Anxiety and Depression

Anxiety and Depression

About The Author

Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis. Clinical Practice Guideline, Number 5. Rockville, MD. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 93-0550. April 1993.

Depression Guideline Panel. Depression in Primary Care: Volume 2. Treatment of Major Depression. Clinical Practice Guideline, Number 5. Rockville, MD. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 93-0551. April 1993.

Learning Objectives

Upon completion of the course you'll be able to:

1. Describe the prevalence of depressive illnesses in the population at large.

Depressive illnesses affect the lives of million of Americans and cost billion of dollars.
In the United States, nearly 10 million people experience a depressive illness during any 6-month period.

2. Pinpoint symptoms of depressive illness.

Persistent sad, anxious or “empty” feelings
Decreased energy, fatigue, being “slowed down”
Loss of interest or pleasure in usual activities, including sex
Sleep disturbances (insomnia, early-morning waking, or oversleeping)
Appetite and weight changes (either loss or gain)
Feelings of hopelessness, pessimism
Feelings of guilt, worthlessness, helplessness
Thoughts of death or suicide, attempts
Difficulty in concentrating, remembering, making decisions
Chronic aches or persistent bodily symptoms that are not caused by physical disease.

3. List symptoms exhibited by a manic-depressive individual during the manic phase.

Decreased need for sleep
Increased risk-taking
Increased energy
Unrealistic beliefs in their own abilities
Increased talking and physical, social and sexual activity
Feelings of mood elevation or irritability
Aggressive response to frustration.

4. Provide a 3-step clinical evaluation of depressive illnesses.

physical examination which includes a neurological examination and lab tests.
a medical and psychiatric history
a mental status examination

5. Discuss causes of depression listing genetic, biochemical, environmental and other factors.

high incidence of depressive illness could be inherited
mood disorders could be a function of a biochemical disturbance and could be treated with drugs
sleep patterns of both unipolar and bipolar depressed patients are different from those in persons who do not have a mood disorder.
Personal losses, financial problems, physical illness midlife crises, sex role expectations, and psychosocial phenomena, such as personality, upbringing, and negative thinking style have been cited as contributors to depressive illness.
Social conditioning also has been cited as contributing to a higher incidence of depression among women.

6. Discuss treatments for depressive illnesses using drug, psychosocial and electroconvulsive therapies.

Three categories of drugs are most often prescribe: tricyclics, monoamine oxidase inhibitors (MAOIs) and lithium.
There are “talking” therapies during which problems are discussed and resolved through the emotional support, insights and understanding gained from the verbal give-and-take. Other therapies concentrate on behaviors: patients are taught to be more effective in obtaining rewards and satisfaction through their own actions.
Although ECT has received unfavorable publicity, it continues to be the most effective treatment for major endogenous or delusional depression.

7. Discuss childhood depressions, adolescent’s depression and depression among the aged.

Childhood depression may be recognized or misdiagnosed when depressive symptoms are mixed with other type of behavior, such as hyperactivity, delinquency, school problems, or psychosomatic complaints.
Manic-depressive disorder in adolescents is often manifested by episodes of impulsivity, irritability, and loss of control alternating with periods of withdrawal.
The wide range of estimates of occurrence of depression among older populations–from 10 percent to 65 percent–attests to the difficulties of diagnosing depression in an elderly person. Symptoms of depression are often misdiagnosed as senility (organic brain syndrome) or mistaken for the everyday problems of the aged.

8. Describe the scope of depression in women and contrast it with depression

Women are disproportionately affected by depression, experiencing it at roughly twice the rate of men.
Research continues to explore how the illness affects women and to identify new areas that hold promise of deepening our understanding.

9. Identify varies factors unique to women that contribute to depression.

Varied factors unique to women’s lives are suspected to contribute to depression–developmental, reproductive, hormonal, genetic, and other biological factors; abuse and oppression; interpersonal factors; and certain psychological and personality characteristics.

10. Answer patient’s questions about depression.

Who gets depressed?
What is depression?
How will I know if I am depressed?
What should I do if I have these symptoms?
How will I treatment help me?
What type of treatment will I get?

11. List classes of health care providers who can treat depression.

General health care provider
physician
physician assistant
nurse practitioner
Mental health specialists
psychiatrist
psychologist
social worker
psychiatric nurse specialist

12. Compare the effectiveness of three kinds of treatments for major depressive disorder.

antidepressant medicine
psychotherapy
antidepressant medicine combined with psychotherapy.
How well each of these treatments works depends on the type of depression, how severe the depression is, how long you have been depressed, how you as an individual may react to treatment, and other factors.

