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 1
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Mood & Anxiety Disorders in Primary Care: A Review Arun V. Ravindran, MB, MSc, PhD, FRCPC, FRCPsych Professor and Director, Global Mental Health and Office.
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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
2
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
4
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
• 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
• 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
• 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
• 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
• 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
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
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
• 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