A 21-year-old woman is seen by a family physician in a student-run free clinic within a residential chemical dependency program for women. She has just finished withdrawing from intravenous heroin. She is experiencing anxiety and insomnia and is asking for medications to help her sleep at night and function during the day. The young woman has a 10-month-old baby. She had been on a methadone program during her pregnancy. The patient states that her mother is bipolar and often uses various drugs including heroin. Her brother sells heroin but claims to not use it anymore. He does sell heroin to her and her mother at a discount. The patient admits to having been sexually abused as a child and states that the heroin numbs some of the pain from her childhood. Unfortunately, she has bad nightmares (related to posttraumatic stress disorder [PTSD]) that make sleeping difficult. She did return to injecting heroin after the baby was born and lost custody of her child. She is motivated to maintain sobriety so she can be with her baby again. The family physician listens with compassion and empathy and prescribes some non-addicting medications to help her with the anxiety, insomnia, and nightmares. A follow-up appointment is set for the following week, as it is clear that this young woman needs a lot of support in addition to close management of pharmacologic therapy.
Over half of mental health treatment in the United States occurs within primary care, and about 25% of all primary care patients have diagnosable mental health disorders (most commonly, depression and anxiety).1 Frequent mental distress, defined in one study as 14 or more days of poor mental health in the past month, was reported by 9.4% of U.S. adults for the combined periods 1993–2001 and 2003–2006.2
Access to mental health services is difficult in many areas of the country. In a study based on National Health Interview Survey data, unmet need for mental healthcare increased from 4.3 million in 1997 to 7.2 million in 2010.3 Unmet need was higher among children (ages 2–17 years); working-age adults (ages 18–64 years); women; uninsured persons; and persons with low incomes, those in fair or poor health, and those with chronic conditions. This makes it vital that primary care clinicians be well versed in the identification and care of these conditions.
Mental health disorders include anxiety disorders, mood disorders, schizophrenia and other psychotic disorders, dementia, and eating disorders. This chapter covers the first three of these categories; information on dementia can be found in Chapter 243, Dementia.
Anxiety disorders are the most common class of mental disorders in the general population and include PTSD, generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, phobias, and separation anxiety disorder.4
The most common mood disorders are major depressive disorder (MDD) (Figure 238-1), dysthymic disorder, ...