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DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head of Psychiatry Department Arab Board of Psychiatry Representative

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Page 1: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

DEPRESSION & ANXIETYMany Faces

Different Management

Jamal Hafez, MDProfessor of PsychiatryThe Lebanese University

Dar Al-Ajaza Al-Islamia HospitalHead of Psychiatry Department

Arab Board of Psychiatry Representative

Page 2: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

2

Depression and general practice

• France: 1 patient of 3 has significant psychiatric symptoms

• 15-20% of patients have a psychiatric disorder with or without other medical condition

• 5-10% of a GP’s patients have a depression

Page 3: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

3

Prevalence of Anxiety Disorders Lifetime % Current %

• Any anxiety disorder 24.9 17.2

• Panic disorder 3.5 2.3

• Agoraphobia without 5.3 2.8

panic disorder

• Social phobia 13.3 7.9

• Simple phobia 11.3 8.8

• Generalized anxiety 5.1 3.1 disorder

Results from National Co morbidity Survey , Kessler and al. 1994

Page 4: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

4

Under diagnosis of Depression and Anxiety

• Emphasis on somatic rather than cognitive/mood complaints

• Belief that depression and anxiety are a natural reaction to circumstance (counter transference)

• Reluctance to stigmatize patient with psychiatric diagnosis

• Nonspecific symptoms, overlap with medical illness

• Time limitations in primary care

Page 5: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

5

Anxio-Depression A new spectrum in psychiatry

• The categorical classification of mental disorders (DSM-IV , ICD-10) has limitations

• No clear boundaries between classes of disease, or even between psychopathology and normality

• Combining several types of related disorders into a large group defined as a “spectrum” has a heuristic value : it gives new insights and permits epidemiological, genetic and above all therapeutic research

• This is especially true for anxiety and depression

Page 6: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

6

AnxietyAnxiety - - DepressionDepression

Syndromal OverlapSyndromal Overlap

Page 7: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

7

Symptoms of Depression(DISC & GAPS)

Depressed mood and/or

Interest reduction (anhedonia)plus

• Sleep disturbance• Concentration impairment, memory loss

• Energy loss, fatigue, • Guilt, feelings of worthlessness• Appetite changes, significant weight loss (or gain)

• Psychomotor retardation or agitation• Suicidal thoughts

Page 8: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

8

What is Anxiety ?

• Cognitive (automatic ideas)

• Behavioral (avoidance)

• Physical

Page 9: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

9

Physical Symptoms of Anxiety

• Nervousness, restlessness

• Trembling

• Trouble falling or staying asleep

• Sweating

• Poor concentration

• Palpitations

• Frequent urinations

• Muscular tension

• Easily fatigued

• Light-headedness or dizziness

• Irritable mood

• Hypervigilance

• Shortness of breath

Page 10: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

10

Anxiety Disorders

DSM-IV Classification

American Psychiatric Association (1994)

GAD Panic Disorder

AgoraphobiaSocialPhobia

OCD PTSDSpecificPhobia

Page 11: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

11

GAD = generalized anxiety disorder

OCD = obsessive-compulsive disorder

PTSD = post-traumatic stress disorder

PMDD = premenstrual dysphoric disorder

DepressionDepressionPanic disorder

Panic disorder

PTSDPTSD OCDOCD

Social anxiety

disorder

Social anxiety

disorder

GADGAD

Specific phobiaSpecific phobia

PMDDPMDD

Different disorders with some common features

Page 12: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

12

Profile of the Anxious Depressed Patient

• Anxiety symptoms affect 9 out of 10 depressed patients

• Mixture of anxiety, tension and depression

• Impaired functioning compared with primary depressives

• Increased : hypochondrias is, depersonalization, chronic depression

• Reduced response to drug therapy and psychosocial intervention

• More severe and chronic illness

• Greater risk of suicide

Page 13: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

13

PANIC DISORDER

Page 14: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

14

Panic DisorderDSM-IV Classification

• Recurrent unexpected panic attacks

• At least one of the attacks has been followed by one or more of the following for at least one month:

- persistent concern about having additional attacks

- worry about the implications of the attack

- a significant change in behaviorAmerican Psychiatric Association (1994)