13. Classify unipolar forms of primary into three groups.

Major depressive disorder consists of one or more moods disorders episodes of major depression with
or without full recovery between episodes.
Dysthymic disorder features a low-grade, more persistent depressed mood and associated symptoms
for at least 2 years, during which a major depressive episode has not occurred. Over extended followup, many patients with this disorder develop episodes of major depression.
Depression not otherwise specified (DNOS) is a residual category for patients with symptoms and signs of depression that do not meet the formal diagnostic criteria for either major depressive or dysthymic disorder.

14. Classify bipolar disorders into three groups.

Bipolar I disorder features at least one manic episode along with (nearly always) major depressive episodes.
Bipolar disorder not otherwise specified is a residual category that includes bipolar II disorder, a condition characterized by recurrent episodes of major depression along with hypomanic (but not full-blown manic) episodes, as well as other forms that do not meet formal criteria for bipolar I or cyclothymic disorder.
Cyclothymic disorder is characterized by numerous periods of mild depressive symptoms insufficient in duration or severity to meet the criteria for major depressive episodes interspersed with hypomanic episodes; it lasts at least 2 years by definition. Patients with this condition are rarely free of mood symptoms.

15. List 3 risk factors for major depressive disorder.

Risk factors for major depressive disorder include female gender, a history of depressive illness in first-degree relatives, and prior episodes of major depression.

16. List 10 risk factors for depression.

Prior episodes of depression.
Family history of depressive disorder.
Prior suicide attempts.
Female gender.
Age of onset under 40.
Postpartum period.
Medical comorbidity.
Lack of social support.
Stressful life events.
Current substance abuse.

17. Provide a differential diagnosis of depressive disorders.

Conduct a clinical interview to determine whether the nine specific signs/symptoms of major depressive disorder according to DSM-III-R are present.
Interview the patient to investigate the possibility of concurrent substance or alcohol abuse and current use
of medications that may cause depressive symptomatology.
Conduct a medical review of systems to detect the existence of medical disorders that may biologically cause or be commonly associated with depressive symptoms.
Interview the patient further to detect the presence of another concurrent nonmood psychiatric condition that may be associated with and be responsible for the depressive symptoms.
Exclude alternative causes (1 through 4, above) for depressive symptoms or syndromes to diagnose a primary mood disorder.

18. Describe clinical features and course of major depressive disorder.

Major depressive disorder may begin at any age, although it usually begins in the mid-20s and 30s. Symptoms develop over days to weeks. Some people have only a single episode, with a full return to premorbid functioning. However, more than 50 percent of those who initially suffer a single major depressive episode eventually develop another.

19. Discuss the epidemiology of major depressive disorder.

The point prevalence for major depressive disorder in the Western Industrialized nations is 2.3 to 3.2 percent for men and 4.5 to 9.3 percent for women. The lifetime risk for major depressive disorder is 7 to 12 percent for men and 20 to 25 percent for women.

20. Explain the costs of untreated major depressive disorder.

Patients with major depressive disorder have substantial amounts of physical and psychological disability, as well as occupational difficulties.

21. List 5 major depressive disorder subgroups and for each subgroup describe essential features diagnostic treatment and prognostic implications.

Melancholic
Atypical
Postpartum psychosis/depression
Seasonal
Postpartum psychosis/depression.

22. Describe psychotic features.

Psychotic features refer to the presence of delusions or hallucinations. They occur in 15 percent of patient with major depressive disorders.

23. Describe melancholic features.

Psychomotor retardation or agitation
Loss of interest or pleasure
Lack of reactivity to usually pleasant stimuli
Worse depression in the morning
Early morning awakening

24. Describe atypical features.

overeating
oversleeping
weight gain
a mood that still responds to events (reactive mood).
extreme sensitivity to interpersonal rejection
a feeling of heaviness in the arms and legs.

Anxious features include:

marked anxiety
difficulty in falling asleep
phobic symptoms
symptoms of sympathetic arousal

25. Describe seasonal pattern.

episodes are recurrent (at least two episodes by some criteria, three by other criteria).
there has been a regular temporal relationship between the onset of the major depressive episodes and a particular period of the year (such as regular onset of depression in fall and offset in spring).
seasonal episodes substantially outnumber nonseasonal episodes.

