Anxiety and depression

Notes

## Basic introduction

  • According to the World Health Organization (WHO), depression is defined as “A common mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration”h
  • Anxiety is apprehension over what is about to happen and what could happen in future as opposed to depression which is the feeling of sadness about the future, as though it is hopeless.
  • Normal anxiety is generally beneficial but it becomes pathological when its duration is long, and/or is of high intensity and/or frequency such that it begins to interfere with a person's functioning and overall well-being.
  • Occasionally, people with depression often experience anxiety in one form or another
  • In anxiety disorder, a person experiences fear, panic or anxiety in situations where, ordinarily, a person would not feel anxious or threatened
  • Classification of anxiety disorders:

_Panic disorder – that is a sudden period of intense fear that is characterized by:

||| A feeling that a bad thing is going to happen

||| Numbness

||| Palpitations

||| Shaking

||| Shortness of breath

||| Sweating

_Phobias (fear out of proportion) e.g.

||| Agoraphobia- Fear of open spaces or of being in crowded, public places

||| Atychiphobia- Fear of failure.

||| Automysophobia- Fear of being dirty

||| Autophobia- Fear of being alone or of oneself

||| Aviatophobia- Fear of flying

||| Necrophobia- Fear of death

_Obsessive-compulsive disorder (OCD)

||| Obsessions are repeated thoughts, urges, or mental images that cause anxiety e.g. aggressive thoughts towards others or self

||| Compulsions are repetitive behaviors that a person with OCD feels the urge to do in response to an obsessive thought e.g. excessive cleaning

_Generalized anxiety disorder (GAD)

||| This is characterized by persistent and excessive worry

||| Patients suffering from GAD experience excessive anxiety and worry

||| They usually expect the worst even when there is no apparent reason for concern

  • Classification of depression:

_Recurrent depressive disorder

_Bipolar effective disorder

||| That is characterized by both manic and depressive episodes

||| Where the episodes are separated by periods of normal mood

  • Globally, the proportion of patients with depression who are explicitly recognized as being depressed is < 50%. This is due to:

_Inaccurate assessment

_Incorrect diagnosis

_Inadequate number of health-care providers

_Poverty

_Social stigma associated with mental disorders

## Some causes of depression and anxiety

  • Abuse:

_Emotional

_Physical

_Sexual

  • Conflict

_Family members

_Friends

_Personal

  • Death

_Loss of a loved one

  • Genetic predisposition

_Various genes may be involved

  • Major events

_Divorce

_Losing a job

_New job

_Retirement

_Stressful life events

  • Some medications

_Corticosteroids

_Interferon-alpha

_Isotretinoin

  • Serious illnesses

_Another sickness

_Depression co-existing with a major illness

  • Substance abuse
  • Unknown causes

## Pathophysiology of depression and anxietyc,d,e,f,g

  • Serotonin (5-HT) and norepinephrine (NE) are known to be key neurotransmitters in the etiology of depression and anxiety
  • From the raphe nuclei and locus ceruleus, 5-HT and NE, respectively, send projections up to the prefrontal cortex and limbic system where emotional depressive symptoms are thought to be mediated
  • There are also 5-HT and NE-rich tracks into the spinal cord that are postulated to modulate pain perception

## Statisticsa,b,d,e,f,g

  • Depression affects > 300 million people globally
  • Depression is the 4th leading cause of disease burden globally (accounting for 4.4% of total disability adjusted life years, DALYs, in the world in 2000)
  • Depression and anxiety are two times more prevalent in women than in men
  • 69% of cases of depression present as unexplained physical symptoms
  • Globally, the proportion of patients with depression who:

||| Seek care for their depression is 33%

||| Are explicitly recognised as being depressed is < 50%

||| Receive some form of therapy for their illness is 50%

||| Receive an adequate dose and duration of antidepressant treatment is 25%

## Types of depression:

  • Bipolar disorder
  • Chronic dysthymia
  • Minor
  • Postpartum
  • Psychotic
  • Seasonal affective disorder (SAD)

