Managing Psychotic Disorders in the Primary Care Setting Anne Dohrenwend, Ph.D., ABPP McLaren Regional Medical Center Heather Kirkpatrick, Ph.D., ABPP Genesys Regional Medical Center Presentation Outline Introduction: Facts about Psychosis in Primary Care Part I: Case Examples Part II: Guidelines for Management Psychosis Defined Loss of ego boundaries or gross impairment in reality testing Psychotic Symptoms Hallucinations Auditory or visual Disorganized speech Catatonic behavior Delusions Fixed, false beliefs Prevalence One study of 1,000 adults in primary care found 3.7% of patients being seen in the office reported one or more psychotic symptoms Most common was a belief that others were spying on them or following them Olfson, Weissman, Leon, Farber, Sheehan (1996). Psychotic symptoms in primary care. Journal of Family Practice. 43(5):481-8. Psychotic Disorders … Psychotic symptoms are the defining feature Psychotic Disorders Brief Psychotic Dx Delusional Disorder Schizoaffective Disorder Schizophrenia Schizophreniform Shared Psychotic Dx Substance-Induced Psychotic Dx Prevalence Disorder Lifetime prevalence Schizophrenia + 0.7-1.2% Schizophreniform Delusional Disorder .03% Brief Psychotic Disorder unknown, but uncommon Schizoaffective Disorder unknown, but less than schizophrenia Substance Induced unknown, but probably Psychotic Disorder highest Disorders with Associated Psychotic Symptoms Alzheimer’s Dementia Lewy Body Disease/Dementia Amnesic Disorders Cognitive Disorders Mood Disorders with Psychosis Specifiers Major Depression with Psychosis Mania with Psychosis PART I Case Examples Case I 71 yr old wf known to the PCP. Pt is always very well groomed, appropriate. Longstanding complaints re: husband, e.g. stealing her things, breaking her things. This appt. pt. tells PCP that husband has her followed, at all times, and has bugged the house. Husband is in the waiting rm. Interventions Cognitive Screen Normal range on Folstein Ramparts suggested frontal impairment Referred for neuropsychological assessment Referred to neurology Interventions Interviewed daughter Non-bizarre delusions noted Held family meeting and discovered driving while taking photos of cars behind her disconnecting lights, phones looking for bugs purchasing secret storage areas for her belongings was hospitalized, briefly once, due to pointing gun at husband’s head Interventions MRI T2 signal abnormalities in subcortical white matter, some periventricular. Mildly atrophic frontal lobes and left superior parietal lobe EEG normal Frontotemporal Dementia Critical Event Occurs Patient becomes overwhelmed, anxious in office. Falls to her knees crying Sent to ER for inpatient psychiatric treatment Sent home due to dementia diagnosis, e.g., no local psychiatric floor accepting patients with dementia Interventions Referred to Cottage Hospital, with geriatric unit pt. has inpatient stay, but psychiatrist diagnoses personality disorder; admits he did not read neuropsychological testing results pt sent home with no improvement Interventions Referred pt to geriatric psychiatrist at Henry Ford Frontotemporal Dementia confirmed Klonopin, .5 TID prescribed Interventions Educated family Restricted driver’s license Suggested separation from husband Referred husband for counseling Recommended hospitalization under geriatric psychologist at next outburst Recommended family obtain legal guardianship Results After two sessions, patient failed to follow through with geriatric psychiatry Patient continues to be seen by the PCP who prescribes Klonopin, which does help to calm patient. SSRI tried with no positive effect. Family failed to follow through with recommendations for guardianship Case II 56 yr old white female sees her PCP for for reoccurring abdominal pain (8 out of 10, sharp, transient, interferes with eating). She believes tubing was left in her stomach during surgery years ago. Pt. had several studies (x-ray, ultrasound) showing no object in the abdomen. Accompanied by her newly wed husband. No known psych hx. Delusional Disorder Interventions Obtained permission to have a meeting where x-ray results were viewed with both husband and pt, together Asked psychologist to join and attend this meeting Confronted patient with delusional diagnosis and need for treatment Results Husband believed wife who explained that the tubing moved around and was not always visible in the abdomen Strongly urged pt to see psychiatrist for evaluation, but she refused Decided on close f/u with PCP Other Possible Interventions Involuntary Hospitalization MRI Attempt to contact alternative family member Case III 19 yr old AA male, HS graduate, unemployed, living with older sister. Sister says pt. has had slow decline in function over a year. Says he plays videos all day. Mood is sad or flat. Can’t make decisions, “like whether to turn the light switch on or off.” Sister took pt to the ER. They diagnosed Major Depression, urged her to bring the pt to his PCP for treatment. Case III, Continued Explored possible reasons for poor function No history of learning disability or MR No head injury Mild to moderate depression No homicidal or suicidal ideation Psychosis Pt. vague about hearing voices Ideas of reference: music had a special messages for him New Onset Schizoaffective Disorder, Depressive Type Interventions Made appt. to see psychiatrist in one month (first available appointment) Treated with Seroquel, (50mg daily for one week, increased to 100mg) F/u on a weekly basis until pt saw psychiatry Results Dramatic improvement in behavior Psychotic symptoms controlled Pt care successfully transferred to psychiatry Case IV 50 yr old wf arrives to appt. with her husband. Husband says he has taken her to