Depression and Anxiety Management

1. Depression and Anxiety Management Kathleen Roose, RN

2. Goal The goal of this presentation is to provide National Guard medical case managers with information about the symptoms, implications, and management of depression and anxiety.

3. Objectives • List three risk factors for depression and anxiety. • Describe three signs that an individual is experiencing depression or anxiety. • Discuss the ways depression and anxiety affect the quality of life for families and individuals. • Identify three common pharmaceutical treatments for depression and anxiety.

4. Depression and Anxiety Overview • Currently affect 9.1% of the U.S. population • Manifest in many different ways • Impact a person’s family, relationships, jobs, and physical health • Treatment plan must include suicide risk assessment and prevention • Can be treated with medications and psychotherapy

5. Risk Factors for Depression • Having biological relatives with depression • Women at statistically greater risk • Traumatic childhood experiences • Lack of social support • Serious illness or chronic pain • Stressful life events, such as death of a loved one or financial difficulties • Previous episode of depression

6. Risk Factors for Depression (continued) • Pregnancy and childbirth (post partum depression) • Alcohol or drug abuse • Use of certain medications • Having personality traits such as low self-esteem, being overly dependent, self-critical, or pessimistic

7. Signs and Symptoms of Depression • Feelings of sadness, hopelessness, pessimism • Feelings of guilt, worthlessness, helplessness • Lack of interest or pleasure in things previously enjoyed (ahedonia) • Lack of energy or motivation, fatigue • Difficulty concentrating, remembering, making decisions • Restlessness, irritability

8. Signs and Symptoms of Depression (continued) • Changes in sleeping habits (insomnia or hypersomnia) • Changes in appetite or weight (anorexia, or overeating) • Thoughts of death or suicide; suicide attempts • May be masked by alcohol or drug abuse, particularly in men

9. Clinical Depression vs. Normal Sadness • To distinguish a depressive disorder from normal sadness, severity, duration, and other symptoms should be considered. • Depression involves symptoms that persist and impair daily life.

10. Medical Conditions Associated with Increased Risk of Depression • Severe or chronic medical conditions – medications may contribute to depression • Hypothyroidism – May be diagnosed as depression and go undetected • Chronic pain conditions – orthopedic problems, migraine headaches, fibromyalgia • Neurological conditions, including Traumatic Brain Injury (TBI), stroke, and spinal cord injuries • Insomnia and sleep disorders (may be caused by depression or may cause depression) • Diabetes

11. Impact of Depression and Anxiety on Daily Activities and Relationships • Increased risk of divorce • Spouses of depressed people are more likely to be depressed themselves • Children of depressed people are more likely to be depressed • Increased absences, reduced performance quality and lost productive time at work • Increased risk of unemployment and lower income

12. Physical Complications of Depression and Anxiety • Heart disease and heart attacks • Impaired clotting • Impaired blood flow to heart • Changes in heart rate • Obesity • Increased pain sensation • Cognitive impairment, particularly in the elderly • Risk of suicide

13. Treatments for Depression and Anxiety

14. Psychotherapy • Cognitive behavioral therapy: • Form of talk therapy most commonly used to treat depression and anxiety • Patient learns to identify negative beliefs and behaviors and replace them with healthy, positive ones • Based on the idea that the patient’s own thoughts, rather than outside people or situations, determine how the patient feels and behaves

15. Antidepressant Medications: Selective serotonin-reuptake inhibitors (SSRIs) • Frequently the first medications prescribed for newly-diagnosed patients • May effectively treat both depression and anxiety • Target the neurotransmitter serotonin • Examples of SSRIs: • citalopram (Celexa) • paroxetine (Paxil) • fluoxetine (Prozac) • sertraline (Zoloft)

16. "What you thought before has led to every choice you have made, and this adds up to you at this moment. If you want to change who you are physically, mentally, and spiritually, you will have to change what you think." - Dr. Patrick Gentempo

