Practical approaches to mental health (AAFP Scientific Assembly)

Family physicians are urged to screen their patients for mental illness and treat those whose conditions are not severe.

By — Posted Oct. 17, 2011

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When a doctor prescribed an antidepressant for the daughter of Thomas Griffin Jr., MD, nearly 20 years ago, the intention was to ease her postpartum depression symptoms. Instead, she committed suicide.

"Unfortunately, we didn't know she had bipolar spectrum disorder," Dr. Griffin, a family physician in Oro Valley, Ariz., told colleagues during a session of the American Academy of Family Physicians Scientific Assembly in Orlando, Fla., Sept. 14-17.

Antidepressants increase the risk of suicide in bipolar patients, research shows.

Dr. Griffin grieved his daughter's death for months. When he returned to work, he did so with a new focus borne of that tragedy -- never overlook a patient with bipolar disorder.

Nearly two decades later, bipolar disorder and many other mental illnesses still are underdiagnosed and not properly managed, medical experts say.

One in four adults -- about 57.7 million Americans -- experiences a mental health disorder in any given year, according to the National Alliance on Mental Illness. Of these people, about 6% have a serious mental health condition such as bipolar disorder, major depression or schizophrenia.

Left untreated, mental illness can lead to unemployment, substance abuse, homelessness and suicide, the alliance says. And yet, only 36% of adults with mental illness received medical treatment for their condition within a 12-month period, according to 2005 data from the National Institute of Mental Health.

Part of the problem, experts say, is that the responsibility of identifying mental health conditions increasingly is falling on primary care physicians, many of whom have limited time for office visits and little training in treating such disorders.

To help physicians properly diagnose and manage mental illness, the fifth edition of the Diagnostic and Statistical Manual of Disorders is expected to include practical information for primary care doctors. The manual is scheduled for release in 2013.

Some of the proposed changes include reducing the 10 personality disorder categories to six and widening the criteria for anorexia nervosa and bulimia nervosa.

At the AAFP meeting, medical experts reminded physicians that they are often the first to see mental illness, and it is their responsibility not only to detect the conditions but also to treat them.

"Primary care physicians are in a perfect position, because they see people over and over again and should be able to pick up on changes and dysfunction in the patient" over time, Dr. Griffin said.

Overlooking mental illness

Among the most overlooked mental health conditions is postpartum depression, said family physician Barbara Yawn, MD, MPH. She led a session on the illness, which affects 10% to 15% of mothers within a year after giving birth, according to the Centers for Disease Control and Prevention.

Medical experts consider the illness to be underdiagnosed. A 2000 Pediatrics study of 214 women who brought their children to a pediatric clinic found that 40% of the women reported high levels of depressive symptoms, but only 29% were identified as depressed.

"People still have the mistaken idea that having a new baby is such an exciting event that there couldn't be a very big problem with postpartum depression," said Dr. Yawn, director of research at Olmsted Medical Center in Rochester, Minn. Another problem, she said, is that staff often gush over babies when new mothers come in for a medical visit. Such a reaction makes it difficult for women to admit they are having problems.

She recommends that doctors encourage their staffs to ask new mothers how they are feeling. If a woman mentions problems such as being tired, Dr. Yawn suggests staff reply, "It can be kind of tough to be a new mom. You might want to talk to the doctor about that."

Dr. Yawn encourages physicians to screen all new mothers for postpartum depression using the Edinburgh Postnatal Depression Scale. The 10-question survey can be administered while patients wait for their office visit.

If women have a score of 10 or higher, she suggests giving them the nine-question Patient Health Questionnaire, which helps assess the severity of depression. In these instances, she also recommends that physicians talk to patients to determine if the depressive symptoms could be due to another factor, such as hypothyroidism or domestic violence.

Dr. Yawn said most women diagnosed with postpartum depression can be treated with an antidepressant. She suggests that a nurse call the patient within 10 days of prescribing the drug to see how the mother is doing. Women who regularly think about harming themselves or their baby should be sent to an emergency department for care, she added.

