February 08, 2013

Psychiatry in Primary Care Setting

Dr. Felicitas Artiaga-Soriano

Outline
Why we need psychiatry in primary care? Why we need primary care in psychiatry? Why we can not afford not to integrate? What is Psychiatry Integrated Primary Care? What do patients think?

MENTAL HEALTH IN PHILIPPINES

No mental health law has been established We are one of the 3 countries in the world that still doesnt have law for mentally ill. Its mental health budget is only 0.02% of its total health budget, the latter being 3% of its GDP

MENTAL HEALTH
Mental health is essential for individual well-being AND for enhancing human development. You cant really run away from psychiatry. You will be parents later on and you will need to understand psychosocial development for your kids. So if you want your kid to have OCD para malinis lagi bahay niyo, magstricto ka sa anal stage. Kung gusto niyo maging paranoid anak niyo, trust vs. mistrust, trouble in parenting from 0-3. Mental health is the art and science of preventing mental illness, prolonging a productive life, and promoting mental efficiency through organized community effort. Charles Edward Amory Winslow The move now/ the belief now is that psychiatric problems are social problems...so we are now moving on to community efforts, while in the schools the training is usually is for doctors to say in there clinics with their white coats.

Ppt Notes: The Philippines has a mental health policy that is hampered by a miniscule budget and limited legislative authority. 7,8 No mental health law has been established.9 Its mental health budget is only 0.02% of its total health budget, the latter being 3% of its GDP

The most common diagnoses in primary care settings are depression, anxiety and substance use disorders You do not see depression alone or anxiety alone, they are usually together. People that use substances usually also have depression. A study conducted in 3 urban slum health centers showed 17.5% had psychiatric disorders In primary health clinics in 3 towns in Bulacan, 34.5% needed mental health intervention - Ignacio, 1990

Primary Care Providers (PCPs)

PCPs preferred 8 to 1 8 times as many undiagnosed, asymptomatic adults stated more likely to see PCP than a psychiatric professional for help with a mental health issue TIP: Remember just memorize one drug from each drug class! Mental Illness Strikes More Each Year Than Other Serious Illnesses

Ppt Notes: This is a realization.so how can we do this in a country where stigma is still a force to reckon with? ADVOCACY

Way Behind
1963 Community Mental Health Center Act President Kennedy Return mental health care to the mainstream of American medicine. Idea was Community Mental Health Centers organized around hospitals, providing close collaboration between medical and community-based mental health Yet to be fulfilled here in the Philippines NCMH tried to devolve there patients, they returned the patients to their communities and provinces. But since they have stayed in NCMH for a long time once they have returned to the community there was no longer bonding. So pinabayaan nila yung mga mentally ill and they started wandering the streets so there was an increase in the number of taong grasa. So when they noticed that there was an increase in the number of mentally ill in the streets NCMH had to collect them back

Ppt Notes: Failure of Community Mental Health Systems In many areas Community Health Centers now manage the bulk of care for uninsured persons with serious mental illness as the community mental health centers in those areas will not care for the uninsured Even in communities where Community Mental Health Systems meet the needs, the Community Health Centers are managing most of the medical needs of persons with serious mental illness. Cortez, Carmelo, Cortez, Tin and Cruz, Hecil edited by: Ilao

Serious mental illnesses are lifetime. TIP: Kung gusto niyo magtravel around the world, dapat mag cardio, psychiatry or neuro kayo. Most see PCPs anyway - 54% of people with diagnosed psychiatric conditions are treated in primary care only Primary care providers write 75% of all psychotropic medication prescriptions. Minor tranquilizers are addicting, major tranquilizers like your antipsychotics are NOT addicting.

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Psychological Status of Primary Care Patients

Causes of Common Symptoms in Primary Care Medicine

Chest pain, fatigue, dizziness, headache, back pain, edema, dyspnea, insomnia, abdominal pain, numbness

Insert lecturer here

[Dra. Soriano talking to an oncologist] When you diagnose a patient with cancer and you tell them they have only 3-6 months to live, do you ask your patients at the end how do you feel? Or do you ask the relatives to come in and process how they feel? Do you refer them to a psychiatrist to do that? They you usually dont do that kasi daw mahabang usapan or baka magalit! So what happens to the depression, anxiety and psychological distress of the patients? They dont know. Remember that in any illness there is a psychological distress.

Common Presentation of Patients

Multiple somatic complaints Admixture of somatic and affective symptoms Symptoms in the context of obvious life stressors Hindi makatulog dahil may namatay you can connect it to grief.