17. Antidepressant Medications: Serotonin and norepinephrine reuptake inhibitors (SNRIs) • Target both serotonin and norepinephrine • May be effective for patients who do not respond to SSRIs • Examples: • venlafaxine (Effexor XR) • desvenlafaxine (Pristiq) • duloxetine (Cymbalta)

18. Antidepressant Medications: Tricyclic Antidepressants • Were the standard treatment for depression before the introduction of SSRIs • Multiple, frequent side effects • May benefit people with depressive symptoms that do not respond to SSRIs • Examples: • amitriptyline (Elavil, Endep) • imipramine (Tofranil) • desipramine (Norpramin) • nortriptyline (Pamelor, Aventyl)

19. Antidepressant Medications: Atypical Antidepressants • Called “atypical” because they do not fit into other categories of antidepressants • Cause fewer sexual side effects than other antidepressants • Some, such as trazodone and mirtazapine, are sedating and frequently prescribed for insomnia • Examples: • bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL) • trazodone (Oleptro) • mirtazapine (Remeron, Remeron SolTab). • nefazodone (is not commonly prescribed due to link to dangerous liver problems)

20. Other Medications for Depression • Monoamine oxidase inhibitors (MAOIs) • Often highly effective for depression that does not respond to other treatment • Prescribed as a last resort due to high risk for dangerous drug and food interactions • Side effects are common • Examples: • isocarboxazid (Marplan) • phenelzine (Nardil) • tranylcypromine (Parnate) • selegiline (Emsam, Eldepryl, Zelapar)

21. Medications for Anxiety: Benzodiazepines • Prescribed for anxiety and panic disorders • Have sedating effects • Quick acting • Habit-forming, usually prescribed for short-term use • Examples: • alprazolam (Xanax) • chlordiazepoxide (Librium) • clonazepam (Klonopin) • diazepam (Valium) • lorazepam (Ativan)

22. Other Medications for Anxiety • buspirone (BuSpar) • Has not been shown to cause drowsiness or dependence • Must take for 2 weeks before feeling any effect • Side effects include insomnia, nervousness, light-headedness, upset stomach, nausea, diarrhea, and headaches.

23. Suicide Risk and Prevention

24. Suicide Risk and Prevention “Suicide is a permanent solution to a temporary problem.” • Phil Donahue Suicide risk assessment and prevention is essential to the care of all people with depression and anxiety.

25. Statistics about suicide • In the United States, there is a suicide every 15 minutes. • Based on a data from a 2008-2009 study, more than 2.2 million adults (1.0 percent) reported making suicide plans in the past year, and more than 1 million said they attempted suicide in the past year. • Young adults (ages 18-29) are at higher risk.

26. Suicide and the National Guard • Risk of suicide is higher for National Guard Soldiers than for active duty Soldiers • Lack of protective factors, such as ongoing social support following deployment, may play a role. • Suicide rates for Soldiers doubled from 2009 to 2010. • Awareness and prevention programs have been heavily promoted recently to improve this problem.

27. Suicide Risk and Prevention • Step one: Identify risk factors • Suicidal behavior, including previous attempts or self-injury • Current or past psychiatric disorders • Key symptoms • Ahedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations • Family history of suicide, attempts, or psychiatric hospitalizations • Triggering events, including intoxication or acute pain • Change in treatment • Access to firearms

28. Suicide Risk and Prevention • Step two: Identify protective factors • Internal – coping abilities, religious beliefs, frustration tolerance • External – responsibility to family (particularly children), positive therapeutic relationships, social supports

29. Suicide Risk and Prevention • Step three: Conduct suicide inquiry • Ask specific questions about thoughts, plans, behaviors, intent • Step four: Determine risk level and intervene as appropriate • Step five: Document all assessment and action taken, including rationale

30. Suicide Risk Levels

31. Act To Prevent Suicide! • Provide patients with crisis hotline information. • All potential patient safety issues, including moderate to high suicide risk, should be immediately reported to the service member’s chain of command. • It is everyone’s responsibility to act to prevent suicide.

