PSYCHIATRY & PSYCHOTROPICS FOR INTERNIST

Professor Md. Mahabubul Islam Majumder Professor & Head, Department of Medicine Comilla Medical College, Comilla Bangladesh

Contents

1. Introduction 2. Prevalence of psychiatric illness, Drug use 3. Comorbidities 4. Psychotropic drugs 5. Role of Internists 6. Conclusion

INTRODUCTION

Internists

• Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment and compassionate of adults across the spectrum from health to complex illness. – Caring the whole patient.

www.ACP.org

Cont…

• Mental health services are an essential element of the health care services.

• Promotion of mental health and the diagnosis and treatment of mental illness in the individual and family context are integral components.1,2

1. American Academy of Family Physicians. Family physician, scope, philosophical statement." AAFP Reference Manual. Leawood, KS: AAFP, 1999.

2. American Academy of Family Physicians. Mental Health, physician responsibility." AAFP Reference Manual. Leawood, KS: AAFP, 1999.

Cont…

• Mental health issues are frequently unrecognized and even when diagnosed- not treated adequately.

• Recognition and treatment of mental illness are significant issues for primary care physicians, who provide the majority of mental health care.

1. J Fam Pract. 1998;46(5):410-418. 2. N Engl J Med. 1992;326(16):1080-1084. 3. Gen Hosp Psychiatry. 1997;19(2):98-111. 4. Am J Manag Care. 1998;4(9):1319-1322, quiz 1323-1324. 5. 2008 statistical data from World Health Organization, Global Health Observatory database, Avenue Appia

20, 1211 Geneva 27, Switzerland. 6. 2008 statistical data from Substance Abuse and Mental Health Services Administration’s “National

Expenditures for Mental Health Services and Substance 7. Abuse Treatment Report”

Cont…

• Internists are playing an increasing role in providing mental health care.

• Psychotropic drugs is used by internists in treating and caring for mental disorders.

• J Med Assoc Thai. 2009 Feb;92(2):266-72.

Cont…

• Internists reported positive attitudes and relatively high competence.

• They were least committed to treat patients with substance misuse.

BMC Health Services Research 2014 14:208, DOI: 10.1186/1472-6963-14-208

Cont……

• Geriatrics are fastest growing segment the coming decades.

• Older adults get many psychotropic medications and less care from psychiatrist.

• Psychotropic use in cognitive disorder is highly controversial.

J Am Geriatr Soc. Published online July 3, 2015 abstract. Journal of Mental Health Research in Intellectual Disabilities.2013; 33:1021-1026

Contd……. • Geriatric patients are sensitive to

Psychotropics side effect and greater potential for polypharmacy related adverse events.

J Am Geriatr Soc. Published online July 3, 2015 abstract.

Contd…….

• In emergency department –medical and surgical disorders are misdiagnosed as psychiatric condition 9.1%.

• DSM defines psychiatric presentation of a medical illness as a mental disorder.

Emergency Medicine Clinics May 1, 2000, vol-18, issue 2, page 199-209.

Contd…….

• Attend the “whole” person is part of the preamble of many discussions.

• Psychiatric factors precipitate physical health problems; physical health problems with psychiatric consequence and the effect of concurrent mental and physical health problems on one another.

Aging 2000: Our healthcare destiny: vol. 1, Biomedical issues chapter 24.

Contd…….

• Psychiatrists do very little physical examination themselves, preferring to stick to mental status examination.

• Management of medical illness is left for internists.

Oxford university Press , 2010, Demystifying Psychiatry: A resource for patients and families.

Prevalence:

• In general population, depression, anxiety disorders and adjustment disorders are common (10%), and psychosis is rare (1.2%).

• In specialized psychiatric services, psychosis are the most common disorders.

Davidson’s Principles and Practice of Medicine, 22nd edition,2014.

Cont…

Study led by ICDDR,B - • Mental disorders are a serious overlooked

problem. • Overall prevalence is 6.5 – 31% among

adults. • Anxiety and neurosis most commonly

reported.

1. Basic psychiatry 2014; 14:216. 2. The independentbd.com 27 Feb. 2016 3. icddr,b & national institute of mental health news -2015.

