Anxiety and Depression Management for General Providers Meaghan Rudolph RN MS PMHCNS-BC Stephanie Mahnks RN MSN PMHNP-BC Massachusetts General Hospital Dept of Psychiatry
Nothing to disclose Disclosures
Prevalence Current estimates indicate that 50% of the population experience at least one mental disorder in their lifetime and that at least 25% have suffered a mental disorder in the past year. At least 1/3 of office visits in primary care have a direct and explicit psychological component. Recognition, diagnosis, treatment, and referral depend overwhelmingly on general practitioners.
Assessment What is the patient telling me? Their interpretation of symptoms How this is impacting them What is the patient NOT telling me? Appearance, what do they look like usually? What is different from their usual presentation? Who and what is with them? Take in the whole picture: movement, mannerisms, attire, gait Start your assessment in the waiting room *Once have some data for mood/thought disorder, be sure these are primary psych, r/o all medical causes
Females > Males Depression Female lifetime prevalence M.D. 21.3%; dysthymia--8% Male lifetime prevalence M.D. 12.7%; dysthymia 4.8% Culture May express somatic concerns more than sadness/mood disturbance Onset mean age of onset 40 50% onset between 20 and 50 years of age.
Risk Factor for Depression Prior episode Family history Lack of social support Stressful life event Current substance abuse Medical comorbidity
Depression? Reactive sadness Emotional response to event Few hours/days Does not interfere with functioning Grief Interpersonal loss Sadness tied to the event, no loss of self-esteem Medical/Medication induced Thyroid, menopause, CHF, Caffeine, benzo, birth control, antihypertensive
Diagnostic Criteria Depression Depressed Mood or Loss of interest or pleasure (for two weeks) Plus 4 or more of these: Weight/appetite change Change in sleep Psychomotor agitation/retardation Fatigue/loss of energy Feelings of worthlessness or guilt Cognitive changes/difficulty concentrating Thought of death/suicide
Depressive Disorders Major Depressive Disorder Single Episode Recurrent Dysthymic Disorder Milder, chronic disorder Distinguishing feature duration (2 years) Seasonal Affective Disorder Depressive episodes related to seasonal variation in light. Depressive symptoms in fall and winter; full remission in spring and summer Has occurred for at least two years
SIGECAPS S Sleep decreased or increased I Interest deficit; anhedonia G Guilt including worthlessness/ hopelessness/regret E Energy--deficit C Concentration--deficit A Appetite increased or decreased P Psychomotor activity--agitation/retardation S Sex deficit of desire S Suicide ideation/planning present
Assessment Mnemonics To diagnosis depression need: Depressed mood/anhedonia for two weeks PLUS 4 SIG E CAPSS Symptoms To diagnose dysthymia Depressed mood/anhedonia for two years PLUS 2 of *SIG E CAPSS Symptoms
PHQ-9 Name: Date: Over the last two weeks, how often have you been bothered by any of the following problems? Not at all Several days More than half the days Nearly every day Little interest or pleasure in doing things 0 1 2 3 Feeling down, depressed, or hopeless 0 1 2 3 Trouble falling or staying asleep, or sleeping too much 0 1 2 3 Feeling tired or having little energy 0 1 2 3 Poor appetite or overeating 0 1 2 3 Feeling bad about yourself, or that you are a failure, or that you have let yourself or your family down 0 1 2 3 Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 Moving or speaking so slowly that other people could have noticed? Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual. 0 1 2 3 Thoughts that you would be better off dead, or of hurting yourself in some way 0 1 2 3 Total = + + + PHQ-9 score 10: Likely major depression Depression score ranges: 5 to 9: mild 10 to 14: moderate 15 to 19: moderately severe
Hallmark: Bipolar DO ELEVATED MOOD described as euphoric: unusually good, cheerful or high EXPANSIVE QUALITY OF MOOD characterized by unceasing and indiscriminate enthusiasm for interpersonal, sexual, or occupational interactions Must last at least 1 week (or less if hospitalization is required) Uninvolved people may not recognize pathology those who know the patient recognize it as abnormal
Mania Assessment DIGFAST D = Distractibility and easy frustration I = Irresponsibility and erratic uninhibited behavior G = Grandiosity F = Flight of ideas A = Activity increased with weight loss and increased libido S = Sleep is decreased (but feel rested) T = Talkativeness (noticed by others)