32. Case Study: SGT Laura Daniels

33. Case Study SGT Lara Daniels, a 34-year-old female, is seen by her primary care provider today. SGT Daniels has been working as a physical therapy assistant until six months ago, when she went on medical leave before the birth of her third child. “I really need to get back to work,” she states during visit. “We can’t afford all this time off.” She is married, and has been in the National Guard for the last eight years.

34. Case Study SGT Daniels is in good general health, but complains today of insomnia and back pain, stating that an old work injury had been aggravated by the delivery of her last child. She states she has been experiencing pain every day, and requests medication for this as well as for something to help her sleep. After further questioning, SGT Daniels admits that she has been feeling more sad and irritable than usual. “I’m just under a lot of stress,” she says. “Things are hard between my husband and me right now.”

35. Case Study • What risk factors does SGT Daniels have for depression and anxiety? • What signs and symptoms for depression and anxiety does she display? • What health problems that she describes could be related to or a result of depression or anxiety? • Discuss SGT Daniels’ suicide risk level, including risk and protective factors.

36. Case Study After a thorough evaluation, SGT Daniels’ primary care provider believes she is likely suffering from a depressive disorder. He carefully assesses her suicide risk today; SGT Daniels denies thoughts or plans of self-harm. Her provider refers her to a psychiatrist and orthopedic specialist for further evaluation, and prescribes her a sleep aid and PRN pain medication for her to take in the meantime.

37. Case Study SGT Daniels follows up with the psychiatrist, who diagnoses her with major depression. After trying several medications, she is prescribed Zoloft and begins weekly psychotherapy with good results. After several months, SGT Daniels reports she is feeling better. She has also started physical therapy for her back pain, and states her pain is now better controlled. While she still reports financial stress, she now states, “I feel like I can handle it better. I’m much happier now.”

38. Case Study • In addition to the medication and psychotherapy prescribed by her provider, what other measures can be taken to improve SGT Daniels’ recovery and reduce risk of relapse?

39. "Better keep yourself clean and bright; you’re the window through which you must see the world." - George Bernard Shaw

40. References Centers for Disease Control and Prevention. (2012, April 20). An Estimated 1 in 10 U.S. Adults Report Depression. http://www.cdc.gov/Features/dsDepression/ HealthDay. (2011, October 20). Suicide Rates Vary by Region: CDC. U.S. News. Retrieved from http://health.usnews.com/health-news/family-health/brain-and-behavior/articles/2011/10/20/suicide-rates-vary-by-region-cdc Keyes, C. (2011, January 19). Suicide rate doubles for Army National Guard. Retrieved from http://articles.cnn.com/2011-01-19/us/army.suicide.rate_1_army-suicides-suicides-among-active-duty-soldiers-suicide-rate?_s=PM:US Mayo Clinic Staff. (2012, February 10). Depression (major depression). Retrieved from http://www.mayoclinic.com/health/depression/DS00175 National Institute of Mental Health. (2011, November 15). Mental Health Medications. Retrieved from http://www.nimh.nih.gov/health/publications/mental-health-medications/what-medications-are-used-to-treat-anxiety-disorders.shtml

41. References U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration. (2009). Suicide Assessment Five-step Evaluation and Triage. Retrieved from http://www.vahealth.org/Injury/preventsuicideva/documents/2011/pdf/SAFE-T%20Pocket%20Card.pdf Warman, D., & Beck, A. (2003, June). Cognitive-behavioral therapy. Retrieved from http://www.nami.org/Template.cfm?Section=About_Treatments_and_Supports&template=/ContentManagement/ContentDisplay.cfm&ContentID=7952 University of Maryland Medical Center (2011). Depression. Retrieved from http://www.umm.edu/patiented/articles/depression_000008.htm