1 / 41

DEPRESSION & ANXIETY Many Faces Different Management

DEPRESSION & ANXIETY Many Faces Different Management. Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head of Psychiatry Department Arab Board of Psychiatry Representative. Depression and general practice.

linh
Download Presentation

DEPRESSION & ANXIETY Many Faces Different Management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. DEPRESSION & ANXIETYMany FacesDifferent Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head of Psychiatry Department Arab Board of Psychiatry Representative

  2. Depression and general practice • France: 1 patient of 3 has significant psychiatric symptoms • 15-20% of patients have a psychiatric disorder with or without other medical condition • 5-10% of a GP’s patients have a depression Dar Al-Ajaza Al-Islamia Hospital in Beirut

  3. Prevalence of Anxiety Disorders Lifetime % Current % • Any anxiety disorder 24.9 17.2 • Panic disorder 3.5 2.3 • Agoraphobia without 5.3 2.8 panic disorder • Social phobia 13.3 7.9 • Simple phobia 11.3 8.8 • Generalized anxiety 5.1 3.1 disorder Results from National Co morbidity Survey , Kessler and al. 1994 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  4. Under diagnosis of Depression and Anxiety • Emphasis on somatic rather than cognitive/mood complaints • Belief that depression and anxiety are a natural reaction to circumstance (counter transference) • Reluctance to stigmatize patient with psychiatric diagnosis • Nonspecific symptoms, overlap with medical illness • Time limitations in primary care Dar Al-Ajaza Al-Islamia Hospital in Beirut

  5. Anxio-Depression A new spectrum in psychiatry • The categorical classification of mental disorders (DSM-IV , ICD-10) has limitations • No clear boundaries between classes of disease, or even between psychopathology and normality • Combining several types of related disorders into a large group defined as a “spectrum” has a heuristic value : it gives new insights and permits epidemiological, genetic and above all therapeutic research • This is especially true for anxiety and depression Dar Al-Ajaza Al-Islamia Hospital in Beirut

  6. Anxiety - Depression Syndromal Overlap Dar Al-Ajaza Al-Islamia Hospital in Beirut

  7. Symptoms of Depression(DISC & GAPS) Depressed mood and/or Interest reduction (anhedonia) plus • Sleep disturbance • Concentration impairment, memory loss • Energy loss, fatigue, • Guilt, feelings of worthlessness • Appetite changes, significant weight loss (or gain) • Psychomotor retardation or agitation • Suicidal thoughts Dar Al-Ajaza Al-Islamia Hospital in Beirut

  8. What is Anxiety ? • Cognitive (automatic ideas) • Behavioral (avoidance) • Physical Dar Al-Ajaza Al-Islamia Hospital in Beirut

  9. Nervousness, restlessness Trembling Trouble falling or staying asleep Sweating Poor concentration Palpitations Frequent urinations Muscular tension Easily fatigued Light-headedness or dizziness Irritable mood Hypervigilance Shortness of breath Physical Symptoms of Anxiety Dar Al-Ajaza Al-Islamia Hospital in Beirut

  10. DSM-IV Classification Anxiety Disorders GAD SocialPhobia SpecificPhobia Panic Disorder OCD Agoraphobia PTSD American Psychiatric Association (1994) Dar Al-Ajaza Al-Islamia Hospital in Beirut

  11. Different disorders with some common features PMDD PTSD OCD Depression Panic disorder Specific phobia Social anxiety disorder GAD GAD = generalized anxiety disorder OCD = obsessive-compulsive disorder PTSD = post-traumatic stress disorder PMDD = premenstrual dysphoricdisorder Dar Al-Ajaza Al-Islamia Hospital in Beirut

  12. Profile of the Anxious Depressed Patient • Anxiety symptoms affect 9 out of 10 depressed patients • Mixture of anxiety, tension and depression • Impaired functioning compared with primary depressives • Increased : hypochondrias is, depersonalization, chronic depression • Reduced response to drug therapy and psychosocial intervention • More severe and chronic illness • Greater risk of suicide Dar Al-Ajaza Al-Islamia Hospital in Beirut

  13. PANIC DISORDER Dar Al-Ajaza Al-Islamia Hospital in Beirut

  14. Panic DisorderDSM-IV Classification • Recurrent unexpected panic attacks • At least one of the attacks has been followed by one or more of the following for at least one month: - persistent concern about having additional attacks - worry about the implications of the attack - a significant change in behavior American Psychiatric Association (1994) Dar Al-Ajaza Al-Islamia Hospital in Beirut

