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)

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

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”)

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

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)

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”

“Target Population” (Sacramento) Schizophrenia Schizoaffective disorder Bipolar disorder Psychotic disorder NOS Major depression, recurrent Borderline personality disorder

Notable exceptions

Substance abuse Dementia Child conditions Eating disorders Developmental disability PTSD Panic disorder

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

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

Medical Concerns With Psychotropic Medications

A broad area, but will summarize here Antipsychotics Mood Stabilizers Anxiolytics Antidepressants

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)

Antipsychotics

Neuroleptic Malignant Syndrome Fever Rigidity (typically high CPK) Delirium Unstable VS Can occur at any time during antipsychotic

Rx Admit to ICU

Mood Stabilizers

Lithium Depakote Tegretol

Lithium

Neurotoxicity Dermatologic Increased WBCs Hypothyroidism Renal

Depakote

Increased LAE, increased NH3 Pancreatitis Weight gain Sedation Thrombocytopenia

Tegretol

Blood dyscrasias Sedation

Anxiolytics

Sedation Withdrawal syndrome Cognitive effects with high sustained doses

Antidepressants

SSRI side effects TCA side effects Caution about TCA with Paxil and Prozac Caution no MAOI with or “near” SSRI

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

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

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

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