26. Describe clinical features and course dysthymic disorder.

The essential feature of dysthymic disorder is a chronic of mood disturbance (sadness in adults; sadness and, possibly, irritability in children and adolescents) present most of the time for at least 2 consecutive years (1 year for children and adolescents).

27. List the causes of manic or hypomanic episodes.

Psychoactive substances, such as cocaine and amphetamines; head trauma; certain neurologic diseases; endocrinopathies; and some other disorders can produce secondary manic and hypomanic episodes similar to those seen in primary bipolar disorder. In addition, in some patients with a family history of bipolar disorder, antidepressant medications can precipitate a manic or hypomanic episode.

28. List features of cyclothymic disorder.

Cyclothymic disorder features numerous, alternating hypomanic and mild depressive periods, lasting daysto weeks and nearly continuous. There are few truly symptoms-free periods. The symptoms fluctuate, but never reach the severity/duration, criteria of major depressive or manic episodes. The course is chronic, often lasting years.

29. Describe anxiety disorders.

Depressive symptoms or syndromes often accompany anxiety, panic, or phobic disorders. Furthermore, anxiety disorder may be the forerunner of and part of the longitudinal course of a mood disorder. The presence of both anxiety/panic and a major depressive disorder results in a more severe disorder with greater impairment than does either disorder alone. When the patient complains of anxiety symptoms, major depressive symptoms should be elicited.

30. Provide a diagnosis of eating disorders.

The practitioner is advised to ask about anorexia nervosa and bulimia nervosa in young women who present with any mood disorder, especially those with amenorrhea. If present, the eating disorder is the principal target of treatment.

31. Describe the diagnosis and treatment of obsessive-compulsive disorders.

For those depressed patients whose disorder has some obsessive features, the mood disorder is the initial focus of treatment. If full-blown OCD is present with depressive symptoms or manic-depressive disorder, the OCD is usually the initial objective of treatment. Evidence from OCD medication treatment trials suggests that, if the OCD is treated successfully, the depressive symptoms usually abate.

32. Define somatization disorder.

Somatization is defined as the presentation of somatic symptoms by patients with underlying psychiatric illness or psychosocial distress. These somatic symptoms have no, or insufficient, underlying organic cause.

33. Explain personality disorder.

Personality disorders are not uncommon among mood-disordered patients. The presence of a personality disorder does not exclude diagnosis of a mood disorder, if present. When both a major depressive and personality disorder are present, more frequent and longer major depressive episodes, as well as poorer interepisode recovery (if untreated), may be anticipated.

34. Explain the relationship between major depressive and other current general medical disorders.

The general medical disorder biological causes depression for example, hypothyroidism may cause depressive symptoms.
The general medical disorder triggers the onset of the depression in those who are genetically vulnerable to depressive disorders; for example, Cushing’s disease may precipitate a major depressive episode.
The general medical disorder psychologically causes the depression; for example, a patient with cancer may become clinically depressed as a psychological reaction to the prognosis, pain, and incapacity. The general medical disorder and the mood disorder are not causally related.

35. List 8 risk factors that predispose cancer patients to develop depressive disorders.

social isolation
recent losses
a tendency to pessimism
socioeconomic pressures
a history of mood disorder
alcohol or substance abuse
previous suicide attempt(s)
poorly controlled pain

36. List medications reportedly associated with depression.

Cardiovascular drugs
Hormones
Psychotropics
Anticancer Agents
Anti-inflammatory Anti-infective agents

37. Provide a differential diagnosis of depression.

assess the patient for the nine specific sings/symptoms of major depressive disorder
investigate the possibility of concurrent substance or alcohol abuse
detect the existence of medical disorders
detect the presence of another concurrent nonmood
psychiatric condition
exclude alternative causes

38. List 7 steps in detecting and treating conditions.

Maintain high index of suspicion and evaluate risk depressive factors
Detect depressive symptoms with clinical interview and/or self-report questionnaire
Define mood syndrome (clinical history, interview, report by spouse or significantother).
Define potential known cause of mood syndrome (medical medications, substance abuse, and other casual nonmood psychiatric disorders).
Treat potential causes
Reevaluate for mood syndromes
If mood syndrome is still present, treat as primary mood disorder

39. List 3 key objectives of treatment.

to reduce and ultimately remove all signs and symptoms of the depressive syndrome
to restore occupational and psychosocial function to that of the asymptomatic state
to reduce the likelihood of relapse and recurrence

