Mood & Anxiety Disorders in Primary Care: A Review

1. Mood & Anxiety Disorders in Primary Care: A Review Arun V. Ravindran, MB, MSc, PhD, FRCPC, FRCPsych Professor and Director, Global Mental Health and Office of Fellowship Training, Department of Psychiatry; Graduate Faculty, Department of Psychology and Institute of Medical Sciences; University of Toronto Chief, Division of Mood and Anxiety Disorders, Centre for Addiction and Mental Health Toronto, Ontario, Canada

2. Anxiety Disorders

3. Anxiety What is Anxiety? • Diffuse, unpleasant, vague sense of apprehension often accompanied by autonomic symptoms When do you treat Anxiety? • “Anxiety symptoms exist on a continuum and milder forms of recent onset often remit without treatment.” • Need for treatment determined by: • Severity and persistence of symptoms • Presence of co-morbidity • Disability + Impaired function • Impact on social function

4. Posttraumatic stress disorder Social anxiety disorder Depression Panic disorder Obsessive-compulsive disorder Generalized anxiety disorder The Spectrum of Anxiety Disorders

5. Co-morbidity in Anxiety Disorders

6. Anxiety Disorders – DSM-IV – Fear vs. Distress Disorders Panic Disorder Agoraphobia Specific Phobia Social Phobia PTSD ASD OCD GAD AD / GMC / SU / NOS

7. Key Fears in Anxiety Disorders • PD/A – Dying, going crazy or losing control • SP – Harm from an external object or situation • SAD – Humiliation or embarrassment • GAD – Future events involving real life concerns • PTSD – Re-experiencing trauma in memories/dreams • OCD – Harm, uncertainty, uncontrollable actions

8. Epidemiology of Anxiety Disorders Disorder Life Time Prevalence Panic Disorder 2 – 5% Specific Phobias 1 – 19% Agoraphobia 0.2 – 5% Social Phobia 5 – 12% General Anxiety Disorder 1 – 6% Post Traumatic Stress Disorder 2 – 8% Obsessive-Compulsive Disorder 2 – 3% As a group 20-30%

9. Psychophysiology of Anxiety Disorders Triple Vulnerability Model Genetic contribution to temperament Generalized Psychological Vulnerability Generalized Biological Vulnerability Disorder Sense of diminished control Early Learning Experiences and Familial/Social Environment

10. Key Decision Points in the Management of Anxiety Disorders A. Identify anxiety symptoms Determine if anxiety causing distress or functional impairment Assess suicidality • B. Differential diagnosis • Is anxiety due to other medical or psychiatric condition? • Is anxiety comorbid with other medical or psychiatric condition? • Is anxiety medication-induced or drug-related? • Perform physical exam & baseline laboratory assessment C. Identify specific anxiety disorder Panic, specific, SAD, OCD, GAD, PTSD • Co-morbid mental disorders • If substance abuse: avoid BZDs • If another anxiety disorder: consider therapies that are 1st-line for both disorders • If mood disorder: consider therapies that are effective for both disorders, also refer to depression or bipolar disorder guidelines Comorbid medical conditions If medical: assess benefits and risks of medication for the anxiety disorder, but consider impact of untreated anxiety • D. Consider psychological and pharmacological treatment • Patient preference and motivation extremely important when choosing treatment modality • If formal psychological treatment not applied, all patients should receive education and support to encourage them to face their fears BZD=benzodiazepine, SSRI=selective serotonin reuptake inhibitors, SNRIs=serotonin norepinephrine reuptake inhibitorsMAOIs=monoamine oxidase inhibitors

11. Treatment of Anxiety Disorders in Primary Care: General Principles • Screening • Beck Anxiety Inventory (BAI; 21 items) • Interventions • Pharmacotherapy (mild to moderate) • CBT (mild to moderate) • Antidepressants + CBT (moderate to severe) • Maintain antidepressants + CBT boosters – 1-2 years

12. The “CBT Package” – The Proven Intervention • Psychoeducation • Monitoring/early cue detection • Applied relaxation • Imaginal and in vivo exposure • Coping skills rehearsal • Cognitive restructuring

13. Case History Jenny, 56-year-old accountant, married with three grown children • Describes herself as a ‘worrier’ • Has worried more “for the past 1 year” about her children’s health, finances, marital relationship, the future Jenny is likely suffering from: • Clinical Depression • Generalized Anxiety Disorder • Adjustment Disorder • Alcohol dependence What further information is useful in her diagnosis?