Common Somatic Complaints

Musculoskeletal aches and pains Prolonged fatigue Sleep disturbances

Somatic Symptom Superhighway

DISEASE IS A 3 LEGGED MONSTER

Emotional distress and psychiatric disorder can also present as somatic symptoms masakit ang likod, chest pain, etc. A break up can cause chest pain when you have an ECG done it will be normal, but you still have chest pain because of the emotional distress.

3-year incidence of 10 Common Symptoms in Primary Care

Disease is a 3 legged monster and we always focus at the biological factors we forget the social factors and the psychological factors.

Effects of Physical and Psychological Stress

Even asthma can be psychological and neurodermatitis. Some schizophrenia patients start with skin itchiness and lesions.

Physical stress and psychological stress have the SAME effects.

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The Mind-Body Connection

Insert lecturer here

DEPRESSION Depression and Diabetes

Risk factor for type 2 diabetes mellitus Decreased adherence due to denial Worse control Increased costs Morbidity and Mortality Sooner Diabetic patients bawal mastress because it causes the sugar level to increase.

Depression Causes Heartbreak

Increased Depression risk with Ischemic Heart Disease Depression post MI > outcome Depression cardio-vascular risk = smoking risk Nicotine has a calming effect Six-fold increase in mortality

Short term effect of cortisol is glucose release from the liver and muscle. Long-term effects are immune changes, loss of muscle and bone mass, loss of insulin sensitivity and hippocampus neuronal death.

Major Depression Prevalence: Chronic Medical Illness

Heart disease 15 to 23% Diabetes 11 to 12% Chronic obstructive pulmonary disease (COPD) 10 to 20% Always think that there is a negative feeling that comes with discomfort from a negative illness.

COMMON DIAGNOSTIC CATEGORIES Depression

Maybe masked by somatic complaints May not have overt symptoms of sadness, despair, dejection Common in Asian Culture Asians - smiling depression. Makikita mo lang sa mata yung depression pero laging nakangiti. But they will always complain of aches and pains in any part of the body, like chest pain.

When you have depression you have an increased risk in being infected, because when you are depressed your temperature is low and it is easier for infectious agents to spread because you have a low temperature.

Anxiety and Panic Disorders

Somatic manifestations from different organ systems Usually no organic cause discovered despite repeated evaluations or if any intensity not commensurate. Sick role exaggerating the pain but it is subconscious. The secondary gain during the sick role is usually subconscious.

Biopsychosocial Model of Illness

Mixed Anxiety and Depression

Symptoms referable to the two syndromes present Somatic complaints over multiple organ systems Usually not one syndrome predominates You will get lost, symptoms do not match and it is difficult to diagnose.

Somatization syndromes
From the hazard from the illness dont forget that there are psychosocial effect like change in attitude, behavior and quality of life. SO YOU HAVE NO RIGHT TO GET ANGRY AT YOUR PATIENTS! Complaints referable to multiple organ systems Fatigue, weakness and multiple aches, dizziness, light headedness Minimal or no psychological symptoms PE is normal; just refer these patients to psychiatry.

Alcohol and Drug Problems

Somatic complaints maybe referable to organ dysfunction related to substance or its physiologic effects Even without overt signs, symptoms or complaints screen because of high prevalence of alcohol and drug problems When one uses alcohol or other drugs, there is usually a depression.
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edited by: Ilao

10 DEADLY BEHAVIORS
Tobacco use Insert lecturer here Poor diet Lack of physical activity Alcohol abuse Avoidable infectious exposure Exposure to toxins Gun use Unsafe sex Unsafe driving Illicit drug use Almost all psychological problems are because of behavior. More than half - smoking, being inactive and eating badly.

Ppt Notes: 50% of mortality is from 10 leading causes of death Links to unhealthy behavior conditions Good information (but information alone does not work) Motivation is a key determinant (Is the agenda important to the patient?) Self efficacy (confidence) is a reliable predictor of behavior change Skills mastery action planning problem solving Psychosocial context helps or impedes

Substance Abuse Treatment in Primary Care Works

Screening and Brief Intervention and Referral to Treatment (SBIRT) 536,000 people across all settings in 17 states 14.8% were positive Protocol-driven brief intervention in primary care. 30 positive trials

Groundbreaking Report! Medicines Do Not Work If You Do Not Take Them

125,000 deaths per year 10% of hospital admissions 23% of nursing-home admissions 1/3 of prescriptions never filled 1/2 of prescriptions filled are taken incorrectly Usual they have a denial, thats why they dont take medications.