40. List disadvantages of medications in the treatment of major depression.

Need for repeated medical visits to monitor response and adjust dosage.
Unwanted side effects
More severe (but infrequent) medication reactions, such as allergic reaction
Potential use in suicide attempts
Failure of many patients (10 to 30 percent) to complete treatment
Lack of efficacy in some cases of major depressive disorder
Need for strict adherence to the medication schedule.
Need for continuation phase treatment

41. List 3 advantages of psychotherapy.

Lack of physiologic side effects, such as those found with medication or ECT.
Logical possibility that psychotherapy is effective for some patient for whom medication are not effective.
Theoretical possibility that psychotherapy may make the depression less likely to recur once treatment stops because patients learn to cope with or avoid factors contributing to recurrence.

42. Describe disadvantages of psychotherapy.

Psychotherapy has rarely been tested in patients with severe or psychotic depressions.
Many patients (10 to 40 percent) fail to follow through with the full treatment.
Many time-limited forms of psychotherapy, as well as all forms of longer term psychotherapy, have not been tested for efficacy in randomized controlled trials.
Psychotherapy is not effective for all patients with major depressive disorder.
The quality of the therapy affects outcome.
Therapy sessions are time-consuming and may be inconvenient.
Psychotherapy may be expensive, depending on the type of therapy and the provider.
Treatment effects are usually measurable later (6 to 8 weeks than with medication (4 to 6 weeks).

Course Outline

Part 1: Depressive Illness: Overview Patient's Guide

Chapter 1. Depressive Illnesses

Depression Is An Illness
Recognizing Serious Depression
Clinical Evaluation
Suicide
Causes of Depression
Genetic Factors
Biochemical Factors
Environment and Other Factors
Treatments
Drug Therapy
Psychosocial Therapy
Electroconvulsive Therapy
Treatment Choice
Mild Episodes
Moderate Depressions
Severe Depressions
Hospitalisation
Chronic Depressions
Childhood Depressions
Adolescent Depressions
Depression Among The Aged
Helping The Depressed Persons
Where To Receive Treatment

Chapter 2. Depression In Women

A Picture of Dipression
What is Depression?
Types of Depressive Illness
Symptoms of Depression and Mania
Causes of Depression
The Many Dimensions Of Depression In Women
Women At Risk
Developmental Roles
Reproductive Life Cycle
Specific Cultural Considerations
Depression Is A Treatable Illness
Helping Resources
Helping Yourself
Helping The Depressed Person
References

Chapter 3. Depression Is A Treatable Illness: A Patient's Guide

People Who Treat Depression
Symptoms of Depression
Another Form of Depression
Preparing For Your First Visit
Severe? Moderate? Mild?
Treating Depression
Types of Treatment
How Treatment Works
Choosing a Treatment
About Hospitalization
If You Have Concerns About Your Treatment. . .
Antidepressant Medicines
My Questions About Medicine
Feeling Better
Psychotherapy
Types of Psychotherapy
Choosing Psychotherapy
Electroconvulsive Therapy
Light Therapy
Taking Care of Yourself
Talking to Others About Depression
Your Family and Friends
Your Children
Weekly Activity Record

Part II. Detection and Diagnosis of Depression

Panel Members
Abstract
Executive Summary
Overview

Chapter 1. Guideline Development

Background
Definition of Depression
Literature Reviews and Guideline Developement
Interpretation of Scientific Literature

Chapter 2. Guideline: Overview of Mood Disorders

Major Depressive Disorder
Clinical Features and Course
Epidemiology
Costs of Untreated Major Depressive Disorder
Subgroups of Major Depressive Disorder
Dysthymic Disorder
Clinical Features and Course
Epidemiology
Costs of Untreated Dysthymic Disorder
Depression Not Otherwise Specified
Clinical Features and Course
Epidemiology
Costs of Untreated DNOS
Bipolar Disorders
Clinical Features and Course
Epidemiology
Subtypes of Bipolar Disorder
Cyclothymic Disorder
Mood Disorder in Special Age Populations
Children and Adolescents
Geriatric Patients

Chapter 3. Guideline: Depression Co-Occurring with Other Psychiatric Conditions

Alcohol/Drug Abuse or Dependency
Anxiety Disorders
Eating Disorders
Obsessive-Compulsive Disorders
Somatization Disorder
Personality Disorders
Grief and Adjustment Reactions

Chapter 4. Guideline: Depression Co-Occurring with Other General Medical Disorders

