anxiety&depression in primary care
TRANSCRIPT
Sherif Saad Osman , M.D.Consultant of Psychiatry
ANXIETY AND DEPRESSION IN PRIMARY
CARE
3
.
MIND
(PSYCH)
BODY
(SOMA)
BODY
(SOMA)
MIND
(PSYCHE)
MIND – BODY INTERACTION
4THE BIO-PSYCHO-SOCIAL MODEL
STRESS
Stress : Experiencing events that are perceived as endangering one’s
physical or psychological well-being.
The events are known as stressors and the result as the stress response
The response to stressors is influenced by
Controllability, predictability and challenge to our limits.
Holmes Life Events Scale
Different psychological responses to stress include
Anxiety
Anger and aggression
Apathy and depression
Cognitive impairment
STRESS
Yerkes-Dodson law:
Performance improves as a function of anxiety up to a threshold
beyond which there is a fall off in performance
Too little stress is just as bad as too much stress,we need to get a balance.
ANXIETY AND DEPRESSION IN PRIMARY CARE8
General practitioner who sees 40
patients a day can expect that eight
will require support or treatment for
anxiety or depression (20%) -- and
that's not counting those whose
disorders go unrecognized.
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L IFETIME PREVALENCE
OF
COMMON PSYCHIATRIC D ISORDERS
Kessler 1994; Kessler 1995; DSM-IV-TR™ 2000.
*In menstruating women. Lifetime prevalence (%)
0 2 4 6 8 10 12 14
7.8%Posttraumatic stress
disorder (PTSD)
5.1%Generalized anxiety
disorder (GAD)
3.5%Panic disorder
2.5%Obsessive-compulsive
disorder (OCD)
16 18
Alcohol dependence 14.1%
Major depressive disorder 17.1%
13.3%Social anxiety disorder
5%*Premenstrual dysphoric
disorder (PMDD)
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DEPRESSION—MEDICAL COMORBIDITIES
Kessler 1999; Carney 1987; Frasure-Smith 1993; AHCPR Guidelines 1993; Anderson 2001; Bing 2001; Reifler 1986; Rovner 1989; Breslau 1991; Minden 1987; Joffe 1987.
Prevalence Comments
General population 10% 12-month prevalence
Coronary artery disease 18% Current episode of depression
Myocardial infarction 16% 6-months post-MI
Cancer 20%-25% At some time during illness
Diabetes 25% Meta-analysis of 42 studies
HIV 36% 12-month prevalence
Alzheimer’s disease 17%-31% Current episode of depression
Migraine 22%-32% Lifetime prevalence in young adults
Multiple sclerosis Up to 50% Lifetime prevalence
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WORLD PSYCHATRIC DAY, 10-10- 2011
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MAJOR DEPRESSION:
5 OF 9 SX:12
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SAD-A FACES: A MNEMONIC FOR
THE CORE SYMPTOMS OF DEPRESSION
S = Sleep — insomnia/hypersomnia; often the earliest symptom; may be overlooked if the patient has been given sleeping tablets
A = Appetite or weight change (increase or decrease)
D = Dysphoria — “bad mood”, irritability, sadness; the essential abnormality; few complain of it spontaneously
A = Anhedonia — loss of interest in work, hobbies, sex
F = Fatigue—affects almost all; often manifests as difficulty completing tasks
A = Agitation/retardation—especially in the elderly
C = Concentration — diminished; difficulty with simple tasks, conversation, decision-making; may lead to a misdiagnosis of dementia in the elderly
E = Esteem — low; guilt; events from the past may assume new significance
S = Suicidal thoughts—present in two-thirds of depressed patients; 10%–15% will commit suicide.
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THE CORE SYMPTOMS OF
ANXIETY Cognitive:
Fear of dying or going mad
Decreased attention and concentration
Somatic
Cardiovascular: palpitations, chest pain, tachycardia, flushing
Respiratory: hyperventilation, shortness of breath
Neurological: dizziness, headache, paraesthesia, vertigo
Gastrointestinal: choking, dry mouth, nausea, vomiting, diarrhoea
Musculoskeletal: muscle ache and tension, restlessness
Psychological
Derealisation, depersonalisation, speeding or slowing of thoughts,
distractibility, irritability, insomnia, vivid dreams.
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A SCREENING TEST FOR
ANXIETY AND DEPRESSION
Score one point for each “Yes”.
Have you felt keyed up, on edge?
Have you been worrying a lot?
Have you been irritable?
Have you had any difficulty relaxing?
If “Yes” to two of the above, go on to ask:
Have you been sleeping poorly?
Have you had headaches or neck aches?
Have you had any of the following: trembling,
tingling, dizzy spells, sweating, urinary
frequency, diarrhoea?