14. Generalized Anxiety Disorder (GAD): The Facts “Inappropriate and/or extreme worry with multiple somatic anxiety” - Restlessness - Poor concentration - Fatigue - Irritability - Sleep difficulties - Tension • 5% of the general population • Onset in adolescence, disability and chronic course • Comorbidity and vulnerability to MDD

15. Treatment of GAD • Pharmacotherapy • Antidepressants • Beta blockers • Benzodiazepines • Anticonvulsants • Buspirone • Psychotherapy • CBT • Recent advances • Focus on “worries” • Mindfulness and acceptance

16. Case History Sam, 24-year-old computer programmer, single and living on his own • 1 year history of physical symptoms • Has seen several physicians – multiple investigations • Convinced that he has heart disease and believes that it is being missed Which of the following is most likely? • Hypothyroidism • Panic Disorder • Schizophrenia • Incompetent Physicians

17. Panic Disorder and Panic Disorder with Agoraphobia (PD/A) “Characterized by panic attacks and avoidance behaviour” • Prevalence • Lifetime 3-5% • Specialty clinics 10-60% • Impaired function • High rates of utilization • Early evidence of anxiety • Common medical/psychiatric co-morbidity

18. PD/A Diagnosis (DSM-IV) Diagnostic criteria: recurrent panic attacks Cognitivesymptoms 4 or more of the following: • Dyspnea or the sensation of being smothered • Depersonalization or derealization • Fear of going crazy or of losing self-control • Fear of dying • Palpitations or tachycardia • Sweating • Trembling or shaking • Feeling of choking • Chest pain or discomfort • Nausea or abdominal upset • Dizziness, feeling of unsteadiness or faintness • Numbness or tingling sensation • Flushes or chills Physical symptoms

19. Billy Crystal and Robert De Niro in Analyze This – Panic Disorder

20. Treatment of PD/A • Pharmacotherapy • Antidepressants • Benzodiazepines • Psychotherapy • CBT plus • Breathing retraining • Relaxation exercises • Recent advances • Mindfulness based CBT (MBCT)/Mindfulness based stress reduction (MBSR) • Sensation focused intensive treatment (SFIT) • Virtual reality exposure therapy

21. PD/A: Treatment Outcomes • CBT vs. pharmacotherapy vs. combination • Similar benefit short-term • CBT better on long term • CBT useful • Sequential PT + CBT – new trend • In General • Low remission rate – 20-50% • High rates of relapse – 25-85% on discontinuation Good initial response – less probability of relapse

22. Case History Brian, 30-year-old graduate student, engaged to be married in 6 months • Is very anxious and apprehensive about the event • “I don’t like being looked at”, “I think people will laugh at how I look or what I say” • History of shyness, being ‘quiet’ What further information would be useful for diagnosis? What is the likely diagnoses?

23. Social Phobia/Social Anxiety Disorder (SAD) Carly Simon Barbra Streisand Donny Osmond

24. SAD: Signs and Symptoms Cognitive: • Fear of scrutiny, humiliation and embarrassment, • Exposure promotes anxiety Physical: • Blushing, sweating, tremor Behavioural: • Avoidance and anticipatory anxiety in social/performance situations • Good Insight

25. Nicholas Cage in Adaptation – Social Phobia

26. Treatment of SAD Pharmacotherapy vs. CBT vs. combination Goals: • Improve cognitive and physical symptoms • Reduce anticipatory anxiety and avoidance • Treat comorbid conditions • Improve functioning Methods • Psychoeducation • CBT plus • Social skills training • Exposure therapy

28. Performance-Specific Anxiety • SAD vs. shyness vs. performance anxiety • Proposed overlap with non-generalized SAD • Evidence for benefit with propranolol (RCTs) • Surgical patients and surgeons • Dental patients • Medical students • Benzodiazepines – decrease anticipatory anxiety but may impair performance

29. Specific Phobias Specific phobia is excessive or irrational fear of object or situation, and is usually associated with avoidance of feared object • Lifetime prevalence: 12.5% • Median age of onset: 7 years Common Phobias: animal and blood-injection, claustrophobia, heights Treatment • Pharmacotherapy: Difficult to use and unproven • Psychotherapy: In vivo and virtual exposure

30. Case History Sonya – 33 year old housewife brought against her wishes by her husband • Vague complaints – 3-4 years • “I don’t understand what is wrong with her” – husband • Superstitious about leaving the house without knocking on the door posts. “It’s bad luck if I don’t.” • Spends half an hour each night checking and double-checking that the doors and windows are locked and all kitchen appliances are turned off • Not able to cope with housework because she spends too much time on one task. “I’m a perfectionist.” What would your diagnosis be?

