Revised/Abridged

UPDATE in PSYCHIATRY

Robert K. Schneider, MD

Assistant ProfessorDepartments of Psychiatry and Internal Medicine

The Medical College of Virginia of

the Virginia Commonwealth University

September 16, 1999

Hurricane Floyd Cancels Schneider’s Update in Psychiatry

Richmond Times-Dispatch

Update in PsychiatryAnnals of Internal Medicine

October 5, 1999

• Drs Schneider and Levenson

• Psychiatric literature of 1998 reviewed

• Journal Editors and leaders in Consultation Liaison Psychiatry were polled

• Articles selected:– expanded or introduced psychiatric information

important to the general clinical internist– sound experimental design

Update in PsychiatryObjectives

• Why now?

• Organizing principles.

• Choose one topic of clinical importance in the

following Update in Psychiatry.

“de facto mental health system” Regier,1978

• 54% of people with mental illness who seek

treatment are exclusively seen in the

“general medical sector”

• 25% of patients in primary care setting have

a diagnosable mental illness

Why Now?• Epidemiology

– ECA Study – “de facto mental health system”– Managed Care

• Genetic basis for disease– Twin studies– Human Genome Project

• Neuroscience Research– CT to MRI to PET to SPECT scanning– Neurotransmitter basic science

• Somatic Therapies– Psychiatric Medication Explosion (“SSRI Surge”)

Organizing Principles DSM-IVAffective Disorders

Anxiety Disorders

Psychotic Disorders

Substance Abuse

Other

Organizing Principles DSM-IVAffective Disorders Major Depression, Bipolar Disorder,

Dysthymia

Anxiety Disorders

Psychotic Disorders

Substance Abuse

Other

Organizing Principles DSM-IVAffective Disorders Major Depression, Bipolar Disorder,

Dysthymia

Anxiety Disorders GAD, Panic Disorder, PTSD,

OCD, Phobias

Psychotic Disorders

Substance Abuse

Other

Organizing Principles DSM-IVAffective Disorders Major Depression, Bipolar Disorder,

Dysthymia

Anxiety Disorders GAD, Panic Disorder, PTSD,

OCD, Phobias

Psychotic Disorders Schizophrenia, Schizoaffective

Substance Abuse

Other

Organizing Principles DSM-IVAffective Disorders Major Depression, Bipolar Disorder,

Dysthymia

Anxiety Disorders GAD, Panic Disorder, PTSD,

OCD, Phobias

Psychotic Disorders Schizophrenia, Schizoaffective

Substance Abuse Alcohol, Cocaine, Nicotine, Other

Other

Organizing Principles DSM-IVAffective Disorders Major Depression, Bipolar Disorder,

Dysthymia

Anxiety Disorders GAD, Panic Disorder, PTSD,

OCD, Phobias

Psychotic Disorders Schizophrenia, Schizoaffective

Substance Abuse Alcohol, Cocaine, Nicotine, Other

Other Psychiatric Aspects of Medical Disease:

Stroke, Dementia, HIV, CAD

Other Psych:

Personality Disorders, Eating Disorders, Somatization

Affective Disorders

• Update in the AHCPR Depression

Guidelines

• Optimum length of continuation phase

therapy in depression

• Intensive standardized treatments for

depression reviewed

Treating major depression in primary care practice

Schulberg HC, Katon W, Simon GE, Rush AJ.

Arch Gen Psychiatry, 1998;55:1121-1127

• AHCPR Depression Guidelines were published in 1993

• Most of the evidence was from psychiatric patients from the specialty mental health sector

• Most Guidelines not validated in clinical practice

AHCPR Depression Guidelines:Update• The Guidelines are effective on depressed

patients from primary care setting

• There is a high attrition rate in patients treated for depression

• In patients with mild to moderate depression, antidepressants and time-limited depression-targeted psychotherapy are both effective

• A more prominent role for mental health specialists is needed in more severely depressed patients

AHCPR Depression Guidelines

Optimal length of continuation therapy in depression: A prospective assessment during long-term fluoxetine treatment

Reimherr FW, Amsterdam JD et al. Am J Psychiatry, September 1998; 155:1247-1253

• Fluoxetine 20 mg. daily for 12 weeks

• 395/839 (47%) full remission at 12 weeks

• Randomized to placebo or continued treatment– 12 weeks (0 weeks continuation phase)– 26 weeks (14 weeks continuation phase)– 50 weeks (38 weeks continuation phase)

Optimal length of continuation phase

Length of Continuation Phase

(total treatment)

Placebo-Relapse

Control-Relapse

O weeks (12 weeks) 48.6% 26.4% 14 weeks (26 weeks) 23.2% 9.0% 38 weeks (50 weeks) 16.2% 10.7%

Optimal length of continuation phase

• Continuation phase treatment should be at least 26 weeks (6.5 months)

• Total treatment is then 38 weeks (9 months)

• The study attempted to mimic primary care setting by not distinguishing between single episode depression, recurrent depression and bipolar II

• A fixed dosage and time were used during acute phase treatment

Cost-effectiveness of treatments for major depression in primary care

practiceLave JR, Frank RG, Schulberg HC, Kamlet,

MS. Arch Gen Psychiatry, 1998; 55:645-651.