Have you been worried about your health?
Have you had difficulty falling asleep?
A
N
X
I
E
T
y
S
C
A
L
e
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A SCREENING TEST FOR
ANXIETY AND DEPRESSION
Score one point for each “Yes”.
Have you had low energy?
Have you had loss of interests?
Have you lost confidence in yourself?
Have you felt hopeless?
If “Yes” to ANY question, go on to ask:
Have you had difficulty concentrating?
Have you lost weight (due to poor appetite)?
Have you been waking early?
Have you felt slowed up?
Have you tended to feel worse in the morning?
D
E
P
R
E
S
S
I
O
N
S
C
A
L
e
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Anxiety DepressionAdaptive Debilitating
Future-oriented Past-oriented
Helplessness Hopelessness
Worse in the p.m. Worse in the a.m.
Blames external factors Blames internal factors (self)
Trouble falling asleep Early morning awakening
Potential suicide risk Definite suicide risk
Differentiating Anxiety and Depression
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DIAGNOSTIC CRITERIA FOR MIXED
ANXIETY-DEPRESSIVE DISORDER Presence of persistent or recurrent dysphoric mood
lasting 4 weeks and accompanied by 4 of the following
symptoms:
–concentration or memory difficulties
–Sleep disturbances
–Fatigue or low energy
–Irritability
–Worry
–Being easily moved to tears
–Hypervigilance
–Anticipating the worst
–Hopelessness or pessimism about the
future
–Low self-esteem or feelings of
worthlessness
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Symptoms are not due to A medication, drug
abuse, or A medical condition and cause
significant distress or impairment in social,
occupational, or other important areas of
functioning. Symptoms do not meet criteria of
any other mental disorder DSM-IV, diagnostic
and statistical manual of mental disorders,
fourth edition. Adapted from the American
Psychiatric Association.
The patient has three or four of the symptoms ofmajor depression (which must include depressedmood and/or anhedonia), and they are accompaniedby anxious distress. The symptoms must have lastedat least 2 weeks, and no other DSM diagnosis ofanxiety or depression must be present, and they areboth occurring at the same time.Anxious distress is defined as having two or more of the following symptoms: irrational worry, preoccupation with unpleasant worries, having trouble relaxing, motor tension, fear that something awful may happen.
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PROPOSED D IAGNOSTIC CRITERIA FOR
M IXED ANXIETY DEPRESSION IN DSM-V
Depression and anxiety in Primary Care
Depressive and anxiety disorders are common,occurring in up to 25% of primary care patients
Depressive and anxiety disorders are moredisabling, both socially and in terms of physicalfunctioning, than many chronic physical illnesses,such as diabetes, hypertension, arthritis and backpain.
The economic impact is immense, both in directcosts to health care systems and in indirect costs tothe community.
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Major Depression
Hypertension
Diabetes
Arthritis
Back Pain
Disability ScoreDisability Days
0 0 5 10 205 15 2515 10
WHO Collaborated project
Greater disability level than other chronic diseases
1. Ustun TB et al, eds, John Willy & Sons 1995
Despite this, there is considerable evidence that the medical profession deals poorly with these disorders.
In up to half of patients presenting with anxiety or depression, the diagnosis is missed, and in those who are recognized a significant proportion are not treated.
Most patients with the depressive and anxiety disorders present and are managed in primary care settings
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Depression and anxiety in Primary Care
PREVALENCE OF DEPRESSION AND ANXIETY IN PRIMARY CARE
World Health Organization [WHO] study on psychological
disorders in primary care:
--25 000 consecutive adults were screened at 15 sites in 14 countries. Over 5 000 were further assessed with detailed psychiatric interviews.
-- A quarter had a recognizable mental disorder.
-- The commonest being a depressive disorder (11.7%) or an anxiety disorder (10.5%), with 4.6% having both.
Only half of the mental disorders were recognised by the primary care physician; among those patients with a recognised mental disorder, half were offered drug treatment.
National Comorbidity Study in the United States: A 12-month prevalence of 11.3% for depressive disorders and 17.2% for anxiety disorders.
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DEPRESSION & ANXIETY
26
Depression & Anxiety
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Depression and anxiety in Primary Care
DEPRESSION ANXIETY27
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Depression and anxiety in Primary Care
ANXIETY IS A COMMON
SYMPTOM OF DEPRESSION
Sadock and Sadock 2003.
Depression WithAnxiety Symptoms
90%
Depression
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MDD AND ANXIETY DISORDERS
Anxiety
Disorders59%
Major
Depression
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*Anxiety disorders included panic disorder, agoraphobia without panic disorder, social phobia, simple phobia, and GAD. Kessler RC, et al. Arch Gen Psychiatry. 1 994 ;5 1 :8- 1 9.