Cont…

• In Bangladesh in non-psychiatric patients . - The rate of psychotropic drugs prescribing was 8.3% - 11.2% in SSMC and HFRCMH more in elderly and female. • Benzodiazepines followed by

antidepressants and antipsychotics. • Psychotropics use is more in different

systemic disorders.

Bangladesh J Pharmacol.2015; 10:148-151.

Cont…..

• Mental disorders constitute major health problem & contribute 13% of health, specially in low and middle income community.1,2

• The prevalence of depressive disorders approx.- 8%.

• As in adults, the prevalence of depression in girls 3 times as great as that in boys for the same age group. 3

1. BMC Psychiatry 2014; 14:216 2. WHO 2008 3. JAMA. 2000;283(2):212-220

l

Cont….. • No mental health authority in this country

even no human right NGO. • WHO ranks BD in top 10 causes of global

disability & premature mortality.3

1. WHO AIMS report on mental health system in Bangladesh 2007. 2. Arch. Gen. Psychiatry 2011; 68:241-251. 3. Psychiatry serv. 2003; 54:142-4

Cont…

• 11% to 36% of primary care patients have a psychiatric disorder, urban family medicine practices revealing that over 40% (2008 statistical data from WHO) 2,3.

1. 1. JAMA. 1998;279(7):526-531. 2. Arch Gen Psychiatry. 2005;62(6):617-627. 3. J Am Acad Child Adolesc Psychiatry. 2010;49(10):980-989

Cont…

• Increased trend of psychotropic drug use in children and adolescents in the UK.

• Stimulant prescriptions rose significantly from 0.03 per 1,000 in 1992 to 2.9 per 1,000 in 2001.

• Increased prescribing was also noted for antidepressants (1.6-fold), hypnotics/anxiolytics (1.3-fold)

• Eur J Epidemiol. 2009;24(4):211-6. doi: 10.1007/s10654-009-9321-3. Epub 2009 Mar 5.

Cont… • Psychotropic medication use was more

prevalent among women than men.

J Clin Epidemiol. 2004 Mar;57(3):309-17 General hospital psychiatry, 1998; 20(6):371-376.

Co morbidity:

• Co morbidity as HTN, Dyslipidemia, DM, obesity, asthma, CVD is very high >50% cases, and with poor outcome, and ↑ length of hospital stay. 1,2,3

• 80% patient with BD has medical morbidity.4,5

1. Current Opin Psychiatry 2008; 21(4):398-402 2. Psychosom Med 2005: 67(1):1-8. 3. Psychosomatics 2007; 48(5) : 412-417. 4. Bipolar disord, 2004; 6:388-73. 5. Jama, 2005; 293:2528-30

Cont…

• Many patients somatize their psychological issues.

• 1 in 3 patients emergency department with acute chest pain is panic disorder or depression.

• 80% of patients with depression present initially with physical symptoms.

• Presentation creates a challenge for physicians.

• Gen Hosp Psychiatry. 1997;19(3):169-178.

Cont…

• Functional somatic syndrome, psychological factors influence presentation, management and outcome of medical condition.

Davidson’s Principles and Practice of Medicine, 22nd edition,2014 • Arch Gen Psychiatry. 2005;62(6):617-627

Cont…

• Patients CHD &DM are much more likely to have mental health conditions - depression and anxiety.

• On the other hand, patients with chronic mental illness lose up to 25 years of life early death from CVD.

• http://psychiatry.duke.edu/com-2004-2005

Cont…

• Etiology of psychiatric disorders is multi- factorial -

• Organic mood disorders – – Neurological – Stroke, ICSOL, epilepsy – Endocrine – Hypothyroidism, hyperthyroidism – Malignant disease – Infection – CTD – Drugs – Phenothiazine, Steroid.

Davidson’s Principles and Practice of Medicine, 22nd edition,2014.

PSYCHOTROPIC DRUGS • Psychotropic drugs -most prescribed class. • Synonymous terms psychotropic,

psychoactive and psychotherapeutic drugs. • 4 categories are - Antipsychotics or

neuroleptics, Antidepressants, Anti manic and anti anxiety drugs.