the ER multiple times, thinking she would be hospitalized, but she is repeatedly sent home. He is concerned because she is sleeping in the car. The patient appears unkempt, dirty. She rocks back and forth. Speech is tangential. Affect and mood are very anxious. Case IV, Continued Evaluated anxiety cleanliness rituals Resulting in inability to touch or move through certain areas fear of losing things Husband reveals that pt checks and rechecks garbage to be sure nothing is unintentionally thrown out Obsessive Compulsive Disorder, with Poor Insight Interventions Paged psychiatry on call Clarified pt hx in ER Established risk to self due to functionality debilitation inability to enter home, poor hygiene, poor nutrition, poor insight (specifier) Results Psychiatry arranged for direct admit to floor-pt stayed 2 weeks Important Points Re: Transfer We contacted patient registration and told them to expect the patient and her husband Faxed psychiatry our notes and recent labs Case V 45 yr old wm makes appt. with PCP for psych medication refills. He says he is schizophrenic, new to the area, on no medications. Thinks he knows med names, but not doses. Hx of multiple suicide attempts. Affect is flat. Behavior is cooperative. Reports anxiety and hearing voices. Schizophrenia, (did not establish type) Interventions Did not treat this patient due to seriousness of symptoms, e.g. suicide attempts Referred to the ER Results Pt. accepted for inpatient treatment Guidelines for Management When confronted with psychotic symptoms: Know legal standards Attempt to determine onset of symptoms Rule out medical causes Form collaborative treatment plan Part II Guidelines for Management Guidelines for Mangement Know the legal standards Legal Standards HIPPA allows for disclosure “SPECIAL SITUATIONS” We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations: To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you to prevent a serious threat to your health and safety or the health and safety of the public or another person.” Know your state’s statutes for involuntary admission Legal parameters Depend upon state mental health code Fairly standard, but should check “Mental health statutes” as search term HIPAA Michigan’s Mental Health Statute 330.1401 “Person requiring treatment” defined; exception. Sec. 401. (1) As used in this chapter, “person requiring treatment” means (a), (b), or (c): (a) An individual who has mental illness, and who as a result of that mental illness can reasonably be expected within the near future to intentionally or unintentionally seriously physically injure himself or herself or another individual, and who has engaged in an act or acts or made significant threats that are substantially supportive of the expectation. (b) An individual who has mental illness, and who as a result of that mental illness is unable to attend to those of his or her basic physical needs such as food, clothing, or shelter that must be attended to in order for the individual to avoid serious harm in the near future, and who has demonstrated that inability by failing to attend to those basic physical needs. (c) An individual who has mental illness, whose judgment is so impaired that he or she is unable to understand his or her need for treatment and whose continued behavior as the result of this mental illness can reasonably be expected, on the basis of competent clinical opinion, to result in significant physical harm to himself or herself or others. This individual shall receive involuntary mental health treatment initially only under the provisions of sections 434 through 438 of this act. (2) An individual whose mental processes have been weakened or impaired by a dementia, an individual with a primary diagnosis of epilepsy, or an individual with alcoholism or other drug dependence is not a person requiring treatment under this chapter unless the individual also meets the criteria specified in subsection (1). An individual described in this subsection may be hospitalized under the informal or formal voluntary hospitalization provisions of this chapter if he or she is considered clinically suitable for hospitalization by the hospital director. History: 1974, Act 258, Eff. Nov. 6, 1974;¾Am. 1975, Act 179, Eff. Aug. 6, 1975;¾Am. 1995, Act 290, Eff. Mar. 28, 1996. Michigan’s Mental Health Statute A. expected within the near future to intentionally or unintentionally seriously physically injure himself or herself or another individual, and who has engaged in an act or acts or made significant threats that are substantially supportive of the expectation. B. unable to attend to those of his or her basic physical needs such as food, clothing, or shelter C. whose judgment is so impaired that he or she is unable to understand his or her need for treatment and whose continued behavior as the result of this mental illness can reasonably be expected, on the basis of competent clinical opinion, to result in significant physical harm to himself or herself or others. An individual whose mental processes have been weakened or impaired by a dementia, an individual with a primary diagnosis of epilepsy, or an individual with alcoholism or other drug dependence is not a person requiring treatment under this chapter unless the individual also meets the criteria specified in subsection (1). A, B or C. Illinois Mental Health Code 405 ILCS 5/3-600) (from Ch. 91 1/2, par. 3-600) Sec. 3-600. A person 18 years of age or older who is subject to involuntary admission and in need of immediate hospitalization may be admitted to a mental health facility pursuant to this Article. (Source: P.A. 80-1414.) (405 ILCS 5/3-601) (from Ch. 91 1/2, par. 3-601) Sec. 3-601. Involuntary