Primary Care Psychiatry

Introduction

• Speaker: David Rebedu

  • Background: Family practice trained with extra training from Neuroscience Education Institute

  • Focus of talk: Primary care psychiatry

  • No financial disclosures mentioned

  • Will discuss off-label uses for medications

Learning Objectives

• Goal: How to select the correct medication for the right patient at the right time.

• Consider both medication uses and side effects for optimal patient benefit.

• Q&A throughout the presentation; questions can be entered via an app or through a QR code.

Symptom Clusters in Psychiatry

• Concept of symptom clusters for assessing mental health conditions.

  • Reference to Stahl's Psychopharmacology, suggesting 40-50 distinct symptoms in DSM.

  • Acknowledgement of a meta-analysis indicating a greater number of symptoms.

  • Emphasis on overlaps between conditions such as anxiety, bipolar disorder, and ADHD.

• Suggestion to maintain a reference chart for visual aid during diagnosis in clinical settings.

Side Effects and Weight Management

• Patient concerns about side effects, particularly weight management.

• Weight loss associations with specific medications:

  • Bupropion: Should cause weight loss.

  • Fluoxetine: Causes weight loss.

  • Lamotrigine (Lamictal): Weight neutral or weight loss.

• Overview of medications primarily discussed: anxiety, depression, bipolar disorder medications.

• Mention of safe medications for breastfeeding.

Dosing Strategies

• Discussion of various dosing strategies in medication administration:

  • Flexibility in dosing speed (e.g., slow vs rapid titration).

  • Adjustment based on patient tolerance to side effects and urgency of symptoms.

  • Use of lower doses initially for sensitive patients to minimize side effects.

  • Example: Quickly titrate medication for severely depressed patients, emphasizing rapid symptom relief.

Assessing Efficacy

• Key performance indicators to measure medication efficacy:

  • Aim for at least a 30% benefit from initial low-dose treatment before switching medications.

  • Discussed tools such as PHQ-9 and GAD-7 for tracking symptom improvement.

  • Aim for 80% symptom relief before determining the effectiveness of the treatment plan.

  • Note that most patients may require combination therapies rather than a single medication.

• Clarification that not achieving complete remission is common in clinical practice.

Management of Suicidal Ideation

• Special considerations for acute patients presenting with suicidal ideation:

  • Assessing patient safety and deciding between sending to ER or managing in outpatient care.

  • The importance of having a safety plan and open communication about crises.

  • Discussion of effective treatments for acute symptoms, such as using Aripiprazole for energy-boosting in depressive states.

  • Emphasis on monitoring for any potential medication side effects, especially tardive dyskinesia.

Medications for Depression and Anxiety

• Medications discussed for various scenarios:

  • Aripiprazole (Abilify): Generally well tolerated, low side effect profile (weight gain, cholesterol).

  • Quetiapine (Seroquel): Effective for insomnia, dosages mentioned (25-50 mg).

  • Bupropion: Enhances energy, with additional benefits for weight loss and focus.

  • Buspirone: For anxiety, takes weeks to achieve full effect; initially best as needed.

  • Hydroxyzine: Effective sedating agent for severe anxiety.

  • Benzodiazepines: Recommended for acute severe anxiety situations (e.g., agoraphobia).

Alternative Approaches to Management

• Non-medication alternatives outlined:

  • Light box therapy for seasonal depression (5000-10,000 lux for 30 minutes).

  • The efficacy of exercise on mental health, dancing being particularly highlighted as beneficial.

  • The impact of diet on mood - avoidance of highly processed foods and refined sugars recommended.

  • Creating a 'dopamine menu' to encourage quick, healthy mood boosts through non-substance activities.

Common Antidepressants and Their Uses

• Discussion of various antidepressants:

  • Escitalopram: Quick onset, well-tolerated; recommended as a first-line option.

  • Vortioxetine: Good for cognitive dysfunction; established considerations for use in anxiety/depression.

  • Citalopram and Sertraline: Tolerated by patients; worth considering as inexpensive options.

  • Severities in costs for different antidepressant treatments discussed (Cost Plus Drugs).

Pharmacogenomics Considerations

• Discussion on pharmacogenomics, especially relevant to the use of medications like Paroxetine and Tramadol.

• Importance of genetic testing for effectiveness of certain medications, particularly in relation to enzyme CYP2D6.

Challenges with Specific Medications

• Overview of challenges and considerations with medications:

  • Citalopram's black box warning for QTc prolongation in higher doses, especially for elderly.

  • Bupropion: Clarification on the seizure risk and recommended dosing.

  • Duloxetine and its associated side effects, including GI distress.

Treatment for Special Populations

• Considerations for treating pediatric populations and the aging demographic:

  • Fluoxetine approved for children aged six and above, with lower risks of withdrawal symptoms due to long half-life.

• Discussion on particular cases in ADHD management.

• Emphasized importance of medication safety and tolerability in older populations, referencing mirtazapine and doxepin as options.

Importance of Monitoring and Responsible Prescribing

• Monitoring requirements for high-risk medications to avoid complications.

• Importance of knowing one’s limits in prescribing, especially with complex cases or polypharmacy situations.

• Recommendations for reaching out for psychiatric specialty care when necessary.

Conclusion

• The speaker concluded with encouragement for continuous learning and monitoring new evidence in primary care psychiatry.

• Acknowledgment of the complexity in treating psychiatric disorders and the variability in patient responses to treatments.