Similar to postpartum depression, major depression often goes undetected, said Dr. Griffin, who led a session on depression, suicide and mood disorders. Some physicians mistakenly think a depressed patient has to be sad, he said. A more accurate indicator is that the individual is having less fun or enjoys things less than he or she did in the past.

NIMH data show that major depressive disorder is one of the most common mental disorders in the U.S., affecting about 6.7% of adults in any given year. Within a 12-month period, 52% of people with depression received treatment for the condition, according to NIMH.

Dr. Griffin screens his patients for depression with the PHQ-9 and uses the Mood Disorder Questionnaire to assess whether they have bipolar disorder or other mood-related conditions. The MDQ is available online at no cost.

To make sure he does not overlook bipolar disorder, Dr. Griffin also talks to a patient about how he or she is feeling and looks for symptoms of the illness, which include irritability, distractibility, insomnia, grandiosity, racing thoughts and pressured speech.

When treating depressed or bipolar patients, he tells them, "What I'm giving you might make you feel worse, but don't panic, because that will give us really good information about what might be going on and then we can select the proper treatment."

To monitor patients' reactions to antidepressants, Dr. Griffin sees them within two weeks.

Diagnosing eating disorders

Among the challenges in diagnosing mental illness is that some conditions have similar symptoms, medical experts say. Two examples are anorexia and bulimia, which are commonly misdiagnosed as depression, said David Paul Robinson, MD, a pediatrician and adolescent medicine physician in Tallahassee, Fla. He led a session at the meeting on eating disorders.

When Dr. Robinson sees a patient who has been losing weight, he typically says, "You looked better last year. What do you think about gaining 12 pounds?" If the patient starts to cry at the thought of putting on weight, he said the problem probably is anorexia or bulimia, not depression.

About 3% of youths 13 to 18 will have a severe eating disorder some time in their lives, according to NIMH. The disorders are more than 2½ times more common in girls than in boys. To help diagnose an eating disorder, Dr. Robinson recommends looking for signs of the illness. Patients with anorexia are preoccupied with food, calories and weight and often wear baggy or layered clothing. Bulimia is characterized by binge eating followed by vomiting or excessive exercise. Other symptoms include a chronically inflamed and sore throat, worn tooth enamel and acid reflux disorder.

After diagnosing an eating disorder, Dr. Robinson calculates the patient's body mass index and checks vital signs. He takes a patient history with the parent in the room so he can watch the adult's response when the child responds to questions about eating habits. A child with an eating disorder often will lie about how much food he or she consumes, said Dr. Robinson, an associate clinical professor at Florida State University College of Medicine.

He weighs patients at every visit but does not let them see their weight. He recommends that physicians avoid telling those with an eating disorder, "You look great." Patients often interpret that comment as meaning they have gained weight and are fat.

Dr. Robinson encourages physicians to see such patients regularly. He also suggests including counselors and nutritionists in the management of such patients.

Antidepressants can help treat patients with bulimia by reducing binge-eating episodes and depression and lessening the chance of relapse, Dr. Robinson said. But he said the drugs are not effective in treating anorexia. He recommends hospitalizing patients who weigh less than 75% of the expected body weight for their height.

Dr. Yawn said learning how to identify and manage mental health disorders can be a challenge. "In family medicine, we are supposed to be able to treat common illnesses," she said. "It is incumbent upon us to learn how to treat" these disorders.

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Family physicians stay on front lines to treat substance abuse

Most of the patients Raymond M. Pomm, MD, sees started abusing drugs between ages 12 and 13. At least one began taking drugs at age 6.

"Substance abuse is a big problem, and it's not getting smaller," Dr. Pomm, an addiction psychiatrist in Jacksonville, Fla., said during a session on addiction that he led at the American Academy of Family Physicians Scientific Assembly in Orlando, Fla., Sept. 14-17.

He told family physicians they are on the front line of the issue.

"You're the first [health professionals] seeing them," he said.

