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  • © Henk Parmentier, Wonca WPoMH 2007
  • © Henk Parmentier, Wonca WPoMH 2007
  • © Henk Parmentier, Wonca WPoMH 2007
  • © Henk Parmentier, Wonca WPoMH 2007
  • © Henk Parmentier, Wonca WPoMH 2007
  • © Henk Parmentier, Wonca WPoMH 2007
  • © Henk Parmentier, WoncaWPoMH2007

Parmentier 02 Parmentier 02 Presentation Transcript

  • Primary Care Mental HealthAnxiety disorders
    Dr Henk Parmentier
    24th January 2011
  • Introduction
    Dr Henk Parmentier
    General Practitioner
    • Wonca: http://www.globalfamilydoctor.com/
    • Wonca Mental Health: http://www.WWPOMH.ning.com
    • Mental Health in Family Medicine Journal: http://www.radcliffe-oxford.com/journals/J20_Mental_Health_in_Family_Medicine/default.htm
  • objectives
    Learn about: Anxiety Disorders
    Definitions
    Recognition
    treatment
  • The Role of Mind & Body Separation
    Since Hippocrates, conditions currently regarded as mental illness were treated by general physicians for 2000 years
    The idea of insanity as a disease of the mind, different from other illnesses, emerged in the 18th century from Cartesian dualism
    4
  • Public Attitudes
    ‘Unfortunately, the linguistic distinction between mental and physical illnesses, and the mind/body distinction from which this was originally derived, still encourages many lay people, and some doctors and other health professionals, to assume that the two are fundamentally different.’ (Kendell 2001)
    5
  • Mind and Body: dump Descartes !
  • Mind – Body“The only way to separate the mind from the bodyis with an axe.”
  • Primary Care Mental Health
    mental disorders are found in all countries, in women and men, at all stages of life, among the rich and poor, and in both rural and urban settings
    up to 60% of people attending primary care clinics have a diagnosable mental disorder.
  • Primary Care Mental Health
    effective treatments exist for mental health disorders and can be successfully delivered in primary care
  • The Size Of The Problem
    Disability days by diagnosis
    (Andrews et al, J Ment Health Policy Econ, 2000 Dec 1;3(4):175-186)
  • depression
    WHO predicts that by the year 2020 depression will be the second most important cause of disability after ischaemic heart disease
    Murray & Lopez 1997
  • Excess Consultation Rate UK Anti-Depressants (Centre for Innovation in Primary Care 2001)
    12
  • Extra Consultations (Centre for Innovation in Primary Care 2001)
    13
  • Cause or effect?
    Depression
    Cardiovascular
    disease
    Depression has been associated with
    increased risks of MI and mortality
    (Barefoot & Schroll 1996)
    Major depressive disorder occurs in between
    15% and 23% of patients with acute coronary
    syndromes and constitutes an independent
    risk factor for both morbidity and mortality
    (Glassman et al. 2002)
    Many patients who are free of depression
    following an acute MI experience an episode
    of depression within a year.
    (Ranga KR et al 2002)
  • Depression and Cardiovasular Mortality Post-MI:
    6 and 18 month outcome
    Frasure-Smith N, et al. JAMA 1993;270:18191825.
    Frasure-Smith N, et al. Circulation 1995;91:9991005.
  • Previously Identified Risk Factors for Coronary Artery Disease
    Genetic Factors
    Diabetes
    Hypertension
    ThrombocyteDysfunction
    Hyperlipidemia
    Smoking
    Obesity
  • Major depression – CV risk
  • Depressionindependent risk factor for myocardial infarction
    Platelets:
    upregulation of platelet imidazoline and serotonin receptors and enhanced intraplatelet calcium mobilization seen in patients with depression resulting in increased platelets activation
    Sauer,Berlin,Kimmel:Selective serotonin reuptake inhibitors and myocardial infarction:Circulation. 2001 Oct 16;104(16):1894-8
  • Prevalence of unexplained symptoms in consecutive new attendees to medical clinics at a UK Teaching Hospital
    Nimnuan and Wessely, 2000
  • Unexplained symptoms
    Kroenke et al, Arch Fam Med, 1994
  • Stress is normal
  • Primary care for mental health
    Mental health care
    Primary care
    General health care
    Primary care for mental health
    Primary care for mental health forms an essential part of both:
    • comprehensive mental health care
    • general primary care.
