Considering Depression and Anxiety



OVERVIEW



  • Depression and anxiety are common in patients with medically unexplained symptoms (MUS); most patients have elements of both
  • MUS are not the same as depression and anxiety, although MUS predispose to emotional disorder and emotional disorders predispose to MUS
  • Many patients with MUS will play down their emotional symptoms for fear of being mislabelled
  • Questionnaires such as the Patient Health Questionnaire (PHQ9) and Generalized Anxiety Disorder scale (GAD7) or Hospital Anxiety and Depression Scale (HADS) can help patients see that their emotions are typical of depression or anxiety




Introduction


In this chapter we outline a clinical approach to the detection and assessment of depressive and anxiety disorders. Treatment is covered separately in Chapters 15–17.


Epidemiology


Major depressive disorder, diagnosed using standard criteria (see Box 4.1) is common in the general population and in patients with MUS. Typical population-based studies suggest a prevalence of around 2% with a lifetime incidence of 6–9% for women and 3–5% for men. It occurs across all ages with a peak incidence at around 40 years old.






Box 4.1 Major depressive episode (proposed criteria DSM 5)


A. Five (or more) of the following criteria have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure
1 Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood

2 Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

3 Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gain

4 Insomnia or hypersomnia nearly every day

5 Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

6 Fatigue or loss of energy nearly every day

7 Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

8 Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

9 Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide




Generalised anxiety disorder (Box 4.2) has a prevalence of 3-4% in woman and 2–3% in men. The prevalence of panic disorder (1%) (Box 4.3) and phobic disorders (1–2%) is slightly lower.






Box 4.2 Generalized Anxiety Disorder (proposed criteria DSM 5)


A. Excessive anxiety and worry (apprehensive expectation) about two (or more) domains of activities or events (for example, domains like family, health, finances, and school/work difficulties)

B. The excessive anxiety and worry occur on more days than not for 3 months or more

C. The anxiety and worry are associated with one or more of the following symptoms:
1 Restlessness or feeling keyed up or on edge

2 Being easily fatigued

3 Difficulty concentrating or mind going blank

4 Irritability

5 Muscle tension

6 Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

D. The anxiety and worry are associated with one (or more) of the following behaviors:
1 Marked avoidance of situations in which a negative outcome could occur

2 Marked time and effort preparing for situations in which a negative outcome could occur

3 Marked procrastination in behavior or decision-making due to worries

4 Repeatedly seeking reassurance due to worries




 






Box 4.3 Panic Disorder (proposed criteria DSM 5)


A. Recurrent unexpected panic attacks defined as: a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: 1) palpitations, pounding heart, or accelerated heart rate; 2) sweating; 3) trembling or shaking; 4) sensations of shortness of breath or smothering; 5) feeling of choking; 6) chest pain or discomfort; 7) nausea or abdominal distress; 8) feeling dizzy, unsteady, lightheaded, or faint; 9) derealization (feelings of unreality) or depersonalization (being detached from oneself); 10) fear of losing control or going crazy; 11) fear of dying; 12) paresthesias (numbness or tingling sensations); 13) chills or hot flushes

B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
1 Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, going crazy).

2 Significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).




However, these psychiatric definitions of depressive and anxiety disorders were developed in secondary care where only a small proportion of those with symptoms of any of the emotional disorders are seen. At a population level the presence of symptoms of emotional disorder is continuously distributed (Figure 4.1) and the classical psychiatric diagnostic categories have limited value. In primary care most patients present with a mixed picture of anxiety and depression and meet the criteria for more than one diagnosis. Taken as a group depressive and anxiety disorders have a prevalence of around 10% in women and 5% in men.



Figure 4.1 Symptoms of depressive and anxiety disorders are continuously distributed in the population. Reprinted from Mayou R, Sharpe M, Carson A. (2003) ABC of Psychological Medicine. BMJ books, with permission from John Wiley & Sons Ltd.

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Dec 9, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Considering Depression and Anxiety

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