Anxiety And Depression

1. Anxiety And Depression Dennis Mungall , Pharm.D. Director,Virtual Education, Non traditional Doctor of Pharmacy Program Associate Professor , Pharmacy Practice Ohio State University/ College of Pharmacy

2. Learning Objectives • Understand the various anxiety disorders , Depression and how each disorder presents • Understand the treatment strategies for each disorder • Understand the signs and symptoms of each disorder • Understand the consequences to the health care system of anxiety and depression

3. History of Depression It is thought that ancient man saw mental illness as possession by supernatural forces. Ancient human skulls have been found with large holes in them, a process that has become known as trepanning. The accepted theory is that it was an attempt to let evil spirits out. We cannot be certain of this, but we do know that again and again human kind has returned to the idea of mental illness being caused by “evil forces”.

4. History of Depression And yet in certain of these cases there is mere anger and grief and sad dejection of mind………those affected with melancholy are not every one of them affected according to one particular form but they are suspicious of poisoning or flee to the desert from misanthropy or turn superstitious or contract a hatred of life. Or if at any time a relaxation takes place, in most cases hilarity supervenes. The patients are dull or stern, dejected or unreasonably torpid……they also become peevish, dispirited and start up from a disturbed sleep.” Arateus (AD 150)

5. History of Depression Hippocrates (460-377 BC) lived at the time of Hellenic enlightenment, when great advances were made in all areas of knowledge. He applied Empedocles’ theory to mental illness and was insistent that all illness or mental disorder must be explained on the basis of natural causes. Unpleasant dreams and anxiety were seen as being caused by a sudden flow of bile to the brain, melancholia was thought to be brought on by an excess of black bile4, and exaltation by a predominance of warmth and dampness in the brain. Temperament was thought to be choleric, phlegmatic, sanguine or melancholic depending on the dominating humor

6. History of Depression By the end of the fifteenth century psychological problems were greatly entwined with legal and religious issues and were not seen alone. The devil was seen as the cause of all ills .Mental disorder was equated with sin. They also stated that where doctors could find no cause for a disease and where the disease did not respond to traditional treatment it was caused by the devil. A witch was stripped and her pubic hair was shaved before presentation to judges, so that the devil would have nowhere to hide. On being found guilty a witch would be burnt at the stake. Literally hundreds of thousands of women and children suffered this fate and probably many of the mentally ill.

7. History of Depression • Robert Burton’s anatomy of melancholy appeared for the first time in 1621.2 He described in detail the psychological and social causes (such as poverty, fear and solitude) that were associated with melancholia and seemed to cause it • In Early nineteenth century Heinroth believed that sin was the causal factor in mental illness. Not sin in the theological sense, but the offending of an individual’s morals by their own thoughts. He was referring to an internal conflict • The man who exemplified the hard-nosed scientific feel of this era was the German psychiatrist Wilhelm Griesinger (1817-1868). For him mental diseases were somatic diseases6, and the cause of mental illness was always to be found in the brain. He firmly believed that psychiatry and neuropathology were one

8. History of Depression • Freud successfully realised was that neurophysiological and psychological knowledge need not be contradictory. • Psychoanalysis predominated until the 1970s, which was followed by renewed interest in genetic, biochemical and neuropathological causes of mental disorder which came to be known as biological psychiatry

9. Introduction

10. Lifetime Prevalence of Depression and Anxiety Disorders

11. Comparision with Other Medical Conditions

12. Sx Overlap of Anxiety and Depression

13. Sx Overlap ( cont.)

14. Physical Symptoms Risk Of Psychiatric Disorder Percent Physical Symptoms (#) Kroenke et al. Arch Fam Med. 1994;3:774.

15. Somatic Symptoms In Mood And Anxiety Disorders Kroenke et al. Arch Fam Med. 1994;3:774.

16. Lifetime Rates Of Anxiety Disorders InAlcohol-Dependence ** * **

17. Mood/Anxiety Disorder Occurring Prior To Substance Dependence Percent Alcohol Dependence Drug Dependence Merikangas et al. Psychologic Med. 1998;28:773.

18. Primary Care Presentation

19. Anxiety and Depression in Primary Care

20. Depression and Gender

21. Days Lost from Work

22. Costs of Depression in the United States Costs of Depression in the United States Cost Center Amount ($ billion)Direct costsInpatient care 8.3Outpatient care 2.8Partial care 0.1Pharmaceuticals 1.2Total direct costs 12.4Indirect costsAbsenteeism 11.7Decreased productivity 2.1Suicide 7.5Total indirect costs 31.3

23. Recovery Rates

24. Relapse Rates

25. Utilizers of Medical Care

26. Depression

27. Case Study

28. Depression Prevalence

29. Morbidity and Mortality

30. Morbidity and Mortality

31. Suicide

32. Depression : DSM IV

33. Major Depressive Episode:Criteria

34. Criteria (cont.)

35. Hamilton Rating Score for Depression

36. Interview Techniques • Depressed or Down • Restless • Fatigued • Guilty • Inability to Concentrate

37. Associated Features

38. Associated Features (cont.)

39. Depression Risk Factors • Recent childbirth • Medical comorbidity • Alcohol or substance abuse • Recent separation or bereavement • Prior episodes • Family history • Prior suicide attempts • Female gender Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis. Clinical Practice Guideline, Number 5. Rockville, MD. U.S. Department of Health and Human Service, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 93-0550. April 1993.

40. Recurrent Depression Risk Factors • Inadequate treatment • Poor medication compliance • Frequent +/- multiple episodes • Preexisting dysthymia • Onset after age 60 • Long duration or severe index episode • Seasonal pattern • Familial mood disorders • Comorbid anxiety or substance abuse disorder

41. Factors Complicating Diagnosis OfLate Life Depression • Comorbid general medical/neurologic illness • Cognitive decline • Multiple losses/bereavement

42. Disease Management

43. Depression Treatment Outcome The Five Rs Remission Recovery Relapse Recurrence x Response x Symptoms x Syndrome Acute 6-12 Weeks Continuation 4-9 Months Maintenance  1 Year Treatment Phases Kupfer. J Clin Psychiatry. 1991;52(Suppl 5):28.

44. Response to Therapy

45. Relapse

46. Compliance

47. Guidelines

48. Criteria For An Adequate Trial Of Antidepressant Treatment • Accurate diagnosis • Appropriate antidepressant • Adequate dose/duration

49. Initial Approach to RX

50. Initial Approach to RX