Improving recognition of psychiatric disorders in a primary care practice

A high percentage of patients who seek care from primary care physicians have a psychiatric disorder, either as the primary illness or secondary to a medical illness or drug use. Drs Thompson and Petersen discuss a number of approaches that physicians can take to better recognize psychiatric disorders, so that they may treat or consult on the less complicated conditions and refer complex or resistant conditions to a psychiatrist.     

Detection and diagnosis of psychiatric disorders in primary medical care settings

Research efforts accelerated in the 1990s to define the presentation of common psychiatric disorders in primary care settings. Two diagnostic instruments, the DSM-IV-PC and the PRIME-MD, were introduced in 1994, and a self-report form of the PRIME-MD, the PHQ, was published in 1999. These tools have streamlined the larger, often cumbersome psychiatric nomenclature of the DSM-III and DSM-IV and appear to be more useful in general medical settings. It still is not practical to use either instrument in its entirety for all patients in a busy primary care practice. Studies have suggested an efficient and effective, two-step method of screening primary care patients for psychiatric disorders, however. In this approach, a limited number of probing questions extracted from the PRIME-MD or PHQ (or DSM-IV-PC) are posed to patients, either in person or by a written self-report (i.e., a general health update or review of systems). Then a follow-up evaluation is done to confirm or refute positive screening results. Short, simple questionnaires that address specific topics (e.g., CAGE for alcohol screening or the GDS for mood disorders in older adults) complete and complement this approach. This method has the advantage of being easy to incorporate into routine office practice using minimal physician or office staff time, while showing acceptable sensitivity and specificity in studies to date. More research, particularly prospective studies, is needed to confirm the effectiveness of this approach and expand it beyond the few available studies that have focused mostly on depressive disorders.     

Sleep disorders in psychiatric practice

Sleep disorders medicine and psychiatry interface in numerous ways. Most psychiatric patients have a complaint about sleep, and regardless of the theoretical orientation of a psychiatrist, understanding of a patient's sleep function is an important part of assessment. The success or failure of treatment will be strongly influenced by the effect of that treatment on the patient's sleep disorder. The psychiatrist can provide expertise in treating patients with primary sleep disorders, offering pharmacologic consultations, and recommending psychotherapy or behavioral management. Conversely, a knowledge of primary sleep disorders should make the psychiatrist a more effective practitioner.     

Physical symptoms that predict psychiatric disorders in rural primary care adults

Rationale, aims and objectives There is a robust association between physical symptoms and mental distress, but recognition rates of psychiatric disorders by primary care doctors are low. We investigated patient‐reported physical symptoms as predictors of concurrent psychiatric disorders in rural primary care adult outpatients. Method A convenience sample of 1092 patients were assessed with a two‐stage diagnostic system consisting of a brief screening questionnaire and a clinician‐administered semi‐structured interview that linked common physical symptoms with the concurrent presence of psychiatric disorders. Results Somatoform physical symptoms were highly predictive of the concurrent presence of a psychiatric disorder, with odds ratios ranging from 10.4 (fainting spells) to 54.6 (shortness of breath). Aggregate analysis of somatoform and non‐somatoform symptoms relative to no physical symptom produced odds ratios of 3.0 or higher for headaches, chest pain, dizziness, sleep problem, shortness of breath, tired or low energy, and fainting spells. As the number of symptoms (especially somatoform) increased, the odds of a psychiatric disorder increased. Conclusion Although individual physical symptoms are valid triggers for suspecting a psychiatric disorder, the most powerful correlates are total number of physical complaints and somatoform symptom status.     

A streamlined method for diagnosing common psychiatric disorders in primary care

Primary care practitioners treat the majority of patients with psychiatric disorders, but many patients in general medical practices continue to suffer from undiagnosed mental illnesses. Over the past 10 years, clinical investigators have focused on enhancing the detection of psychiatric disorders in primary care. Several diagnostic tools have been developed for use by clinicians who are not psychiatrists. However, the time constraints of real-world office practice and the often-cumbersome psychiatric nomenclature have limited their use. Recent studies have tested even more streamlined diagnostic methods that require only a few minutes of physician time while correlating strongly with formal psychiatric evaluations. This article consolidates these research findings with practical experience in the rapid detection of 5 psychiatric conditions commonly encountered in primary care: depression, anxiety, stress reactions, substance abuse, and cognitive impairment. An efficient, 2-step method is described that consists of carefully targeted screening questions followed by a confirmatory evaluation. The screening questions and confirmatory examination can be incorporated easily into most primary care practices.     

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.

     

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.     

