Primary Care of the “County Mental Health” Patient
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Transcript of Primary Care of the “County Mental Health” Patient
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Primary Care of the “County Mental Health” Patient
James A. Bourgeois, O.D., M.D.
Alan Stoudemire Professor of Psychosomatic Medicine
University of California, Davis Medical Center (1/11/04)
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Learning Objectives At end of seminar, attendees will be able to: Define the concept of “target population”
psychiatric patients Be able to use clinical literature specific to the
primary care management of serious psychiatric illness
Verbalize understanding of the mission and clinical personnel in the community mental health paradigm
Apply interviewing and observation techniques to communicate with chronically mentally ill patients
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Community Mental Health
Movement began in 1960s In concert with two major trends, without
which chronic hospitalization would have been inevitable
Development of practical antidepressant and antipsychotic medications
Trend towards libertarianism and empowerment of even impaired persons (“mainstreaming”)
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Community Mental Health Centers
Mandated program with federal legislation Various and complex funding models Meant to be arranged county-by-county Much local control Localities tend to define scope of population
served Intent in multidisciplinary service, focus on
concurrent “medical” and “social” models Need access to inpatient units for “crises” and
some long-term patients
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Personnel at CMHCs
Psychiatrists (M.D., D.O) Psychologists (Ph.D., Psy.D., some M.S.) Social Workers (M.S.W., some B.S.) Clinical Nurses (R.N., many with masters) “Clinicians” (various backgrounds, many
are psychologists and social workers in pursuit of training closure and licensure)
Case Managers (various backgrounds)
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Who is served?
Common fallacy – CMHC exists to serve “all” psychiatric illness
Reasonable assumption given psychiatric training, but:
Intent is “serious mentally ill” Using Sacramento example, “Core/Target
Population”
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“Target Population” (Sacramento) Schizophrenia Schizoaffective disorder Bipolar disorder Psychotic disorder NOS Major depression, recurrent Borderline personality disorder
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Notable exceptions
Substance abuse Dementia Child conditions Eating disorders Developmental disability PTSD Panic disorder
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Implications for Primary Care
Serious mentally ill patients may not communicate cogently and may not seek timely primary care
Increased risk of smoking and other maladaptive behaviors
Despite mental illness, considered “competent” unless judicially conserved
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How to Deal With These Patients
Understand clinical presentation of the core population illnesses (separate topical lectures)
Alert to medical side effects of common psychotropic medications
Willingness to collaborate with CMHC personnel
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Medical Concerns With Psychotropic Medications
A broad area, but will summarize here Antipsychotics Mood Stabilizers Anxiolytics Antidepressants
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Antipsychotics
Atypical >> Typical is the contemporary standard of care
Risperidone, Olanzapine, Quetiapine, Ziprasidone, Aripiprazole, Clozapine
EPS Prolonged QTc Neutropenia (Clozapine) DM, lipids (Clozapine, Olanzapine notably but
some risk with all)
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Antipsychotics
Neuroleptic Malignant Syndrome Fever Rigidity (typically high CPK) Delirium Unstable VS Can occur at any time during antipsychotic
Rx Admit to ICU
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Mood Stabilizers
Lithium Depakote Tegretol
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Lithium
Neurotoxicity Dermatologic Increased WBCs Hypothyroidism Renal
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Depakote
Increased LAE, increased NH3 Pancreatitis Weight gain Sedation Thrombocytopenia
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Tegretol
Blood dyscrasias Sedation
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Anxiolytics
Sedation Withdrawal syndrome Cognitive effects with high sustained doses
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Antidepressants
SSRI side effects TCA side effects Caution about TCA with Paxil and Prozac Caution no MAOI with or “near” SSRI
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Emergency Management
A whole separate topic Quick review For any toxic ingestion: STAT Chem 7,
LAE, NH3, UDS, blood alcohol, tylenol level, EKG
Accept no arguments
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Acute Mental Status Changes in “Psychiatric Patient”
All “suicide attempt labs” (prior) Plus: CPK (looking for NMS) Low threshold for CT or LP STAT blood levels of prescribed meds, e.g.
anticonvulsants, Lithium, TCA
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Other Considerations
Arrange pre-emptive communication channels between all personnel seeing patient at CMHC and your clinic’
Arrange for records transfer to-fro Use case managers and other “day-to-day”
therapists as confederates You need a means of access to PROMPT
CMHC follow-up, specifically including psychiatry follow-up
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Discussion/References
Primary Psychiatry 8(8) Aug 2001 several helpful articles on Primary Care of Psychiatric Patients
Integrate Telepsychiatry into care plan, esp. if local psychiatric resources are sparse