Personality disorders in the primary care setting

Patients who suffer from personality disorders often exhibit self-destructive behaviors in the clinical setting and are noncompliant. By recognizing the disorder and intervening, primary care providers can help improve patient outcomes and minimize damaging clinical interactions. This article discusses the different types of personality disorders and provides diagnosis, treatment, and referral guidelines.     

Ventricular arrhythmia: management guidelines for the primary health care setting

Ventricular arrhythmia is a common problem in the ambulatory setting. Ventricular arrhythmias that appear to be similar on the electrocardiograph may have different prognostic significance, depending on the patient's age and the presence of underlying heart disease or ventricular dysfunction. The ultimate goal in the care of any patient with ventricular arrhythmia is prevention of sudden cardiac death. Patients can usually be classified into one of five diagnostic categories, based on symptoms and evidence of underlying heart disease. This article discusses the classification of ventricular arrhythmias as either benign, potentially malignant or malignant. The risks of antiarrhythmic therapy and specific management plans for each of the five diagnostic categories are provided. These management plans are meant to serve as a framework for the clinician who provides primary care to these patients. An explanation of terms used commonly in the interpretation of ventricular arrhythmias is included, as well as guidelines for the assessment of patients with ventricular arrhythmias.     

Management of patients with atopic eczema in the primary care setting

Nurses in primary care are ideally placed to successfully manage patients with common skin conditions such as eczema. The ability to manage the condition involves combining knowledge of the disease process, aggravating triggers, allergens and the role of the topical therapies that in combination are used to control the condition. Nurses must be able to offer the patient practical information about the application of therapies and changes to lifestyle and environment to enable the patient/carer to anticipate and control potential exacerbations of the disorder. This article cannot discuss all age groups and types of eczema in definitive detail, but introduces the principles of care for this group of patients.     

Postpartum disorders in primary care: diagnosis and treatment

Postpartum psychiatric illness consists of a highly prevalent group of disorders, which can result in serious dysfunction and require treatment. Patients are more likely to seek help for these disorders from their primary care physicians rather than mental health professionals. While severe postpartum depression and psychoses are easily recognized, milder or more insidious forms of depressive illness frequently are missed. Heightened sensitivity to and screening for the presence of these prevalent psychiatric disorders facilitates and enhances recognition of postpartum disorders and leads to more expeditious treatment.     

Emergencies in diabetic patients in the primary care setting

The diabetic patient poses special problems in the primary care setting. Symptoms that are relatively unimpressive on initial presentation, such as polyuria or dizziness, may actually be the beginning of serious medical complications. With careful evaluation and follow-up, some patients, such as those who have mild hypo- and hyperglycemia and certain infections, can be managed as an outpatients; however, many cardiovascular conditions, such as cardiac ischemia or limb-threatening peripheral vascular disease, require immediate transfer to an acute care facility. In all situations, close monitoring of glucose levels during all phases of care--in the office, in the hospital and at home--is essential to achieving target glycemic control and rapid detection of clinical conditions that often first manifest as alterations in glycemic control.     

Major depressive illness in women: assessment and treatment in the primary care setting

Depressive illness in women carries with it a tremendous price to the woman's sense of well-being and health. Primary care providers who have frequent and continuous contact with women at risk for developing a depressive disorder are in an excellent position to diagnose and treat depression.     

Warfarin therapy in older adults: managing treatment in the primary care setting

Oral anticoagulant therapy with war farin is commonly used to prevent thromboembolic events in patients at risk. The degree of anticoagulation is variable among individuals and is influenced by many factors; therefore, patients must be monitored frequently to assess for potential adverse effects related to treatment. Individuals older than age 65 are at particular risk for thromboembolic events as well as anticoag ulant-related complications. Because of these factors, elderly individuals pose a unique challenge in maintain ing anticoagulant control. The purpose of this article is to revisit the role of warfarin therapy for elderly individ uals in the primary care setting and to provide nurse practitioners with the information necessary to prescribe and monitor this medication appropriately. This article provides indications for warfarin therapy and also identifies potential barriers to effective management with specific implications for the older population.     

Panic disorder in primary care: Comorbid psychiatric disorders and their persistence

Objective

Although 70–80% of panic disorder patients use primary care to obtain mental health services, relatively few studies have examined panic patients in this setting. This study aimed to examine both the lifetime and current comorbid psychiatric disorders associated with panic disorder in primary care, the duration and severity of the disorder, and the sociodemographic factors associated with it.

Design

Patients were screened for panic disorder. Panic disorder and the comorbid disorders were determined using the Structured Clinical Interview for DSM-IV Axis I and II.

Setting

Eight different health care centers in primary care in the city of Espoo.

Subjects

Finnish-speaking, between 18 and 65 years of age.

Main outcome measures

Comorbid psychiatric disorders, the duration and severity of the disorder, and the sociodemographic factors.