  15. Shortness of breath smothering sensations Dizziness, unsteady feelings or faintness Palpitations tachycardia Trembling / shaking Sweating Choking Nausea / abdominal distress Depersonalization derealization Paresthesias Flushes / chills Chest pain or discomfort Fear of dying Fear of going crazy or doing something uncontrolled Symptomatology of Panic Attacks Pary & Lewis (1992) Dar Al-Ajaza Al-Islamia Hospital in Beirut

  16. 0 5 10 15 20 Lifetime Prevalence of Anxiety DisordersThe Zurich Study GAD Dysthymia Simple phobia Agoraphobia Social phobia Recurrent brief anxiety Sporadic panic Panic disorder OCD Recurrent brief depression Major depression Prevalence (%) Angst (1993) Dar Al-Ajaza Al-Islamia Hospital in Beirut

  17. Comparative Tolerability ofPanic Disorder Treatments SSRIs Benzodiazepines Tricyclicantidepressants Anticholinergiceffects + - +++ Dependence - +++ - Withdrawalsymptoms + +++ + Cognitiveimpairment - ++ + Cardiotoxicity - - ++ +++ very frequent++ frequent+ infrequent Rickels & Schweizer (1990) Klerman (1992) Rosenberg (1993) Dar Al-Ajaza Al-Islamia Hospital in Beirut

  18. Pharmacological treatment of panic disorder • SSRI are well established as an effective treatment for all types of depression • In panic disorder trials, SSRI improve: - frequency of panic attacks - anxiety associated with panic attacks - functional ability in panic disorder patients - depressive symptomtology Dar Al-Ajaza Al-Islamia Hospital in Beirut

  19. OBSESSIVE COMPULSIVE DISORDEROCD Dar Al-Ajaza Al-Islamia Hospital in Beirut

  20. Contamination Pathological doubt Aggressive impulse Somatic concerns Need for symmetry Sexual impulse OBSESSIONS IN OCD Rasmussen & Eisen (1992), Zetin & Kramer (1992) Dar Al-Ajaza Al-Islamia Hospital in Beirut

  21. COMPULSIONS IN OCD •Washing •Precision •Need to ask or confess • Checking • Counting •Symmetry •Hoarding Rasmussen & Eisen (1992), Zetin & Kramer (1992) Dar Al-Ajaza Al-Islamia Hospital in Beirut

  22. Differential Diagnosis of OCD • Symptoms perceivedas excessive • Marked distress • Non-delusional Zohar & Zohar-Kadouch (1990) Dar Al-Ajaza Al-Islamia Hospital in Beirut

  23. 0 20 40 60 80 100 Most Common Co-morbiditiesin OCD Major depressivedisorder Panic disorder Simple phobia Social phobia Alcohol & drugs abuse Tourette’s Syndrome Prevalence (%) Jermain & Crismon (1990), Rasmussen & Eisen (1992) Dar Al-Ajaza Al-Islamia Hospital in Beirut

  24. Treatment of Co-morbid OCD Efficacy in SSRIs Clomipramine Imipramine Desipramine MAOIs Benzodiazepines OCD +++ +++ ++ + + + Depression ++++ ++++ ++++ ++++ ++++ + Goodman et al (1992) + Little evidence; ++++ Robust evidence Dar Al-Ajaza Al-Islamia Hospital in Beirut

  25. SOCIAL ANXIETY DISORDER Dar Al-Ajaza Al-Islamia Hospital in Beirut

  26. ESSENTIAL FEATURES OF SOCIAL PHOBIA • Fear of scrutiny by other people in social situations • Marked and persistent fear of performance situations in which embarrassment or humiliation may occur • Avoidance of the feared situations • Fear is disabling or causes marked distress Dar Al-Ajaza Al-Islamia Hospital in Beirut

  27. SYMPTOMS OF SOCIAL PHOBIA • Physical- Tachycardia - Trembling - Blushing - Shortness of breath - Sweating - Abdominal distress • CognitiveAutomatic alarming thoughts and beliefs about social situation • Behavioral-Freezing - Avoidance Dar Al-Ajaza Al-Islamia Hospital in Beirut

  28. SOCIAL Attending parties, weddings etc… Conversing in a group Initiating conversation with members of opposite sex Speaking on telephone Interacting with authority figure (teacher, boss…) Ordering food in a restaurant PERFORMANCE Public speaking Eating in public Writing a cheque Using a keyboard Using public toilet Taking a test Trying on clothes in a store Speaking up at a meeting FEARED SITUATIONS Dar Al-Ajaza Al-Islamia Hospital in Beirut

