DEPRESSION AND ANXIETY Ian M Chung Practitioner in Psychological Medicine Sydney, Australia.
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Transcript of DEPRESSION AND ANXIETY Ian M Chung Practitioner in Psychological Medicine Sydney, Australia.
DEPRESSION AND ANXIETYDEPRESSION AND ANXIETY
Ian M ChungPractitioner in Psychological Medicine
Sydney, Australia
COPYRIGHT © IAN M CHUNG 2005
Ian M ChungIan M Chung
General practitioner since 196580% of practice in Psychological MedicinePrincipal Counsellor of Lawcare Program,
NSW Law SocietyPast Member of NSW Medical BoardEducator of general practitioners Not a psychiatrist, academic or expert Is a clinician and practitioner
COPYRIGHT © IAN M CHUNG 2005
Mental illness in GP populationMental illness in GP population
Much mental illness is covert or hiddenPrimary carers fail to recognise one out of
two patients with mental illnessIncidence of mental illness varies in different
areas and practices and at different timesUntreated mental illness is time-consuming
and costly
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The cost of untreated mental illness:The cost of untreated mental illness:WHO “Burden of Disease” studyWHO “Burden of Disease” study
To patient• Morbidity, mortality, financial, productivity,
family suffering, reputation
To community• Productivity, financial ($4-5 bil pa in
Australia), loss of community cohesion
To doctor • ?
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Obstacles to diagnosis of mental illnessObstacles to diagnosis of mental illnessPatient
• Ignorance, stigma, fear of the implications, lack of finances or resources to treat
Doctor• Knowledge and/or skill deficit, attitude,
misinterpretation or interest issues, lack of facilities and resources, time, remuneration issues, discomfort with emotional issues (personal or cultural)
Society• Different priorities, financial, lack of community
education, health policy, community attitudes
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The GP perspectiveThe GP perspective
General practice is total (bio-psycho-social) and should address continuing patient care in the context of their family and community
The GP has an ongoing relationship with the patient and their family
General practice provides opportunity for early diagnosis before the condition is well-defined or fully developed
The GP sees the patient before they are “educated” by the process of investigation and elimination
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The main mental illnesses seen in General The main mental illnesses seen in General PracticePracticeDepression and anxiety are the major mental
illnesses, alone or co-morbid, or as manifestations of other mental conditions or medical illness
Both depression and anxiety have a range of severity and forms
Specificity of diagnosis is important Somatisation is very common: the mind and body are
one also patient prefers to c/o an illnessDrug use and illness must be excludedAny illness needs the GP to consider the full
circumstances of the patient
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Depression and Mood Disorders: a Depression and Mood Disorders: a chronic disorder, a disease of losses chronic disorder, a disease of losses more than sadnessmore than sadness
Major depressive disorder: depressed mood and anhedonia nearly every day for two weeks; include major depression in remission
Minor depressive disorderDysthymia: chronic sub-clinical depressionAdjustment disorder with depressed moodExclude bipolar disorder and melancholiaExclude drugs and physical illness
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Special Depressive DisordersSpecial Depressive Disorders Depression in women
• In all cultures depression is more prevalent in women than men
• Premenstrual dysphoric disorder• Depression in pregnancy and breast feeding• Post-natal depression• Peri-menopausal depression
Depression in the elderly• Bereavement, loss of independence, illness, onset of dementia• Suicide is high in single men aged over 75
Depression in children• Separation and abuse• Adolescence
Seasonal affective disorder
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Anxiety Disorders: the disease of fears Anxiety Disorders: the disease of fears and worryand worry Panic disorder with or without agoraphobiaGeneralised anxiety disorder
• Chronic anxiety
• “Free floating” anxiety)
Specific phobias Social phobia: fear of negative evaluationObsessive compulsive disorder, pathological doubt,
spontaneous and intrusive phenomena Post-traumatic stress disorderAnxiety associated with drugs and illness
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Somatoform DisordersSomatoform Disorders
Somatisation disorder• Fatigue, pain or other symptoms not feigned• Without discernable clinical explanation• Causes distress and impairment of significant duration
Conversion disorder Pain disordersHypochondriasis
• Pre-occupation and fear of illnessBody dysmorphic disorder
• Pre-occupation with imagined defects in appearance
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Aetiological factors in mental illnessAetiological factors in mental illness
External• Life stressors
o Conflicto Losso Disappointmento Excess loado Deprivation
• Drugs and alcohol
Internal• Personality
o Neuroticismo Family traits and
dispositions• Past
o Traumatised o Deprived o Under/over-lovedo Under/over-protectedo Under/over-criticised
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The Mind-Body ConnectionThe Mind-Body Connection
Descarte’s dualistic theory was wrongThe mind and body are one: holisticThe brain and body are in constant interactive
connection via nerves and hormonesThoughts, feelings and memories affect the
body’s functions and vice versa; anatomical, biochemical and physiological changes can be demonstrated
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Neuro-science is in rapid and dramatic Neuro-science is in rapid and dramatic transitiontransition
90% of current knowledge in neuro-science was unknown at the start of the “Decade of the Brain” (1991-2001)
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Learning enhances adult neurogenesis in Learning enhances adult neurogenesis in the hippocampal formationthe hippocampal formation
Elizabeth Gould1, Anna Beylin1, Patima Tanapat1, Alison Reeves1 and Tracey J. Shors2
1 Department of Psychology, Princeton University, Princeton, New Jersey, USA2 Department of Psychology & Centre for Neuroscience, Rutgers University, Piscataway, New Jersey, USA
Thousands of hippocampal neurons are born in adulthood, suggesting that new cells could be important for hippocampal function. To determine whether hippocampus-dependent learning affects adult-generated neurons, we examined the fate of new cells labeled with the thymidine analog bromodeoxydridine following specific behavioral tasks. Here we report that the number of adult-generated neurons doubles in the rat dentate gyrus in response to training on associative learning tasks that require the hippocampus. In contrast, training on associative learning tasks that do not require the hippocampus did not alter the number of new cells. These findings indicate that adult-generated hippocampal neurons are specifically affected by, and potentially involved in, associative memory formation.
