Depression and Anxiety

Purpose: The purpose of this course is to provide an overview of two of the most common psychiatric disorders seen in primary care: depression and anxiety. The incidence, pathophysiology, signs and symptoms, diagnostic criteria, and treatment for each disorder will be discussed.

Objectives:

After completion of this course, the participant will be able to

  • demonstrate familiarity with the pathophysiological changes in depression and anxiety
  • identify the diagnostic criteria for depression and anxiety
  • demonstrate familiarity with the SIG-E-CAPS pneumonic in the diagnosis of depression
  • demonstrate familiarity with the treatment modalities for depression
  • demonstrate familiarity with the treatment modalities for generalized anxiety disorder and other anxiety disorders
  • demonstrate familiarity with the role of lifestyle in management of depression and anxiety

Case

A 32-year-old white female, who is the mother of three, presents to the primary care clinician with lack of energy, back pain, early morning wakening and irritability. She reports that she is so engrossed in her children’s lives that she has no time to do anything herself. On the rare evening that she has an evening free she chooses to go to sleep instead of going out.

Her physical exam is unremarkable. Her past medical history is unremarkable except for three healthy vaginal births. She is on no medications and has no allergies to medications.

Introduction

Depression is one of the most common disorders encountered by the primary care clinician. Unfortunately, it remains under diagnosed and under treated.

While depression has obvious implications on quality of life it can also affect quantity of life. Those who suffer from depression are more likely to commit suicide, have medical illness poorly controlled, abuse substances, lose work time and have problems in their personal lives.

Anxiety is also a common medical diagnosis. Many different types of anxiety exist from generalized anxiety disorder to obsessive compulsive disorder. Death rates are higher among anxious individuals as anxiety negatively affects the endocrine and immune system. Those with anxiety also have a higher rate of suicide1.

Both conditions have a negative social stigma, which partly explains why these conditions are under diagnosed. Patients and physicians are often reluctant to bring up the topic of depression or anxiety. Many times depression and anxiety co-exist.

Depression affects 20 percent of women and 12 percent of men across a lifespan. Anxiety incidence is variable depending on the type of anxiety[1].

  • Generalized anxiety disorder (GAD) 4.1-6.6%
  • Social phobia 2.6 – 13.3%
  • Panic disorder 2.3-2.7%
  • Obsessive compulsive disease 2.3-2.6
  • Post traumatic stress disorder – 1-9.3%

The prevalence of anxiety is high, one estimate proposes that 18% of primary care patients are afflicted with an anxiety disorder and around 7% are generalized[2]. Only 60% of those diagnosed with generalized anxiety disorder were treated in 2002[3].

GAD disrupts the lives of about 10 million Americans4 and is often a predecessor to major depression. GAD is also associated with other mood disorders, functional impairment and alcohol and other substance dependence disorders[4].

The white population is more commonly affected with depression than the black population9. Panic disorder has equal incidence in the white, black and Hispanic population1. Females are more commonly diagnosed with both depression and anxiety than males.

Depression rates peak between the ages of 25 and 449. Generalized anxiety disorder has its onset in the 20’s or early 30’s, but as children they are often characterized by being nervous about grades and social events. Panic disorder is most common in the late teens and early 20’s and than again the late 40’s and early 50’s. OCD is typically diagnosed in the mid 20’s to early 30’s1.

Many disease states increase the risk of mental health disease. Chronic disease is associated with increased rates of depression and anxiety. Some diseases are more prone to mental health conditions than others. Chronic obstructive pulmonary disease (COPD) patients are at much higher risk for developing depression than the general population[5]. A recent study suggested that the risk of depression in COPD is higher than those with diabetes5.

Heart disease is also linked to depression. Recent guidelines recommend that patients who have had a recent heart attack should be screened for depression regularly[6].