Treatment cost, cost offset, and cost-effectiveness

of collaborative management of depression

Von Korff MV, Katon W, Bush T, et. al. Psychosom Med, 1998; 60:143-149

Intensive standardized treatments for depression are better than

“usual care”Lave et. al.• 276 primary care patients

with major depression• standardized nortriptyline

therapy by PCP• IPT by mental health

professionals• PCP usual care

Von Korff et. al.• 217 and 153 primary

care patients with major depression

• “collaborative care”

(2 models used)• PCP usual care

Intensive standardized treatments for depression

• Improve outcomes, but do not produce a “cost offset”

• “Cost Offset” The theory that more effective treatment of a mental illness will reduce general medical costs

• The value of intensive treatment of depression in primary care is better health outcomes, not spending less money

Anxiety Disorders

• Health care phobias are common, but rarely treated

• Assaultive and non-assaultive traumas that produce PTSD are very common in the community setting

The epidemiology of blood-injection-injury phobia

Bienvenu OJ, Eaton WW Psychological Medicine, 1998; 28:1129-36

• 1920 community residents in the Baltimore

Epidemiologic Catchment Area (1993-1996)

• Lifetime prevalence of 3.5% (onset age 5.5 years)

• 80% had symptoms in the last 6 months

• More than 1/2 had told their treating clinicians

• None received treatment

Health care-related phobias

• Examples of health care-related phobias – needles – the sight of blood or open wounds – pain – anesthesia – dental procedures

• Effectively treated with systematic desensitization

Story

Trauma and PTSD in the community, The 1996 Detroit area survey of

traumaBreslau N, Kessler RC, et. al.

Arch Gen Psychiatry, July 1998;55:626-632• A representative sample (2181) persons aged 18-

45 years old in the Detroit metropolitan area screened for traumatic events

• 90% of respondents had experienced one or more traumas

• Most prevalent trauma: the unexpected death of a loved one

• Contingent risk for PTSD (all traumas)– women: 13% men: 6.2%

Categories of traumatic events

• Personally experienced assaultive violence (37.7%)– combat, rape, mugging

• Other injury or shocking experience (59.8%)– MVA, diagnosis with life-threatening illness, witnessing

someone being seriously injured

• Learning of about traumas to others (62.4%)– a close friend or loved one experiencing the above

• Sudden unexpected death of a loved one (60.0%)

Schizophrenia and Psychotic Disorders

• Continuing trend of “deinstitutionalization’

• More patients with severe mental illness in

the community

• “Atypical” neuroleptic usage becoming

more widespread

“Other”

• Mental Health Services

• Psychiatric Aspects of Medical Disease

• Geropsychiatry

• Somatoform Disorders

• Personality Disorders

• Eating Disorders

Mental Health Services

• Care of patients with severe mental illness

has further shifted from public mental

hospitals to general hospitals and the

community

Changing patterns of psychiatric inpatient care

in the United States, 1988-1994Mechanic D, McAlpine DD, Olfson M.

Arch Gen Psychiatry, 1998; 55: 785-791

• Data from 1988-1994

• National Hospital Discharge Survey

• Inventory of Mental Health Organizations and

General Hospital Mental Health Services

Further “Deinstitutionalization” 1988-1994

• Decrease 12.5 million inpatient days in mental hospitals

• Increase 1.2 million inpatient psychiatric days in general medical hospitals

• 90% increase in discharge rates of patients with SMI in private nonprofit general hospitals

• decreased private funding (40% to 25%)

• Increased public funding (45% to 60%)

Geropsychiatry

• “Standard” dose haloperidol (2-3mg./day) is effective for psychosis and disruptive behaviors in Alzheimer’s patients

• Tardive dyskinesia is 3-5 times more likely in the elderly taking neuroleptics than in younger patients

A randomized, placebo-controlled dose-comparison trial of haloperidol

for psychosis and disruptive behaviors in Alzheimer's disease.

Devanand DP, Marder K, Michaels KS, et al.

Am J Psychiatry, 1998; 155:1512-1520.• 2 phases (6 weeks), randomized, double blind, placebo controlled

• 71 outpatients with Alzheimer’s disease

• Three dosages:– 0.5-0.75 mg/day (“low dose”)– 2-3 mg/day (“standard dose”)– placebo

Haloperidol for psychosis and disruptive behaviors in

Alzheimer's disease

Dosage Response Rate2-3mg/day 55-60%

0.5-0.75mg/day 25-35%placebo 25-30%

20% EPS side effects in standard dosage

Prospective study of tardive dyskinesia in the elderly: rates and

risk factors. Woerner MG, Alvir JMJ, Saltz BL, et al. Am J Psychiatry, 1998; 155:1521-1528

• 261 neuroleptic-naïve patients

• Older than 55 years (mean 77years)

• Prospectively followed (mean 115 weeks)

• Haloperidol prescribed for 68% of patients

Tardive dyskinesia is 3-5 times more likely in the elderly

CumulativeRates

Time

25% 1 year34% 2 years53% 3 years

Tardive Dyskinesia is 3-5 times more likely in the elderly

• Tardive Dykinesia associated with– higher doses– longer treatment– EPS signs early in treatment (20% at “standard dose”)– previous ECT

• However- – Spontaneous Tardive Dyskinesia occurs at rates

ranging from 5-37% in the elderly

Update in Psychiatry Conclusions• There is an explosion of clinically relevant

psychiatric information occurring• The need for primary care physicians trained to

recognize, diagnose and properly manage mental illnesses is only going to increase

• Internists need a matrix to organize this new psychiatric information

• This first Update in Psychiatry is one source for the internist to advance knowledge in this area

Where’s Waldo