31. Obsessive Compulsive Disorder (OCD) • Obsessions and/or compulsions • Recurrent, persistent ideas, thoughts, impulses or images • Repetitive, purposeful and intentional behaviours that are performed in response to an obsession • Repetitive, unpleasant and ego dystonic + resisted • Excessive/unreasonable • Marked distress and impact on functioning • Affects 2-3 % of the population, with onset in teens

32. OCD: Common Obsessions and Compulsions • Obsessions • Repetitive thoughts about contamination • Repetitive doubts • Intense need for orderliness and symmetry • Aggressive impulses • Repeated sexual imagery • Compulsions • Behaviours • Hand washing • Ordering • Checking • Demanding reassurance • Repeating actions • Mental Acts • Counting • Repeating words silently

33. Jack Nicholson in As Good As It Gets - OCD

34. Treatment of OCD • Pharmacotherapy • Serotonergic agents • AAPs • Combination • Psychotherapy • CBT with focus on • Exposure and response prevention • Cognitive interventions • Poorer outcomes in • Males • Early onset • Delayed treatment

35. Case History Goran, a 47-year-old parking attendant • Complains of feeling tired and ‘down’ for the past 5-6 months, since being robbed and beaten up at work last year • Has difficulty sleeping due to nightmares, is ‘jumpy’ and irritable • Feels distant from family and friends • Constant sense of inner and physical tension Do you think Goran is suffering from: • Fibromyalgia • Fatigue • Post traumatic stress • Overwork

36. PTSD: Key Features • Exposure to threat to life or physical integrity AND • Emotional reaction of fear, helplessness or horror • Persistent intrusive reexperience of the event • Avoidance of trauma-associated stimuli and numbing – emotional and behaviouralwithdrawal • Persistent symptoms of increased arousal • Duration 1 month to years • Prevalence 3-4 % • High risk of suicide +

37. Damian Lewis in Band of Brothers - PTSD

38. PTSD - Treatment Both Pharmacotherapy and Psychotherapy are useful Pharmacotherapy • Antidepressants and atypical antipsychotics Psychotherapy • Trauma focused therapies best results • CBT, exposure therapy beneficial • Less effective - IPT, psychodynamic therapy, supportive therapy • Different types of trauma may respond to different psychotherapies, benefit across subtypes

39. Acute Stress Disorder Follows within 1 month acute exposure to threat and lasts few days to 4 weeks Intervention: Brief and immediate Focus on high risk population Components: • Information Education • Psychological support • Crisis intervention • “Emotional first aid” Does immediate intervention prevent PTSD?

40. Anxiety Disorders: Primary Care Perspectives • Often present with somatic symptoms or complaints related to co-morbid conditions • High utilizers of primary care • May need to treat multiple anxiety disorders • Education and CBT-based brief interventions useful • Deal with barriers to care

41. Unipolar Depression

42. A Case History Maria, a 47-year-old married lady, reports feeling ‘not her usual self’ for the past 6-8 months • She reports feeling both sad and anxious • She has difficulty sleeping and is always tired • Her appetite has decreased and she has lost 15 lbs. in the past 6 months • Her brother died in a car accident about 1 year ago. She feels guilty about an argument they had just before, and thinks about it a lot. What is your diagnosis?

43. Mood/Affective Disorders Definition: Mental illnesses presenting with altered mood/affect as the primary symptom • Affect: External expression of an internal state (i.e. mood) • Affect is more transient, mood is more sustained • Two broad syndromes of mood disorders • Depression • Mania

44. How Common Are Mood Disorders and What is Their Disease Burden? • Life time prevalence • Unipolar depression 8-20% • Bipolar disorder 1% • WHO: Depression is the leading cause of disability • Impact on: • Quality of life • Impaired function (occupational, social) • Suicide • Physical health

45. What Causes Mood Disorders? • Genetic vulnerability • Social and environmental factors • Life stressors • Early childhood experiences • Social determinants • Neurobiological factors • Neurotransmitter/neurohormonal challenges • Neural circuitry Usually a multi-factorial etiology

46. Defining a Depressive Disorder (DSM) • Clinically significant behavioural or psychological syndrome, associated with • Distress/disability • Increased risk of death/pain • Not simply • Lowered mood • Response to loss • Maladaptive reaction to stress • Two key forms • Major depressive disorder (MDD) • Dysthymic disorder (DD)/Persistent depressive disorder (DSM5)

47. Depression is Complex, Multidimensional Emotional Symptoms • Feelings of guilt • Suicidal • Lack of interest • Sadness Associated Symptoms • Brooding • Obsessive rumination • Irritability • Excessive worry over physical health • Pain • Tearfulness • Anxiety or phobias Physical Symptoms • Lack of energy • Decreased concentration • Change in appetite • Change in sleep • Change in psychomotor skills APA. DSM-IV-TR; 2000:352,356.

48. Nicole Kidman in The Hours - Depression

49. What Are the Important Subtypes of MDD and DD? • Chronic depression • Melancholic depression • Atypical depression • Psychotic depression • Postpartum depression • Seasonal affective disorder

50. How Do Patients with Depression Present in Primary Care? • Less than 20% seek help from family physicians • Only 50% are recognized as depressed • 2/3 present in practice with somatic symptoms only • Common screening tools for primary care • Brief Hamilton Depression Rating Scale (HDRS; 7 items) • Beck Depression Inventory (BDI-II; 21 items) • Patient Health Questionnaire (depression only) (PHQ-9; 9 items) • Screening tools are specially useful in high risk populations