WHY WE NEED PRIMARY CARE IN PSYCHIATRY? The Seriously Mentally Ill (SMI) Need more whole body care
SMI diabetes, dyslipidemia, lung disease, liver disease, hypertension, obesity cardiovascular disease, infectious disease, dental disease Die 25 years too early 70% - 1 (chronic health condition); 45% - 2; 30% - 3 Why? Because of their life lifestyle. Since most of them are in denial or depressed they dont drink their medications and kain lang sila ng kain, kaya lalong lumalala yung sakit nila. They also have a sedentary lifestyle, eat-sleep-eat cycle.

Lower Income Higher Psychiatric Problems

Psych problems >2x more common Low-income frequently only have access to PCP Depression(23%), tobacco abuse(6.7%), anxiety(6.0%) - 3 of top 5 dx charted 50% 2 medical problems. 50% of these included depression, anxiety, or alcohol abuse.
Ppt Notes: medical problems, lower functional status and greater disability

Look Under the Rock

Estimated 50 percent of mental health problems go unidentified Most do have contact with PCPs Meet and treat people where they are

Ppt Notes: Mainecare members with and without serious mental illnesses revealed that persons living with serious mental illnesses, when compared to an age and gender matched Medicaid population, have significantly higher prevalence of major medical conditions that are in large part preventable, including diabetes, metabolic syndrome, lung and liver diseases, hypertension, cardiovascular disease, infectious diseases, and dental disorders. Seventy percent of Maines population living with serious mental illnesses has at least one of these chronic health conditions, 45% have two and almost 30% have three or more

Desegregate Mental Health Treat Mild Illness Prevent Severe Illness

If there was increased detection of early stage psychiatric illness in primary care, there would be prevention of individuals going on to more severe episodes of major psychiatric illnesses Outcome = DECREASED Morbidity, Mortality and Money Outcome of Segregating Mental Health dead at 55 COD = heart attack

Stigma Kills
In schizophrenia no treatment for: 30.2% with diabetes 62.4% with hypertension 88.0% with dyslipidemia
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edited by: Ilao

Always think that even if your patients are mentally ill or schizophrenic and may also have other medical problems. May karapatan pa rinInsertsilang magkaroon ng ibang sakit! naman lecturer here

Depression Plus DM or CHF

1y costs with $22,960, $11,956 without. Depressed spent significantly more in nearly every health care cost category except specialty mental health care. Mental health care costs - less than 1 %

Philippine National Mental Health Program

The National Mental Health Program (NMHP) now, under the Degenerative Disease Office of the National Center for Disease Prevention and Control (NCDPC), Department of Health. It just shows how the mental health program is so rejected. It aims at integrating mental health within the total health system, initially within the DOH system, and the local health system. Within the DOH, it has initiated and sustained the integration process within the hospital and public health systems, both at the central and regional level. Furthermore, it aims at ensuring equity in the availability, accessibility, appropriateness and affordability of mental health and psychiatric services in the country.

Ppt Notes: Medicare participants who have diabetes or congestive heart failure as well as depression have significantly higher health care costs than their counterparts who do not have co-existing depression Medicare claims of 14,903 participants for a 12-month period between November 2004 and August 2006.The majority of participants had diabetes. Many had congestive heart failure. About 20 percent had both.

WHAT IS PSYCHIATRY INTEGRATED PRIMARY CARE? Family Doctors Perspective

To provide holistic care, we must always strive to meet patients where they are physically, emotionally and spiritually. The integration of primary medical and psychiatry services is a constant reminder to be conscious of all areas since no one area can be fully addressed in isolation of the others. Spiritually is also important especially here in the Philippines.

WHY WE CAN NOT AFFORD NOT TO INTEGRATE? $653,000,000,000

Non-adherence = $100 billion Depression = $83 Billion Nicotine = $193 Billion Alcohol = $185 Billion Obesity = $92 Billion

Different Levels of Integration

Behavior Kill 50%

Tobacco(435 000 deaths; 18.1% of total US deaths) Poor diet andinactivity (400 000 deaths; 16.6%) Alcohol(85 000 deaths; 3.5%) Microbial agents (75 000) Toxins(55 000) MVA (43 000) Firearms(29 000) Sexual (20 000) Drugs (17 000)

Goals
Meet the primary care needs De-fragment and De-stigmatize care Allow collaboration in the moment Reduce psychological and social barriers Cut costs of chronic disease care Promote cross-education Be financially viable

Top 10 Leading Causes of Disability in the World

Psychiatric conditions are the leading cause of disability in the US and Canada for ages 15-44 1. Unipolar major depression 2. Tuberculosis 3. Road traffic accidents 4. Alcohol use 5. Self-inflicted injuries 6. Manic-depressive (bipolar illness) 7. War 8. Violence 9. Schizophrenia 10. Iron deficiency anemia It has been predicted that depression will be the worlds major cause of disability by 2020