Individuals afflicted with metabolic syndrome are more likely afflicted with depression than those without the condition[7]. This is important to recognize as patients with metabolic syndrome need to make lifestyle changes to prevent complications of the disease and depressed patients are less likely to make these changes. Individuals with metabolic syndrome are at risk for diabetes, heart disease and stroke.

Infertile couples are also noted to be at higher risk of depression and other mental health conditions. Women were noted to have more binge-eating than fertile women. Men were noted to have increased rates of social phobia and obsessive-compulsive disorder, but both conditions were noted to be subclinical[8].

A more lasting, but milder form of depression is called dysthymia. It can last for years before it is treated or recognized. It is diagnosed when a patient has a depressed mood on most days for most of the day for at least two years. These patients are withdrawn, pessimistic, irritable and are unable to find joy in life. Many people – including the patient themselves - mistakenly think these individuals are just this way by nature.

Pathophysiology

The exact pathophysiological mechanism responsible for both anxiety and depression are not known. The role of neurotransmitters is strongly implicated in the pathogenesis of both conditions. Serotonin, norepinephrine and dopamine are three neurotransmitters that have been looked at.

Many factors contribute to psychiatric illness beyond the absolute level of neurotransmitters. The receptor regulation and sensitivity are also linked to mental disease. Likely there needs to be neuronal receptor regulation over time to affect mood[9]. The role of pathophysiology is important in the pharmacologic treatment of depression.

Signs and Symptoms

For the diagnosis of major depression the patient must demonstrate at least one of the following: depressed mood and/or reduction of interest or pleasure in activities. In addition, they must exhibit at least four physical symptoms such as weight/appetite changes, decrease in energy, fatigue, concentration difficulties, and sleep disturbance for a minimum of two weeks. Bereavement, general medical conditions, medications, drug or alcohol abuse cannot account for these symptoms. Bereavement is normal after certain events (e.g. death of a loved one), but symptoms should not persist beyond two months. The symptoms must result in significant impairment of social, occupational or school functioning[10]. A well known pneumonic is often used for the clinician to diagnose depression: SIG-E-CAPS (table 1).

Table 1: SIG-E-CAPS pneumonic

S / Sleep disturbance – either insomnia or hypersomnia.
I / Loss of interest in everyday activities – anehdonia.
G / Guilt – helplessness, hopelessness, worthlessness
E / Lack of energy
C / Difficulty concentrating
A / Appetite disturbance – either increased or decreased
P / Psychomotor blunting or agitation
S / Suicidal thoughts, thoughts of death
Also ask the patient if they feel depressed.

Sleep disturbance is most commonly early morning wakening, known as terminal insomnia.

Passive suicidal ideation is common with depression, which is not thoughts of suicide, but a preference to not be alive. Risk factors for suicide include: the existence of a mental health disorder (the presence of anxiety and depression increases the risk), lack of social support, substance abuse and availability of a weapon. Health care providers need to evaluate for a plan and a method to carry that plan out.

Mania is important to rule out. This would indicate bipolar disease or manic-depression. To assess for this ask the patient if he/she ever feels the opposite of depressed. Do they ever feel really charged up and do not sleep or spend a lot of money? Mania is a feeling of elation that lasts greater than 3 weeks and is associated with pressured speech, decreased need for sleep, feelings of grandiosity, impaired functioning, increased activity, flight of ideas, easy distractibility and poor decision making such as excessive spending or sexual indiscretion.

It is important to assess for psychosis as this may indicate depression with psychotic features or schizo-affective disorder. Ask the patient if delusions/hallucinations are present? Do they have special powers?

It is also important to ask about homicidal thoughts. Depressed patients are at risk to physically or verbally attack other people. Anyone with homicidal thoughts should be hospitalized.

Generalized anxiety disorder (GAD) is characterized by excessive anxiety or worry without proof or out of proportion to the given situation. The patient is in a continual state of tension and anxiety. The symptoms persist beyond six months and the anxiety is in response to various stressors. The DSM IV lists the criteria for GAD as three or more of the following symptoms - which impair normal functioning, cause distress and are not due to another medical or psychological problem - needing to be present most days for the past 6 months10. These symptoms include: irritability, sleep disturbance, fatigue, feeling restless, on edge or keyed up, lacking concentration and muscle tension.

