DEPRESSION AND ANXIETY Ian M Chung Practitioner in

Ian M Chung Ø General practitioner since 1965 Ø 80% of practice in Psychological

Mental illness in GP population Ø Much mental illness is covert or hidden Ø

The cost of untreated mental illness: WHO “Burden of Disease” study Ø To patient

Obstacles to diagnosis of mental illness Ø Patient • Ignorance, stigma, fear of the

The GP perspective Ø General practice is total (bio-psycho-social) and should address continuing patient

The main mental illnesses seen in General Practice Ø Depression and anxiety are the

Depression and Mood Disorders: a chronic disorder, a disease of losses more than sadness

Special Depressive Disorders Ø Depression in women • In all cultures depression is more

Anxiety Disorders: the disease of fears and worry Ø Panic disorder with or without

Somatoform Disorders Ø Somatisation disorder • Fatigue, pain or other symptoms not feigned •

Aetiological factors in mental illness Ø External • Life stressors o Conflict o Loss

The Mind-Body Connection Ø Descarte’s dualistic theory was wrong Ø The mind and body

Neuro-science is in rapid and dramatic transition Ø 90% of current knowledge in neuro-science

Learning enhances adult neurogenesis in the hippocampal formation Thousands of hippocampal neurons are born

Antidepressants do more than relieve symptoms Ø Depression affects pre-frontal cortex, amygdala, striatum, thalamus

Pre-treatment Ø The patient needs to present for treatment, which implies that the patient

The diagnosis of mental illness: before DSM IV or ICD 10 Ø Maintain your

Treatment Ø First establish a therapeutic alliance with patient Ø Make the diagnosis Ø

Comprehensive and integrated approach to therapy Ø Medical: pharmacotherapy • To medicate or not?

Treatment Goals Ø Response • Find the right drug and take it for long

Treatment options for non-responding patients Ø Switching antidepressants Ø Augmentation: some evidence suggests… •

Final words… Ø Caring for our patient ought to mean treating the whole patient:

And a personal perspective… Ø It has been a privilege to have been given

Copyright © Ian M Chung 2005 The foregoing presentation is copyright. Except as permitted

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Ian M Chung Ø General practitioner since 1965 Ø 80% of practice in Psychological Medicine Ø Principal Counsellor of Lawcare Program, NSW Law Society Ø Past Member of NSW Medical Board Ø Educator of general practitioners Ø Not a psychiatrist, academic or expert Ø Is a clinician and practitioner COPYRIGHT © IAN M CHUNG 2005

Mental illness in GP population Ø Much mental illness is covert or hidden Ø Primary carers fail to recognise one out of two patients with mental illness Ø Incidence of mental illness varies in different areas and practices and at different times Ø Untreated mental illness is time-consuming and costly COPYRIGHT © IAN M CHUNG 2005

The cost of untreated mental illness: WHO “Burden of Disease” study Ø To patient • Morbidity, mortality, financial, productivity, family suffering, reputation Ø To community • Productivity, financial ($4 -5 bil pa in Australia), loss of community cohesion Ø To doctor • ? COPYRIGHT © IAN M CHUNG 2005

Obstacles to diagnosis of mental illness Ø Patient • Ignorance, stigma, fear of the implications, lack of finances or resources to treat Ø 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) Ø Society • Different priorities, financial, lack of community education, health policy, community attitudes COPYRIGHT © IAN M CHUNG 2005

The GP perspective Ø General practice is total (bio-psycho-social) and should address continuing patient care in the context of their family and community Ø The GP has an ongoing relationship with the patient and their family Ø General practice provides opportunity for early diagnosis before the condition is well-defined or fully developed Ø The GP sees the patient before they are “educated” by the process of investigation and elimination COPYRIGHT © IAN M CHUNG 2005

The main mental illnesses seen in General Practice Ø Depression and anxiety are the major mental illnesses, alone or co-morbid, or as manifestations of other mental conditions or medical illness Ø Both depression and anxiety have a range of severity and forms Ø Specificity of diagnosis is important Ø Somatisation is very common: the mind and body are one also patient prefers to c/o an illness Ø Drug use and illness must be excluded Ø Any illness needs the GP to consider the full circumstances of the patient COPYRIGHT © IAN M CHUNG 2005

Depression and Mood Disorders: a chronic disorder, a disease of losses more than sadness Ø Major depressive disorder: depressed mood anhedonia nearly every day for two weeks; include major depression in remission Ø Minor depressive disorder Ø Dysthymia: chronic sub-clinical depression Ø Adjustment disorder with depressed mood Ø Exclude bipolar disorder and melancholia Ø Exclude drugs and physical illness COPYRIGHT © IAN M CHUNG 2005

Special Depressive Disorders Ø 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 Ø Depression in the elderly • Bereavement, loss of independence, illness, onset of dementia • Suicide is high in single men aged over 75 Ø Depression in children • Separation and abuse • Adolescence Ø Seasonal affective disorder COPYRIGHT © IAN M CHUNG 2005

Anxiety Disorders: the disease of fears and worry Ø Panic disorder with or without agoraphobia Ø Generalised anxiety disorder • Chronic anxiety • “Free floating” anxiety) Ø Specific phobias Ø Social phobia: fear of negative evaluation Ø Obsessive compulsive disorder, pathological doubt, spontaneous and intrusive phenomena Ø Post-traumatic stress disorder Ø Anxiety associated with drugs and illness COPYRIGHT © IAN M CHUNG 2005

