Primary Care Mental HealthAnxiety disorders

Dr Henk Parmentier

24th January 2011

Introduction

Dr Henk Parmentier

General Practitioner

• Wonca: http://www.globalfamilydoctor.com/

• Wonca Mental Health: http://www.WWPOMH.ning.com

• Mental Health in Family Medicine Journal: http://www.radcliffe-oxford.com/journals/J20_Mental_Health_in_Family_Medicine/default.htm

objectives

Learn about: Anxiety Disorders Definitions Recognition treatment

The Role of Mind & Body Separation

Since Hippocrates, conditions currently regarded as mental illness were treated by general physicians for 2000 years

The idea of insanity as a disease of the mind, different from other illnesses, emerged in the 18th century from Cartesian dualism

4

Public Attitudes ‘Unfortunately, the linguistic distinction

between mental and physical illnesses, and the mind/body distinction from which this was originally derived, still encourages many lay people, and some doctors and other health professionals, to assume that the two are fundamentally different.’ (Kendell 2001)

5

Mind and Body: dump Descartes !

Mind – Body “The only way to separate the mind from the

bodyis with an axe.”

Primary Care Mental Health

mental disorders are found in all countries, in women and men, at all stages of life, among the rich and poor, and in both rural and urban settings

up to 60% of people attending primary care clinics have a diagnosable mental disorder.

Primary Care Mental Health

effective treatments exist for mental health disorders and can be successfully delivered in primary care

The Size Of The Problem

(Andrews et al, J Ment Health Policy Econ, 2000 Dec 1;3(4):175-186)

prev disability days total (million) % of total

depression 3.9% 11.6 6.0 24%

anxiety 6.5% 9.0 7.8 31%

psychosis 0.4% 7.7 0.4 2%

Disability days by diagnosis

depression

WHO predicts that by the year 2020 depression will be the second most important cause of disability after ischaemic heart disease

Murray & Lopez 1997

Excess Consultation Rate UK Anti-Depressants (Centre for Innovation in Primary Care 2001)

12

Extra Consultations (Centre for Innovation in Primary Care 2001)

Condition Extra consults per patient per condition

per year

Extra consults per patient per year allowing for co-

morbidity

Diabetes 1.32 0.62

Hypertension 1.51 1.12

CHD 1.95 0.99

Ulcer healing drugs 2.9 1.92

Asthma/COPD 2.44 2.04

Antidepressants 4.21 3.60

Antipsychotics < 60 5.32 5.32

13

Depression

Cardiovascular disease

Depression has been associated with increased risks of MI and mortality

(Barefoot & Schroll 1996)

Cause or effect?Cause or effect?

Many patients who are free of depression following an acute MI experience an episode

of depression within a year. (Ranga KR et al 2002)

Major depressive disorder occurs in between15% and 23% of patients with acute coronarysyndromes and constitutes an independentrisk factor for both morbidity and mortality

(Glassman et al. 2002)

Wonca WPoMH

Depression and Cardiovasular Mortality Post-MI:6 and 18 month outcomeDepression and Cardiovasular Mortality Post-MI:6 and 18 month outcome

Frasure-Smith N, et al. JAMA 1993;270:18191825. Frasure-Smith N, et al. Circulation 1995;91:9991005.

3%

6.4%

17%

20%

0

5

10

15

20

25

6 months 18 months

% o

f cor

onar

y de

aths

Non-depressed patients

Depressed patients

Previously Identified Risk Factors for Coronary Artery Disease

Genetic Factors Diabetes Hypertension Thrombocyte

Dysfunction Hyperlipidemia Smoking Obesity

Major depression – CV risk

Depressionindependent risk factor for myocardial infarction

Platelets: upregulation of platelet imidazoline and

serotonin receptors and enhanced intraplatelet calcium mobilization seen in patients with depression resulting in increased platelets activation

Sauer,Berlin,Kimmel:Selective serotonin reuptake inhibitors and myocardial infarction:Circulation. 2001 Oct 16;104(16):1894-8

Prevalence of unexplained symptoms in consecutive new attendees to medical clinics at a UK Teaching Hospital

Nimnuan and Wessely, 2000

Clinic Prevalence (95% CI)ChestCardiologyGastroenterologyRheumatologyNeurologyDentalGynaecology

59% (46-72)56% (46-67)60% (45-73)58% (47-69)55% (45-65)49% (37-61)57% (50-68)

Total 56% (52-60)

Unexplained symptoms

Depression Anxiety

Abdominal pain 63% 53%

Chest pain 66% 49%

Dizziness 58% 52%

Short of breath 63% 46%

Headache 53% 46%

Back pain 54% 46%

Kroenke et al, Arch Fam Med, 1994

Stress is normal

Primary care for mental healthPrimary care for mental health

Primary care for mental health forms an essential part of both:

• comprehensive mental health care • general primary care.

