Managing patients’ mental health concerns is inevitable in primary care. Learn how to efficiently evaluate and treat psychiatric conditions.
Steve is a 48-year-old, married, underemployed electrician with diabetes who recently moved to the area. Last week, he presented to the ER in diabetic ketoacidosis after running out of medication. You are his new physician.
As you ask him questions about his life, Steve admits he doesn't have an interest in anything and says it takes too much effort to resist sugary foods. He hasn't been treated for depression, but you suspect he is suffering from it and that it's a significant contributor to his struggles with glycemic control.
You can manage diabetes in your sleep but are less confident practicing primary care psychiatry. Treating psychological conditions in primary care is a challenge, and because of how little time you have with patients like Steve, you feel you're unable to effectively diagnose and treat psychiatric illness.
It's really no surprise Steve is depressed because depression is frequently comorbid with diabetes, as a study in Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy notes. This frequent comorbidity in depression and diabetes demonstrates how unavoidable practicing primary care psychiatry is. Increasing your ability to efficiently and effectively optimize your patients' mental health will allow them to be more successful on their path to recovery.
The role of primary care psychiatry
For a plethora of reasons ranging from stigma to a lack of access to psychiatrists, primary care physicians are often the first to hear about a patient's struggles with stress, anxiety, depression or any number of other mental health struggles. Sometimes patients don't talk about these struggles directly but instead present with the somatic manifestations that occur in relation to the symptom.
For example, a 19-year-old healthy-appearing male presents to the emergency room concerned he is having a heart attack. He has had two normal cardiac work-ups in the last year for similar complaints. He is given a dose of lorazepam and discharged after being told he is having a panic attack. He follows up with you the next day to discuss his cardiac symptoms.
Sometimes mental health conditions become apparent because of a person's struggle with physical symptoms. Getting to the root of the issue to help understand what is driving the physical complaints is the only way to help them recover.
Many physicians in primary care feel undertrained in this area and struggle to adequately evaluate and treat psychiatric conditions. Dr. Shawn Hersevoort, a psychiatrist who specializes in primary care psychiatry, teaches doctors a simple method to use when diagnosing and treating psychological conditions in primary care. In his lecture "Anxiety, PTSD, OCD, and Related Disorders in Primary Care," now available for CME credit through AudioDigest, Dr. Hersevoort shares a practical framework to use when asking screening questions within the time limitations of a typical office visit.
Assessing psychological conditions in primary care
In medicine, our preliminary diagnosis comes from understanding a patient's symptoms. When a patient complains of chest pain, we ask about specifics, and these clarifying questions help us determine the source. Is it cardiac? Gastrointestinal? Musculoskeletal? Psychiatric?
When a patient reports they have anxiety, panic attacks, depression or any other mental health symptom, we also need to ask for more information. To understand the impact of this symptom on the patient, have them describe the extent, severity, frequency and potential triggers just like you would ask a patient about their chest pain. Understanding these specifics will determine the next steps needed.
Dr. Hersevoort recommends using three categories of questions when screening for psychiatric conditions. This will allow you to quickly sort through a patient's concerns and determine if they need further investigation.
1. How bad is it? What is the severity of the symptom?
Is the complaint mild, moderate or severe? Dr. Hersevoort recommends thinking of mild as 25% impairment, moderate as 50% impairment and severe as greater than 75% impairment. For example, if you show a snake to someone who has a snake phobia, they will be severely anxious. Their panic will dominate them at that moment.
2. What is the frequency? How often do these symptoms happen?
If the person with the snake phobia lives in a city without snakes, their phobia may not need more discussion. But if a patient instead describes a fear of elevators interfering with their ability to get to work, that would require further evaluation and management.
3. What is making you feel this way? Does a particular situation trigger the symptom?
Is the anxiety they're describing generalized and nonspecific? Do they report worrying about "everything" (as with generalized anxiety disorder), or do they only feel panic when they need to ride a train, speak in front of others or engage in social activities? Do their panic attacks come out of nowhere without warning or are they triggered by something specific? Understanding the situations that bring on the anxiety will help sort out which anxiety they may have.
Assessing the mental health needs of your patients
Effective treatment of psychological conditions in primary care is often the key to illness recovery and the successful management of chronic conditions. If you understand the high prevalence of comorbidity between mental and physical illnesses, you're more likely to ask questions that will lead to treatment of all the contributing factors.
Dr. Hersevoort's lecture will help you learn how to quickly screen your patients for psychiatric conditions and guide them on how to efficiently and effectively manage their conditions. He also discusses how to decide which medication to prescribe, gives recommendations on the highest-yield rating scales and describes various "rules of thumb" to follow, including a few "don't make this mistake" rules.