ComorbidityMajority with AD develop lifetime MDD;>50 % with MDDdevelop lifetime AD
AnxietyDisorders*
25 %lifetime
prevalence
MajorDepression1 7 % lifetimeprevalence
ANXIETY-DEPRESSION COMORBIDITY
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Posttraumaticstress disorder Panic disorder
OCD
Depression
48% of patients with PTSD Up to 65% of patients with panic disorder*
67% of patients with obsessive-compulsive disorder
GADSocial anxiety
disorder
42% of patients with generalized anxiety disorder
34% to 70% of patients with social anxiety disorder
DEPRESSION—ANXIETY COMORBIDITIES
*Figures for panic disorder and depression not specified as lifetime in DSM-IV-TR™.
Kessler 1995; DSM-IV-TR™ 2000; Brawman-Mintzer 1993; Rasmussen 1992; Stein 2000; Van Ameringen 1991; Wittchen 1999.5/13/2017 1:43:21 PM
DEPRESSION AND ANXIETY IN
PRIMARY CARE32
Mr. Nasser 28 years old Chief manger presented to primary care clinic complaining of muscular ache, abdominal discomfort, dry mouth, palpitation.He has excessive worry and sense of impending disaster without evidence of appropriate real danger, started 9 month ago. He had history frequent attack of shortness of breath, cold extremities and wet palm during the last 7 month.
HOW YOU WILL APPROACH NASSER?
Mrs Z. 40 years old nurse presented to primary care clinic complaining of insomnia, decreased appetite, easy fatigability, dull headache and irregular menstrual cycles.She has depressed mood most of the day, loss of interest,, hopelessness, and pessimistic and guilty thought.
HOW YOU WILL PROCEED DURING THIS CONSULTATION?
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*Symptoms of GAD and SAD.DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.
SYMPTOM OVERLAP OF
ANXIETY AND DEPRESSION
Depressed mood
Loss of interest or pleasure
Appetite disturbance
Worthlessness
Suicidal ideation
Low self-esteem
Agitation
Irritability
Fatigue
Difficulty concentrating
Sleep disturbance
Muscle tension
GI complaints
Pain
Anxiety
Worry
Dry mouth
Palpitations
Sweating
Trembling
Blushing
Stuttering
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DEPRESSION—IMPLICATIONS
OF ANXIETY COMORBIDITIES
Increased severity of symptoms
Increased impairment of mental and physical functioning
Delayed recovery
In patients with comorbid panic disorder and depression,
Increased prevalence of suicide attempts
Decreased work productivity and attendance
Increased service use (medical, mental health, social services)
Brown 1996; Coryell 1988; Roy-Byrne 2000.
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Impaired occupational functioning=6 or more lost workdays or days spent being less productive; Impaired social functioning=low rates of social support and high rates of negative social interactions.Kessler RC, et al. Am J Psychiatry. 1999;1 56:1 91 5-1 923.Kessler RC, et al. Arch Gen Psychiatry. 1994;5 1 :8- 1 9.
IMPACT OF ANXIETY
ON FUNCTIONING & HEALTH:-
0
5
10
15
20
25
30
35
40
45
50
Impaired social
functioning
Impaired occupational
functioning
Fair/poor perceived
mental health
Pati
en
ts (
%)
Controls (n=5,217)
Pure GAD (n=92)
Comorbid GAD + MDD (n=99)
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ETIOLOGY OF MAD
Depression and anxiety may occur as primary disorders or secondary to a range of medical conditions, drug use or other psychiatric disorders.
The causes of primary depression and anxiety are include:-
biological factors such as genetics, neurotransmitter abnormalities, neuroendocrine abnormalities and
psychosocial factors (life events, environmental stress, and premorbid personality).
In the primary care setting it is the secondary causes that need to be excluded.
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ETIOLOGY OF MAD
SECONDARY DEPRESSION
The more common conditions associated with depressioninclude:
Endocrine disorders (hypothyroidism, hyperthyroidism,
Cushing’s disease and Addison’s disease),
Infections (infectious mononucleosis, influenza, tertiary
syphilis and AIDS),
Neurological disorders (multiple sclerosis, Parkinson’s disease)
and cerebrovascular disorders.
Underlying malignancies should also be considered.
Drugs commonly associated with depression are antihypertensive agents, corticosteroids, oral contraceptives and antineoplastic agents.Recreational drugs such as alcohol and amphetamines can cause depression either during intoxication or withdrawal.
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ETIOLOGY OF MAD
SECONDARY ANXIETY
anxiety disorders, consider endocrine disorders such as thyroid, parathyroid, and adrenal dysfunction (phaeochromocytoma), seizure disorders and cardiac conditions such as arrhythmias, supraventriculartachycardia, and mitral-valve prolapse.