Not Working is Costly

Mood disorders are the: 7th most costly 2nd most disabling

Ppt Notes: De-fragments we all share the same information Normalizes care entering the clinic means only that you are entering a medical clinic. If your PCP works with these psychiatric folks and you see them in the halls, say hi etc, when youre visiting your PCP, it seems more normal. Your PCP may even call a therapist or psychiatrist into the exam room with them to help out with more immediate problems sometimes just to introduce and chat! Improves care what could be better than knowing as much as possible, in a more wholistic fashion, about an individuals life when you are trying to treat them? De-stigmatizes psychiatry in the words of one of our patients -- psychiatry -- its not just for weirdos anymore!

[a print screen of the questionnaire] There are some questionnaires that you can be used, you can bring this along with you. There are some questions were you can know if there is depression, alcohol use disorder and others. It is just a check list so its easy to use yes no questions lang.
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Cortez, Carmelo, Cortez, Tin and Cruz, Hecil

Roadblocks Diagnosis and Treatment of Psychological Disorders Insert lecturer here (Patients)
Patients reluctance to express psychological feelings They dont like to be told that they have weakness in personality. Stigma associated with psychological illness Somatization of psychological symptoms Presence of co-occurring medical problems

Non-judgmental Good Communicator Motivated to build something more than individual practice. Not hyper-sensitive Know your insecurities even your defense mechanisms, para hindi kayo mag-away ng patients mo. Not expecting everyone else to change for them

WHAT DO PATIENTS THINK? Most Importantly What do Patients Think?

Its easier to get care when I need it I know folks understand me and care about me Because they all get to know all aspects of your life. They all know what meds you are on and can ask and tell what is wrong, even when you dont know what you might forget to ask For me, the best part of this is that we rarely need just psych or just medical services. Often as in my case we have interconnected medical issues. Physical health issues that affect psychiatric health or vice versa By having both services together and connected, it is far easier on the patient to get coordinated services which helps to get to the root of the problems, and more quickly! I knew that my PCOS/hormone issues were affecting my depression, but in the past I was forced to be the point person between two doctors who had absolutely nothing to do with each other. Very difficult. This process has become a breeze now and takes the burden off of me, which lets me concentrate on getting better.

Roadblocks (Mental Health Professionals)

Mental health professionals unwilling to assimilate into the primary care culture Mental health professionals that think the current mental health system works well Mental Health professionals that fail to understand that the medical model is taught to be a biopsychosocial model Mental Health professionals that believe that office furnishings are an important part of their therapeutic skills

Roadblocks (Primary Care Providers)

Lack of time, focus and interest on psychological issues Inadequate interview and diagnostic skills Inadequate undergraduate and postgraduate training Lack of support from mental health professionals Primary care practitioners that prefer to keep the psychiatric medical care separate from all the other medical care Primary Care practitioners that follow the BIOpsychosocial Medical Model not the Integrated BioPsychoSocial Model of Healthcare Primary care practitioners that dont believe in psychiatry Primary care practitioners that are hesitant to consult with nonphysicians

MEETING HALFWAY Issues in Assessment and Management

Familiarity with common somatic and psychological presentation to raise index of suspicion and facilitate more thorough assessment Recognition of that different behavioral constructs regardless of final diagnosis may necessitate treatment Determine degree of danger to self and others So if the patient is suicidal admit them do not let them go home, unless someone will watch them 24hours and will never leave their side. Assess for co-morbid medical factors and conditions which can influence management

Family Doctors Perspective

The interface between providers in our office encourages a free flow of information and feedback which allows us to be more immediately responsive to patients needs, provides a supportive environment for patients which reinforces treatment, and promotes true health and wellness

Physician Attributes Which Facilitate Diagnosis and Management

Positive attitude towards patients with psychological difficulties Belief in the role that psychological factors may have in physical and mental disorders Psychological disorders are amenable and important to treat Ask more open ended questions Do not seem to rush or brush aside matters brought up by patients Do not interrupt or finish statements or responses of patients Convey empathy
Empathy, you understand and feel anothers feeling for yourself, while sympathy you have compassion for that person but you dont necessarily feel her feelings. [From the net]

Areas of Competence of PCP and Non-Psychiatrist

Recognition and diagnosis of psychological disorders Appropriate use of psychotropic agents Techniques of simple forms of psychotherapy

Qualities needed
Experienced Independent Thinker Flexible Confident Experience on a health team
edited by: Ilao

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