Depression Anxiety Dr Donna Grant MRCPsych MBBS BSc

Depression & Anxiety Dr Donna Grant (MRCPsych, MBBS, BSc (Hons)) Consultant Psychiatrist Priory Hospital Chelmsford Stump Lane, Springfield Chelmsford. CM 1 7 SJ Medical Secretary: Carole Dolbear Telephone: 01245 244703 Email: caroledolbear@priorygroup. com

Contents • • • Causes of depression Who gets depression Symptoms of depression Suicide Management of depression Questions Symptoms of Anxiety Who gets anxiety Symptoms of anxiety The different anxiety disorders Management of anxiety

Causes of Depression Ø No single cause. Ø Ø Ø Ø External stresses Personality Family History Giving birth Loneliness Alcohol and/or drugs Physical ill-health

Depression – Who is affected • Lifetime risk: > 20% • Females>Males • Average onset late 30’s • Highest prevalence in lower social groups • Urban>rural • Unmarried

Emotional symptoms of Depression • Low mood (pervasiveness & > 2 wks) • Tearfulness • Loss of interest in activities that would normally have given pleasure • Inability to experience pleasure • Loss of reactivity to external events • Irritability • Anxiety

Cognitive (thinking/thoughts) symptoms of Depression • • • Reduced speed & expressivity speech Poor concentration / memory Negative views of self, world, future Hopelessness/worthlessness Guilt Thoughts of death/Deliberate Self Harm/Suicide

Biological symptoms of Depression Mood usually worse in mornings Sleep – waking very early Poor appetite Weight loss Loss of sex drive Fatigue / lack of energy Physical complaints eg. Constipation/aches & pains • Changes to menstrual periods • •

Social symptoms of Depression • Not doing well at work • Avoiding contact with friends and taking part in fewer social activities • Neglecting your hobbies and interests • Having difficulties in your home and family life

Severity of depression Doctors describe depression by how serious it is: Mild depression – has some impact on your daily life Moderate depression – has a significant impact on your daily life Severe depression – makes it almost impossible to get through daily life; a few people with severe depression may have psychotic symptoms

Psychotic symptoms of Depression Hallucinations Delusions Confused and disturbed thoughts Lack of insight and self-awareness

Suicide • • Incidence of 1/10, 000/year Approx. 1% of all deaths Males>Females 3: 1 Age>45 (rising with young men) Divorced/single/widowed Urban>rural Higher risk if there is a family history of suicide 90% mental ill-health

What can make people feel suicidal? • • • Current problems Social difficulties Mental state affected by alcohol/drugs Known mental illness Coping resources

Management of Depression Mild • Lifestyle changes, eg getting more exercise, cutting down on alcohol, giving up smoking and eating healthily • Sleep/anxiety management • Self-help – www. getselfhelp. co. uk – www. mind. org. uk • Psychological (talking) therapies • Antidepressants

Moderate to severe depression • Antidepressants before talking therapy • Continuing treatment – On-going regular review – Try a different antidepressant if lack of response – Monitor risk

Which antidepressant for which patient? Previous successful/unsuccessful antidepressant in past • Previous side effects Establish whether. . . • Sleepless, agitated, lethargic, oversleeping, not driving • Are there symptoms of: – Anxiety/panic – Obsessive Compulsive Disorder (OCD) – Eating disorder – Pain Consider any physical conditions that may interfere with antidepressant treatment, ie – Heart disease – Epilepsy – Alcohol misuse

Case study • A 65 y. o man with no previous mental health problems • Work related stresses off work • Severely depressed + suicidal thoughts • Offered an in-patient admission, but declined • Intensive psychological therapy & reluctantly started an antidepressant • Very quickly noticed an improvement with the above combination

Other types of Depression postnatal depression – some women develop depression after they have a baby; this is known as postnatal depression and it's treated in a similar way to other types of depression, with talking therapies and antidepressant medicines bipolar disorder – also known as "manic depression", in bipolar disorder there are spells of both depression and excessively high mood (mania); the depression symptoms are similar to clinical depression, but the bouts of mania can include harmful behaviour, such as gambling, going on spending sprees and having unsafe sex seasonal affective disorder (SAD) – also known as "winter depression", SAD is a type of depression with a seasonal pattern usually related to winter

Questions so far? ? ?

Anxiety Disorders • Anxiety can be completely normal! • Anxiety is the main symptom of several conditions: • Generalised anxiety disorder (GAD) • Panic disorder • Phobias • Simple phobias • Complex phobias (e. g. Agoraphobia) • Social Phobia • Post Traumatic Stress Disorder (PTSD) • Obsessive Compulsive disorder (OCD)

Anxiety Symptoms - Rapid pulse - Sweating - Nausea - Feeling unable to breathe or a choking sensation - Feeling faint or dizzy - Numbness or pins and needles - Chest pains or chest tightness - Headache - An urgency to go to the toilet - Muscle tension - Trembling

Statistics Lifetime risk: All anxiety disorders 15 – 20 % Phobic disorders 2 – 7 % GAD 4 – 6 % OCD 2 – 4 % Panic disorder 2 – 3 %

Generalised Anxiety Disorder – Who is affected GAD is a common condition, estimated to affect up to approx. 5% of the UK population. Slightly more women are affected than men, and the condition is more common in people from the ages of 35 to 59. High co morbidity.