Drugs commonly associated with anxiety are sympathomimetics such as amphetamines, cocaine and caffeine. Drugs that increase serotonin release, such as LSD and MDMA (“ecstasy”), can cause acute and chronic anxiety. Prescription medications to consider include sympathomimetics, antihypertensives (especially captopril), and non-steroidal anti-inflammatory drugs.
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Why it is under-recognized?
Depression
&
Anxiety
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Depression and anxiety in Primary Care
Why it is under-recognized?
1. Patient Issues.
2. Physician Issues
3. Health System Issues
4. Societal Issues
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Depression and anxiety in Primary Care
1- Stigma.
2- Ignorance of Depression and Anxiety.
3- Self-blame as one of the elements of depression can prevent the patient from seeking help.
4- Failure to complete a course of adequate treatment.
5- Presentation (by focusing on somatic symptoms, pain or discomfort) and ignoring the depressive and anxiety symptoms.
Patient Issues:
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1- Knowledge about depression and anxiety.
a) in the US it is not included in most training programs for primary care physicians.
b) 40% judged their psychiatric placements to have no relevance to their practice.
2- Skills development. (Diagnosis and Treatment)
3- Lack of Time.
Physician Issues:
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-Insurance Covering.-Structure (liaison, screening scales, depression
clinics …….etc ).-Training skills.
-Need for educational programs.-Cost to society (awareness of work days lost or
work impairment).
Health System Issues:Social Issues:
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MANAGEMENT OF
DEPRESSION AND ANXIETY
PHARMACHOTHERAPY
TCA
SSRI
SNRI
MOI
OTHERS
PSYCHOTHERAPY
PSYCHOEDUCATION
CBT
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45SEVEN PRINCIPLES OF TREATMENT
Diagnosis
Discontinuation
Psychotherapy
Side-effects
Dose
Drugs of choice
Duration
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46 OLD ANTIDEPRESSANTS
TCA• desipramine• nortriptyline• imipramine
Tetracyclics/others• maprotiline• mianserin• trazodone
Dual action• amitriptyline• clomipramine• dothiepin
MAOIs• phenelzine• isocarboxazid• tranylcypromine
Old antidepressants
Selective TCA• lofepramine
TCA-related• amoxapine• doxepin
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47 NEW ANTIDEPRESSANTS
SSRI• citalopram
• escitalopram• fluoxetine• fluvoxamine• paroxetine• sertraline
New antidepressants
5-HT re-uptake inhibitors and receptor antagonists• nefazodone
NaSSA• mirtazapine
NDRI• bupropion
SNRI• venlafaxine• milnacipran
RIMA• moclobemide
NARI• reboxetine
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3A4 2D6 1A2 2C19 2C9
Escitalopram* 0 + 0 0 0
Citalopram 0 + + 0 0
Fluoxetine ++ +++ + ++ ++
Paroxetine + +++ + + +
Sertraline + + + ++ +
0 = Negligible+ = Very weak interaction
Inhibitory effects of SSRIs on drug metabolising CYP450 isoenzymes
++ = Moderate interaction+++ = Strong interaction
•Anti-Arrhythmic•B-blockers•Haloperidol•Neuroleptics
•Caffeine•Ciprofloxacin•Theophylline•Verapamil
•Diazepam•Propranolol•Moclobemide•Imipramine
•Miconazole•Phenytoin•S-warfarin•NSAIDs
ANXIETY AND DEPRESSION IN
PRIMARY CARE
Depressive and anxiety disorders are common in primary care settings, yet up to half the patients who present with these disorders may not be diagnosed and others may not be treated.
The cornerstone of detection is an understanding of the common presenting symptoms and syndromes.
Patients with depression or anxiety frequently present complaining of physical symptoms, which may obscure the psychiatric diagnosis.
The doctor's consultation technique is important: an empathic style, open questions and a willingness to hear the patient out will help reveal the diagnosis.
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ANXIETY AND DEPRESSION IN
PRIMARY CARE
Clinical depression is diagnosed when there are at least three or four symptoms (low mood, loss of interest, sleep disturbance, lost concentration, fatigue, disturbed appetite, agitation or retardation, feelings of worthlessness or guilt, suicidal thoughts) present every day for at least two weeks.
Anxiety disorders include panic disorder, phobias, obsessive-compulsive disorder, post-traumatic stress disorder and generalized anxiety disorder.
Screening tools (simple questionnaires designed to identify signs and symptoms of anxiety and depression) can be effective.
Once a depressive or anxiety disorder is detected, possible causes to be explored include underlying medical conditions, psychiatric conditions, and drug or alcohol use.
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