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Anxiety and Depression Gil C. Grimes, MD September 2006.

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Presentation on theme: "Anxiety and Depression Gil C. Grimes, MD September 2006."— Presentation transcript:

1 Anxiety and Depression Gil C. Grimes, MD September 2006

2 Outline Definitions Prevalence Risk Factors Complications Treatment

3 Anxiety Definition DSM-IV Criteria –Excessive anxiety and worry about a number of events and activities –Duration at least 6 months –Patients find it difficult to control worry –Distress or impaired function

4 Anxiety Definition –At least 3 of the follow 6 symptoms Feeling restless, fidgety, jittery, keyed up, on edge, or difficulty sitting still Being easily fatigued Difficulty concentrating or mind going blank Irritable Muscle tension, aches, or soreness Trouble falling asleep, staying asleep, or restless nonrestorative sleep

5 Anxiety Definition Rule out general medical condition, substance abuse, or other mental condition –Angina or MI –Hypoglycemia –Hyperthyroidism –Carcinoid syndrome –Drug Effects Acyclovir, anabolics, ACE inhibitors, Baclofen, and others (Medical letter 2002;44(1134):59) Street Drugs Toxins like organophsotates, mercury, arsenic

6 Anxiety Definition Differentiation from depression –Feature favoring anxiety Difficulty falling asleep Phobic avoidance behavior Rapid pulse Breathing disturbances Apprehensive expectations Tremors Palpitations Faintness Depersonalizations Derealization

7 Anxiety Definition Look for co-morbidities –Panic disorder –Social phobias or agoraphobia –Obsessive-compulsive disorder –PTSD –Acute stress disorder –Separation anxiety disorder Treatment will differ with these co- morbidities

8 Anxiety Diagnosis Chief Complaints –Manifold complaints –Psychological such as anxiety, tremor, dyspnea, palpitations –Functional such as insomnia, inability to relax, difficulty concentrating ROS –Motor- trembling, twitching, shaking, tense, restless, fatigued –Autonomic- dyspnea, palpitations, tachycardia, sweating, clammy, dry mouth, light-headed, abdominal distress, flushes dysphagia

9 Anxiety Prevalence Onset age 20-30 years Lifelong illness Female:Male 2:1 (males may be more somatizers) Survey data –3-3.3% over one year in 2 national survey’s 1 –14.8% in urban FM office 2 –28.8% lifetime prevalence nationally 3 1- Am J Psychietry 1999;156(12):1915 Level 2c 2- Arch Fam Med 2000;9(9):876 Level Level 1c 3- Arch Gen Psychiatry 2005;62(6):593 Level 1c

10 Anxiety Risk Factors Genetics –32% heritability 1 Meta-analysis of aggregate familial risk 10-17% risk first degree relatives 80-90% risk in monozygotic twins –Co-morbid psychiatric disorders (depression) 1- Am J Psychiatry 2001;158(10):1568 Level 1a

11 Anxiety Complications Increased utilization of health care –Cohort 1232 patients –Followed 3 months prior and 12 months after index visit –Twice the cost is anxiety present 1 Increased risk for progression of disability 2 –Cohort of 1,002 women >65 with functional limitations 1- J Fam Pract 1999;48(10):769 Level 2b 2- J Am Gerietri Soc 2005;53(1):34 Level 1b

12 Anxiety Complications Increased of suicidal ideation and attempts –7.076 persons in Netherlands cross-sectional study 11.4% had SI 2.9% had attempt overall 42% of GAD had SI OR 7.01 12.1% of GAD had attempt OR 5.87 –Second study 4,796 persons New SI 2% attempt 0.84% overall 5.9% with GAD developed SI OR 4.23 3% with GAD had Attempt OR 2.3 Arch Gen Psychiatry 2005;62(11):1249 Level 1b

13 Depression Definition Depressed mood with 5 or more of the following –Sleep disturbance –Psychomotor retardation or agitation –Appetite disturbance (or weight change) –Concentration difficulties –Energy low –Sleep disturbance –Psychomotor retardation or agitation –Appetite disturbance (or weight change) –Concentration difficulties –Energy low