Substance Use Alcohol Marijuana Vaping Edibles Ilicits Stimulants Impact on presentation, treatment and prognosis
Treatment Modalities Collaborative Care Psychotherapy CBT Interpersonal therapy Supportive therapy Group Therapy Complementary techniques Relaxation Meditation Exercise Light Therapy ECT (electroconvulsive therapy)
Psychopharmacologic Treatment of Depression Medication Severity of illness Sustained physiological symptoms Selective serotonin reuptake inhibitors (SSRIs) Serotonin/norepinephrine reuptake inhibitors(snris) Atypical antidepressants Tricyclic antidepressants (TCAs) Monamine oxidase inhibitors (MAOIs)
Treatment Efficacy of medication in general is comparable between classes, but fine tuned to patient profile Initial selection of medication: Target symptoms identified Side effects/patient preference Comorbid illness Drug/drug interactions First degree relative response Cost Characteristics of Depression Agitated, irritable, suicidal ideation: SSRI Apathy, low energy: dopamine, SNRI
Determining Treatment Escitalopram* Fewer side effects Less drug drug interactions Citalopram Paroxetine Wt gain, sexual dysfunction Sertraline GI toxicity
Treatment with SSRIs Some patients may experience increased energy/activation early after initiation of treatment But onset usually delayed 2-4 weeks If no response after 6-8 weeks Wait- failure of a med is often due to adequate trial Increase dose When tapering UP schedule face to face/phone to assess efficacy Increase if SE tolerable Max dose Change SSRI Cross taper Treatment may be indefinite Best augmentation if partial response: psychotherapy Consider augmenting with another appropriate agent
Serotonin Syndrome After initiation of serotonergic agent (24 hours) Life theratenting Neuromuscular hyperactivity (tremor, hyperreflexia) Hyperthermia Agitation, altered MS Treatment Discontinue agents Supportive care to normalize VS Serotonin antagonists Future: determine treatment without use of serotonergic agents
Frequency, Intensity, and Burden of Side Effects Ratings (FIBSER)
Managing Side Effects Most Side Effects are Immediate, go away with time Anorgasmia Reduce dose Sildenafil prn Add bupropion Weight Gain Exercise Diet
Augmenting Treatment Tolerating current SSRI well Illness severity Time urgency Willingness to take other medications Modality Additional SSRI Additional Agent Bupropion Trazodone Antipsychotic Mood Stabilizer
Continuation and Maintenance Continuation After resolution of major depressive episode Preserve and enhance remission Relapse prevention Maintenance After recovery Prevention of subsequent episodes Pharmacotherapy 6 months + Maintain/restore baseline functioning Eliminate any residual symptoms
Discontinuation Syndrome Abruptly stopping SSRI Occurs within 1-4 days Symptoms Dizziness Fatigue Headache Nausea Least Risk: Fluoxetine Intermediate: Citalopram, escitalopram, sertraline Most: Paroxetine
Management of Discontinuation Syndrome Taper slowly as per specific drug recs/patient situation Need to taper (adverse effect, pregnancy) Severity of symptoms Length of treatment (longer then 3-5 weeks requires taper) Longer ½ life 2-3 weeks Shorter ½ life (<24 hours) 4 weeks
Assessment of anxiety Varies with each disorder disorders In the last few months have you Been frequently worried about several things in life? Is it hard to control or stop worrying? Any recurrent panic attacks? Do experiences cause significant trouble at home or work
GAD 7 Over the last 2 weeks, how often have you been bothered by the following problems? 1. Feeling nervous, anxious, or on edge 2. Not being able to stop or control worrying 3. Worrying too much about different things 4. Trouble relaxing 5. Being so restless that it's hard to sit still 6. Becoming easily annoyed or irritable 7. Feeling afraid as if something awful might happen Add the score for each column Total Score (add your column scores) =
Diagnosis of Anxiety DO Inclusion and exclusion criteria Duration Symptoms Modifiers and alternatives Includes symptoms that cannot be explained by another psychiatric disorder Symptoms cannot be explained by: medical condition substance use
Generalized Anxiety Disorder (GAD) Excessive anxiety and worry that is difficult to control occurring more days than not for at least six months Associated with at least three symptoms: Restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance r/o substance abuse; r/o medical causes