GAD affects quality of life as it impairs functioning. Patients often procrastinate, practice avoidance, have poor problem solving skills, miss work and do not maintain daily responsibilities.

The physical symptoms of anxiety include: elevated blood pressure, increased respiratory and heart rate, muscle tension, and reduced blood flow to the intestines resulting in nausea or diarrhea. Tremor, shaking, furrowed brow, dilated pupils, cold clammy hands and diaphoresis may also be present. Physical findings often do not point to the diagnosis of anxiety. Needle track marks, ascites and hepatomegaly suggest substance abuse

When evaluating a patient with non-specific or vague complaints, anxiety or depression must be considered in the differential. Common complaints of patients with GAD include: fatigue, sweating, dry mouth, flushing, nausea, diarrhea, urinary frequency, insomnia, weakness, irritability, restlessness and muscle tension and chills.

Other conditions need to be evaluated for when anxiety is considering such as substance abuse, withdrawal, reactions to medications. Many medications may lead to signs and symptoms of anxiety. This includes prescription as well as non-prescription or illegal drugs. Common prescription drugs that may lead to signs and symptoms suggestive of anxiety include: thyroxin, theophylline, digoxin, steroids and narcotics. Amphetamines, marijuana, cocaine and withdrawal from alcohol, nicotine or sedative-hypnotics may also cause anxiety. Social conditions that may be found on history include major life events such as a death, marriage or divorce. A family history may be positive for mental illness.

Medical conditions can mimic anxiety. Medical conditions to consider when anxiety is present include: chronic obstructive pulmonary disease, angina, myocardial infarction, arrhythmias, valvular disease, anemia, asthma, and hypoglycemia.

Psychological testing such as the Beck Anxiety Inventory, the Hamilton Anxiety Rating Scale and the Anxiety Disorders Interview Schedule can be used in the diagnosis of this condition.

When the diagnosis of anxiety is made it is important to keep other diagnoses as a consideration especially when treatments are not effective. Other clues that anxiety is not causing the issue include: symptoms starting after age 35, anxiety symptoms not related to life stressors, no avoidance behaviors and a lack of childhood history of significant forms of anxiety are clues to the need for further evaluation[11]. GAD should be a diagnosis of exclusion after other diseases have been ruled out.

Panic disorder is associated with recurrent episodes or panic attacks. Panic attacks are short-periods of intense fear that come on very quickly. At least four symptoms must be present to diagnose panic attack including: shortness of breath, chest pain, palpitations, increased heart rate, sweating, trembling, dizziness, fainting, nausea, abdominal distress, numbness, chills or hot flashes, sensation of choking, depersonalization or fear of dying.

Obsessive compulsive disorder (OCD) is a disorder characterized by obsessions and compulsions that cause distress for the person suffering from them. Obsessions are recurrent and persistent thoughts, images or impulses that cause stress and anxiety. Compulsions are repetitive behaviors carried out by the individual to reduce anxiety caused by the obsession.

Phobia is a fear of something. Everyone is afflicted with specific fears, but when does a phobia become a disease. Agoraphobia is a fear of a specific item. Those with agoraphobia often fear being embarrassed by a public onset of a panic attack and often become socially isolated.

Social phobias, also known as social anxiety disorder (SAD), are persistent fears in social situations that impair the ability to function socially. These situations cause the person to feel anxiety which is excessive.

Post-traumatic stress disorder (PTSD) happens after a trauma that included a real or threatened death or injury. PTSD is characterized by at least one of the following: re-experienced the event; recurrent dreams; flashbacks; intense psychological distress from the previous trauma; or physiological changes when exposed to trauma cues.