  • WHO pyramid of care for mental health
    Primary care for mental health must be supported by other levels of care including :
    • community-based and hospital services,
    • informal community care services,
    • and self-care.
  • Generalized Anxiety Disorder: DSM-IV Diagnostic Criteria
    Excessive anxiety and worry present most of the time for > 6 months
    Difficult to control worry
    Associated with (at least 3 items):
    Restlessness
    Being easily fatigued
    Concentration difficulties
    Irritability
    Muscle tension
    Sleep disturbance
    Focus of anxiety and worry not confined to features of an Axis I disorder
    Causes clinically significant distress or functional impairment
    Not due to medication, illness, or substance abuse
    DSM-IV-TR. APA 2000
  • Generalized Anxiety Disorder: ICD-10 Summary
    Anxiety is generalized and persistent and not associated with a particular environmental circumstance (i.e. it is free-floating)
    Anxiety present most days for at least several weeks at a time and usually for several months
    Symptoms should involve elements of:
    Apprehension
    E.g. Worry about future, feeling “on edge”, difficulty concentrating
    Motor tension
    E.g. Restlessness, fidgeting, tension headaches, trembling
    Autonomic overactivity
    E.g. Light-headedness, sweating, tachycardia, epigastric discomfort
    Must not meet full criteria for depressive episode, phobic anxiety disorder, panic disorder, or obsessive-compulsive disorder
    ICD-10, WHO 1992
  • DSM-IV and ICD-10 GAD Diagnostic Criteria: Some Differences
    Rickels & Rynn. J Clin Psychiatry. 2001;62(suppl 11):4-12
    Starcevic. Anxiety Disorder in Adults. Oxford University Press. 2005:102-140
  • The epidemiology of generalized anxiety disorder in Europe.
    Lieb R, Becker E, Altamura C.
    Eur Neuropsychopharmacol. 2005 Aug;15(4):445-52.
    Max-Planck-Institute of Psychiatry, Unit Clinical Psychology and Epidemiology, München, Germany.
    The objective of this paper is to provide a review on available data to date on the epidemiology of GAD in Europe, and to highlight areas for future research. MEDLINE searches were performed and supplemented by consultations with experts across Europe to identify non-published reports. Despite variations in the design of studies, available data suggest that
    (a) about 2% of the adult population in the community is affected (12-month prevalence),
    (b) GAD is one of the most frequent (up to 10%) of all mental disorders seen in primary care,
    (c) GAD is a highly impairing condition often comorbid with other mental disorders,
    (d) GAD patients are high utilizers of healthcare resources, and
    (e) despite the high prevalence of GAD in primary care, its recognition in general practice is relatively low.
  • Anxiety: dictionary
    Feeling anxious
    Full of mental distress because of fear of danger or misfortune; greatly worried
  • Anxiety: symptom
    Anxiety disorders
    affective disorders
    anxiety
  • Acute Illness
    Gender
    &
    sexuality
    Financial worries
    Chronic Illness
    Side effects
    medication
    Relationship worries
    Illness
    Anxiety
    &
    Depression
    Illness in family
    Personality
    disorders
    Bereavement
    Work
    Housing
    Terminal Illness
    Pain syndromes
    Alcohol
    &
    drugs
    The law
  • Finding GAD in the Symptom “SOUP”
    Sweaty
    Cramps
    Worry
    Can’t think
    Headaches
    Loner
    Useless
    Tense
    No energy
    Sad
    Stress
    Suicidal
    Depressed
    Jumpy
    Irritable
    Need a drink
    Angry
    Crying
    Weight
    Insomnia
    Restless
    Sad
    Wake up
    Appetite
    Antisocial
    Off sex
    IBS
    Feel Bad
    Frightened
    Nervy
    Worthless
    Breathless
    Heart Race
    Fatigue
    Guilty
    Worried
    Forget
    Anxious
    GI pain
    Panicky
    Pain
    Shy
    Buzzy
    Shaky
    Dizzy
    Flat
    Etc…..