Panic Disorder Recurrent panic attacks as characterized by at least four of the follow symptoms: Palpitations, sweating, trembling, sensation of shortness of breath, sensation of choking, chest pain, nausea or abdominal pain, dizziness, chills or heat sensation, paresthesias, fear of losing control, fear of dying Derealization vs. depersonalization At least one panic attack is followed by at least one month of the following: Persistent worry about consequences i.e. ongoing panic attacks Maladaptive changes to avoid panic attacks
Post Traumatic Stress Disorder (PTSD) Exposure to actual or threatened death, serious injury or sexual violation, either first hand or witnessed. Person must have at least one of the follow intrusion symptoms for at least one month following experience: Memories, dreams, flashbacks, exposure distress, physiological reactions In addition, affected persons must experience one of the following avoidance symptoms for at least one month following experience: Internal reminders, i.e. avoid thoughts or feelings, External reminders, i.e. avoid people or places In addition, affected persons must experience at least two of the following negative symptoms for at least one month following experience: Impaired memory, negative self-image, blame, negative emotional state, decreased participation, detachment, inability to experience positive emotions And two of the following arousal behaviors: Irritable or aggressive, reckless, hypervigilance, exaggerate startle response, impaired concentration, sleep disturbance
Treatment Modalities SSRIs gold standard Block serotonin reuptake pump Desensitizes serotonin receptors, particularly 1A receptors
Which one?
Fluoxetine MDD, OCD, PMDD, bulimia nervosa, panic d/o, bipolar depression, treatment resistant depression in combination with olanzapine, social anxiety d/o, PTSD has antagonist properties of 5HT2C receptors would could increase norepinephrine and dopamine
Fluoxetine side effects: increased serotonin can cause diminished dopamine responsible for emotional flattened, cognitive slowing, apathy most side effects are immediate and go away with time notable SE: sexual dysfunction, GI, CNS (insomnia, h/a), sweating, bruising life threatening: rare seizures, induction of mania, activation of SI weight gain and sedation are unlikely dose range once daily: 20-80 mg for anxiety disorders
Fluoxetine Stopping med: taper rarely necessary as med has long half-life and will taper itself upon abrupt discontinuation Notable drug interactions: Tramadol: increase risk of seizures Use with caution with TCAS as can increase level Can cause fatal serotonin syndrome when used with MAOIs and need to have stopped MAOI For at least two weeks prior to starting Prozac, conversely do not start MAOI after stopping Prozac for at least five weeks NSAIDS may impair efficacy of SSRIs
Sertraline -MDD, panic d/o, PTSD, GAD, OCD, social anxiety d/o Block serotonin reuptake pump Desensitizes serotonin receptors, particularly 1A receptors Also has some ability to block dopamine reuptake pump Some patients may experience increased energy/activation early after initiation of treatment, however onset usually delayed 2-4 weeks If no response after 6-8 weeks, may increase dose or may change SSRI Treatment may be indefinite Side effects the same Augmentation therapies: same as above Also rare sedation an rare weight gain Dosing 50-200 mg once daily
Sertraline With PMDD dose may fluctuate throughout the month based on symptoms Mild taper to avoid withdrawal effects: dizziness, nausea, GI symptoms, generally 50 percent dose reduction for three days, then repeat until discontinued Drug interactions: same as above
Citalopram MDD, PMDD, OCD, Panic d/o, GAD, PTSD, social anxiety d/o Block serotonin reuptake pump Desensitizes serotonin receptors, particularly 1A receptors Also has mild antagonist actions at H1 histamine receptors No known activation effect, onset usually within 2-4 weeks If no response after 6-8 weeks, may increase dose or may change SSRI Treatment may be indefinite Side effects similar however sedation more common due to mild antihistamine properties Augmentation therapies: same as above Weight gain unusual Dose range is 20-40 mg daily Taper similar to Sertraline and not usually necessary Drug interactions: same as above
Augmenting treatment trazodone: best response for insomnia benzodiazepines: panic attacks gabapentin: ongoing anxiety Wellbutrin
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