Mood & Anxiety Disorders in Primary Care: A ReviewArun 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 TorontoChief, Division of Mood and Anxiety Disorders, Centre for Addiction and Mental HealthToronto, Ontario, Canada

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Anxiety Disorders

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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 3

Generalized anxiety disorder

Depression

Social anxiety disorder

Panic disorder

Obsessive-compulsive disorder

Posttraumatic stress disorder

The Spectrum of Anxiety Disorders

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Co-morbidity in Anxiety Disorders

Anxiety Disorders

Mood Disorders

Substance Use

Disorders

Medical Conditions

Somatoform Disorders

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Anxiety Disorders – DSM-IV – Fear vs. Distress Disorders

Panic DisorderAgoraphobia

Specific PhobiaSocial Phobia

PTSD

ASD

OCD

GAD AD / GMC / SU / NOS6

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

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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%

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Psychophysiology of Anxiety Disorders

Triple Vulnerability ModelGenetic contribution to temperament

Sense of diminished control

Generalized Biological Vulnerability

Generalized Psychological Vulnerability

Early Learning Experiences and Familial/Social

Environment

Disorder

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A. Identify anxiety symptomsDetermine if anxiety causing distress or functional impairment

Assess suicidality

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 conditionsIf medical: assess benefits and risks of

medication for the anxiety disorder, but consider impact of untreated anxiety

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

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

C. Identify specific anxiety disorderPanic, specific, SAD, OCD, GAD, PTSD

Key Decision Points in the Management of Anxiety Disorders

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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

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

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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?13

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

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Treatment of GAD

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• Pharmacotherapy• Antidepressants• Beta blockers• Benzodiazepines• Anticonvulsants• Buspirone

• Psychotherapy• CBT

• Recent advances• Focus on “worries”• Mindfulness and acceptance

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

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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

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PD/A Diagnosis (DSM-IV)

Diagnostic criteria: recurrent panic attacks

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Cognitive symptoms

Physical symptoms

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

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

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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

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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

21Good initial response – less probability of relapse

Case HistoryBrian, 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?

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Social Phobia/Social Anxiety Disorder (SAD)

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Barbra Streisand Donny Osmond Carly Simon

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

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Nicholas Cage in Adaptation – Social Phobia

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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

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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

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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

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Case HistorySonya – 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? 30

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

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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

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Jack Nicholson in As Good As It Gets - OCD

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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

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Case HistoryGoran, 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

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PTSD: Key Features

• Exposure to threat to life or physical integrity AND

• Emotional reaction of fear, helplessness or horror

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Persistent intrusive reexperience of the event Avoidance of trauma-associated stimuli and numbing – emotional and behavioural withdrawal Persistent symptoms of increased arousal Duration 1 month to years Prevalence 3-4 % High risk of suicide

Damian Lewis in Band of Brothers - PTSD

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PTSD - TreatmentBoth 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 38

Acute Stress Disorder

Follows within 1 month acute exposure to threat and lasts few days to 4 weeks

Intervention: Brief and immediateFocus on high risk population

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Components: • Information Education

• Psychological support

• Crisis intervention

• “Emotional first aid”

Does immediate intervention prevent PTSD?

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

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Unipolar Depression

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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?42

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

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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

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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

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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)

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Depression is Complex, Multidimensional

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APA. DSM-IV-TR; 2000:352,356.

Physical Symptoms• Lack of energy• Decreased

concentration• Change in appetite• Change in sleep• Change in

psychomotor skills

Associated Symptoms• Brooding• Obsessive rumination• Irritability• Excessive worry over

physical health• Pain• Tearfulness• Anxiety or phobias

Emotional Symptoms• Feelings of guilt• Suicidal• Lack of interest• Sadness

Nicole Kidman in The Hours - Depression

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

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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

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High Risk Groups and Symptomatic Presentation of MDDHigh Risk Clinical Groups High Risk Symptom Presentations

Past history of depression Unexplained physical symptoms

Family history of depression Pain

Psychosocial adversity Fatigue

High users of the medical system Insomnia

Chronic medical conditions Anxiety

Other psychiatric conditions Substance abuse

Times of hormonal challenge

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Patten et al., 2009; J Affect Disord.