    Hot flashes
    Edgy
    Always
    Most of the time
    Sometimes
    Most of my life
    Since I lost my job
  • Overlap Between Anxiety Disorders and Depression Can Make Diagnosis Difficult
    Comorbidity of depression and anxiety disorders can also confound diagnosis
    Stahl's Essential Psychopharmacology Online © 2009 Cambridge University Press.
  • Anxiety Continuum
    Cardiovascular symptoms
    Respiratory symptoms
    Gastro-Intestinal / Genito-urinary symptoms
    How GAD usually presents to PCPs….
    Mysterious pains
    Worried / anxious but NO somatic symptoms
    Worried / anxious but WITH somatic symptoms
  • Unexplained Medical Symptoms & Misdiagnosis of GAD… a Viscous Cycle
    Investigations
    -ve findings
    Unexplained medical
    symptoms
    Misdiagnosed, untreated
    Persistent
    GAD
    Medical consequences
    HPA, cytokines
    Exacerbation of
    Existing chronic illness
    Development of new
    illnesses
  • Screening Tools
    Alert the physician to the possibility a disorder might exist
    Trigger further investigation using diagnostic criteria and instruments
    Examples
    GAD-7
    ASQ-15
  • GAD 7
    †Score >10 indicates possibility of GAD
  • 42
    Anxiety-causing medicinal substances
    • Levodopa
    • Neuroleptics (akathisia)
    • Bronchodilators
    • Thyroid hormones
    • Anti-inflammators
    • SSRI’s
    • Withdrawal from alcohol and benzodiazepine use
    Anticholinergics
    Some blood pressure medicine
    Caffeine
    Digitalis (toxic doses)
    Sympathomimetic drugs (ephedrine)
  • hyperventilation
  • Hyperventilation (over-breathing)
    About 60% of attacks are accompanied by hyperventilation and many panickers overbreathe even whilst relaxed.
  • hyperventilation
    The most important thing to understand about hyperventilation:
    it can feel as if you don’t have enough oxygen, the opposite is true. It is a symptom of too much oxygen.
    With hyperventilation, your body has too much oxygen. To use this oxygen (to extract it from your blood), your body needs a certain amount of Carbon Dioxide (CO2).
    When you hyperventilate, you do not give your body long enough to retain CO2, and so your body cannot use the oxygen you have. This causes you to feel as if you are short of air, when actually you have too much.
  • hyperventilation and panic attack symptoms
    Light headiness
    Giddiness
    Dizziness
    Shortness of breath
    Heart palpitations
    Numbness
    Chest pains
    Dry mouth
    Clammy hands
    Difficulty swallowing
    Tremors
    Sweating
    Weakness
    Fatigue
  • Breathing exercises
    Hold your breath. Holding your breath for as long as you comfortably can will prevent the dissipation of carbon dioxide. If you hold your breath for a period of between 10 and 15 seconds and repeat this a few times that will be sufficient to calm hyperventilation quickly.
    Breathe in and out of a paper bag. This will cause you to re-inhale the carbon dioxide that you exhaled. Naturally there are many times when this would be inappropriate and may appear a little strange. It really helps though.
    Thirdly you can take vigorous exercise while breathing in and out through your nose. A brisk walk or jog whilst breathing through the nose will counter hyperventilation. Regular exercise will decrease general stress levels decreasing the chance of panic attacks.
    If you find that your breathing pattern is irregular or uncomfortable a lot of the time, the best way to ‘reset’ it is by exercising. Start off gradually and check with your doctor if you are not used to exercise.