• Anticonvulsants/ antiepileptic are 5th group psychotropic according to WHO.

1. KAPLAN &SADOCK'S POCKET HANDBOOK OF PSYCHIATRIC DRUG TREATMENT, Wolter kluwer, 6th edition,2014. 2. IMDBDVINA ACCESS AND USE OF PSYCHOTROPIC MEDICINES-WHO.

Cont……

• There is no psychotropic drug that is effective in all patients.

KAPLAN &SADOCK'S POCKET HANDBOOK OF PSYCHIATRIC DRUG TREATMENT,Wolter kluwer, 6th edition,2014

Cont…

• They were prescribed not only for mental but also for musculoskeletal and chronic pain disorders.

• A quarter of the patients received psychotropic drugs as well as long-term medications without diagnosis

• J Med Assoc Thai. 2009 Feb;92(2):266-72.

Cont…..

• Many drugs of one class are used to treat disorders previously assigned to another class.

• Multi-morbidities with polypharmacy given mass adverse effects with psychotropics – also remains controversial.

Aging health (2013); 4(3):255-264.

NUTRITION REVIEW ARCHIVE APRIL 22, 2013

Cont…

Precaution: • Adverse effects are unavoidable risk of

medication. • Clinicians should be fully aware of any

warnings and precautions and should anticipate how to respond to more common adverse effects.

KAPLAN &SADOCK'S POCKET HANDBOOK OF PSYCHIATRIC DRUG TREATMENT,Wolter kluwer, 6th edition,2014

Cont…

• The risk of adverse drug events and hospital-related morbidity and mortality among older adults occur with potentially inappropriate medication use.

Am J Geriatr Pharmacother. 2006 Dec; 4(4):297-305.

Cont…

• With psychotropic medication B vitamin depletion is common, lithium depletes folic acid.

• Selections of Psychotropics on case-by-case basis in order to minimize the adverse effect.

•

NUTRITION REVIEW ARCHIVE APRIL 22, 2013.

Role of Internists

• Internist has important role in primary care, 70% of mental is treated in US by internist.

• Despite a high prevalence of depression, it is often unrecognized, barriers to provide drugs or appropriate medication.

BMC Psychiatry 2010 10:30. DOI: 10.1186/1471-244x-10-30. (Japan study)cs.

Cont…

• Psychiatric diagnoses lacked in a substantial part of cases.

• Closer interdisciplinary cooperation between internists and psychiatrists is recommended to improve psychotropic drug therapy in older, often multimorbid patients in internal medical wards.

• Dtsch Med Wochenschr. 2014 Feb;139(9):417-22. doi: 10.1055/s-0034-1369817. Epub 2014 Feb 20 KAPLAN & SADDCK’S, POCKET HANDBOOK OF PSYCHIATRIC DRUG TREATMENT 6th edition, 2014.

Cont…

• The introduction of manual appeared to influence some of the practices associated with the prescribing and administration of psychotropic medications.

• Among internists,35% were very confident and 48% were mostly confident about their overall ability to manage, which should be improved.

1. Int J Nurs Stud. 2008 Oct;45(10):1403-10. doi: 10.1016/j.ijnurstu.2008.01.004. Epub 2008 Mar 4 2. JAMA. 1998;279(7):526-531. 3. Psychiatr News. 1998;(March):17

Cont…

• Compared with others. internists would generally be most comfortable with the prescription of Psychotropics.

• younger, rather than older, internists would be more comfortable with prescribing psychotropic medications.

• Int J Psychiatry Med. 2006;36(1):85-92.

Cont…

• A medicine unit is accoutered to handle acute psychiatric and medical illness in one setting run as a co-attending model.

• Unless they are effectively treated, these patients will lengthen hospital stay, double early readmission rates.

1. Today’s Hospitalist, February 2016. www.todays hospitalist.com. 2. PLOS One. 2011; 6&25987

Conclusion

• Internists play important role in treat of psychiatric patients globally,

• Psychiatric disorders and comorbidities should be evaluated.

• Clinical guidelines for many different combinations of co morbidities is necessary.

• Medicine-Psychiatry integrated care will widen the two fields.

• Evolving med-psych models should be adopted.

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THANKS