Psychiatry and Primary Care

This ongoing column is dedicated to the challenging clinical interface between psychiatry and primary care. These two fields are intertwined in an inexorable relationship, which we will highlight through reviews of relevant articles and empirical studies.

Changing Provider Patterns in Mental Health Care

According to the findings of a recent study by Wang and colleagues, over the past 15 years or so, there has been an increase in the proportion of mental health needs being provided by primary care physicians. In comparing data from the original (1990–1992) and replication (2001–2003) studies of the National Comorbidity Survey, investigators determined that more mental health care is being provided by primary care clinicians (a 153% increase). This finding may, in part, be explained by the rise of safer antidepressants, particularly selective serotonin reuptake inhibitors and venlafaxine.¹

Exercise as an Augmentation Strategy for Antidepressant Monotherapy

Because so much mental health care is being provided by primary care clinicians in general medicine settings, the integration of effective and low-risk augmentation strategies is imperative. In this small but encouraging study, Trivedi and colleagues² explored the efficacy of exercise as an augmentation strategy for individuals suffering from major depression and on antidepressant monotherapy. The intervention consisted of both supervised and home-based sessions. While only eight of 17 patients completed the study, there were significant decreases in the Hamilton Rating Scale for Depression (mean decrease of 10.4 points) and the Inventory of Depressive Symptomatology Self-Report (mean decrease of 18.8 points). While larger samples and controls are needed to verify these data, the findings are particularly relevant for patients who are sensitive to medications and/or intolerant of increases in antidepressant medication, and for clinicians who limit their intervention strategies to antidepressant monotherapy.

Anticholinergic Drugs and Cognitive Impairment in the Elderly

In this French study,³ researchers examined the effects of anticholinergic medications on cognitive functioning in a cohort of 372 participants over the age of 60. In the year preceding the study, 9.2 percent of the participants had continuously used anticholinergic medications. In comparing groups, 80 percent of those continuously exposed to anticholinergic medications versus 35 percent of the remainder of the sample demonstrated cognitive impairment. Those with continuous anticholinergic exposure had significantly greater impairments in performance on several specific aspects of cognitive functioning, including reaction times, attention, delayed nonverbal memory, and narrative recall. Overall, the use of anticholinergic medications strongly predicted mild cognitive impairment (OR=5.12, p=0.001). When performing mental status examinations (psychiatric settings) or administering the Mini-Mental Status Examination (primary care settings), clinicians need to be alert to the patient's use of anticholinergic drugs and their potential negative effects on cognitive performance.

Chronic Pain and Problem Solving

In a portion of this large study⁴ undertaken in 14 rural practices by 47 physicians, investigators examined the effects of three interventions on patients suffering from both pain and psychosocial problems. The majority of participants suffered from joint (54%) and back pain (48%), most for longer than a year. The three interventions were (a) usual care (n=155), (b) self-education via a mailed booklet, with a notation in the medical record for the physician to inquire about pain concerns (n=132), and (c) the preceding intervention plus telephone contact by a research nurse (n=184). The research nurse assessed participants' pain and psychosocial problems, explored patient preferences for pain management, reviewed the mailed self-education booklet, provided a problem-solving approach to psychosocial problems, and alerted the physician to the patient's psychosocial issues. Telephone contacts by the research nurse averaged three per participant. In comparing the three strategies, at six months, there was a significant difference between the control group and the intervention group with nursing contact. Specifically, there were significant reductions in self-report measurements of bodily pain and limitations in emotional and physical roles as well as increases in vitality. These findings suggest that in pain patients with psychosocial problems, emotional support and problem solving can actually reduce pain scores and improve overall functioning. This conclusion underscores the importance of psychiatrists recommending brief psychotherapy intervention for pain patients with psychosocial stressors.

Conclusion

Primary care physicians are providing more mental healthcare than in the past. The use of exercise for antidepressant augmentation, an awareness of the deleterious effects of anticholinergic drugs on mental functioning, and the use of problem-solving approaches in patients with pain will hopefully facilitate patient management in both psychiatric and primary care settings.