DEPRESSION AND ANXIETY Ian M Chung Practitioner in Psychological Medicine Sydney, Australia

DEPRESSION AND ANXIETYDEPRESSION AND ANXIETY

Ian M ChungPractitioner in Psychological Medicine

Sydney, Australia

COPYRIGHT © IAN M CHUNG 2005

Ian M ChungIan M Chung

General practitioner since 196580% of practice in Psychological MedicinePrincipal Counsellor of Lawcare Program,

NSW Law SocietyPast Member of NSW Medical BoardEducator of general practitioners Not a psychiatrist, academic or expert Is a clinician and practitioner


Mental illness in GP populationMental illness in GP population

Much mental illness is covert or hiddenPrimary carers fail to recognise one out of

two patients with mental illnessIncidence of mental illness varies in different

areas and practices and at different timesUntreated mental illness is time-consuming

and costly


The cost of untreated mental illness:The cost of untreated mental illness:WHO “Burden of Disease” studyWHO “Burden of Disease” study

To patient• Morbidity, mortality, financial, productivity,

family suffering, reputation

To community• Productivity, financial ($4-5 bil pa in

Australia), loss of community cohesion

To doctor • ?


Obstacles to diagnosis of mental illnessObstacles to diagnosis of mental illnessPatient

• Ignorance, stigma, fear of the implications, lack of finances or resources to treat

Doctor• Knowledge and/or skill deficit, attitude,

misinterpretation or interest issues, lack of facilities and resources, time, remuneration issues, discomfort with emotional issues (personal or cultural)

Society• Different priorities, financial, lack of community

education, health policy, community attitudes


The GP perspectiveThe GP perspective

General practice is total (bio-psycho-social) and should address continuing patient care in the context of their family and community

The GP has an ongoing relationship with the patient and their family

General practice provides opportunity for early diagnosis before the condition is well-defined or fully developed

The GP sees the patient before they are “educated” by the process of investigation and elimination


The main mental illnesses seen in General The main mental illnesses seen in General PracticePracticeDepression and anxiety are the major mental

illnesses, alone or co-morbid, or as manifestations of other mental conditions or medical illness

Both depression and anxiety have a range of severity and forms

Specificity of diagnosis is important Somatisation is very common: the mind and body are

one also patient prefers to c/o an illnessDrug use and illness must be excludedAny illness needs the GP to consider the full

circumstances of the patient


Depression and Mood Disorders: a Depression and Mood Disorders: a chronic disorder, a disease of losses chronic disorder, a disease of losses more than sadnessmore than sadness

Major depressive disorder: depressed mood and anhedonia nearly every day for two weeks; include major depression in remission

Minor depressive disorderDysthymia: chronic sub-clinical depressionAdjustment disorder with depressed moodExclude bipolar disorder and melancholiaExclude drugs and physical illness


Special Depressive DisordersSpecial Depressive Disorders Depression in women

• In all cultures depression is more prevalent in women than men

• Premenstrual dysphoric disorder• Depression in pregnancy and breast feeding• Post-natal depression• Peri-menopausal depression

Depression in the elderly• Bereavement, loss of independence, illness, onset of dementia• Suicide is high in single men aged over 75

Depression in children• Separation and abuse• Adolescence

Seasonal affective disorder


Anxiety Disorders: the disease of fears Anxiety Disorders: the disease of fears and worryand worry Panic disorder with or without agoraphobiaGeneralised anxiety disorder

• Chronic anxiety

• “Free floating” anxiety)

Specific phobias Social phobia: fear of negative evaluationObsessive compulsive disorder, pathological doubt,

spontaneous and intrusive phenomena Post-traumatic stress disorderAnxiety associated with drugs and illness


Somatoform DisordersSomatoform Disorders

Somatisation disorder• Fatigue, pain or other symptoms not feigned• Without discernable clinical explanation• Causes distress and impairment of significant duration

Conversion disorder Pain disordersHypochondriasis

• Pre-occupation and fear of illnessBody dysmorphic disorder

• Pre-occupation with imagined defects in appearance


Aetiological factors in mental illnessAetiological factors in mental illness

External• Life stressors

o Conflicto Losso Disappointmento Excess loado Deprivation

• Drugs and alcohol

Internal• Personality

o Neuroticismo Family traits and

dispositions• Past

o Traumatised o Deprived o Under/over-lovedo Under/over-protectedo Under/over-criticised


The Mind-Body ConnectionThe Mind-Body Connection

Descarte’s dualistic theory was wrongThe mind and body are one: holisticThe brain and body are in constant interactive

connection via nerves and hormonesThoughts, feelings and memories affect the

body’s functions and vice versa; anatomical, biochemical and physiological changes can be demonstrated


Neuro-science is in rapid and dramatic Neuro-science is in rapid and dramatic transitiontransition

90% of current knowledge in neuro-science was unknown at the start of the “Decade of the Brain” (1991-2001)


Learning enhances adult neurogenesis in Learning enhances adult neurogenesis in the hippocampal formationthe hippocampal formation