Diagnostic work up

Ruling out other medical conditions is a critical part of the work-up of depression and anxiety disorder. Laboratory evaluation should include:

  • Complete blood count
  • Basic metabolic panel
  • Thyroid function test
  • Drug screen and urinalysis

Other tests to consider based on the initial presentation may include:

  • Liver function tests
  • Vitamin B-12 levels
  • Erythrocyte sedimentation rate
  • Antinuclear antibody
  • Rapid plasma reagin
  • Human immunodeficiency virus testing
  • Arterial blood gas
  • Dexamethasone suppression test (Cushing disease)
  • Cosyntropin stimulation test (Addison’s Disease)
  • Electroencephalogram
  • Lumbar puncture
  • CAT scan of the brain
  • Cardiovascular work up

Treatment

Many different treatments are available for depression and anxiety. Ideally a collaborative method is recommended for best depression treatment as this maximizes adherence, quality of life and treatment outcome[12]. Management should include adequate follow up with monitoring of effectiveness of treatment. The Institute of Clinical System Improvement12 recommends a team approach to depression management with the involvement the primary care physician, psychiatrist, and care manager.

The primary goal of treatment is for the patient to have minimal symptoms and achieve complete remission. Additional goals include: restoration of functionality, prevention of further episodes, and prevention of a neurodegenerative process.

Patients need to be active members in the treatment of their depression. Patients and families need to be educated about their disease and this is the responsibility of not only the patient, but the treating clinicians as well as the depression case manager. Ideally the involvement of a case manger would improve education and adherence to treatment. Most depressed patients are not assigned a care manager and the role of teaching, motivating the patient and assuring follow up are the role of the treating clinician.

The depressed patient is a clinical challenge with treatment as the disease is often characterized by decreased energy and motivation, pessimism, and social isolation.

Patients who do not understand the disease are likely to have reduced rates of treatment compliance. Patients need to understand the basics of the disease including its cause, symptoms and the natural course of the disease12.

Understanding how treatment affects the disease is another critical aspect to the management of the disease. Patients need to understand that medications work over a period of weeks to months. Patients who assume that they will feel better after taking one to two doses of medication are much less likely to adhere to treatment.

Understanding side effects of treatments is another critical aspect of treatment. Many side effects of medications used to treat depression are temporary and will improve as the body adapts to the medications. Knowing this may help get the patient through the initial weeks of therapy. Patients also need to understand about the discontinuation syndrome so they do not attempt to stop the medications abruptly without consulting their health care provider.

Other points of education that are critical to convey to the patient include12:

  • Signs and symptoms suggestive of relapse
  • The amount of time treatment will take
  • How to communicate with the health care provider
  • Prognosis

Patients should understand that depression is a very treatable medical disease and not a problem with their internal character. American society strongly stigmatizes against mental disease. Depressed patients should be treated. If active treatment is stopped, recurrence rates are high and patients should be educated about what to look out for that would indicate relapse.

Lifestyle changes are primary interventions that should be encouraged in all patients. This includes activities such as exercise, nutrition, smoking cessation and alcohol restriction.

Exercise is an effective strategy in the management of depression. Exercise in the depressed individual can be associated with other barriers due to the disease. These include: low energy level and feelings of guilt if exercise sessions are missed. Developing a plan that will maximize adherence is a critical aspect in the prescription of exercise. Discuss with the patient what type of exercise he/she enjoys (walking, swimming, group exercise). People comply with exercises that they enjoy much more readily. Provide information about aerobic exercise prescription guidelines so patients can derive benefits from exercise.

Patients should be taught about the FITT principal. This is a pneumonic to help patients remember how to exercise aerobically. F stands for frequency, which should occur 3-7 times a week. Exercise ideally should occur most days of the week, but this is not the ideal strategy for someone who has low energy or deconditioned. Use clinically judgment to determine how often a depressed patient should exercise, encouraging them to gradually increase the number of days they exercise as conditioning and energy levels allow.