  • Management and Treatment of GAD
    Treatment Guidelines
  • The WFSBP Guidelines for the Pharmacological Treatment of Anxiety Disorders, OCD and PTSD - First Revisionwww.wfsbp.orgBandelow B, et al.(2008) World J Biol Psychiatry 9: 248-312
  • Nice anxiety
    A&E
    Presentation in A&E or other settings with a panic attack
    • If a patient presents with a panic attack, he or she should:
    • Be asked if they are already receiving treatment for panic disorder
    • undergo the minimum investigations necessary to exclude acute physical problems
    • not usually be admitted to a medical or psychiatric bed
    • be referred to primary care for subsequent care, even if assessment has been undertaken in A&E
    • be given appropriate written information about panic attacks and why they are being referred to primary care
    • be offered appropriate written information about sources of support, including local and national voluntary and self-help groups.
  • Treatments for Anxiety Disorders – Evidence From Controlled Studies
    Insufficient Proof
    • Typical Neuroleptics
    Lack of Evidence or Negative Studies
    • Beta blockers
    • Herbal preparations
    • Other psychological treatments
    • Hypnosis
    Effective
    • SSRIs (escitalopram etc.)
    • SNRIs venlafaxine, duloxetine
    • Tricyclic antidepressants
    • Benzodiazepines
    • Pregabalin (only GAD)
    • Buspirone (only GAD)
    • Irreversible MAOIs
    • Moclobemide (only SAD)
    • Quetiapine (only GAD)
    --------------------------
    • Cognitive/behavior therapy
    • Psychoanalysis -1 study
    In God we trust.
    Everybody else needs to provide evidence.
    Anon
    Bandelow et al. World J Biol Psychiatry.
    2008;9(4):248-312.
  • Bandelow et al. World J Biol Psychiatry. 2008;9(4):248-312.
  • Bandelow et al. World J Biol Psychiatry. 2008;9(4):248-312.
  • WFSBP Recommendations: Generalized Anxiety Disorder
    Bandelow et al. World J Biol Psychiatry. 2008;9(4):248-312.
  • WFSBP 2008 GAD Treatment Guidelines
    Yes
    Continue
    FIRST-LINE
    Pregabalin
    SSRIs
    SNRIs
    4-6
    Weeks
    Further
    4-6 weeks
    Partial
    Response?
    Change dose
    or
    switch
    No
    • Benzodiazepines (2nd line because of abuse potential)
    • Treatment-resistant patients with no history of dependence
    • Add-on to SSRIs/SNRIs in first few weeks until onset of efficacy of antidepressant
    • TCAs
    • Imipramine effective, but potentially lethal in overdose and tolerability less than first-line
    Second line
    World Federation of Societies of Biological Psychiatry
    Bandelow B, et al. The World Journal of Biological Psychiatry. 2008; 9(4): 248-312
  • QOF
    Bibliotherapy
    Preferred reading list
    CBT
    Local “primary care counselling service”
    CBT online
    www.livinglifetothefull.com
  • Finding GAD in the Symptom “SOUP”
    Sweaty
    Cramps
    Worry
    Can’t think
    Headaches
    Loner
    Useless
    Tense
    No energy
    Sad
    Stress
    Suicidal
    Depressed
    Jumpy
    Irritable
    Need a drink
    Angry
    Crying
    Weight
    Insomnia
    Restless
    Sad
    Wake up
    Appetite
    Antisocial
    Off sex
    IBS
    Feel Bad
    Frightened
    Nervy
    Worthless
    Breathless
    Heart Race
    Fatigue
    Guilty
    Worried
    Forget
    Anxious
    GI pain
    Panicky
    Pain
    Shy
    Buzzy
    Shaky
    Dizzy
    Flat
    Etc…..
    Hot flashes
    Edgy
    Always
    Most of the time
    Sometimes
    Most of my life
    Since I lost my job
  • Thank you
    Henk.parmentier@gmail.com