Managing Depression in Primary Care

• Assessment• Suicide risk• Physical health• Psychosocial issues• Psychiatric morbidity

• Management: “Stepped care approach”• Watchful waiting• Guided self-management• Brief psychological/pharmacological interventions• Referral to specialists

• Determine diagnosis and point in continuum of care52

What Are the Phases of Treatment for Depression and Their Goals?• Acute

• Target goals• Remission• Restoration of function

• Outcome measures• Maintenance

• Resolve residual symptoms• Treat co-morbidities• Prevent recurrence

Use chronic disease management model53

What Are the Effective Interventions for Depression?• Pharmacotherapy

• Antidepressant agents• Older agents – TCAs, MAOIs• Newer agents – SSRIs, SNRIs, atypical antipsychotics, novel agents

• Psychological therapies• Cognitive Behaviour Therapy (CBT)• Interpersonal Therapy (IPT)• Other modalities, supportive therapy

• Combination: Medication + psychotherapy• Psychosocial interventions• Neurostimulation

• Electroconvulsive Therapy (ECT)• Rapid transcranial magnetic therapy (rTMS)• Investigational modalities

• Chronic disease management model

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Psychotherapy: Best Modalities• Cognitive behaviour therapy (CBT)

• Basis: Thoughts, emotions and behaviours are inter-related• Focus on dispelling cognitive misperceptions of self, others and

surroundings and modifying maladaptive emotional and behavioural responses

• Interpersonal therapy (IPT)• Basis: Problematic interpersonal relationships may contribute to

depressive onset and maintenance• Focus on at least 1 key area: Role transitions, Interpersonal role

disputes, Grief, Interpersonal deficits• Pick the most appropriate form based on the need• Both forms effective in acute and maintenance treatment

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Psychotherapy: Other ModalitiesPsychodynamic psychotherapy Behavioural activationBasis: Psychological dysfunction results from conscious or unconscious conflicts and defense mechanisms

Focus on recognizing the conflict and understanding sources/influences to promote psychological healing

Basis: “Depression is a consequence of compromised environmental sources of positive reinforcement”

Focus on increasing patient activity and rewarding experiences, and de-emphasizing particular cognitions/ mood states

Motivational interviewing Computer/internet/telephone psychotherapy

Basis: Individuals with dysfunctional behaviours wish to change but lack initiative/commitment

Focus on resolving ambivalence, building motivation, and working towards specific, realistic goals to achieve the desired change

CBT, IPT, supportive therapy, etc. in distance delivery formats

Advantages: Immediate help, anonymity, low cost, flexible schedule, ease of access for remote communities

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Neurostimulation Therapies

ECT rTMS

Induction of a convulsion (seizure) by the application of electrical current to the brain

Application of a magnetic field (1.5-2.5T), delivered through the skull

Indications: Treatment resistance, intolerant of antidepressants, psychotic depression

Indication: Treatment resistance, severe depression

Physical and cognitive side effects Short term side effects: Headache and scalp pain.

Investigational therapies

VNS, DBS and MST

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How does Depression Affect Physical Health?• Increase the effect of risk factors

• Obesity• Smoking• Cardiovascular• Immune

• Increase the risk of chronicity• Worsen pain disorders• Reduce treatment adherence• Reduce participation in prevention

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What is the Long-term Outcome of Depressive Disorders?• MDD

• Variable duration• Spontaneous recovery in many• Longer illness poor outcome• Often recurrent• 20% non-recovery and chronic course

• Dysthymia/Persistent depressive disorder• Chronic fluctuating course• Superimposed MDD double depression• Poor function

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Bipolar Disorder

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Case History

Susan, a 20-year-old university student, presents with symptom of 2 months’ duration (worsening in last 2 weeks)• Has started many projects, but is easily distracted and does

not complete them – has affected her grades • Is sleeping less (but does not feel tired)• Has been buying unneeded things impulsively from the

internet• Her friends say her mood is unpredictable, and that she gets

overly excited or angry about even little things.