General health care

Primary care

Mental health care

Primary care for mental health

Primary care for mental health must be supported by other levels of care including : community-based and

hospital services, informal community care

services, and self-care.

WHO pyramid of care for mental healthWHO pyramid of care for mental health

Generalized Anxiety Disorder: DSM-IV Diagnostic Criteria

– Excessive anxiety and worry present most of the time for > 6 months

– Difficult to control worry– Associated with (at least 3 items):

• Restlessness • Being easily fatigued • Concentration difficulties• Irritability• Muscle tension• Sleep disturbance

– Focus of anxiety and worry not confined to features of an Axis I disorder

– Causes clinically significant distress or functional impairment– Not due to medication, illness, or substance abuse

DSM-IV-TR. APA 2000

Generalized Anxiety Disorder: ICD-10 Summary

– Anxiety is generalized and persistent and not associated with a particular environmental circumstance (i.e. it is free-floating)

– Anxiety present most days for at least several weeks at a time and usually for several months

– Symptoms should involve elements of:• Apprehension

– E.g. Worry about future, feeling “on edge”, difficulty concentrating• Motor tension

– E.g. Restlessness, fidgeting, tension headaches, trembling• Autonomic overactivity

– E.g. Light-headedness, sweating, tachycardia, epigastric discomfort

– Must not meet full criteria for depressive episode, phobic anxiety disorder, panic disorder, or obsessive-compulsive disorder

ICD-10, WHO 1992

DSM-IV and ICD-10 GAD Diagnostic Criteria: Some Differences

DSM-IV ICD-10

Diagnostic classification

Independent category

Residual category

Worry/anxiety symptom

Excessive anxiety and worry

Persistent free-floating anxiety

Duration ≥6 months Several months

Autonomic hyper-activity and physical symptoms

Not essential Must be present

Functional impairment Must be present Not specified

Rickels & Rynn. J Clin Psychiatry. 2001;62(suppl 11):4-12Starcevic. Anxiety Disorder in Adults. Oxford University Press. 2005:102-140

The epidemiology of generalized anxiety disorder in Europe.Lieb R, Becker E, Altamura C.

Eur Neuropsychopharmacol. 2005 Aug;15(4):445-52.Max-Planck-Institute of Psychiatry, Unit Clinical Psychology and Epidemiology, München, Germany.

The objective of this paper is to provide a review on available data to date on the epidemiology of GAD in Europe, and to highlight areas for future research. MEDLINE searches were performed and supplemented by consultations with experts across Europe to identify non-published reports. Despite variations in

the design of studies, available data suggest that

(a) about 2% of the adult population in the community is affected (12-month prevalence),

(b) GAD is one of the most frequent (up to 10%) of all mental disorders seen in primary care,

(c) GAD is a highly impairing condition often comorbid with other mental disorders,

(d) GAD patients are high utilizers of healthcare resources, and

(e) despite the high prevalence of GAD in primary care, its recognition in general practice is relatively low.

Anxiety: dictionary

Feeling anxious Full of mental distress because of fear of

danger or misfortune; greatly worried

Anxiety: symptom

anxiety

Anxiety disorders

affective disorders

Anxiety&

Depression

Financial worries

Relationship worries

Bereavement

Housing

Work

Illness

Acute Illness

Chronic Illness

Illness in family

Gender&

sexuality

Side effectsmedication

Terminal Illness

Pain syndromes

Personalitydisorders

Alcohol&

drugsThe law

33

Finding GAD in the Symptom “SOUP”

Stress

Insomnia

Irritable

Nervy

Jumpy

Weight Angry

Wake up

Feel Bad

Sad

Crying

SadAppetite Antisocial

Frightened

WorriedGuilty Fatigue

No energySuicidal

Heart Race

Forget

Can’t think

Shy

Loner

Panicky

Useless

Worthless

Depressed

Anxious

HeadachesTense

GI pain

BuzzyFlat

Pain

Breathless

Dizzy

Off sex

Restless

Edgy

Sweaty

Shaky

Cramps

IBS

Need a drink

Always Most of the time Sometimes Most of my life Since I lost my job

Etc…..Hot flashes

Worry

Overlap Between Anxiety Disorders and Depression Can Make Diagnosis Difficult

Stahl's Essential Psychopharmacology Online © 2009 Cambridge University Press.