Improving rates of herpes zoster vaccination with a clinical decision support system in a primary care practice

Rationale Herpes zoster (shingles) is a localized neurocutaneous eruption of blisters caused by reactivation of the varicella zoster virus. The cost of care for herpes zoster and its complications is estimated at $1.1 billion. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends a one‐time dose of the vaccine for adults aged 60 years or older. Despite that recommendation, utilization of the vaccine is very low. One way to boost the delivery of preventive services such as vaccinations is with a computerized clinical decision support system. Our study found that the herpes zoster vaccination rate increased significantly after the implementation of such a system. Aims To study utilization of herpes zoster vaccine before and after the implementation of a web‐based clinical decision support software solution in a primary care practice. Methods Billing data was utilized to determine number of herpes zoster vaccination administered to patients for a 12‐month period during the implementation of the software solution. Results The utilization of vaccinations improved from 63 to 117 (53.8% increase) for one primary care practice and from 54 to 127 (42.5% increase) in the other primary care practice. Conclusion Herpes zoster vaccination rate significantly improved with implementation of a web‐based clinical decision support system.     

Effect size in psychiatric evidence-based practice care

Developing evidence-based practice skills requires a familiarity with the language and terminology of clinical research. Few articles discuss concepts, such as effect size, that must be understood to determine if the findings of studies are clinically meaningful. Clinically meaningful results of studies are determined by the effect size of an intervention. The effect size of an intervention, such as cognitive-behavioral therapy, can be calculated from the findings of different studies using different designs and populations. However, the determination and use of an effect size is important to clinicians using research findings to guide practice.     

Personality disorders in primary care.

Managing patients with personality disorders is an unfortunate, yet inevitable, aspect of the primary care practice. The epidemiology and origin of these disorders are briefly discussed. This article discusses both formal criteria for diagnosis and informal indicators that are clues for the physician to consider these disorders. In addition, relevant clinical cases are presented and reviewed. This article also outlines some practical management strategies to help the physician more effectively and efficiently deal with these troublesome patients.     

The recognition, diagnosis, and treatment of mental disorders by primary care physicians

A valid and reliable vignette-based measure of DSM-III psychiatric diagnostic knowledge was administered to practicing primary care physicians (PCPs; generally, internal and family practice medicine) and mental health professionals (MHPs, in psychiatry and psychology). Recognition, diagnosis, and treatment recommendations were measured for 14 different disorders. Contrary to other reports, PCPs consistently recognized the presence of mental disorder and did so virtually as well as MHPs, although both PCPs and MHPs showed more under-recognition than over-recognition. Diagnostic accuracy, however, was substantially lower, with that of MHPs exceeding PCPs for the general classes of affective, anxiety, somatic, and personality disorders, but not for the organic disorders. In making specific diagnoses, significantly fewer PCPs than MHPs gave an accurate diagnosis for eight of the 14 disorders: dysthymic disorder, major depression with psychotic features, agoraphobia with panic attacks (marginally), generalized anxiety disorder, adjustment disorder with anxious mood (marginally), psychologic factors affecting physical condition, and two personality disorders. Overall, PCPs were most accurate in identifying organic disorders (81% correct), least accurate in identifying the personality disorders (14%), and intermediate in identifying the affective (47%), anxiety (49%), and somatic disorders (49%). In most cases, both PCPs and MHPs preferred referral to treatment in primary care, but more PCPs than MHPs recommended treatment in primary care for certain anxiety and somatic disorders. Some differences in the recommended use of antidepressants in primary care were also found. Implications for the provision of mental health care by primary care physicians are discussed.     

Treating eating disorders in primary care

Binge-eating disorder, bulimia nervosa, and anorexia nervosa are potentially life-threatening disorders that involve complex psychosocial issues. A strong therapeutic relationship between the physician and patient is necessary for assessing the psychosocial and medical factors used to determine the appropriate level of care. Most patients can be effectively treated in the outpatient setting by a health care team that includes a physician, a registered dietitian, and a therapist. Psychiatric consultation may be beneficial. Patients may require inpatient care if they are suicidal or have life-threatening medical complications, such as marked bradycardia, hypotension, hypothermia, severe electrolyte disturbances, end-organ compromise, or weight below 85 percent of their healthy body weight. For the treatment of binge-eating disorder and bulimia nervosa, good evidence supports the use of interpersonal and cognitive behavior therapies, as well as antidepressants. Limited evidence supports the use of guided self-help programs as a first step in a stepped-care approach to these disorders. For patients with anorexia nervosa, the effectiveness of behavioral or pharmacologic treatments remains unclear.     

Improving quality of primary health care in a Sudanese dispensary

Nursing in a poverty-stricken war zone means working with poor facilities and coping with different attitudes. Sue Campbell explores how working overseas does not need to curtail the nurse's professional development, and shows how some of the trends followed in the UK can apply abroad.