Rapid diagnosis and treatment of anxiety and depression in primary care: the somatizing patient.

The somatic presentations of anxiety, mixed anxiety and depression, and depressive disorders are commonly seen by primary care physicians, and several studies have indicated that patients who present with such psychiatric disorders in the primary care setting often do not have their disorders appropriately diagnosed. Underlying psychosocial problems often hide behind somatic screens. When physicians fail to relate the somatic symptoms to the feelings that motivated the visit, the subsequent negative workup or poor response to therapy can compromise the patient's recovery and level of satisfaction. Although not equivalent to an extensive clinical interview, the Goldberg depression screening scale and the author's SWIKIR anxiety screening scale can be used to substantially reduce the number of undiagnosed, readily treatable psychiatric disorders in the primary care population. Once an accurate diagnosis has been obtained, psychotropic medications can be used to safely and effectively manage anxious and depressed patients. Selective serotonin reuptake inhibitors have proved extremely effective in the treatment of major depression, and buspirone has excellent efficacy for the management of generalized anxiety disorder.

Benzodiazepine dependence and withdrawal: identification and medical management.

BACKGROUND: Primary care physicians prescribe benzodiazepines for the treatment of anxiety. Although most patients use the benzodiazepines appropriately, some patients experience benzodiazepine abuse, addiction, or physical dependence, each one of which is a distinct syndrome. Benzodiazepine dependence, which relates to the development of tolerance and an abstinence syndrome, can be produced by three disparate benzodiazepine use patterns. These distinct benzodiazepine use patterns can in turn create distinct withdrawal syndromes. High-dose benzodiazepine use between 1 and 6 months can produce an acute sedative-hypnotic withdrawal syndrome. In contrast, low-dose therapeutic range benzodiazepine use longer than 6 months can produce a prolonged, subacute low-dose benzodiazepine withdrawal syndrome. Daily, high-dose benzodiazepine use for more than 6 months can cause a combination of an acute high-dose benzodiazepine withdrawal and a prolonged, subacute low-dose withdrawal syndrome. In addition, patients may experience syndrome reemergence. METHODS: A literature search was conducted using the medical subject headings benzodiazepines, substance abuse, substance dependence, substance withdrawal syndrome, and benzodiazepines adverse effects. The years 1970 to the present were reviewed. RESULTS AND CONCLUSIONS: Medical management for acute benzodiazepine withdrawal includes the graded reduction of the current benzodiazepine dosage, substitution of a long-acting benzodiazepine, and phenobarbital substitution. However, the medical management of benzodiazepine dependence does not constitute treatment of benzodiazepine addiction. Primary care physicians can accept complete, moderate, or limited medical responsibility regarding patients with substance use disorders. However, all physicians should provide diagnostic and referral services.

Anxiety and substance use disorders: the treatment of high-risk patients.

Primary care physicians routinely treat patients with various anxiety disorders. These patients may have a substance use disorder or may be at high risk for abuse or addiction. Routine treatment of anxiety disorders with psychoactive drugs is successful in many patients, but it can lead to iatrogenic dependence in high-risk patients. This article describes addiction risk factors, drug pharmacodynamics, environment and environmental cues, and genetics. With these addiction risk factors in mind, the physician can apply a stepwise treatment protocol described in three progressive levels: conservative, nonpharmacological approaches; nonpsychoactive pharmacotherapy; and psychoactive pharmacotherapy. In addition, proper prescribing practices for high-risk patients are described in terms of diagnosis, dosage, duration, discontinuation, dependence, and documentation.

Anxiety and substance use disorders: a primer for primary care physicians.

Primary care physicians encounter many patients with primary and secondary anxiety and substance use problems. Some patients have a dual diagnosis of both an anxiety and a substance use disorder. Symptoms may be overdiagnosed, underdiagnosed, and misdiagnosed. This article provides the primary care physician with an overview of the relation between psychoactive substance use disorders and anxiety symptoms. Also described are drug use patterns and diagnostic criteria for psychoactive substance use disorders. A model for understanding the role of anxiety symptoms during drug use is provided.

The impact of a county wide sex education effort on adolescent pregnancies in one South Carolina Regional Medical Center.

PIP: South Carolina ranks 18th among all US states with regard to its incidence of adolescent pregnancies. No formal sex education was provided in any of Spartanburg County's schools before 1976, even though adolescents aged 12-16 years accounted for 9% of all deliveries at Spartanburg Regional Medical Center (SRMC), a county-owned tertiary care center which accepts complicated obstetrical cases from a three-county catchment area. Docs Oughta Care (DOC), an international voluntary organization of concerned primary care physicians, together with teams of male and female family medicine residents at SRMC, developed slide presentations on human reproductive anatomy, venereal disease, and pregnancy prevention. The presentations were factual, with neither scare tactics nor heavy moral overtones. Respect for self and others, independent thinking, a positive self image, and understanding peer pressures were central themes. Following the announcement of the availability of the teams to all Spartanburg County schools in the fall of 1978, junior and senior high schools in the four largest of seven school districts requested visits. The majority of students reached were aged 13-17 years. However, lack of resident interest and leaders led to waning enthusiasm for the presentations after 1980 and their cessation during 1982-85. Within 2-3 years of the program's launch, the percentage of adolescents under age 16 years delivering babies at SRMC declined from the usual level of 9% to slightly more than 4% of all deliveries. This reduction persisted beyond the decline of the DOC program, although some recidivism was noted as the peak of the effort passed.^ieng