Gould et al Nat Neuro 1999; 2: 260-265
Emotions and learning cause structural brain changes.
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Antidepressants do more than relieve Antidepressants do more than relieve symptomssymptoms
Depression affects pre-frontal cortex, amygdala, striatum, thalamus
Untreated major depression causes hippocampal atrophy
Antidepressants cause neutogenesis in the dentate gyrus
Untreated anxiety causes enlargement of the amygdala and increased secretion of cortisol releasing factor (CRF)
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Pre-treatmentPre-treatment The patient needs to present for treatment, which
implies that the patient is sufficiently in pain or sufficiently worried
The therapist needs to be:• Interested in mental illness
• Alert to presentation
• Know how to confirm the diagnosis
• Understand treatment strategies
• Able and willing to educate the patient
Treatment begins in the waiting room• An atmosphere receptive to whatever the patient has
to bring there
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The diagnosis of mental illness: before The diagnosis of mental illness: before DSM IV or ICD 10DSM IV or ICD 10
Maintain your index of suspicionHeed the patient’s message: hear and see itKnow the disease presentationsKnow the follow-up questionKnow the criteria for each conditionTake the care needed to listen and clarifyUse a diagnostic scale if neededIf in doubt or disinterested, REFER!
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TreatmentTreatment
First establish a therapeutic alliance with patientMake the diagnosisExplain the diagnosis and treatment to patient Prioritise and implement the treatment plan Involve family and others when necessary Continuation management and tracking the
progress towards full remissionHow long to treat?Relapse prevention
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Comprehensive and integrated approach Comprehensive and integrated approach to therapyto therapy Medical: pharmacotherapy
• To medicate or not? • What dose?
Psychological• Psycho-education• CBT• Behavior therapy• Structured problem solving• Relaxation/meditation/hypnosis
Lifestyle: balanced life• For example, Yerkes-Dobson curve
Spiritual: sense of self/purpose/direction• For example, logotherapy (Victor Frankl)
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Treatment GoalsTreatment GoalsResponse
• Find the right drug and take it for long enough
• Augment if necessary
• Referral if necessary
Enhance recovery • Instigate and maintain all therapeutic strategies
Aim for full remission• Optimise all treatment strategies
Prevent Relapse• Educate patient as to their vulnerabilities
• Continue medication long enough
• Maintain life activities and directions
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Goals of treatmentin major depressive disorder
Frank et al. Arch Gen Psychiatry 1991; 48: 851-855.Rush et al. Psychiatric Ann 1995; 25: 704-709.
Thase et al. J Clin Psychiatry 1997; 58: 393-398.Cunningham. Ann Clin Psychiatry 1997; 9: 157-164.
HAM-D score ≤7 Patient virtuallyasymptomatic
/Psychosocial occupational functioning restored
≥50% decrease from baseline in HAM- D or MADRS scores
1 2CGI score of or
Response Remission
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Treatment options for non-responding Treatment options for non-responding patientspatients
Switching antidepressants Augmentation: some evidence suggests…
• Lithium• Atypical antipsychotics
o Risperidoneo Olanzapine
• Antiepileptics/anticonvulsantso Valproic acido Carbamazepineo Gabapentin
Combination of antidepressants ECT
Fava J Clin Psychiatry 2001; 62 (Suppl 18): 4-11
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Final words…Final words…
Caring for our patient ought to mean treating the whole patient: body and mind
Mental illness (MI) is common, disabling and often missed - which is costly to all concerned
Treatment of MI is neither difficult nor necessarily time consuming
Treating MI is effective and satisfyingTreating MI gives the GP an enlightening glimpse
into the human condition Failure to treat is negligent
COPYRIGHT © IAN M CHUNG 2005
And a personal perspective…And a personal perspective…
It has been a privilege to have been given a glimpse into the minds of so many patients, and to have been allowed to start to understand the human condition.
Copyright © Ian M Chung 2005
The foregoing presentation is copyright. Except as permitted by applicable copyright legislation, no part of the foregoing
presentation may be reproduced or distributed in any form or by any means without the express written permission of the
copyright owner, Ian M Chung.
Email [email protected]
Web www.ianmchung.com