologist but have a mentor who's an IM attending (primarily research-focused but has worked as a preceptor and attending in both outpatient GIM and in-patient hospital medicine throughout her career). She's of the strong opinion that if internists don't feel comfortable diagnosing and managing MDD for at least a couple of medication trials, they shouldn't be practicing primary care. Thoughts?

So, one medication (like an SSRI), and titrating it a little up or down for effect . . . yes, an outpatient IM or FM should be comfortable doing that.

Adding on a second agent, cross-titrating both of them, or if other diagnosis (bipolar, etc) . . . No. A Psychiatrist should be involved.

Unfortunately we have a scarcity of mental health providers. Where I'm at, the wait time to get an outpatient psychiatry appointment is ~ 2 months.

 

[Kaustikos]

I'm a psychologist but have a mentor who's an IM attending (primarily research-focused but has worked as a preceptor and attending in both outpatient GIM and in-patient hospital medicine throughout her career). She's of the strong opinion that if internists don't feel comfortable diagnosing and managing MDD for at least a couple of medication trials, they shouldn't be practicing primary care. Thoughts?

Yes
They should. Just like a doctor should know how to prescribe antibiotics appropriately. Or anti-hypertensives. But neither of those happen all perfectly. It's the bias.

 

[tylerb1800]

So, one medication (like an SSRI), and titrating it a little up or down for effect . . . yes, an outpatient IM or FM should be comfortable doing that.

Adding on a second agent, cross-titrating both of them, or if other diagnosis (bipolar, etc) . . . No. A Psychiatrist should be involved.

Unfortunately we have a scarcity of mental health providers. Where I'm at, the wait time to get an outpatient psychiatry appointment is ~ 2 months.

Agree with some of above. An IM trained primary care physician should be comfortable with more than just titration of one or two agents for MDD and GAD. Addition of a second agent and/or cross titration should be in your repertoire as well with the limited amount of psychiatrists available. There are good resources online to assist with this as well. I whole heartedly agree that bipolar disorder and other advanced mood disorders should not be managed by primary care.

 

[DrMetal]

There are good resources online to assist with this as well.

Yes, I agree! We should be using online tools to replace psychiatry, in much the same way the MRI has replaced the neurologist. Isn't is a wonderful time to be in medicine!

 

[VA Hopeful Dr]

So, one medication (like an SSRI), and titrating it a little up or down for effect . . . yes, an outpatient IM or FM should be comfortable doing that.

Adding on a second agent, cross-titrating both of them, or if other diagnosis (bipolar, etc) . . . No. A Psychiatrist should be involved.

Unfortunately we have a scarcity of mental health providers. Where I'm at, the wait time to get an outpatient psychiatry appointment is ~ 2 months.

You really think every case of depression that is taking an SSRI and wellbutrin or an SNRI and buspar needs a psychiatrist?

 

[DrMetal]

You really think every case of depression that is taking an SSRI and wellbutrin or an SNRI and buspar needs a psychiatrist?

No, certainly not. If they're stable or need a little bump, we should be fine doing that. But if you're worried that said bump in their dose might trigger a manic episode (because they're also bipolar), and if you're wondering if their abilify should be concomitantly titrated . . . now might be a good time to phone a friend (or use an online tool, as suggested here).

 

[tylerb1800]

Yes, I agree! We should be using online tools to replace psychiatry, in much the same way the MRI has replaced the neurologist. Isn't is a wonderful time to be in medicine!

Woah there! I am not sure if anything that I said above is in regards to replacing psychiatrist especially with ?online tools. I wish there were more psychiatrist in the community. The comment of mine that you quoted above is about cross-tapering antidepressants for MDD or GAD which an internal medicine trained physicians should feel comfortable doing.

I do not adjust psychotropic medication for any advanced mood disorder as I do not feel like my training was appropriate for management of bipolar, schizophrenia, shizoaffective, etc. Psychiatry should be the ones managing this.

 

[Sushirolls]

Psych here...

A failing of IM and FM is that it doesn't pair up with their real world clinical population. For instance up to a 1/3 of the patients in primary care potentially will have some level of mental health to address on a routine clinic day. Yet, virtually all FM/IM residencies lack a single Psychiatry rotation. Our sister board, Neurology, only requires like 2 months on Psychiatry services, and the same for us, 2 months with them.

IMO, FM/IM should have a bare minimum of 4 months Psych in the residency. 2mo outpatient, 1mo inpatient, 1 month CL or Psych ED if available.

Buspar comments above, I don't use it, and typically am taking people off it. Such limited efficacy clinically.

 

[Kaustikos]

Psych here...

A failing of IM and FM is that it doesn't pair up with their real world clinical population. For instance up to a 1/3 of the patients in primary care potentially will have some level of mental health to address on a routine clinic day. Yet, virtually all FM/IM residencies lack a single Psychiatry rotation. Our sister board, Neurology, only requires like 2 months on Psychiatry services, and the same for us, 2 months with them.