## Types of anxiety:

  • Generalized Anxiety Disorder
  • Obsessive-Compulsive Disorder (OCD)
  • Panic Disorder
  • Post-Traumatic Stress Disorder (PTSD)
  • Social Phobia
Symptoms

## Signs and symptoms of anxiety

  • Signs and symptoms of anxiety include:

_Sleep disturbances

_Nausea

_Muscle tension

_Nightmares

_Dizziness

_Feelings of:

||| Fear

||| Panic

||| Uneasiness

_Thoughts:

||| That are uncontrollably obsessive

||| Of persistent flashbacks of the past traumatic experiences

_Ritualistic behaviors such as repeated:

||| Moping of the floor

||| Washing of hand

_Palpitations

­_Dry mouth

_Numbness or tingling in the hands or feet

_An inability to be still and calm

_Shortness of breath

 _Cold or sweaty hands and/or feet

## Signs and symptoms of depression

  • Signs and symptoms of depression are classified into:

_Physical

_Behavioral/attitude

_Emotional signs

  • Physical

_Sleep disturbance

||| Oversleeping

||| Insomnia

||| Sometimes waking up early

_Eating too much or too little food (leading to weight gain or loss)

_Fatigue in the morning

_Headaches

_Vague aches and pains

_Idiopathic digestive disorder

_Over dreaming

  • Behavioral/Attitude

_Loss of interest in activities that were previously enjoyed such as:

||| Sex

||| Hobbies

||| Sports

||| Reading

||| Company

||| Singing

_Unkempt appearance

_Being irresponsible

_Indecision

_Lack of concentration

  • Emotional

_Being sad for a long time

_Unjustified crying

_Feeling:

||| Agitated

||| Guilty

||| Helpless

||| Hopeless and anxiety

||| Irritable

||| Worthless

_Emotionally arousing rumination (deep thoughts)

_Suicidal thoughts

_Persistent thoughts about one death

_Excessive or inappropriate guilt

## Complications of depression and anxiety include:

  • Depression:

_Alcohol abuse

_Anxiety

_Problems in the workplace

_Family conflicts

_Premature death from other medical conditions

_Relationship difficulties

_Self-mutilation

_Social isolation

_Substance abuse

_Suicide

  • Anxiety:

_Bruxism (teeth grinding)

_Depression

_Digestive disorders

_Headaches

_Insomnia

_Substance abuse

Diagnosis
  • Clinical review
  • Reference to a psychologist or psychiatrist
Differential

## Depression

  • Adjustment Disorders

_A group of symptoms, such as stress, sadness or hopeless, and physical symptoms that can occur after a person has gone through a stressful life event

_The reaction to the stress is far much more intense than what is expected for the type of event that occurred

  • Anemia
  • Anorexia nervosa
  • Alcohol abuse
  • Bipolar disorder
  • Chronic Fatigue Syndrome
  • Cushing’s disease
  • Dementia
  • Dissociative Disorders
  • Grief reaction
  • Hypochondriasis (worry of having a serious illness that is not even there)
  • Hypoglycemia
  • Hypopituitarism
  • Hypothyroidism
  • Premenstrual dysphoric disorder
  • Schizoaffective Disorder
  • Schizophrenia
  • Side effects of drugs such as oral contraceptives and propranolol
  • Somatic Symptom Disorders
  • Vitamin B12 deficiency

## Anxiety

  • Thyrotoxicosis
  • Hypoglycemia
  • Pheochromcytoma
  • Temporal epilepsy
Prevention
  • Although anxiety and depression cannot be fully prevented, the risk of their occurrence can be reduced by the following:

_Regular exercises, especially with the elderly

_School-based programmes that promote a pattern of positive thinking in children and adolescents

_Eating healthy foods

_Avoiding drug abuse, including alcohol

_Counselling and support following a traumatic experience

_Observing regular sleep pattern

_Spirituality

Reference

a. Üstün, T. B., Ayuso-Mateos, J. L., Chatterji, S., Mathers, C., & Murray, C. J. (2004). Global burden of depressive disorders in the year 2000. The British journal of psychiatry, 184(5), 386-392.