14 Depression Definition Presenting complaints –97% decreased energy –90% anxiety –~80% sleep disturbance, fatigue, or insomnia –Other common complaints Helplessness/hopelessness Loss of energy or interest Excessive self-criticism/guilt/low self-esteem Delusions Hypochonriasis NEJM 1999;341(18):1329 Level 1c

15 Depression Definition Anxious subtype –Worries, tension, restlessness –Slower response to medications Atypical –Mood reactivity (increased appetite, weight gain, hypersomnia) –More common in females –Earlier onset, more frequent, more chronic Seasonal affective disorder –Increased appetite, carb craving, weight gain, hypersomnia Postpartum depression –Within 4 weeks of delivery –Depressed mood, tearfulness, labile mood J Clin Psychiatry 1998;59(suppl 16):5 Level 5

16 Depression Definition PRIME-MD questions –2-item screening sensitive not specific During the past month have you often been bothered by Anhedonia-little interest or pleasure in things you usually enjoy Depressed mood- feeling down, depressed or hopeless Study of 1000 adult patients Arch Intern Med 1998;158(22):2649 Level 1b

17 Depression Definition Rule out mimics –Neuromuscular disease that affect facial expression –Degenerative neurological disease that causes psychomotor retardation –Delirium –Drug withdrawal (amphetamine) –Thyroid disorders –Tertiary syphilis, AIDS etc. –Neoplasm –Screen and rule out of bipolar

18 Depression Definition Differentiation from Anxiety –Features favoring depression Early morning awakening Hypersomnia Diurnal variation Sad downcast facial expression Slowed speech Slowed thought process Sadness / guilt / hopelessness / despair

19 Depression Prevalence Common among US adults –Face to face survey >43K persons 1 Diagnosis in prior year 5.28% Lifetime 13.23% –Face to face survey 9,090 persons 2 16.2% lifetime prevalence 6.6% in the last 12 months –NIH Survey 9,863 students (age 11-15) 3 25% females and 10% males depressed Higher with substance abuse and bullying 1- Arch Gen Psychiatry 2005;62(10):1097 Level 2c 2- JAMA 2003;289(23):3095 Level 2c 3- Arch Pediatr Adolesc Med 2004;15 Level 2c

20 Depression Risk Factors Major depression in parents 1 –2,427 adolescents and young adults followed 4 years –In one parent OR 2.7 –In both parents OR 3 Alcohol dependence 2 –OR 4.2 for dependence but no association for abuse Alienation form parents in early teens 3 1- Arch Gen Pshychiatry 2002;59(4):365 Level 1c 2- Arch Gen Psychiatry 2002;59(9):794 Level 2c 3- J Am Acad Child Adolesc Psychaitry 2002;41(12):1478 Level 2c

21 Depression Risk Factors Some association of various strength –Bullying or being bullied –Separation or divorce –Adverse life events –History of physical abuse –Chronic illness –Chronic pain –Perimenopausal –Smoking cessation

22 Depression Complications Recurrent Depression –50-80%experience second episode –10-15% die by suicide –Maternal depression 1 Increased antisocial behavior in children Increase risk of psychiatric diagnosis if maternal depression persisted 1- JAMA 2006;295(12):1389

23 Depression Complications Coronary Heart Disease –Increases incidence of CAD in both men and women Adjusted CAD RR 1.73 in women Adjusted CAD RR 1.71 in men –Increases CAD mortality in men Adjusted death from CAD 2.34 in men Associated with increased risk of heart failure Arch Intern Med 2000;160(9):1261 Level 2b and JAMA 2006;295(24):2874

24 Therapy for Anxiety Anxiety –Key is antidepressants for prophylaxis –Effective in Randomized controlled trials for anxiety without depression –Benzodiazepines good short term (no long term evidence) –Hydroxyzine works