Stroke
Dementia
Diabetes
Coronery Artery Disease
Cancer
Chronic Fatigue Syndrome
Fibromyalgia

Chapter 5. Guideline: Depression Associated with Medications

Antihypertensives
Hormones
Histamine-2 Receptor Blockers
Anticovulsants
Levodopa
Antibiotics
Antiarrhythmics

Chapter 6. Guideline: Detection of Depression

Clinical Clues
Screening Instruments
Patient Self-Report Questionnaires
Clinician-Completed Rating Scales
Differential Diagnosis of Depression
Laboratory Tests
Psychological Tests
Ongoing Clinical Reassessment
References
Acronyms

Part III. Treatment of Major Depression

Abstract
Executive Summary
Overview

Chapter 1. Guideline Development and Methodology

Rationale for Guideline Developement-The Cost of Depression
Methodological Background
Specific Methodological Strategies
Review of the Literature
Meta-Analysis

Chapter 2. Guideline: Aims of Treatment

Benefits and Harms of Treatment
Medications
Psychotherapy
Combination of Medication and Psychotherapy
Electroconvulsive Therapy
Clinical Management
Improving Adherence to Treatment
Measuring Outcome
Declaring a Treatment Response or Failure
Switchiing Versus Augmenting Treatments

Chapter 3. Guideline: Strategic Planning for Acute Phase Treatment

Objectives of Acute Phase Treatment
Indiccations for Acute Phase Treatment
Treatment Selection
Selection of Medication
Selection of Psychotherapy Alone
Selection of Combined Treatment
Select of ECT
Treatment Refusal

Chapter 4. Guideline: Acute Phase Management with Medication

Indications for Acute Phase Medication
Evidence of Efficacy
Antidepressant Medication Selection
Frequency of Visits
Medication Dosage Adustments
Antidepressant Drug Blood Levels
Failure to Respond
Continue Medication
Switch Medication
Augment Medication
Add Psychotherapy
Obtain a Consultation

Chapter 5. Guideline: Acute Phase Management with Psychotherapy

Obejectives and Indications
Evidence for Efficacy
Cognitive Therapy
Behavioral Therapy
Interpersonal Psychotherapy
Martial Therapy
Brief Dynamic Psychotherapy
Factors Affecting Response to Psychotherapy
Selection of a Psychotherapy
Frequency of Visits
Failure to Respond

Chapter 6. Guideline: Acute Phase Management with Medication and Psychotherapy

Objectives and Indications
Evidence of Efficacy
Selection of a Combined Treatment
Frequency of Visits
Dosage Adjustments
Failure to Respond

Chapter 7. Guideline: Acute Phase Management with ECT

Chapter 8. Guideline: Special Situations

The Suicidal Patient
Geriatric Depression
Seasonal Depression
Depression and Other Nonpsychiatric Medical Disorders
Depression and Other Psychiatric Disorders

Chapter 9. Guideline: Continuation and Maintenance Treatment Options

Objectives and Indications for Continuation Treatment
Objectives and Indications for Maintenance Treatment
Continuation/Maintenance Phase Management with Medication
Evidence of Efficacy
Frequency of Visits
Medication Dosage Adjustments and Antidepressant
Symptom Breakthrough
Discontinuation of Medication
Continuation/Maintenance Phase Management with Psychotherapy
Cognitive Therapy
Behavioral Therapy
Interpersonal Psychotherapy
Marital Therapy
Brief Dynamic Psychotherapy
Factors Affecting Decisions about Continuation/Maintenance
Frequency of Visits
Symptom Breakthrough
Continuation/Maintenance Phase Management with the Combination of Medication and Psychotherapy
Evidence of Efficacy
Discontinuation of Treatment
A Second Opinion or Referral
Primary Care Practitioners
Patients and Families
Consultations with Mental Health Care Professionals
References
Acronyms
Glossary
Contributors

Comments

"This was my first time to take CEU's at home and it won't be the last. This was a convenient and easy to understand course." - R.I., Alhambra, CA

"This course was well written and simply worded. My husband, a non-medical person, even read the book and understood it." - B.R., Fort Worth, TX

"I learned a lot more than I thought I would. Thank You." - K.M., San Rafael, CA

"Test was a little tricky! Information in textbook was very helpful. Book will continue to be used as a resource manual." - B.B., SC, LPC

"Informative text book that was easy to read and comprehend." - B.E., PC, CA