admission; petition. (a) When a person is asserted to be subject to involuntary admission and in such a condition that immediate hospitalization is necessary for the protection of such person or others from physical harm, any person 18 years of age or older may present a petition to the facility director of a mental health facility in the county where the respondent resides or is present. The petition may be prepared by the facility director of the facility. (b) The petition shall include all of the following: 1. A detailed statement of the reason for the assertion that the respondent is subject to involuntary admission, including the signs and symptoms of a mental illness and a description of any acts, threats, or other behavior or pattern of behavior supporting the assertion and the time and place of their occurrence. Missouri MH Statutes 9) "Likelihood of serious harm" means any one or more of the following but does not require actual physical injury to have occurred: (a) A substantial risk that serious physical harm will be inflicted by a person upon his own person, as evidenced by recent threats, including verbal threats, or attempts to commit suicide or inflict physical harm on himself. Evidence of substantial risk may also include information about patterns of behavior that historically have resulted in serious harm previously being inflicted by a person upon himself; (b) A substantial risk that serious physical harm to a person will result or is occurring because of an impairment in his capacity to make decisions with respect to his hospitalization and need for treatment as evidenced by his current mental disorder or mental illness which results in an inability to provide for his own basic necessities of food, clothing, shelter, safety or medical care or his inability to provide for his own mental health care which may result in a substantial risk of serious physical harm. Evidence of that substantial risk may also include information about patterns of behavior that historically have resulted in serious harm to the person previously taking place because of a mental disorder or mental illness which resulted in his inability to provide for his basic necessities of food, clothing, shelter, safety or medical or mental health care; or Cont. of Missouri MH Statutes (c) A substantial risk that serious physical harm will be inflicted by a person upon another as evidenced by recent overt acts, behavior or threats, including verbal threats, which have caused such harm or which would place a reasonable person in reasonable fear of sustaining such harm. Evidence of that substantial risk may also include information about patterns of behavior that historically have resulted in physical harm previously being inflicted by a person upon another person; New York Mental Health Statutes "in need of care and treatment" means that a person has a mental illness for which in-patient care and treatment in a hospital is appropriate. "in need of involuntary care and treatment" means that a person has a mental illness for which care and treatment as a patient in a hospital is essential to such person`s welfare and whose judgment is so impaired that he is unable to understand the need for such care and treatment. "likelihood to result in serious harm" or "likely to result in serious harm" means (a) a substantial risk of physical harm to the person as manifested by threats of or attempts at suicide or serious bodily harm or other conduct demonstrating that the person is dangerous to himself or herself, or (b) a substantial risk of physical harm to other persons as manifested by homicidal or other violent behavior by which others are placed in reasonable fear of serious physical harm. Guidelines for Management Know legal standards Attempt to determine onset of symptoms Attempt to determine onset of symptoms Chronic course—more likely to be psychiatric Acute—could be medical or psychiatric in origin Late life onset—more likely to be related to dementia General Treatment Plan Know legal standards Attempt to determine onset of symptoms Rule out medical causes Rule out Head Injury substance use/intoxication Cognitive limitations Delirium Medical Tests for evaluation of late-onset psychosis In absence of delirium With delirium/dementia present Blood chemistries Yes Yes Thyroid Function Tests Yes Yes CBC with differential Yes Yes Drug levels Yes Yes ABG or oximetry Only if clinically indicated Yes UA (culture as needed) Yes Yes EKG Only if clinically indicated Yes Chest X-ray Only if clinically indicated Yes EEG Not indicated If needed LP Not indicated If needed CT or MRI May be needed Yes Heavy metal urine analysis Usually not needed Yes Neuropsychological test Only if clinically indicated Only if clinically indicated Khouzam, Battista, Emes, and Ahles (2005). Psychoses in late life: Evaluation and management of disorders seen in primary care. Geriatrics 60(3); 26-33. General Treatment Plan Know legal standards Attempt to determine onset of symptoms Rule out medical causes Form collaborative treatment plan Collaboration with others Obtain info from source other than pt Make a special effort to share information with other providers Be sure the patient is safe Persist until the patient is treated Collaboration with others Involve Neurology Order necessary studies Psychiatry Psychology Neuropsychology In Summary Presentation of psychosis in PC may increase with poor economic conditions and fiscally constrained mental health resources Management of psychosis in PC may involve temporary medical management or involuntary hospitalization And so, we need to prepare our residents for managing psychosis, the third reason for hospitalization Thanks for the opportunity to present to you!