IMO, FM/IM should have a bare minimum of 4 months Psych in the residency. 2mo outpatient, 1mo inpatient, 1 month CL or Psych ED if available.

Buspar comments above, I don't use it, and typically am taking people off it. Such limited efficacy clinically.

I'm sorry? I'm already not a fan of outpatient in general, the last thing I'd want to see is another 2 months of mandatory outpatient.

 

[VA Hopeful Dr]

I'm sorry? I'm already not a fan of outpatient in general, the last thing I'd want to see is another 2 months of mandatory outpatient.

Beyond that, we all see lots of psych in the outpatient months. It's not like those outpatient months are psych-free.

 

[Drrrrrr. Celty]

Psych here...

A failing of IM and FM is that it doesn't pair up with their real world clinical population. For instance up to a 1/3 of the patients in primary care potentially will have some level of mental health to address on a routine clinic day. Yet, virtually all FM/IM residencies lack a single Psychiatry rotation. Our sister board, Neurology, only requires like 2 months on Psychiatry services, and the same for us, 2 months with them.

IMO, FM/IM should have a bare minimum of 4 months Psych in the residency. 2mo outpatient, 1mo inpatient, 1 month CL or Psych ED if available.

Buspar comments above, I don't use it, and typically am taking people off it. Such limited efficacy clinically.

I think 1 month of general outpatient psych is probably not a bad idea. But it's not like I don't manage or do a decent amount of psychiatry in my clinic. And it's not like prescribing psychiatric medications are difficult. I think in the grand scheme of things a psych patient visit and medication management is by far the easier of my patients as opposed to figuring out how to balance a hypertensive emergency patient who shows up in clinic and says they aren't able to see well and have a headache....

IM is already an extremely packed specialty. We're training to be able and comfortable understanding our subspecialties and being able to manage a whole patient. 4 months is literally on average how many months we spend learning how to manage ICU level patients comfortably. 4 months of Psychiatry isn't going to help me when I'm in the hospital or in subspecialty.

We can however say the same about Psych patients needing their psychiatrists to honestly be more of their primary care physicians and the lack of training that Psychiatry does to appropriately manage or deal with even basic medical issues.

 

[Sushirolls]

Very few IM are in 'open' ICUs and are actually intubating or managing as CCM specialist.

IM/FM really don't know how much they mismanaging patients unless that actually did rotations.

Yes, IM and FM are pulled in many directions to learn, experience and master for primary care. I'm pointing out the obvious of patient problem list / chief complaint and what IM/FM does on a daily basis there is a significant disconnect between the training given and the care performed. Its sad.

I see this in numerous ways once patients finally hit my door. For instance using Wellbutrin to treat anxiety symptoms...

 

[Drrrrrr. Celty]

Beyond that, we all see lots of psych in the outpatient months. It's not like those outpatient months are psych-free.

Like I'm not entirely sure what I'd gain from knowing how to manage inpatient psychiatry patients or doing CL? I won't be taking care of Schizophrenia and those with severe mood disorders need someone else. It's like saying that someone with a Crohns disease should be managed by a PCP.

 

[Drrrrrr. Celty]

Very few IM are in 'open' ICUs and are actually intubating or managing as CCM specialist.

IM/FM really don't know how much they mismanaging patients unless that actually did rotations.

Yes, IM and FM are pulled in many directions to learn, experience and master for primary care. I'm pointing out the obvious of patient problem list / chief complaint and what IM/FM does on a daily basis there is a significant disconnect between the training given and the care performed. Its sad.

I see this in numerous ways once patients finally hit my door. For instance using Wellbutrin to treat anxiety symptoms...

A lot of IM residents are going to end up in subspecialties, including CCM. A lot of IM residents will be at open ICUs. We are trained to be able to do the job. We're trained how to manage an enormous amount of medical problems and we are trained to be competent at recognizing them.

And I've had patients come from psychiatrists who have bowel obstructions because of their medications. What's your point?

 

[Redpancreas]

I'm a psychologist but have a mentor who's an IM attending (primarily research-focused but has worked as a preceptor and attending in both outpatient GIM and in-patient hospital medicine throughout her career). She's of the strong opinion that if internists don't feel comfortable diagnosing and managing MDD for at least a couple of medication trials, they shouldn't be practicing primary care. Thoughts?

She's correct. Starting a first line agent (i.e. SSRI) is as easy as listening to the patient and assessing for MDD, ruling out BPD-1 and other contraindications, looking up the dose on Uptodate, monitoring the medication, and counseling the patient on side effects. In case there are things you don't know off the top of your head it's all spelt out for you. If you are too scared to do this yourself whether it be preoccupation about liability, etc. what are you actually doing for your patients?

As others have said more complex patients aught to be referred. A schizophrenic patient also Bipolar Type 1 who's coming to you for depressed mood should be managed by a Psychiatrist because you do not know what you're treating. Half the time the inpatient psych note is not even clear because there are longitudinal, clinical diagnoses which is when I ensure the patient has psychiatry follow-up. There are ways to jump the line and if your clinic has a Behavioral Health Social Worker at the disposal you can refer to them and they can triage and help ensure the patient gets to the psychiatrist after your appointment.

