68.

PSYCHIATRIC DISORDERS IN PRIMARY CARE SETTINGS

SteveM Kick, M.D., M.S.P.H.

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

3. How do persons with psychiatric disorders present to the clinician?

Patients with psychiatric disorders often present to primary care providers with somatic complaints referable to their underlying disorder. For mood disorders, the most frequent complaints are fatigue, alteration in sleep, and chronic pain. Among anxiety disorders, panic disorder has been the most thoroughly studied for association with medically unexplained symptoms. The following table lists the prevalence of panic disorder among patients with medically unexplained symptoms:

Symptoms
Chest pain with negative angiogram Irritable bowel Unexplained dizziness Migraine headache Chronic fatigue Chest pain in emergency department
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Prevalence of Panic Disorder (%)

33-43 29-38 13 4.9 (panic) 1.6 (agoraphobia) 13-30 18

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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.

4. What medical conditions are associated with psychiatric disorders?

A number of medical conditions are associated with symptoms that may mimic psychiatric disorders. Illnesses with significant functional impairment or mortality may be associated with anxious or depressed moods. Usually, medical conditions can be diagnosed with a careful history, physical exam, and prudent laboratory tests, as demonstrated with the differentiation between panic disorder and pheochromocytomas. Panic disorder is associated with intense fear, apprehension, and, often, avoidant behavior, whereas pheochromocytomas present with recurrent bouts of hypertension, palpitations, and sweating; fear and apprehension develop later in the episode. Establishing causal relationships between medical and psychiatric disorders can be difficult, especially when the prevalence of both is high. Such is the case with depression and hypothyroidism. Although it is popular to do a variety of tests, the history and physical exam should guide the clinician. For example, computed tomography or MRI scanning of the brain generally is helpful only if the patient has a dementia or focal neurologic findings; brain scans are not helpful for the diagnosis of other psychiatric disorders. Medications also can result in symptoms that mimic psychiatric disorders. In particular, sedative-hypnotics and centrally acting antihypertensive agents, such as reserpine and clonidine, may produce a depressed mood. Contrary to popular belief, beta-adrenergic blocking agents do not generally cause depressive symptoms. Several agents can cause sleep disturbances and agitation or anorexia, such as pseudoephedrine and thyroxine. A careful medication history with diminution or cessation of the drug may reveal the cause and treat the apparent psychiatric disorder.

5. How common are substance abuse problems in primary care?

Substance abuse and dependence are quite common in primary care settings and carry significant morbidity and mortality. It is estimated that 10% of the adult population and 30-50% of persons in primary care may have alcohol abuse or dependence. The cost to society for medical care and lost productivity was estimated to be $246 billion in 1992. Alcohol abuse and dependence, the most common disorder, may aggravate a number of medical problems, including sleep disturbances, hypertension, diabetes, peptic ulcer disease, anemia, and mood disorders. Often such aggravations or laboratory abnormalities (elevated aspartate aminotransferase, alanine aminotransferase, gamma glutamyl transpeptidase, mean corpuscular volume) may alert the clinician to the possibility of alcohol use. Similarly, alteration in daily activities such as work delinquency and/or legal problems may suggest alcoholism. Screening instruments such as the CAGE questionnaire are easy to use and may have diagnostic sensitivities of 85-89%: 1. Are you Concerned about your drinking? 2. Have others Angered you about your drinking? 3. Have you felt Guilty about your drinking? 4. Have you ever had an Eye-opener (e.g., morning drink)? Unfortunately, clinicians often do not inquire about a history of substance use or use readily available screening tools. Finally, alcohol and other psychoactive substances are strongly correlated with other psychiatric disorders, particularly major depression, bipolar disorder, panic disorder, social phobia, and posttraumatic stress disorder.

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Psychiatric Disorders in Primary Care Settings

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

The M a n a g e m e n t of Chronic Pain

BIBLIOGRAPHY

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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.

69. THE MANAGEMENT OF CHRONIC PAIN

Ro6evt N.Jamison, Ph.D.
1. What is the difference between acute and chronic pain? Acute pain generally is associated with tissue damage and represents a warning of injury to the individual. It is expected to be directly proportional to the sensory input of the tissue damage and to continue until the damaged tissue and/or afferent pathways have returned to normal functioning. Chronic noncancer pain, in contrast, is a persistent condition often associated with an initial episode of acute pain but continuing long past the time when healing would normally take place. Chronic noncancer pain serves no beneficial purpose and is resistant to medical intervention.

2. What are the different categories of pain?

Pain syndromes may be categorized according to the character and history of the symptom: Acute pain is self-limiting, usually of less than 6-month duration, and generally adaptive in nature (e.g., postsurgical pain, dental pain, pain following injury). Recurrent acute pain consists of a series of intermittent episodes of pain that are acute in character but chronic insofar as the condition persists for more than 6 months (e.g., migraine headaches, trigeminal neuralgia, temporomandibular disorder). Chronic nonmalignant pain persists beyond 6 months and is intractable. Pain severity varies over time and may or may not have a known relationship to active pathophysiologic or pathoanatomic process (e.g., chronic mechanical low back pain, diffuse myofascial pain syndrome). Chronic progressive pain increases in severity over time and often is associated with malignancies and degenerative disorders (e.g., skeletal metastatic disease, rheumatoid arthritis).

3. How do psychogenic and organic pain differ?

Chronic pain represents a complex interaction of factors. The pain typically is related to an initial somatic event but, over time, is increasingly influenced by the patients personality, beliefs, and environment. Attempts to reliably distinguish between organic and psychogenic pain have been largely unsuccessful. Many practitioners incorrectly believe that chronic pain reflects either organic pathology or psychogenic symptoms. If physical findings are inadequate