By Mollie Frost
ACP Member Robert McCarron, DO, underscored the importance of having a new primary care psychiatry precourse at this year's meeting.
"The first thing I want to point out is that psychiatrists and psychologists and social workers are not delivering most of this care," he said. "It's actually many of you."
To help internal medicine physicians make the most of their limited time during visits with the 40% of U.S. adults who are struggling with mental health and substance use, he offered the acronym AMPS as an approach to conducting a quick, effective psychiatric review of systems in primary care.
The A stands for anxiety, which is important to ask about because it is both common and treatable, said Dr. McCarron, who is a professor of psychiatry and human behavior, director of education at the Susan Samueli Integrative Health Institute, and associate dean for continuing medical education at the University of California, Irvine, School of Medicine.
He advised asking, "Is anxiety or nervousness a problem for you?"
"Some people, they may not understand what anxiety means exactly, so I throw in 'nervousness' as well," Dr. McCarron said.
If the patient replies yes to anxiety, don't worry about going through a checklist to determine the type. A quicker way to follow up is to ask about how it changes the patient and their daily life, he said. "How does that anxiety change you, your normal you, the you that you want to get back to?" he said.
The M stands for mood disorders, which have two components, depression and mania/hypomania. If you haven't yet screened for depression, two quick questions to ask are, "Have you been feeling depressed, sad, or hopeless over the past two weeks?" and "Have you been disengaged in pleasurable activities over the past few weeks?"
Dr. McCarron noted that it's particularly difficult in psychiatry to figure out if someone has had a manic/hypomanic episode in the past. One approach is asking, "Have you ever felt the complete opposite of depressed, where friends and family were worried about you because you were too happy?" and "Have you ever had excessive amounts of energy running through your body, to the point where you did not need to sleep for days?"
If the patient has had a past manic/hypomanic episode, that significantly changes their care, Dr. McCarron noted. "Their diagnosis going forward is now bipolar disorder, so if they get depressed, it's a bipolar depression—totally different treatment," he said. "In bipolar depression … you don't want to use unopposed antidepressant therapy. That can make things worse."
While the P in AMPS, psychosis, is seen less frequently in primary care, it's still important to ask about, Dr. McCarron said. Two questions to ask to figure out if someone is currently psychotic are, "Do you hear or see things that other people do not hear or see?" and "Do you have thoughts that people are trying to follow, hurt, or spy on you?"
Finally, the S stands for substance use disorder, which affects one in three patients in their lifetimes, Dr. McCarron said. Since alcohol is the most used and misused substance in the U.S., he recommended assuming that your patient is using it.
"I ask the question, 'How much alcohol do you drink per day?' Straightforward and to the point," rather than asking "Do you drink alcohol?" and then following up with another question, Dr. McCarron said.
When asking about other substances, one of the quickest ways is to list out the drugs that are used most frequently (cocaine, heroin, acid, speed, ecstasy, and marijuana), rather than asking if the patient uses recreational, illegal, or illicit drugs, he said. "Then you can also ask if they're using other drugs or medications not prescribed by a doctor." ■