Page 15: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

15

Symptomatology of Panic Attacks

• Shortness of breath smothering sensations

• Dizziness, unsteady feelings or faintness

• Palpitations tachycardia

• Trembling / shaking

• Sweating

• Choking

• Nausea / abdominal distress

• Depersonalization derealization

• Paresthesias

• Flushes / chills

• Chest pain or discomfort

• Fear of dying

• Fear of going crazy or doing something uncontrolled

Pary & Lewis (1992)

Page 16: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

16Dar Al-Ajaza Al-Islamia Hospital in Beirut

May 2006

0 5 10 15 20

Lifetime Prevalence of Anxiety Disorders

The Zurich Study

Angst (1993)

GAD

DysthymiaSimple phobia

AgoraphobiaSocial phobia

Recurrent brief anxietySporadic panic

Panic disorderOCD

Recurrent brief depressionMajor depression

Prevalence (%)

Page 17: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

17

Comparative Tolerability ofPanic Disorder Treatments

SSRIs

Benzodiazepines

Tricyclicantidepressants

Anticholinergiceffects

+

-

+++

Dependence

-

+++

-

Cardiotoxicity

-

-

++

Cognitiveimpairment

-

++

+

Withdrawalsymptoms

+

+++

+

+++ very frequent++ frequent+ infrequent

Rickels & Schweizer (1990)Klerman (1992)

Rosenberg (1993)

Page 18: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

18

• SSRI are well established as an effective treatment for all types of depression

• In panic disorder trials, SSRI improve:

- frequency of panic attacks

- anxiety associated with panic attacks

- functional ability in panic disorder patients

- depressive symptomtology

Pharmacological treatment of panic disorder

Page 19: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

19

OBSESSIVE COMPULSIVE DISORDER

OCD

Page 20: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

20

OBSESSIONS IN OCD

• Contamination

• Pathological doubt

• Aggressive impulse

• Somatic concerns

• Need for symmetry

• Sexual impulseRasmussen & Eisen (1992), Zetin & Kramer (1992)

Page 21: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

21

COMPULSIONS IN OCD• Washing

• Precision

• Need to ask or confess

• Checking

• Counting

• Symmetry

• HoardingRasmussen & Eisen (1992), Zetin & Kramer (1992)

Page 22: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

22

• Symptoms perceivedas excessive

• Marked distress

• Non-delusional

Differential Diagnosis of OCD

Zohar & Zohar-Kadouch (1990)

Page 23: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

23Dar Al-Ajaza Al-Islamia Hospital in Beirut

May 2006

Most Common Co-morbiditiesin OCD

Jermain & Crismon (1990), Rasmussen & Eisen (1992)

Major depressivedisorder

Panic disorder

Simple phobia

Social phobia

Alcohol & drugs abuse

Tourette’s Syndrome

Prevalence (%)0 20 40 60 80 100

Page 24: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

24

Treatment of Co-morbid OCD

OCD

+++

+++

++

+

+

+

Depression

++++

++++

++++

++++

++++

+

SSRIs

Clomipramine

Imipramine

Desipramine

MAOIs

Benzodiazepines

Goodman et al (1992)+ Little evidence; ++++ Robust evidence

Efficacy in

Page 25: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

25

SOCIAL ANXIETY DISORDER

Page 26: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

26

ESSENTIAL FEATURES OF SOCIAL PHOBIA

• Fear of scrutiny by other people in social situations

• Marked and persistent fear of performance situations in which embarrassment or humiliation may occur

• Avoidance of the feared situations

• Fear is disabling or causes marked distress

Page 27: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

27

SYMPTOMS OF SOCIAL PHOBIA• Physical - Tachycardia - Trembling

- Blushing

- Shortness of breath

- Sweating

- Abdominal distress

• Cognitive Automatic alarming thoughts and beliefs about social situation

• Behavioral - Freezing - Avoidance

Page 28: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

28

FEARED SITUATIONS

SOCIAL• Attending parties,

weddings etc…

• Conversing in a group

• Initiating conversation with members of opposite sex

• Speaking on telephone

• Interacting with authority figure (teacher, boss…)

• Ordering food in a restaurant

PERFORMANCE• Public speaking

• Eating in public

• Writing a cheque

• Using a keyboard

• Using public toilet

• Taking a test

• Trying on clothes in a store

• Speaking up at a meeting

Page 29: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

29

COURSE OF SOCIAL PHOBIA

Social phobia is a chronic disorder

- Average duration up to 20 years

- Only 27% of patients recover

- Around 80% of social phobic patients report at least one other psychiatric disorder

Davidson et al 1993

Page 30: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

30

HOW CAN PHYSICIANS RECOGNIZE SOCIAL PHOBIA ?

