MEDICAL PERSPECTIVES ON DEPRESSION AND ANXIETY
BACKGROUND Lifetime prevalence in the world is 12% Prevalence in developed countries (USA, Europe) 18% Prevalence in developing countries ( China, Brazil) 9% In time period between 1992 and 2002... Incidence has doubled in the US. worldwide, women have twice the rate of depression as men. This may be because the causes of depression in each of the sexes are different.
RISK FACTORS Depression occurs more often in people with specific risk factors. These risk factors come together via three broad pathways: Internalizing factors Externalizing factors Adversity
INTERNALIZING FACTORS Genetics Neuroticism Low self-esteem Early onset anxiety disorder Past history of major depressive episode
EXTERNAL FORCES Genetics Substance abuse Conduct disorder
ADVERSITY Trauma during childhood or adulthood Stressful events in the previous year Parental loss Low parental warmth History of divorce Marital problems Low social support Low education
NANCY 57 year old female. Long history of anxiety and depression. Unable/unwilling to take medications or go to counseling. Risk factors: anxiety as a child, unloving parents, loveless marriage Stays in her house all the time, cries all day the day before she comes to see me for her refills because she is so scared to leave her house. Exhibits OCD behaviors in that the house has to be "perfect" all the time. Her husband deliberately leaves his things scattered around so that he can make her miserable. Prays all the time when she is at home alone that God would take her pain and fear away. Was crying when she arrived at the visit, cried through the entire visit, was crying when she left.
JEANIE 50 year old with long history of depression and anxiety. On SSRIs and seeing a counselor off and on. Living a functional, relatively fruitful life, but admits she has bad days where she can't even get out of bed because of all over body pain and feeling overwhelmed. Risk factors: childhood sexual abuse by her father. Mother knew but didn't step in. Now has a special needs adult child and has several chronic illnesses herself including diabetes and diabetic kidney disease. All in all, functioning well despite a really hard life. Holding a full time job, loves the cancer patients she interacts with, gets joy from helping them, married, one child that she helps a lot. Active in church and managing her medical problems well, despite the numerous stressors in her life.
GENETICS Genes probably create vulnerability to depression which is then triggered by external factors Identical twin studies consistently report 37-38% concordance in development of depression Stronger role for genetics in females (42%vs 29%)
EARLY-LIFE ADVERSITY Can affect how genes are expressed. The brain and its neural pathways are very plastic and there is some degree of an individual's DNA "learning" responses to adversity. This can affect how they respond to stress in adulthood. There is evidence that early life adversity causes overactivity of the of the corticosteroid-releasing cells in the hupothalamus, leading to sustained exaggerated release of cortisol in response to stress.
SOCIAL FACTORS Isolation, poor social relationships, criticism from family members, and depression in ones's friends and neighbors can perpetuate depressive episodes. Subjects were more likely to be depressed by a factor of: 93 percent if a person they were directly connected to was depressed 43 percent with a person at two degrees of separation (friend of a friend) 37 percent with a person at three degrees of separation The effect disappeared at four degrees of separation. Female friends were especially influential in the spread of depression
HOW TO RECOGNIZE DEPRESSION Loss of joy in doing things they normally enjoy Feelings of depression, despair or hopelessness Change in appetite Change in sleep Change in speed of activity or speech Unable to concentrate on things like TV/newspaper Feelings like they are a failure and have left everyone down Having thoughts that they would be better off dead or thoughts of suicide
BIG WARNING SIGNS: Constant crying Displaying poor thinking skills/judgement Poor eye contact Withdrawing socially from everyone Wishing for death and/or formulating a plan for ending their life.
ANXIETY
WHAT IS ANXIETY? excessive and persistent worrying complain of poor sleep, fatigue and difficulty relaxing. 4.1 to 6.0 percent among men, and twice that rate for women Social phobia 23.2 and 34.4 percent Specific phobia 24.5 and 35.1 percent Panic disorder 22.6 and 23.5 percent GAD may also be associated with increased rates of substance abuse, posttraumatic stress disorder, and obsessive-compulsive disorder
CAUSES common heritability with major depression and with the personality trait of neuroticism GAD in adult life is associated with a higher-than-average number of traumatic experiences and other undesirable life events Other predictors: Poverty Chronic physical illness (respiratory, cardiovascular, metabolic, cognitive), Chronic mental disorder (depression, phobia and past GAD) Parental loss or separation Low affective support during childhood History of mental problems in parents
MANIFESTATIONS The individual finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms ( only one is required in children) 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) The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
MICHAEL 22 year old male encouraged to see me because parents are concerned something is wrong. Difficulty in school...some alcohol and drug use, changed schools a few times. Difficulty making lasting friendships so changes schools. Goes to College...enjoys himself, enjoys school, parents are thrilled until his grades surface after the first semester...gpa 1.4. Taken out of school, starts working and smoking pot regularly. Parents witness several panic attacks. Started on SSRI and counseling for GAD, 3 years later, working a steady job, only rarely smoking pot. Going back to school. Seems to be finally "getting his act together" at age 24.
TREATMENT Medications Counseling Lifestyle change: exercise, I whole-food diet, good sleep hygiene All of the above Avoidance of triggers including alcohol binges, marijuana, and lack of sleep.