Causes of GAD Not fully understood, but combination of various factors may be involved: q Overactivity in areas of the brain involved in emotions and behaviour q An imbalance of the brain chemicals (serotonin and noradrenaline), which are involved in the control and regulation of mood q Genetic predisposition – you are approx. 5 x more likely to develop GAD if you have a close relative with the condition q A history of stressful or traumatic experiences, such as domestic violence, child abuse or bullying q A painful long-term health condition, such as arthritis q A history of drug or alcohol misuse q Can be for no reason

Psychological symptoms of GAD can cause a change in your behaviour and the way you think and feel about things, resulting in symptoms such as: restlessness a sense of dread feeling constantly "on edge" difficulty concentrating irritability You may withdraw from social situations to avoid feelings of worry and dread. Going to work can be difficult and stressful, and may take time off sick. These actions can make you worry even more about yourself and increase your lack of selfesteem.

Physical symptoms of GAD dizziness tiredness a noticeably strong, fast or irregular heartbeat (palpitations) muscle aches and tension trembling or shaking dry mouth excessive sweating shortness of breath stomach ache feeling sick headache pins and needles difficulty falling or staying asleep (insomnia)

Panic Disorder • Recurrent unexpected severe anxiety with varying degrees of anticipatory anxiety between attacks. • Physical symptoms – sweating, palpitations, weakness and dizziness. • Psychological symptoms – e. g. fear of dying, making a fool of self, going mad, having a heart attack. • Symptoms peak within 10 minutes and last 30 – 45 minutes. • 2/3 go on to develop agoraphobia – a fear of places/ situations from which escape might be difficult or where help won’t be available. Such places are avoided or endured with dread.

Simple Phobia • Develop during childhood/adolescence and can become less severe with age • An overwhelming and debilitating fear of an object, place, situation, feeling or animal such that the person has an exaggerated or unrealistic sense of danger. • If it becomes very severe, a person may organise their life around avoiding the thing that's causing them anxiety. As well as restricting their day-today life, it can also cause a lot of distress and anxiety symptoms

Simple Phobia cont’d Examples: o Animal phobias – such as dogs, spiders, snakes or rodents o Environmental phobias – such as heights, deep water and germs o Situational phobias – such as visiting the dentist or flying o Bodily phobias – such as blood, vomit or having injections o Sexual phobias – such as performance anxiety or the fear of getting a sexually transmitted infection

Complex phobias These phobias tend to be more disabling than simple phobias. They tend to develop during adulthood and are often associated with a deep-rooted fear or anxiety about a particular situation or circumstance. The two most common complex phobias are: agoraphobia social phobia

Agoraphobia is often thought of as a fear of open spaces, but someone with agoraphobia will feel anxious about being in a place or situation where escaping may be difficult if they have a panic attack. The anxiety usually results in the person avoiding situations such as: Being alone Being in crowded places, such as busy restaurants or supermarkets Travelling on public transport

Social Phobia (Social anxiety) • Marked, persistent, unreasonable fear of being observed or evaluated negatively by other people in social or performance situations. • Associated with anxiety symptoms. • Feared situations avoided or endured with dread and distress.

Post Traumatic Stress Disorder • A history of exposure to an extraordinary trauma with a response of intense fear, helplessness or horror. • Later development of re-experiencing symptoms (e. g. flashbacks), avoidance, increased startle and hyper-arousal. • Affects 1: 3 of people who have had a traumatic experience. • More likely if history of depression or anxiety; or lack of support; or family history of mental health problems

Obsessive Compulsive Disorder • Recurrent obsessional thoughts, images or urges that cause feelings of anxiety, disgust or unease. • Relieved temporarily by repetitive compulsive rituals. These can be distressing, time consuming and interfere with social and occupational functioning.

Obsessive thoughts • fear of deliberately harming yourself or others – for example, fear you may attack someone else, such as your children • fear of harming yourself or others by mistake – for example, fear you may set the house on fire by leaving the cooker on • fear of contamination by disease, infection or an unpleasant substance • a need for symmetry or orderliness – for example, you may feel the need to ensure all the labels on the tins in your cupboard face the same way • Thoughts can also be of a sexual or violent nature that you find repulsive or frightening

Compulsive behaviours cleaning and hand washing checking – such as checking doors are locked or that the gas is off counting ordering and arranging hoarding asking for reassurance repeating words in their head thinking "neutralising" thoughts to counter the obsessive thoughts avoiding places and situations that could trigger obsessive thoughts

Treatments for all the anxiety disorders There also many things you can do yourself to help reduce your anxiety, such as: Lifestyle changes : exercising regularly stopping smoking cutting down on the amount of alcohol and caffeine you drink Learn to relax – relaxation/breathing exercises / yoga /pilates

Longer term Treatments for the anxiety disorders - Self help – eg. support groups - Psychological (talking) therapy – Cognitive Behavioural Therapy (CBT) - Pharmacological therapy (medications)– Antidepressants, benzodiazepines, Pregabalin (an anticonvulsant)

Thank You

Questions? ? ?

Dr Donna Grant (MRCPsych, MBBS, BSc (Hons)) Consultant Psychiatrist Priory Hospital Chelmsford Stump Lane, Springfield Chelmsford. CM 1 7 SJ Medical Secretary: Carole Dolbear Telephone: 01245 244703 Email: caroledolbear@priorygroup. com