Psychiatry Becomes Individual with Better Screening, More Therapies

A patient goes to his primary care physician for an illness. While there, he’s screened for depression. That screening leads to a psychiatrist referral, and that referral leads to counseling, maybe treatment. He and his psychiatrist have their pick now from cognitive behavioral therapy (CBT) and differing classes of antidepressants.

The days of treating a patient with depression, anxiety, or PTSD with the same blanket approach are over. Since 2010, psychiatry has gradually adopted the full-service approach, reflecting the need for better mental health screening, better use of technology, and better treatment.

These needs come from more frequent and more concerning reports on the growing burden and reach of mental health disorders in the US. But the resolution started in the most singular setting of healthcare.

“We've had success with depression and anxiety, and that’s because of the integration of mental health care with difficult health care, like in primary care,” Pamela Lusk, DNP, RN, PHMNP-BC, told MD Magazine®. “Somebody will now be screened at least once a year.”

Lusk, a clinical associate professor at the Ohio State University College of Nursing and a Child and Adolescent Psychiatrist for Ponderosa Pediatrics, explained in an interview with MD Mag that starting screenings at the primary care level has made a major difference in treating patients.

Most primary care practices use either the Patient Health Questionnaire-2 (PHQ-2) or the PHQ-9 to screen for depression regularly, as part of their electronic health record driver. By conducting more screenings in primary care, the practitioner can realize the issues and discuss with the patient the appropriate next steps.

One of the reasons for the better synergy between psychiatry and neurology is that different imaging technologies like functional MRIs have come to play a bigger role in finding different patterns that could equate to different psychological disorders.

While a screening cannot replace the diagnostic expertise of a doctor, Lenard Adler, MD, the director of the Adult ADHD Program and professor in the Department of Psychiatry at NYU Langone Health, explained in an interview with MD Mag there have been significant improvements in screening for mental health disorders, including a new depression screener commonly used in primary care settings.

Once a patient is properly screened in a primary care setting, they generally must see a specialists who can develop a treatment plan based on that individual’s needs.

Rather than strictly relying on drugs like antidepressants, there are now more and more different types of non-pharmacologic therapies available to help the patients.

Lusk explained that there is strong research-based evidence showing the benefits of therapies like mindfulness-based stress reduction, an eight-week evidence-based program that includes intensive mindfulness training that has proven effective for patients dealing with stress, anxiety, depression, and trouble with pain.

Another approach that has emerged since 2010 is eye movement desensitization and reprocessing (EMDR) therapy for trauma. This psychotherapy is an eight-phase treatment that helps patients tap into and process emotions.

These types of therapies are particularly effective when treating different types of trauma, where researchers have long suggested taking an individualized approach to treating patients suffering from PTSD and other forms of trauma.

Indeed, psychiatric treatment should and does differ based on the age, gender, and type of trauma the person is suffering from, Charles Marmar, MD, chair of the Department of Psychiatry and Director of the PTSD Research Program at NYU Langone Health, told MD Mag.

“So fundamentally, the approaches we take to single-event trauma—which occurs among otherwise healthy adults who have had an accident or an assault or a recent severe exposure to a life-threatening disaster event or terrorism, who were previously highly functioning before—are usually time-limited,” Marmar said.

Marmar noted they often emphasize practical, short-term CBT, focused on activating memories of the trauma to initiate the healing process.

While these other types of therapies have proven effective, CBT is often touted as a goal-oriented therapy involving a more hands-on, problem-solving approach. It is still one of the most common and effective types of therapies for treating disorders like depression and anxiety.

With psychotherapy becoming increasingly non-pharmacological in recent years, investigators have studied how these types of therapies are effective and safe when they are combined with antidepressant drugs.

Earlier this year, in a phase 2 randomized trial, which included 292 patients with major depressive disorder (MDD), investigators found that maintenance monotherapy was associated with reduced rates of depressive recurrence, but when CBT was provided in the absence of monotherapy, a preventative effect on depressive relapse was found.

The investigators found that those withdrawing from antidepressant medications were linked to higher rates of recurrence than those with maintenance of antidepressant medication treatment, regardless of whether patients achieved recovery with or without acute cognitive behavioral therapy treatment.

Previous research has demonstrated that antidepressant medications and CBT have similar efficacies on acute outcomes for patients with MDD. The combination of the 2 forms of treatment is linked with better acute outcomes than either treatment modality alone.

With new technologies and a bigger emphasis on primary care screenings in place, the industry must always adapt and change their guidelines to reflect the current reality.

Lusk noted the advent of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which is published by the American Psychiatric Association in 2013—13 years following the publishing of DSM-IV-TR.

A major impact to come from DSM-5’s rulings, versus other iterations, is its distinctions between trauma and stress-related disorders from anxiety disorders. The guide also eliminated the multi-axial system for psychiatric assessment and organization of biopsychosocial information, and contains reclassifications of many disorders that reflect a better understanding of current clinical knowledge.

In DSM-5, 6 classes were added and 4 were removed, enabling numerous individual disorders were reclassified from one class to another. Its new distinctions for diseases including mood disorders, bipolar and related disorders, and depressive conditions help shape a new understanding of the individualized patient.

Greater needs linger. Marmar noted there are still few longer-term therapies available to patients—even combinations of behavioral therapy and medication has not been testing into the years a patient would theoretically rely upon them both.

There’s also a lot more research and discussion to come for ketamine, transcranial magnetic stimulation, and cannabidiol—each themselves a fodder for a psychiatry treatment debate.

But, even in the wake of analyses showing the 21^st century is more strife with suicides today than it was before, the tools are in place—and to be used at the right time. It’s no longer on the patient to understand what help they need.

For now, it’s as simple as going to a primary care physician for an illness, and then the process can begin.