Foreword: We Are Here for You xiii
Joel J. Heidelbaugh
Preface: Bridging the Gaps: Managing Behavioral Health in Primary Care xv
Meagan W. Vermeulen
Motivational Interviewing in Primary-Care: Substance Use Disorders beyond AUDIT/DAST 1
Primary-care settings have a unique advantage to reaching a broad range of the population and the ability to address a wide array of presenting problems, including substance-use. With high rates of substance-use in the United States and low rates of substance-use treatment utilization, the primary-care office is key in assessing and supporting patients in changing substance-use behaviors. Motivational interviewing is a conversational tool physicians can use to highlight intrinsic motivation for change and support specific changes patients want to make. Providers can also apply motivational interviewing to a variety of chronic health care behaviors.
Use of Mobile Apps & Stepped-Care Model for Treating Depression in Primary Care 11
Krista L. Herbert and James Michael M. Brennan
Stepped-care (SC) models have been adopted in primary care settings as a method for treating mental health conditions within primary care. In a SC model, a patient’s symptoms are assessed, and an intervention is prescribed that matches the severity of symptoms. Thus, the SC model offers a variety of steps and levels of treatment that range from low to high intensity. Progression in treatment is monitored on a weekly basis and patients are stepped up or down in level of care depending on their clinical response to the intervention.
Attention-Deficit/Hyperactivity Disorder Across the Spectrum: From Childhood to Adulthood 21
Daniel J. Majarwitz and Parvathi Perumareddi
Attention-deficit hyperactivity disorder is a neurodevelopmental disorder involving dysregulation of multiple neural circuits, manifesting in symptoms such as inattention, impulsivity, and hyperactivity. Diagnosis requires onset of symptoms before age 12 years. However, symptoms often persist throughout lifetime, although they may change over time. The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition formally lists the clinical criteria. Management involves pharmacologic agents, such as stimulant and/or nonstimulant medications, and providers should monitor closely for any adverse effects. Nonpharmacologic interventions may be implemented and can be used in conjunction with pharmacotherapy, although medications should be at the forefront of treatment.
Perils and Pitfalls of Social Media Use: Cyber Bullying in Teens/Young Adults 37
Jennifer Caceres and Allison Holley
Social media and technology use has increased over the past several years. Inappropriate use or overuse of social media and internet can lead to increase in mental health disorders. Primary care physicians should screen adolescents and young adults for social media and technology use and cyberbullying using a screening tool developed for healthcare settings. Parents should be educated on keeping open lines of communications with their teens to help navigate appropriate technology behaviors and put proper boundaries in place. Counseling interventional programs and educational programs can be utilized to help prevent cyberbullying and treat those who have been affected.
Mental Health Concerns for College Students: Self-Harm, Suicidal Ideation, and Substance Use Disorders 47
Mental health disorders in college students are an increasing concern within the United States. Many factors lead to the increase in disorders during this transition period but most are centered on the needed adjustments into adult life and lack of foundation to make these changes. Socioeconomic and racial demographics play a role in the risks of developing and seeking treatment of these issues. Mental health first aid may become the first-line modality to finding and treating mental health disorders in these students.
Health Disparities, Substance-Use Disorders, and Primary-Care 57
Angela L. Colistra, Andrea Ward, and Erin Smith
This chapter discusses the barriers related to treating substance use disorders (SUD) in primary-care building an argument that stigma is the largest health disparity left to overcome in this setting. Reviewing the history of treatment in primary-care, common medications prescribed, laws, and regulations that make this care possible in this setting. Owing to the sheer numbers of people with SUD and mental health concerns, primary-care and their related payers must recognize for many regions of the United States those community needs are related to the diagnosis and treatment of SUDs and their related behavioral and physical health problems.
ACE: “What Happened to You” Screening for Adverse Childhood Events or Trauma-Informed Care 71
Courtney Barry and Constance Gundacker
Trauma is common within the United States. It is important for individuals to understand how trauma may affect their health and how trauma in childhood can have adverse effects on a child’s development and health. To reduce retraumatization of patients, it is imperative to use trauma-informed approaches in a clinical encounter. Screening can be an effective way to understand a patient’s trauma history. When screening for trauma, it is important to take a family-centered approach and provide appropriate referrals if a patient screens positive for trauma. Primary care providers are essential players in addressing and preventing trauma.
Adjustment Disorder: Diagnosis and Treatment in Primary Care 83
Adjustment disorder is a disorder characterized by an extreme emotional reaction to a stressor. It is defined diagnostically with either the Diagnostic and Statistical Manual V or ICD-11 definitions. There is currently a diagnostic tool that is still being validated to assist with diagnosing adjustment disorder. The prevalence of this disorder ranges from 0.2% to 40%, depending on the stressful circumstances that the patient experiences. There are several treatments available for adjustment disorder, ranging from psychological interventions, natural therapies to pharmacotherapies.
Person-First Treatment Strategies: Weight Bias and Impact on Mental Health of People Living with Obesity 89
Stigma and bias surrounding body weight is both explicit and implicit, but the most concerning impact on individuals is internalized stigma which is correlated with poor physical and mental health. Strategies to combat this public health concern include increasing awareness, education around the complex disease of obesity, proper use of communication and language surrounding weight, health, and treatment approaches, addressing equipment and practices in the clinical environment, and larger, systemic approaches to policy. Addressing stigma for a condition impacting the majority of our population is critical for the best health and well-being of our patients and ourselves.
Eating Disorders in the Primary Care Setting 103
Eating disorders are mental health disorders with complicating medical, psychiatric, and nutritional comorbidities. Common eating disorder diagnoses include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder, and other specified feeding or eating disorder. Unspecified feeding or eating disorder is most applicable in brief acute care settings. Eating disorders occur across age, gender, racial, ethnic, and socioeconomic variables. Effective assessment, intervention, and collaborative treatment are needed to decrease risk factors and increase opportunities for recovery.
Obsessive Compulsive Disorders in the Primary Care Setting 119
Mental health is a very important component of whole health because the body, mind, and spirit are woven together to create the fabric of a person’s life. Many people in the United States and globally are living with mental health challenges, and it seems that much more attention has been given to anxiety-related mental health conditions in the past few years due to the coronavirus disease 2019 pandemic. The pandemic may certainly have accelerated the onset of mental health conditions for some who were already predisposed, whether it be to depression, anxiety, psychosis, or obsessive-compulsive disorder, to name a few.
Postpartum Depression: Screening and Collaborative Management 127
Perinatal mood disorders are a leading cause of disability worldwide and suicide is a leading cause of maternal death in the first year after giving birth. The three categories of perinatal mood disorders are postpartum blues, postpartum depression, and postpartum psychosis. Identifying risk factors may allow clinicians to provide patients with interventions to potentially prevent development of these disorders. Universal screening for perinatal mood disorders can lead to earlier identification and treatment. Collaborative care methods, incorporating the entire family into treatment, therapy service, and providing support services are recommended as first-line intervention strategies before moving on to pharmacologic management.
Geriatric Depression 143
Elizabeth Gundersen and Benjamin A. Bensadon
Late-life depression is common but underrecognized and undertreated leading to significant morbidity and mortality, including from suicide. The presence of comorbidities necessitates screening followed by a careful history in order to make the diagnosis of depression. Because older adults tend to take longer to respond to treatment and have higher relapse rates than younger patients, they benefit most from persistent, attentive therapy. Although both pharmacotherapy and psychosocial treatments, or a combination of the two, are considered as the first-line therapy for late-life depression, most data support a combined, biopsychosocial treatment approach provided by an interdisciplinary team.