25 Therapy for Anxiety Antidepressants –For anxiety NNT 5.15 Cochrane review 2005 Venlafaxine (effexor) several RCT with good data various ages 1,2 doses up to 225 mg daily –NNT3.2-10 –NNH for side effects 10 nausea, somnolence, dry mouth Paroxitine (paxil) several RCT with good data BUT pregnancy cat D doses 20-50 mg 3,4 –NNT 4-10 –Side effects asthenia, somnolence, nausea, decreased libido 1- JAMA 2000;283(23):3082 Level 1b 2- J Am Geriatr Soc 2002;50(1):18 Level 1b 3- Am J Psychiatry 2003;160(4):749 Level 1b 4- J Clin Psychiatry 2001;62(5):350 Level 1b

26 Therapy for Anxiety Antidepressants –Sertraline (Zoloft) Two RCT adults and adolescents various doses (50-150 adults, 50 adolescents) NNT 4 adults no difference drop outs 1 Significant improvement compared to placebo in adolescents 2 –Fluvoxamine (Luvox) children 6-17 with GAD dose 250-300 mg 3 NNT 3 at 8 weeks NNH 16 1- Am j Psychiatry 2004;161(9):642 Level 1b 2- Am J Psychiatry 2001;158(12):2008 Level 1b 3- N Engl J Med 2001;344(17):1279 Level 1b

27 Therapy for Anxiety Antidepressants –Fluoxetine (Prozac) 20 mg in children and adolescents 1 NNT 4 Mild transient headaches and GI side effects (no drop outs) –Escitalopram (Lexapro) 10-20 mg in adults 2 NNT 5 No significant difference in discontinuation 1- J Am Acad Child Adolesc Psychiatry 2003;42(4):415 Level 1b 2- Depress Anxiety 2004;19(4):234 Level 1b

28 Therapy for Anxiety Benzodiazepines –All equally effective –Insufficient evidence for long term use 1 Systematic review of 8 trial Weak methodology prevents firm conclusions –Many adverse effects, sedation, increased confusion, falls in elderly, ataxia, anterograde amnesia 2 –Associated with increased risk for first motor vehicle collision 3 1- Int Clin Psychopharmacol 2000;15(2):99 Level 2b 2- J Am Geriatr Soc 2000;$*(6):682 Level 2b 3- Lancet 1998;352(9137):1331 Level 2c

29 Therapy for Anxiety Hydroxyzine 1,2,3 –3 randomized control trials –Dosages 12.5 to 50 mg daily –Most common side effects sleepiness, weight gain, dry mouth, loss of concentration, and insomnia 1- J Cloin Psychaitry 2002;63(11):1020 Level 1b 2- Psychopharmacology (Berl) 1998;139(4):402 level 1b 3- Encephale 1994;20(6):785 level 1b

30 Therapy for Depression All antidepressants are equally effective –Efficacy typically seen in 1-4 weeks –Treat for at least 6 months –Do not discontinue during high stress period Counseling also works –Not as fast as medications –Equally effective as medications

31 Therapy for Depression TCAs or SSRI more effective than placebo –SR of 15 RCT –Meta-analyses of TC vs. Placebo NNT 8 NNH 15 –Meta-analysis of SSRI vs. Placebo NNT 7 NNH 39 Ann FAm Med 2005;3(5):449 Level 1a

32 Risk for Suicide Increased in SSRI –SR 702 RCT of SSRI –In 189 trials SSRI vs. Placebo NNH 708 –In 115 trials SSRI vs. TCA no significant difference –In 83 trials SSRI vs. other active comparator NNH 437 BMJ 2005;330(7488):396 Level 1a

33 Risk for Suicide Risk is highest early after initiation Nested case-control study in UK 159,810 patients –Compared relative risk over 90 days –Days 1-9 4.07 for SI and 38 for suicide –Days 10-29 2.88 for SI and 5.1 for suicide –Day 30-89 1.53 for SI and 2 for suicide JAMA 2004;292(3):338 Level 2b

34 Handouts and Questions

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