Results

A sample of 49 panic disorder patients and 44 patients with no current psychiatric diagnosis were identified; 98% of panic disorder patients had at least one comorbid lifetime DSM-IV Axis I disorder. Major depressive disorder and other anxiety disorders were most common comorbid disorders. Lifetime alcohol use disorders also showed marked frequency. Interestingly, the remission rates of alcohol use disorders were notable. The panic symptoms appeared to persist for years. Panic disorder was associated with low education and relatively low probability of working full time.

Conclusions

Also in primary care panic disorder is comorbid, chronic, and disabling. It is important to recognize the comorbid disorders. High remission rates of comorbid alcohol use disorders encourage active treatment of patients also suffering from these disorders.Key Words: Comorbid disorders, Finland, general practice, panic disorder, primary careThere are only a few studies considering the comorbid psychiatric disorders associated with panic disorder in primary care and no earlier study had examined the prevalence of all other psychiatric disorders, both lifetime and current, using a structured diagnostic interview method.

• In this study 98% of panic disorder patients had at least one comorbid lifetime psychiatric disorder.
• Major depressive disorder, other anxiety disorders, and alcohol use disorders were the most common comorbid disorders.
• The panic symptoms appeared to persist for years.

     

Burden of illness and satisfaction with care among patients with headache seen in a primary care setting

OBJECTIVE: To assess the current level of headache burden and the headache management needs at three diverse clinical sites. BACKGROUND: Headache is a common disabling disorder that is costly for the patient and a management challenge for physicians. The determination of whether and how to intervene to improve headache management depends on both the burden of disease and the characteristics of patients that would likely be targeted. METHODS: Patients from three healthcare organizations were identified by administrative records as having either migraine or tension-type headache and then mailed a survey that addressed demographics, headache type, headache-related disability, depression and anxiety, satisfaction with care, general health, worry about headache, problems with headache management, and healthcare utilization. Comparisons were made across sites and between patients with more and less severe headache-related impairments. RESULTS: Of the 789 patients contacted, 385 (50%) returned a survey. While the socio-demographic characteristics of the patients were diverse, headache-related characteristics were similar. These patients have significant problems with headache management, disability, pain, worry, and dissatisfaction with care. Patients who described higher headache-related impairment experienced significantly greater problems in these areas, perceived themselves to be in worse general health, and had significantly greater use of medical services than those with lower headache severity. CONCLUSIONS: Despite various elements of heterogeneity, we observed across the sites a consistent need for improvement in headache management. Future efforts should be directed at developing and evaluating methods for effectively improving headache management.     

Distinguishing symptoms of ADHD from other psychiatric disorders in the adult primary care setting

Attention-deficit/hyperactivity disorder (ADHD) is frequently misdiagnosed or undiagnosed in adults. Owing to the relatively recent recognition of adult ADHD as a valid mental disorder and its overlapping symptomatology with other conditions, primary care physicians often fail to screen for ADHD in patients who present with inattention, impulsivity, and hyperactivity. A substantial proportion of adults with ADHD also have psychiatric comorbidities. Physicians need to recognize the ways in which ADHD symptoms are expressed in adults and distinguish them from symptoms of other disorders, including mood, anxiety, and substance abuse disorders.     

The management of hypercholesterolemia in patients with coronary artery disease: guidelines for primary care

More than 10 million individuals in the United States currently have symptomatic coronary artery disease (CAD). Asymptomatic CAD is even more prevalent. CAD in the United States is responsible for approximately 1.5 million myocardial infarctions, 500,000 deaths, and a total economic burden in excess of $120 billion annually. Fortunately, CAD is preventable in many individuals. Our understanding of CAD has steadily progressed throughout the 20th century, and now several lines of evidence support the importance of cholesterol in both the genesis and management of coronary atherosclerosis. Following identification of the presence of cholesterol in atheromas, Anitschkov early this century demonstrated that atherosclerotic lesions can be induced in susceptible animals by high-saturated-fat and cholesterol diets. These lesions regressed when low-fat and cholesterol diets were resumed. In the 1970s and 1980s, findings from the landmark Framingham Heart, Seven Countries, and Multiple Risk Factor Intervention Trial studies firmly established that hypercholesterolemia was a major risk factor for cardiovascular morbidity and mortality. During the 1980s and 1990s, 21 of 22 angiographic trials demonstrated reduced progression of coronary and/or carotid artery disease using lifestyle, drug, and surgical means for reducing cholesterol. The later trials commonly employed hydroxymethylglutaryl coenzyme A reductase inhibitors (statins), reflecting increasing clinical use of these drugs. In 1988, the Adult Treatment Panel of the National Cholesterol Education Program (NCEP) published guidelines on testing and treating hypercholesterolemic patients, which outlined a more aggressive approach to cholesterol lowering than was currently in practice. Since 1994, five large cardiovascular event trials and a large angiographic trial have shown that aggressive cholesterol lowering reduces both cardiac morbidity and mortality, largely substantiating the NCEP guidelines. Although important clinical questions remain regarding patient subsets and treatment goals, lifestyle changes and appropriate drug therapy have proved to be highly effective in preventing initial and recurrent cardiovascular events.