I do think more Psychiatry primary care didactic and practical experience is warranted in IM residency. It's not as simple as Zoloft->Prozac->second agent. Curbsiders has an episode on this and I have it on my to-do list. Any IM physician who prescribes Wellbutrin for anxiety or abruptly stops an SNRI a patient has been on for months on discharge (because of polypharmacy?!) clearly needs further guidance. That's why there's CME, etc.

Not sure what the argument is about. I feel like everyone's making valid points.

 

[Drrrrrr. Celty]

To answer the original post though I don't disagree. We all went to medical school and did a psychiatry rotation and passed boards which test on a competency of psychiatry. You don't need to remember adult coping mechanisms or Freudian theory, but knowing how to diagnose depression and hidden depression in subpopulations like the elderly is important.


You need to be able to adequately treat patients who come in to your level of competency. For most FM or IM trained individuals they'll know how to dose a few SSRIs, a few atypical antipsychotics, and stuff like welbutrin.

 

[rokshana]

Very few IM are in 'open' ICUs and are actually intubating or managing as CCM specialist.

IM/FM really don't know how much they mismanaging patients unless that actually did rotations.

Yes, IM and FM are pulled in many directions to learn, experience and master for primary care. I'm pointing out the obvious of patient problem list / chief complaint and what IM/FM does on a daily basis there is a significant disconnect between the training given and the care performed. Its sad.

I see this in numerous ways once patients finally hit my door. For instance using Wellbutrin to treat anxiety symptoms...

I think you may want to go back and proofread your post... the poor English makes it very difficult to understand your post...other than the very insulting tone .
Funny how some of the psych people feel that IM/FM should be adept at handling psych pts...yet the expectation for psych handling fairly straightforward medical issues is not there...and y’all do spend 4 months doing medicine rotations...

 

[cbrons]

Psych here...

A failing of IM and FM is that it doesn't pair up with their real world clinical population. For instance up to a 1/3 of the patients in primary care potentially will have some level of mental health to address on a routine clinic day. Yet, virtually all FM/IM residencies lack a single Psychiatry rotation. Our sister board, Neurology, only requires like 2 months on Psychiatry services, and the same for us, 2 months with them.

IMO, FM/IM should have a bare minimum of 4 months Psych in the residency. 2mo outpatient, 1mo inpatient, 1 month CL or Psych ED if available.

Buspar comments above, I don't use it, and typically am taking people off it. Such limited efficacy clinically.

Sorry those 4 months are spent in the medical ICU

 

[Drrrrrr. Celty]

Sorry those 4 months are spent in the medical ICU

Tbh MICU is pretty solid psych training too. Tons of addiction, you learn how to be comfortable with delirium and most antipsychotics and valproate.

 

[cbrons]

Tbh MICU is pretty solid psych training too. Tons of addiction, you learn how to be comfortable with delirium and most antipsychotics and valproate.

Anyone who is "comfortable" with antipsychotics for "treating" delirium is a non-evidence-based practitioner, to put it in very mild terms. And I have never ordered valproate on a medical ICU patient, and can't imagine a situation where such a med would be appropriate (I guess seizures, maybe).

 

[Drrrrrr. Celty]

Anyone who is "comfortable" with antipsychotics for "treating" delirium is a non-evidence-based practitioner, to put it in very mild terms. And I have never ordered valproate on a medical ICU patient, and can't imagine a situation where such a med would be appropriate (I guess seizures, maybe).

Depacon has pretty solid benefits for agitation and delirium. There is an abundance of good literature.

Also if you've never used haldol before then bless your heart.

 

[cbrons]

Depacon has pretty solid benefits for agitation and delirium. There is an abundance of good literature.

Also if you've never used haldol before then bless your heart.

Oh I've used it to chemically restrain someone who is dangerous to themselves or others but I'm under no delusion that its "treating" their delirium.

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[Redpancreas]

Oh I've used it to chemically restrain someone who is dangerous to themselves or others but I'm under no delusion that its "treating" their delirium.

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Agreed, the standard teaching is that we avoid antipsychotics unless the patient is physically aggressive. Geriatrics at my institution likes seroquel to mainly promote sleep-wake cycle but I won't do that unless I consult and they recommend.

 

[Drrrrrr. Celty]

Agreed, the standard teaching is that we avoid antipsychotics unless the patient is physically aggressive. Geriatrics at my institution likes seroquel to mainly promote sleep-wake cycle but I won't do that unless I consult and they recommend.

Seroquel is meh. It's a trash antipsychotic.

Oh I've used it to chemically restrain someone who is dangerous to themselves or others but I'm under no delusion that its "treating" their delirium.

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My language was too fresh. I'm obviously not treating their delirium. That's a complicated pathology. I am symptom controlling for the protecting staff.

 

[aafisahar]

Also if you've never used haldol before then bless your heart.

Haldol is the ****ing best. Put those agitated patients in time out.