In 2008, an estimated 22.2 million people 12 and older were diagnosed with substance dependence or abuse, according to the Substance Abuse and Mental Health Services Administration. Marijuana had the highest levels of dependence or abuse, followed by pain relievers and cocaine.

Dr. Pomm said physicians need to identify addicted patients in their practices and help them manage the disease before they can treat other medical issues effectively. To help detect substance abuse, he encourages doctors to know the signs of addiction for commonly abused drugs such as opioids and stimulants.

He recommends that physicians give patients the four-question CAGE questionnaire if they think a patient is abusing alcohol. The tool, which is available online at no cost, also can be adapted to assess different types of drug addictions.

If a patient tests positive for alcohol addiction, Dr. Pomm said primary care physicians can try treating him or her with medication as long as the individual's condition is not life-threatening. He said that primary care treatment is more likely to be successful if the patient is responsible and has a stable income and support system.

In many cases, patients whose condition is severe should be referred to a specialist for treatment, he said.

To help prevent patients from developing an addiction, he recommends that physicians who prescribe medication for chronic pain administer long-acting opioids.

Dr. Pomm said short-acting medications are more addictive.

"You can act as a catalyst for assisting with the change, but it is the patient who must quit," he told physicians at the AAFP meeting.

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Treatment tips

Here are some patient treatment tips from the American Academy of Family Physicians Scientific Assembly:

Educate patients who refuse vaccines. Physicians should not stop caring for patients who refuse to be vaccinated, said Jonathan L. Temte, MD, PhD, vice chair of the Advisory Committee on Immunization Practices and a professor of family medicine at the University of Wisconsin School of Medicine and Public Health.

Rather, doctors should use evidence-based information to educate such patients on the benefits of immunizations and the reported side effects, said Dr. Temte, who led a session on vaccine safety. He said that when doctors acknowledge patients' immunization concerns and respond with facts, vaccine-refusers often change their minds and get immunized.

Implement disease management plans to assist diabetic patients. Patients with diabetes can be helped with a disease management plan that includes drug prescriptions and lifestyle modifications, said family physician Peter J. Ziemkowski, MD, assistant professor of family medicine at Michigan State University Kalamazoo Center for Medical Studies.

Dr. Ziemkowski, who led a session on diabetes treatment, recommends that physicians talk to diabetic patients about the disease, as well as the activities they engage in, their diet and other habits, such as drinking alcohol and smoking. He encourages doctors to work with patients to create a plan aimed at glycemic control and overall good health.

Ask pregnant women about lead exposure. About 600,000 U.S. women of childbearing age have elevated lead levels in their blood, said Kern Low, MD, a family physician in Pueblo, Colo. Lead can be passed to babies during pregnancy and through breast milk, he added.

Dr. Low, who led a session on lead poisoning, recommends that physicians ask all pregnant patients about their risk factors for lead exposure, such as remodeling a home built before 1978 or working in an automotive repair shop. If a risk factor is identified, he said a blood-lead test should be administered. Women who have high levels of lead should be referred to a specialist, Dr. Low said.

Wash hands to avoid infection. One in 20 hospital patients will contract a health care-associated infection that will keep them in the hospital longer than originally expected, said Vincent Hsu, MD, MPH, an epidemiologist at Florida Hospital in Orlando.

To help protect patients, physicians should wash their hands every time they enter a patient's room, using an alcohol-based solution or soap and water, and should also remove catheters as soon as possible, said Dr. Hsu, who led a session on emerging infections and infectious diseases.

If a patient develops a health care-associated infection, Dr. Hsu recommends that physicians acknowledge what happened.

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External links

American Academy of Family Physicians 2011 Scientific Assembly (link)

National Institute of Mental Health (link)

Mood Disorder Questionnaire (link)

Patient Health Questionnaire (link)

American Psychiatric Association, DSM-5 Development (link)

"Do pediatricians recognize mothers with depressive symptoms?" Pediatrics, December 2000 (link)

CAGE self-assessment questionnaire on alcohol abuse, HealthPartners (link)

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