Consider social phobia by :

• Patients who appear shy or reticent

• Substance misusers

• Depressed patients

• Patients who report anxiety attacks predominantly in social situations

STEIN , 1996

Page 31: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

31

Treatment of Comorbid Anxiety and Depression

Page 32: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

32

Principes d’un bon diagnostic en psychiatrie

• Comprendre le contexte des symptômes selon le modèle bio-psycho-social

• Analyser les facteurs prédisposant, précipitant et de maintien des symptômes

• Ne pas se fier seulement à l’histoire du patient

Page 33: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

33

En cas de doute : traiter comme une depression

Rechercher de principe un trouble dépressif

Oui Non

Traitement du trouble dépressif en premier lieu

Traitement du trouble anxieux

Troubles anxieux au premier plan

Traitement d’un trouble Anxio-Dépressif

Page 34: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

34

Trouble Anxio-Dépressif Traité

Tout va bien

Traitement maintenu six mois puis arrêt

Persistance des troubles dépressifs

Dose efficace ?Durée suffisante ?

Régression partielle

Persistance de l’anxiété? Problème de personnalité?

- Tranquillisants- Relaxation- Techniques cognitives+ Soutien actif

Psychothérapie

Facteur(s) de Stress chronique?

PsychothérapieTraitement d’un trouble Anxio-Dépressif

Page 35: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

35

CBT : Principles of Application for Anxiety Disorders

CBT targets components of anxiety, common to all the anxiety disorders :

• Physiologic activation

• Negative predictions and expectations

• Escape and avoidance behaviors

• Sense of uncontrollability

Page 36: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

36

GOALS OF PHARMACOTHERAPY IN ANXIETY DISORDERS

• Relieve fear/anticipatory anxiety

• Reduce phobic avoidance

• Reduce autonomic/physiological distress

• Improve disability/quality of life

Page 37: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

37

Comparative Tolerability of Long Term Anxiety Treatments

SSRIs

Benzodiazepines

Tricyclicantidepressants

Anticholinergiceffects

+

-

+++

Dependence

-

+++

-

Cardiotoxicity

-

-

++

Cognitiveimpairment

-

++

+

Withdrawalsymptoms

+

+++

+

+++ very frequent++ frequent+ unfrequent

Rickels & Schweizer (1990)Klerman (1992)

Rosenberg (1993)

Page 38: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

38

DA reuptake

inhibition

Reduce depression Psychomotor activation Antiparkinsonian effects

5HT2

block

Reduce depression Reduce suicidal behavior Antipsychotic effects Hypotension Ejaculatory dysfunction Sedation

NEreuptake

inhibition

Reduce depression Anti-anxiety effects Tremors Tachycardia Erectile/ejaculatory dysfunction

5HT reuptakeinhibition

Reduce depression Anti-anxiety effects GI disturbances Sexual dysfunction

Alpha1

block

Postural hypotension Dizziness Reflex tachycardia Memory dysfunction

Anxiety

ACh block

Blurred vision Dry mouth Constipation Sinus tachycardia Urinary retention Cognitive dysfunction

H1

block

Sedation/drowsiness Hypotension Weight gain

AntidepressantAntidepressant

Richelson. In: Current Psychiatric Therapy. 1997: 286-295.

Alpha2

block

Pharmacologic effectsof antidepressants

Page 39: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

39

Ideal Pharmacological Treatment • A single agent effective against major depression and wide spectrum of anxiety symptoms

• Convenient

• Well tolerated

• Low risk of side effects, drug interactions

• Maintains long term effectiveness

Page 40: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

40

Selective Serotonin Reuptake Inhibitors

• Documented efficacy in depression, anxiety and in the elderly

• Selective pharmacologic effect with minimal anticholinergic, adrenergic, histaminic side effects

• Once-daily dosing may improve compliance

• SSRIs with minimal inhibition of cytochrome P-450 enzymes

– Reduce risk of drug–drug interactions after discontinuation

– Have a short washout period

• Minimal cognitive impairment

Page 41: DEPRESSION & ANXIETY Many Faces Different Management Jamal Hafez, MD Professor of Psychiatry The Lebanese University Dar Al-Ajaza Al-Islamia Hospital Head

May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut

41


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