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1. How common are psychiatric disorders in primary care settings? The primary care sector has been labeled a de facto mental healthcare system because almost two-thirds of all patients with psychiatric illnesses in the U.S. are seen exclusively in primary care settings. Prevalence studies in primary care clinics have consistently shown rates of up to 30% for psychiatric disorders meeting DSM-IV criteria. It is probable, however, that significant psychiatric illness exceeds this rate because of so-called mixed or minor disorders that do not meet full diagnostic criteria. In any case, primary healthcare settings carry the burden of patients with psychiatric disorders in the U.S. 2. Which disorders are seen most frequently in primary care settings? Anxiety, mood disturbance, and psychoactive substance abuse are the most common disorders in primary care settings. The following table lists the disorders by decreasing lifetime prevalence rates: Disorder % Major depression 17.1 Alcohol dependence 14.1 Social phobia 13.3 Simple phobia 11.3 9.4 Alcohol abuse Drugdependence 7.5 Dysthymia 6.4 Agoraphobia 5.3 Generalized anxiety disorder 5.1 Panic disorder 3.5 Manic episode 1.6 0.7 Nonaffective psychosis
Symptoms
Chest pain with negative angiogram Irritable bowel Unexplained dizziness Migraine headache Chronic fatigue Chest pain in emergency department
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In patients with 5 or more medically unexplained symptoms, the odds of having panic disorder are 204 to 1. Frequently, patients have a number of nonspecific symptoms that frustrate both patient and provider. For example, a young man with lightheadedness and atypical chest pain underwent magnetic resonance imaging (MRI) scan of the brain, electroencephalogram, Holter monitor testing, exercise treadmill, echocardiogram, cerebral angiography, and numerous blood tests. A careful history revealed that he had panic disorder. In this case, a good history may have saved thousands of unnecessary dollars in testing.
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6. Which psychiatric disorders can the primary care provider treat? The type of psychiatric disorder that a primary care physician can treat varies with the severity of the disorder, expertise of the physician, availability of treatment options, and desires of the patient. Disorders marked by psychosis, severe behavioral changes (such as avoidant behavior), and lethality (suicide or homicide) should be treated by or with a mental health professional. Because psychiatric disorders occur so commonly in general medical settings, the primary care provider must be confident in assessing such patients. Indeed, patients tend to feel more comfortable and less stigmatized with primary care physicians. Often, treatment may be initiated and the patient closely followed. If improvement in symptoms does not occur in 6-8 weeks, the patient may then be referred.
7. Why should the primary care provider not treat every depressed patient with the newer antidepressants such as fluoxetine, which appear safe? It is certainly easy for the primary care physician to prescribe the newer antidepressants, as evidenced by the overwhelming increase in the number of prescriptions. Such drugs are attractive because they are simple to dose, do not require monitoring of serum levels, and generally are well-tolerated. Nonetheless, ease of prescription does not warrant their use outside approved indications. It is not known whether such agents are effective for mixed or minor disorders. In addition, they may precipitate agitation or mania and are therefore to be used cautiously or not at all in persons with a history of hypomania, mania, or agitation. Likewise, they are not free from side effects, may have adverse interactions with nonpsychotropic medications, and are not inexpensive. Therefore they should be used prudently by the primary care provider. In addition, research demonstrates the need for psychotherapy in many depressed patients. Combining psychotherapy with pharmacologic treatment is likely to provide better results. Hence, providing medication alone may treat a depressive illness only partially.
8. How useful are screening instruments for psychiatric case-finding? Currently, several screening instruments are available to the primary care provider, ranging from self-administered questionnaires to more formal interviewer-rated instruments. All have the advantage of suggesting a disorder when the provider faces times constraints. However, even the best instruments have predictive value of only 70-85%, and, unfortunately, few have been adequately validated against standard structured interviews. Such instruments should be used only for case-finding and not for definitive diagnosis.
Commonly Used Screening Instruments
DISORDER PAT1Em-RATED INTERVIEWER-RATED
Depression CES-D
Beck
X X X X X X X X X X X X
Hamilton MOS HADS Anxiety Zung Hamilton Sheehan Beck Cognition HADS
Both
x
X X
SDDS-PC Prime-MD
CES-D = Center for Epidemiologic Studies-Depression, MOS = Medical Outcomes Study, HADS = Hospital Anxiety and Depression Scale. SDDS-PC = Symptom-DrivenDiagnostic Schedule-Primary Care
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I . Brody DS, Hahn SR, Spitzer RL, et al: Identifying patients with depression in the primary care setting: A more efficient method. Arch Intern Med 158(22):2469-2975, 1998. 2. Katon WJ, Walker EA: Medically unexplained symptoms in primary care. J Clin Psychiatry 59 Suppl 20:15-21, 1998. 3. Kessler RC, McGonagle KA, Zhao S, et al: Lifetime and 12-month prevalence of DSM-111-R psychiatric disorders in the United States: Results from the National Comorhidity Survey. Arch Gen Psychiatry 5 1:8-19, 1994. 4. Kessler LG, Cleaty PD, Burke JD: Psychiatric disorders in primary care. Arch Gen Psychiahy 42583-587, 1985. 5. Lustman PJ: Anxiety disorders in adults with diabetes mellitus. Psychiatr Clin North Am 11(2):419-431, 1988. 6. Von Korff M, Shapiro S, Burke JD: Anxiety and depression in a primary care clinic. Arch Gen Psychiatry 44152-156, 1987. I . Walker EA, Katon WJ, Jemelka RP: Psychiatric disorders and medical care utilization among people in the general population who report fatigue. J Gen Intern Med 8:436-440, 1993. 8. Yingling KW, Wulsin LR, Arnold LM, Rouan GW: Estimated prevalences of panic disorder and depression among consecutive patients seen in an emergency department with acute chest pain. J Gen Intern Med 8:231-235, 1993.