What is your assessment of this patient?61

Symptom Overlap: The Complexity of Mood Disorders

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Unipolar Depression

Bipolar Mania Bipolar Depression

Treatment Resistant

Depression

Agitated Depression

Mixed State

Psychosis

*All have potential for psychotic presentation/escalation

Bipolar Disorder and Bipolar Spectrum Disorders• BP I: Mania with/without depression• BP II: Depression with hypomania - Recurrent MDE with

clear-cut hypomanic episodes (lasting at least 4 days)• BP Spectrum/ Complex Subtypes

• Mixed states: Mania and depression

• Rapid cycling, Ultra-rapid cycling, Ultradian

• Cyclothymia

• Substance/Antidepressant-induced hypomania

• Prevalence:• Bipolar I Disorder: 1.2-1.6%

• Bipolar II Disorder: 2-6%

• Bipolar Spectrum Disorders: 6.4%

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Bipolar Disorder: Burden of Disease

• High degree of psychiatric/physical co-morbidity and psychosocial consequences:• Suicidality• Substance abuse• Medical illnesses• Employment and family problems

• Increased mortality than those without bipolar disorder:• 2.5 times more likely to die in 12 months, if untreated

• One of the world’s 10 most disabling conditions• DALYs highest in 14-44 year olds

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Diagnosing Mania

Mood: Abnormally and persistently elevated, expansive or irritable

Duration: At least one week or requiring admissionPLUS

Three (four if irritable mood) or more of the following:• Grandiosity • More talkative• Flight of ideas• Distractibility• Less need for sleep• More goal-directed activity • Excessive involvement in pleasurable activities

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Hypomania: PresentationA distinct period of persistently elevated, expansive

or irritable mood, lasting at least 4 days PLUS

Three (four if irritable mood) or more of the following:

• Grandiosity • More talkative• Flight of ideas• Distractibility• Less need for sleep• More goal-directed activity • Excessive involvement in pleasurable activities

More commonly seen in primary care than mania

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Bradley Cooper in Silver Linings Playbook - Hypomania

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What are the common presentations of Bipolar I and II Disorder to the Family Physician?Psychological Physical

Depression Alcohol/substance use

Anxiety Sexually transmitted diseases

Sleep difficulties

Fatigue

Poor concentration

Social Other

Marital/relationship problems Episodic impulsivity/risk taking

Financial Suicide attempts

Occupational

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The Complex Bipolar Patient

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• Mixed episodes• Both manic and depressive symptoms• comorbid substance use disorders• risk of suicide and psychosis

• Rapid cycling• 4 or more cycles/year with > 8 weeks of well periods• Occurs in Bipolar I and II

The Complex Bipolar Patient: Co-morbidities/Complications

• Anxiety disorders• High co-morbidity (up to 92%)• Risk factor for bipolar disorder• May elevate risk of suicide

• Substance abuse• High rates of co-morbidity vs.

the general population• Higher prevalence of complex

subtypes

• ADHD• Bi-directional relationship• Overlap of symptoms• ADHD as a prodrome

• Personality disorders (cluster B)

• Medical conditions• Obesity• Cardiovascular• Endocrine • Cerebral pathology

• Suicide• 15% suicide rate• 25-50% attempt suicide

in lifetime 70

Bipolar Disorders: Management

Chronic disease management model: Long term, interdisciplinary, education focused and integrated• Bipolar I Disorder

• Emergency management• Acute care/short-term• Mixed/rapid cycling states• Bipolar mania• Bipolar depression

• Bipolar II Disorder• Mainly depression

• Maintenance treatment and prophylaxis71

Issues Specific to Primary Care

• Diagnostic difficulties – screening tools• Patient Health Questionnaire (depression only) (PHQ-9; 9 items)• Mood Disorder Questionnaire (mania only; 17 items)

• Check for “destabilization”/non response to antidepressants • Use antidepressants with caution• Referral for consultation/shared care• Treatment adherence• Risk of suicide /financial difficulties• Medical issues, e.g. obesity, cardiovascular disease• Psychoeducation and support through life transition for patient and

family• Relapse prevention

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What Interventions are Useful for Bipolar Disorders?• Pharmacotherapy

• Antipsychotics• Mood stabilizers

• Lithium carbonate• Anticonvulsants

• Psychotherapy• Psychoeducation• CBT, IPT• Family interventions• Benefits: Improve adherence and function, early identification of

relapse and suicidal ideation, prevent suicide• Neurostimulation

• ECT73

Bipolar Patients: Baseline Investigations and Monitoring• CBC electrolytes• Fasting lipids and glucose• Liver function levels• TSH + ECG• Urine analysis

Regular monitoring:• The above +• Weight, smoking status and alcohol use• Medication serum levels• Cognitive function 74

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On a Lighter Note…

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END

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