Elizabeth Gould1, Anna Beylin1, Patima Tanapat1, Alison Reeves1 and Tracey J. Shors2

1 Department of Psychology, Princeton University, Princeton, New Jersey, USA2 Department of Psychology & Centre for Neuroscience, Rutgers University, Piscataway, New Jersey, USA

Thousands of hippocampal neurons are born in adulthood, suggesting that new cells could be important for hippocampal function. To determine whether hippocampus-dependent learning affects adult-generated neurons, we examined the fate of new cells labeled with the thymidine analog bromodeoxydridine following specific behavioral tasks. Here we report that the number of adult-generated neurons doubles in the rat dentate gyrus in response to training on associative learning tasks that require the hippocampus. In contrast, training on associative learning tasks that do not require the hippocampus did not alter the number of new cells. These findings indicate that adult-generated hippocampal neurons are specifically affected by, and potentially involved in, associative memory formation.

Gould et al Nat Neuro 1999; 2: 260-265

Emotions and learning cause structural brain changes.


Antidepressants do more than relieve Antidepressants do more than relieve symptomssymptoms

Depression affects pre-frontal cortex, amygdala, striatum, thalamus

Untreated major depression causes hippocampal atrophy

Antidepressants cause neutogenesis in the dentate gyrus

Untreated anxiety causes enlargement of the amygdala and increased secretion of cortisol releasing factor (CRF)


Pre-treatmentPre-treatment The patient needs to present for treatment, which

implies that the patient is sufficiently in pain or sufficiently worried

The therapist needs to be:• Interested in mental illness

• Alert to presentation

• Know how to confirm the diagnosis

• Understand treatment strategies

• Able and willing to educate the patient

Treatment begins in the waiting room• An atmosphere receptive to whatever the patient has

to bring there


The diagnosis of mental illness: before The diagnosis of mental illness: before DSM IV or ICD 10DSM IV or ICD 10

Maintain your index of suspicionHeed the patient’s message: hear and see itKnow the disease presentationsKnow the follow-up questionKnow the criteria for each conditionTake the care needed to listen and clarifyUse a diagnostic scale if neededIf in doubt or disinterested, REFER!


TreatmentTreatment

First establish a therapeutic alliance with patientMake the diagnosisExplain the diagnosis and treatment to patient Prioritise and implement the treatment plan Involve family and others when necessary Continuation management and tracking the

progress towards full remissionHow long to treat?Relapse prevention


Comprehensive and integrated approach Comprehensive and integrated approach to therapyto therapy Medical: pharmacotherapy

• To medicate or not? • What dose?

Psychological• Psycho-education• CBT• Behavior therapy• Structured problem solving• Relaxation/meditation/hypnosis

Lifestyle: balanced life• For example, Yerkes-Dobson curve

Spiritual: sense of self/purpose/direction• For example, logotherapy (Victor Frankl)


Treatment GoalsTreatment GoalsResponse

• Find the right drug and take it for long enough

• Augment if necessary

• Referral if necessary

Enhance recovery • Instigate and maintain all therapeutic strategies

Aim for full remission• Optimise all treatment strategies

Prevent Relapse• Educate patient as to their vulnerabilities

• Continue medication long enough

• Maintain life activities and directions


Goals of treatmentin major depressive disorder

Frank et al. Arch Gen Psychiatry 1991; 48: 851-855.Rush et al. Psychiatric Ann 1995; 25: 704-709.

Thase et al. J Clin Psychiatry 1997; 58: 393-398.Cunningham. Ann Clin Psychiatry 1997; 9: 157-164.

HAM-D score ≤7 Patient virtuallyasymptomatic

/Psychosocial occupational functioning restored

≥50% decrease from baseline in HAM- D or MADRS scores

1 2CGI score of or

Response Remission


Treatment options for non-responding Treatment options for non-responding patientspatients

Switching antidepressants Augmentation: some evidence suggests…

• Lithium• Atypical antipsychotics

o Risperidoneo Olanzapine

• Antiepileptics/anticonvulsantso Valproic acido Carbamazepineo Gabapentin

Combination of antidepressants ECT

Fava J Clin Psychiatry 2001; 62 (Suppl 18): 4-11


Final words…Final words…

Caring for our patient ought to mean treating the whole patient: body and mind

Mental illness (MI) is common, disabling and often missed - which is costly to all concerned

Treatment of MI is neither difficult nor necessarily time consuming

Treating MI is effective and satisfyingTreating MI gives the GP an enlightening glimpse

into the human condition Failure to treat is negligent


And a personal perspective…And a personal perspective…

It has been a privilege to have been given a glimpse into the minds of so many patients, and to have been allowed to start to understand the human condition.

Copyright © Ian M Chung 2005

The foregoing presentation is copyright. Except as permitted by applicable copyright legislation, no part of the foregoing

presentation may be reproduced or distributed in any form or by any means without the express written permission of the

copyright owner, Ian M Chung.

Email [email protected]

Web www.ianmchung.com

Documents

DEPRESSION AND ANXIETY Ian M Chung Practitioner in Psychological Medicine Sydney, Australia