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.

5/13/2017 1:43:21 PM

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)

9

5/13/2017 1:43:21 PM

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

5/13/2017 1:43:21 PM

WORLD PSYCHATRIC DAY, 10-10- 2011

5/13/2017 1:43:21 PM

MAJOR DEPRESSION:

5 OF 9 SX:12

5/13/2017 1:43:21 PM

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.

13

5/13/2017 1:43:21 PM

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.

14

5/13/2017 1:43:21 PM

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

15

5/13/2017 1:43:21 PM

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

16

5/13/2017 1:43:21 PM

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

5/13/2017 1:43:21 PM

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

18

5/13/2017 1:43:21 PM

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.

19

5/13/2017 1:43:21 PM

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.

5/13/2017

22

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

23

5/13/2017 1:43:21 PM

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.

24

5/13/2017 1:43:21 PM

DEPRESSION & ANXIETY

26

Depression & Anxiety

5/13/2017 1:43:21 PM

Depression and anxiety in Primary Care

DEPRESSION ANXIETY27

5/13/2017 1:43:21 PM

Depression and anxiety in Primary Care

ANXIETY IS A COMMON

SYMPTOM OF DEPRESSION

Sadock and Sadock 2003.

Depression WithAnxiety Symptoms

90%

Depression

5/13/2017 1:43:21 PM

MDD AND ANXIETY DISORDERS

Anxiety

Disorders59%

Major

Depression

29

5/13/2017 1:43:21 PM

*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

30

5/13/2017 1:43:21 PM

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?

5/13/2017 1:43:21 PM

*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

33

5/13/2017 1:43:21 PM

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.

34

5/13/2017 1:43:21 PM

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)

35

5/13/2017 1:43:21 PM

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.

36

5/13/2017 1:43:21 PM

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.

5/13/2017 1:43:21 PM

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.

38

5/13/2017 1:43:21 PM

Why it is under-recognized?

Depression

&

Anxiety

39

5/13/2017 1:43:21 PM

Depression and anxiety in Primary Care

Why it is under-recognized?

1. Patient Issues.

2. Physician Issues

3. Health System Issues

4. Societal Issues

40

5/13/2017 1:43:21 PM

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:

41

5/13/2017 1:43:21 PM

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:

42

5/13/2017 1:43:21 PM

-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:

43

5/13/2017 1:43:21 PM

MANAGEMENT OF

DEPRESSION AND ANXIETY

PHARMACHOTHERAPY

TCA

SSRI

SNRI

MOI

OTHERS

PSYCHOTHERAPY

PSYCHOEDUCATION

CBT

44

5/13/2017 1:43:21 PM

5/13/2017 1:43:21 PM

45SEVEN PRINCIPLES OF TREATMENT

Diagnosis

Discontinuation

Psychotherapy

Side-effects

Dose

Drugs of choice

Duration

5/13/2017 1:43:21 PM

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

5/13/2017 1:43:21 PM

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

5/13/2017 1:43:21 PM

48

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.

49

5/13/2017 1:43:21 PM

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.

50

5/13/2017 1:43:21 PM

52 5/13/2017 1:43:21 PM