Somatoform Disorders Ø Somatisation disorder • Fatigue, pain or other symptoms not feigned • Without discernable clinical explanation • Causes distress and impairment of significant duration Ø Conversion disorder Ø Pain disorders Ø Hypochondriasis • Pre-occupation and fear of illness Ø Body dysmorphic disorder • Pre-occupation with imagined defects in appearance COPYRIGHT © IAN M CHUNG 2005

Aetiological factors in mental illness Ø External • Life stressors o Conflict o Loss o Disappointment o Excess load o Deprivation • Drugs and alcohol Ø Internal • Personality o Neuroticism o Family traits and dispositions • Past o Traumatised o Deprived o Under/over-loved o Under/over-protected o Under/over-criticised COPYRIGHT © IAN M CHUNG 2005

The Mind-Body Connection Ø Descarte’s dualistic theory was wrong Ø The mind and body are one: holistic Ø The brain and body are in constant interactive connection via nerves and hormones Ø Thoughts, feelings and memories affect the body’s functions and vice versa; anatomical, biochemical and physiological changes can be demonstrated COPYRIGHT © IAN M CHUNG 2005

Learning enhances adult neurogenesis in the hippocampal formation 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. Elizabeth Gould 1, Anna Beylin 1, Patima Tanapat 1, Alison Reeves 1 and Tracey J. Shors 2 1 Department 2 Department of Psychology, Princeton University, Princeton, New Jersey, USA of Psychology & Centre for Neuroscience, Rutgers University, Piscataway, New Jersey, USA Emotions and learning cause structural brain changes. Gould et al Nat Neuro 1999; 2: 260 -265 COPYRIGHT © IAN M CHUNG 2005

Antidepressants do more than relieve symptoms Ø Depression affects pre-frontal cortex, amygdala, striatum, thalamus Ø Untreated major depression causes hippocampal atrophy Ø Antidepressants cause neutogenesis in the dentate gyrus Ø Untreated anxiety causes enlargement of the amygdala and increased secretion of cortisol releasing factor (CRF) COPYRIGHT © IAN M CHUNG 2005

Pre-treatment Ø The patient needs to present for treatment, which implies that the patient is sufficiently in pain or sufficiently worried Ø 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 Ø Treatment begins in the waiting room • An atmosphere receptive to whatever the patient has to bring there COPYRIGHT © IAN M CHUNG 2005

The diagnosis of mental illness: before DSM IV or ICD 10 Ø Maintain your index of suspicion Ø Heed the patient’s message: hear and see it Ø Know the disease presentations Ø Know the follow-up question Ø Know the criteria for each condition Ø Take the care needed to listen and clarify Ø Use a diagnostic scale if needed Ø If in doubt or disinterested, REFER! COPYRIGHT © IAN M CHUNG 2005

Treatment Ø First establish a therapeutic alliance with patient Ø Make the diagnosis Ø Explain the diagnosis and treatment to patient Ø Prioritise and implement the treatment plan Ø Involve family and others when necessary Ø Continuation management and tracking the progress towards full remission Ø How long to treat? Ø Relapse prevention COPYRIGHT © IAN M CHUNG 2005

Comprehensive and integrated approach to therapy Ø Medical: pharmacotherapy • To medicate or not? • What dose? Ø Psychological • • • Psycho-education CBT Behavior therapy Structured problem solving Relaxation/meditation/hypnosis Ø Lifestyle: balanced life • For example, Yerkes-Dobson curve Ø Spiritual: sense of self/purpose/direction • For example, logotherapy (Victor Frankl) COPYRIGHT © IAN M CHUNG 2005

Treatment Goals Ø Response • Find the right drug and take it for long enough • Augment if necessary • Referral if necessary Ø Enhance recovery • Instigate and maintain all therapeutic strategies Ø Aim for full remission • Optimise all treatment strategies Ø Prevent Relapse • Educate patient as to their vulnerabilities • Continue medication long enough • Maintain life activities and directions COPYRIGHT © IAN M CHUNG 2005

Treatment options for non-responding patients Ø Switching antidepressants Ø Augmentation: some evidence suggests… • Lithium • Atypical antipsychotics o Risperidone o Olanzapine • Antiepileptics/anticonvulsants o Valproic acid o Carbamazepine o Gabapentin Ø Combination of antidepressants Ø ECT Fava J Clin Psychiatry 2001; 62 (Suppl 18): 4 -11 COPYRIGHT © IAN M CHUNG 2005

Final words… Ø Caring for our patient ought to mean treating the whole patient: body and mind Ø Mental illness (MI) is common, disabling and often missed - which is costly to all concerned Ø Treatment of MI is neither difficult nor necessarily time consuming Ø Treating MI is effective and satisfying Ø Treating MI gives the GP an enlightening glimpse into the human condition Ø Failure to treat is negligent COPYRIGHT © IAN M CHUNG 2005

And a personal perspective… Ø 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

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 imc@ianmchung. com Web www. ianmchung. com COPYRIGHT © IAN M CHUNG 2005