Comorbidity of depression and anxiety disorders can also confound diagnosis

Anxiety Continuum

Worried / anxious but NO somatic symptoms

Worried / anxious but WITH somatic symptoms

Cardiovascular symptoms

Respiratory symptoms

Gastro-Intestinal / Genito-urinary symptoms

Mysterious pains

How GAD usually presents to PCPs….

Unexplained Medical Symptoms & Misdiagnosis of GAD… a Viscous Cycle

Misdiagnosed, untreated Persistent

GAD

Unexplained medical symptoms

Medical consequencesHPA, cytokines

Exacerbation of Existing chronic illness

Development of new illnesses

Investigations-ve findings

Screening Tools

• Alert the physician to the possibility a disorder might exist– Trigger further investigation using diagnostic

criteria and instruments

• Examples– GAD-7

– ASQ-15

GAD 7

†Score >10 indicates possibility of GAD

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Anxiety-causing medicinal substances

• Anticholinergics• Some blood pressure

medicine• Caffeine• Digitalis (toxic doses)• Sympathomimetic

drugs (ephedrine)

• Levodopa • Neuroleptics (akathisia)• Bronchodilators• Thyroid hormones• Anti-inflammators• SSRI’s• Withdrawal from

alcohol and benzodiazepine use

hyperventilation

Hyperventilation (over-breathing)

• About 60% of attacks are accompanied by hyperventilation and many panickers overbreathe even whilst relaxed.

hyperventilation

• The most important thing to understand about hyperventilation:– it can feel as if you don’t have enough oxygen, the

opposite is true. It is a symptom of too much oxygen.– With hyperventilation, your body has too much

oxygen. To use this oxygen (to extract it from your blood), your body needs a certain amount of Carbon Dioxide (CO2).

– When you hyperventilate, you do not give your body long enough to retain CO2, and so your body cannot use the oxygen you have. This causes you to feel as if you are short of air, when actually you have too much.

hyperventilation and panic attack symptoms

• Light headiness • Giddiness • Dizziness • Shortness of breath • Heart palpitations • Numbness • Chest pains • Dry mouth • Clammy hands • Difficulty swallowing • Tremors • Sweating • Weakness • Fatigue

Breathing exercises• Hold your breath. Holding your breath for as long as you comfortably

can will prevent the dissipation of carbon dioxide. If you hold your breath for a period of between 10 and 15 seconds and repeat this a few times that will be sufficient to calm hyperventilation quickly.

• Breathe in and out of a paper bag. This will cause you to re-inhale the carbon dioxide that you exhaled. Naturally there are many times when this would be inappropriate and may appear a little strange. It really helps though.

• Thirdly you can take vigorous exercise while breathing in and out through your nose. A brisk walk or jog whilst breathing through the nose will counter hyperventilation. Regular exercise will decrease general stress levels decreasing the chance of panic attacks.

• If you find that your breathing pattern is irregular or uncomfortable a lot of the time, the best way to ‘reset’ it is by exercising. Start off gradually and check with your doctor if you are not used to exercise.

Management and Treatment

of GAD

Treatment Guidelines

The WFSBP Guidelines for the Pharmacological Treatment of Anxiety Disorders, OCD and PTSD - First Revision

www.wfsbp.org

Bandelow B, et al. (2008) World J Biol Psychiatry 9: 248-312

Presentation in A&E or other settings with a panic attack• If a patient presents with a panic attack, he or she should:

• Be asked if they are already receiving treatment for panic disorder

• undergo the minimum investigations necessary to exclude acute physical problems

• not usually be admitted to a medical or psychiatric bed• be referred to primary care for subsequent care, even if

assessment has been undertaken in A&E• be given appropriate written information about panic

attacks and why they are being referred to primary care• be offered appropriate written information about sources of

support, including local and national voluntary and self-help groups.

Nice anxietyA&E

Treatments for Anxiety Disorders – Evidence From Controlled Studies

Effective

SSRIs (escitalopram etc.) SNRIs venlafaxine,

duloxetine Tricyclic antidepressants Benzodiazepines Pregabalin (only GAD) Buspirone (only GAD) Irreversible MAOIs Moclobemide (only SAD) Quetiapine (only GAD)-------------------------- Cognitive/behavior therapy Psychoanalysis -1 study

Insufficient Proof Typical Neuroleptics

Lack of Evidence or Negative Studies

Beta blockers Herbal preparations Other psychological

treatments Hypnosis

In God we trust.Everybody else needs to provide evidence.

AnonBandelow et al. World J Biol Psychiatry.2008;9(4):248-312.