  29. COURSE OF SOCIAL PHOBIA Social phobia is a chronic disorder -Average duration up to 20 years - Only 27% of patients recover - Around 80% of social phobic patients report at least one other psychiatric disorder Davidson et al 1993 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  30. HOW CAN PHYSICIANS RECOGNIZE SOCIAL PHOBIA ? Consider social phobia by : • Patients who appear shy or reticent • Substance misusers • Depressed patients • Patients who report anxiety attacks predominantly in social situations STEIN , 1996 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  31. Treatment of Comorbid Anxiety and Depression Dar Al-Ajaza Al-Islamia Hospital in Beirut

  32. Principes d’un bon diagnostic en psychiatrie • Comprendre le contexte des symptômes selon le modèle bio-psycho-social • Analyser les facteurs prédisposant, précipitant et de maintien des symptômes • Ne pas se fier seulement à l’histoire du patient Dar Al-Ajaza Al-Islamia Hospital in Beirut

  33. Troubles anxieux au premier plan Rechercher de principe un trouble dépressif Oui Non Traitement du trouble dépressif en premier lieu Traitement du trouble anxieux En cas de doute : traiter comme une depression Traitement d’un trouble Anxio-Dépressif Dar Al-Ajaza Al-Islamia Hospital in Beirut

  34. Trouble Anxio-Dépressif Traité Tout va bien Persistance des troubles dépressifs Traitement maintenu six mois puis arrêt Dose efficace ? Durée suffisante ? Régression partielle Persistance de l’anxiété? Problème de personnalité? • -Tranquillisants • - Relaxation • Techniques cognitives • + Soutien actif Psychothérapie Facteur(s) de Stress chronique? Psychothérapie Traitement d’un trouble Anxio-Dépressif Dar Al-Ajaza Al-Islamia Hospital in Beirut

  35. CBT : Principles of Application for Anxiety Disorders CBT targets components of anxiety, common to all the anxiety disorders : • Physiologic activation • Negative predictions and expectations • Escape and avoidance behaviors • Sense of uncontrollability Dar Al-Ajaza Al-Islamia Hospital in Beirut

  36. GOALS OF PHARMACOTHERAPY IN ANXIETY DISORDERS • Relieve fear/anticipatory anxiety • Reduce phobic avoidance • Reduce autonomic/physiological distress • Improve disability/quality of life Dar Al-Ajaza Al-Islamia Hospital in Beirut

  37. Comparative Tolerability of Long Term Anxiety Treatments SSRIs Benzodiazepines Tricyclicantidepressants Anticholinergiceffects + - +++ Dependence - +++ - Withdrawalsymptoms + +++ + Cognitiveimpairment - ++ + Cardiotoxicity - - ++ +++ very frequent++ frequent+ unfrequent Rickels & Schweizer (1990) Klerman (1992) Rosenberg (1993) Dar Al-Ajaza Al-Islamia Hospital in Beirut

  38. Pharmacologic effectsof antidepressants Reduce depression Psychomotor activation Antiparkinsonian effects Reduce depression Reduce suicidal behavior Antipsychotic effects Hypotension Ejaculatory dysfunction Sedation Sedation/drowsiness Hypotension Weight gain DA reuptake inhibition H1 block 5HT2 block Blurred vision Dry mouth Constipation Sinus tachycardia Urinary retention Cognitive dysfunction Reduce depression Anti-anxiety effects GI disturbances Sexual dysfunction ACh block Antidepressant 5HT reuptake inhibition NE reuptake inhibition Alpha2 block Alpha1 block Anxiety Reduce depression Anti-anxiety effects Tremors Tachycardia Erectile/ejaculatory dysfunction Postural hypotension Dizziness Reflex tachycardia Memory dysfunction Richelson. In: Current Psychiatric Therapy. 1997: 286-295. Dar Al-Ajaza Al-Islamia Hospital in Beirut

  39. Ideal Pharmacological Treatment • A single agent effective against major depression and wide spectrum of anxiety symptoms • Convenient • Well tolerated • Low risk of side effects, drug interactions • Maintains long term effectiveness Dar Al-Ajaza Al-Islamia Hospital in Beirut

  40. Selective Serotonin Reuptake Inhibitors • Documented efficacy in depression, anxiety and in the elderly • Selective pharmacologic effect with minimal anticholinergic, adrenergic, histaminic side effects • Once-daily dosing may improve compliance • SSRIs with minimal inhibition of cytochrome P-450 enzymes • Reduce risk of drug–drug interactions after discontinuation • Have a short washout period • Minimal cognitive impairment Dar Al-Ajaza Al-Islamia Hospital in Beirut

  41. Thank You Dar Al-Ajaza Al-Islamia Hospital in Beirut

More Related