b. Simon, G. E., VonKorff, M., Piccinelli, M., Fullerton, C., & Ormel, J. (1999). An international study of the relation between somatic symptoms and depression. N Engl J Med, 1999(341), 1329-1335.

c. Stahl, S. M. (2002). The psychopharmacology of painful physical symptoms in depression

d. Shapiro, S., Skinner, E. A., Kessler, L. G., Von Korff, M., German, P. S., Tischler, G. L., ... & Regier, D. A. (1984). Utilization of health and mental health services: three epidemiologic catchment area sites. Archives of General Psychiatry, 41(10), 971-978

e. Wells, K. B., Hays, R. D., Burnam, M. A., Rogers, W., Greenfield, S., & Ware, J. E. (1989). Detection of depressive disorder for patients receiving prepaid or fee-for-service care: results from the Medical Outcomes Study. Jama, 262(23), 3298-3302

f. Lépine, J. P., Gastpar, M., Mendlewicz, J., & Tylee, A. (1997). Depression in the community: the first pan-European study DEPRES (Depression Research in European Society). International clinical psychopharmacology, 12(1), 19-30

g. Katon, W., Von Korff, M., Lin, E., Bush, T., & Ormel, J. (1992). Adequacy and duration of antidepressant treatment in primary care. Medical care, 67-76

h. Marcus, M., Yasamy, M. T., van Ommeren, M., Chisholm, D., & Saxena, S. (2012). Depression: A global public health concern. WHO Department of Mental Health and Substance Abuse, 1, 6-8

i. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf

Management

## General information on management of depression and anxiety:

  • Globally, about 30% of depressed patients achieve remission but up to 70% of patients who respond fail to remitc

## Uncomplicated anxiety

  • Reassurance of the patient
  • Tab Amitriptyline 25-50mg Nocte

## Complicated anxiety

  • Behavioral therapy
  • Psychotherapy
  • Counselling

## Depression

  • Anti-depressants take > 2 weeks to take effect
  • In case there is no improvement after 4 weeks review the diagnosis and medications
  • Tabs Amitriptyline 50mg Nocte (when sedation is required)

OR

  • Tabs Imipramine 50mg Nocte (when sedation is NOT required)

    OR

  • Tabs Fluoxetine 20mg OD (preferably in the morning)

OR

  • Tabs Agomelatine 25 mg OD before food at bedtime. The dose may be increased to 50mg OD if there is no improvement of symptoms after 2wks.

OR

  • Tabs Bupropion 150 mg OD x 3/7, then 150mg BD [up to 200 mg BD] in the morning.

OR

  • Caps Duloxetine 60 mg/day

OR

  • Tabs Escitalopram 10mg daily [up to 20mg daily].

OR

  • Tabs Fluvoxamine 50mg at bedtime. (The dose may be raised in increments of 50 mg a day at intervals of 4-7 days. Doses above 100mg should be taken in two divided doses. Usual adult dose: 300mg daily).

OR

  • Tabs Paroxetine 20mg OD [Morning][max.50mg daily but 40mg in elderly]

OR

  • Tabs Maprotiline initially 25-75mg daily in three divided doses or a single dose nocte. [max.150mg].

OR

  • Mianserin Initially 30-40mg in divided doses or a single dose nocte. Normal dose ranges 30-90mg daily.

OR

  • Tabs Sertraline 50mg daily. Dose adjusted in the increment of 50mg over several weeks to max. of 200mg daily. Once an optimum response is attained reduce the dose to usual therapeutic dose of 50-100mg. Dose of above 150mg should not be given over 8 weeks.

OR

  • Tabs Tianeptine 12.5mg TID

OR

  • Caps Venlafaxine 37.5mg BD. Dose can be increased after several weeks to 75mg BD.

## Other methods of management of depression and anxiety

  • Regular exercise is beneficial for patients with depression and anxiety
  • Electroconvulsive therapy
  • Cognitive-behavioral therapy (CBT)
  • Psychotherapy
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