Advantages and Disadvantages of Anti-anxiety Drugs (I)

Drug Advantages Disadvantages

SSRIs No dependency Sufficient evidence from clinical studies for all anxiety disordersRelatively safe in overdose

Latency of effect 2–6 weeks, initial jitteriness, nausea, restlessness, sexual dysfunctions and other side effects. Some risk of discontinuation syndromes

SNRIs No dependency Sufficient evidence from clinical studiesRelatively safe in overdose

Latency of effect 2–6 weeks, nausea, possible increase in blood pressure and other side effects. Some risk of discontinuation syndrome

Pregabalin No dependency Sufficient evidence from clinical studiesRapid onset of effect

Dizziness, sedation and other side effects

Quetiapine No dependency Preliminary evidence from clinical studiesRapid onset of effect

Somnolence, weight gain and other side effects

TCAs No dependency Sufficient evidence from clinical studies (exception: SAD, PTSD)

Latency of effect 2–6 weeks, anticholinergic effects, cardiac side effects, weight gain and other side effects, may be lethal in overdose

Bandelow et al. World J Biol Psychiatry. 2008;9(4):248-312.

Advantages and Disadvantages of Anti-Anxiety Drugs (II)

Drug Advantages Disadvantages

Benzodiazepines Rapid onset of action Sufficient evidence from clinical studiesRelatively safe in overdose

Dependency possible; sedation, slow reaction time and other side effects. Paradoxical reactions in elderly patients.

Moclobemide No dependency Benign side effect; relatively safe in overdose

Latency of effect 2–6 weeks, inconsistent study results in SAD, no efficacy proofs for other anxiety disorders

MAOIs No dependency Few supporting studies in PD and SAD; latency of effect 2–6 weeks; potentially dangerous side effects and interactions

Buspirone No dependencyRelatively safe in overdose

Latency of effect 2–6 weeks; efficacy proofs only for symptoms of GAD; lightheadedness, nausea and other side effects

Hydroxyzine No dependency Efficacy proofs only for GAD; sedation and other side effects; no experience with long-term treatment

Bandelow et al. World J Biol Psychiatry. 2008;9(4):248-312.

WFSBP Recommendations: Generalized Anxiety Disorder

Treatment Examples Category of Evidence

RecommendationGrade

Recommended Daily Dose for

Adults

SSRIs Escitalopram A 1 10–20 mg

Paroxetine A 1 20–50 mg

Sertraline A 1 50–150 mg

SNRIs Venlafaxine A 1 75–225 mg

Duloxetine A 1 60–120 mg

Calcium channel modulator

Pregabalin A 1 150–600 mg

Atypical antipsychotic

Quetiapine A 1 50–300 mg

TCA Imipramine A 2 75–200 mg

Benzodiazepines Diazepam A 2 5–15 mg

Lorazepam A 2 2–8 mg

Antihistamine Hydroxyzine A 2 37.5–75 mg

Tricyclic Anxiolytic

Opipramol B 3 50–150 mg

Azapirone Buspirone D 5 15–60 mg

Bandelow et al. World J Biol Psychiatry. 2008;9(4):248-312.

WFSBP 2008 GAD Treatment Guidelines

FIRST-LINEPregabalin

SSRIs SNRIs

4-6 Weeks

Continue

No

Partial

Yes

Response?Further

4-6 weeks

Change dose or

switch• Benzodiazepines (2nd line because of

abuse potential)– Treatment-resistant patients with no

history of dependence– Add-on to SSRIs/SNRIs in first few

weeks until onset of efficacy of antidepressant

• TCAs– Imipramine effective, but potentially

lethal in overdose and tolerability less than first-line

World Federation of Societies of Biological Psychiatry Bandelow B, et al. The World Journal of Biological Psychiatry. 2008; 9(4): 248-312

Sec

on

d l

ine

QOF

Bibliotherapy Preferred reading list

CBT Local “primary care counselling service” CBT online

www.livinglifetothefull.com

68

Finding GAD in the Symptom “SOUP”

Stress

Insomnia

Irritable

Nervy

Jumpy

Weight Angry

Wake up

Feel Bad

Sad

Crying

SadAppetite Antisocial

Frightened

WorriedGuilty Fatigue

No energySuicidal

Heart Race

Forget

Can’t think

Shy

Loner

Panicky

Useless

Worthless

Depressed

Anxious

HeadachesTense

GI pain

BuzzyFlat

Pain

Breathless

Dizzy

Off sex

Restless

Edgy

Sweaty

Shaky

Cramps

IBS

Need a drink

Always Most of the time Sometimes Most of my life Since I lost my job

Etc…..Hot flashes

Worry

Thank you

Henk.parmentier@gmail.com