Primary Care Mental HealthAnxiety disorders<br />Dr Henk Parmentier<br />24th January 2011<br />
Introduction<br />Dr Henk Parmentier<br />General Practitioner<br /><ul><li>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/de...
The Role of Mind & Body Separation<br />Since Hippocrates, conditions currently regarded as mental illness were treated by...
Public Attitudes<br />‘Unfortunately, the linguistic distinction between mental and physical illnesses, and the mind/body ...
Mind and Body: dump Descartes !<br />
Mind – Body“The only way to separate the mind from the bodyis with an axe.”<br />
Primary Care Mental Health<br />mental disorders are found in all countries, in women and men, at all stages of life, amon...
Primary Care Mental Health<br />effective treatments exist for mental health disorders and can be successfully delivered i...
The Size Of The Problem<br />Disability days by diagnosis<br />(Andrews et al, J Ment Health Policy Econ, 2000 Dec 1;3(4):...
depression<br />WHO predicts that by the year 2020 depression will be the second most important cause of disability after ...
Excess Consultation Rate UK Anti-Depressants (Centre for Innovation in Primary Care 2001)<br />12<br />
Extra Consultations (Centre for Innovation in Primary Care 2001)<br />13<br />
Cause or effect?<br />       Depression<br />     Cardiovascular<br />       disease<br />Depression has been associated w...
Depression and Cardiovasular Mortality Post-MI:<br />6 and 18 month outcome<br />Frasure-Smith N, et al. JAMA 1993;270:181...
Previously Identified Risk Factors for Coronary Artery Disease<br />Genetic Factors<br />Diabetes<br />Hypertension<br />T...
Major depression – CV risk<br />
Depressionindependent risk factor for myocardial infarction<br />Platelets:<br />upregulation of platelet imidazoline and ...
Prevalence of unexplained symptoms in consecutive new attendees to medical clinics at a UK Teaching Hospital<br />Nimnuan ...
Unexplained symptoms<br />Kroenke et al, Arch Fam Med, 1994<br />
Stress is normal<br />
Primary care for mental health<br />Mental health care<br />Primary care<br />General health care<br />Primary care for me...
general primary care. </li></li></ul><li>WHO pyramid of care for mental health<br />	Primary care for mental health must b...
informal community care services,
and self-care.</li></li></ul><li>
Generalized Anxiety Disorder: DSM-IV Diagnostic Criteria<br />Excessive anxiety and worry present most of the time for > 6...
Generalized Anxiety Disorder: ICD-10 Summary<br />Anxiety is generalized and persistent and not associated with a particul...
DSM-IV and ICD-10 GAD Diagnostic Criteria: Some Differences<br />Rickels & Rynn. J Clin Psychiatry. 2001;62(suppl 11):4-12...
The epidemiology of generalized anxiety disorder in Europe.<br />Lieb R, Becker E, Altamura C.<br />Eur Neuropsychopharmac...
Anxiety: dictionary<br />Feeling anxious<br />Full of mental distress because of fear of danger or misfortune; greatly wor...
Anxiety: symptom<br />Anxiety disorders<br />affective disorders<br />anxiety<br />
Acute Illness<br />Gender<br />&<br />sexuality<br />Financial worries<br />Chronic Illness<br />Side effects<br />medicat...
Finding GAD in the Symptom “SOUP”<br />Sweaty<br />Cramps<br />Worry<br />Can’t think<br />Headaches<br />Loner<br />Usele...
Overlap Between Anxiety Disorders and Depression Can Make Diagnosis Difficult<br />Comorbidity of depression and anxiety d...
Anxiety Continuum<br />Cardiovascular symptoms<br />Respiratory symptoms<br />Gastro-Intestinal / Genito-urinary symptoms<...
Unexplained Medical Symptoms & Misdiagnosis of GAD… a Viscous Cycle <br />Investigations<br />-ve findings<br />Unexplaine...
Screening Tools<br />Alert the physician to the possibility a disorder might exist<br />Trigger further investigation usin...
GAD 7<br />†Score >10 indicates possibility of GAD<br />
42<br />Anxiety-causing medicinal substances<br /><ul><li>Levodopa
Neuroleptics (akathisia)
Bronchodilators
Thyroid hormones
Anti-inflammators
SSRI’s
Withdrawal from alcohol and benzodiazepine use</li></ul>Anticholinergics<br />Some blood pressure medicine<br />Caffeine<b...
hyperventilation<br />
Hyperventilation (over-breathing) <br />About 60% of attacks are accompanied by hyperventilation and many panickers overbr...
hyperventilation<br />The most important thing to understand about hyperventilation:<br /> it can feel as if you don’t hav...
hyperventilation and panic attack symptoms<br />Light headiness <br />Giddiness <br />Dizziness <br />Shortness of breath ...
Breathing exercises<br />Hold your breath. Holding your breath for as long as you comfortably can will prevent the dissipa...
Management and Treatment of GAD<br />Treatment Guidelines<br />
The WFSBP Guidelines for the Pharmacological Treatment of Anxiety Disorders, OCD and PTSD - First Revisionwww.wfsbp.orgBan...
Nice anxiety<br />A&E<br />Presentation in A&E or other settings with a panic attack<br /><ul><li>If a patient presents wi...
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 ...
Herbal preparations
Other psychological treatments
Hypnosis </li></ul>Effective<br /><ul><li>SSRIs (escitalopram etc.)
SNRIs venlafaxine, duloxetine
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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

    1. 1. Primary Care Mental HealthAnxiety disorders<br />Dr Henk Parmentier<br />24th January 2011<br />
    2. 2. Introduction<br />Dr Henk Parmentier<br />General Practitioner<br /><ul><li>Wonca: http://www.globalfamilydoctor.com/
    3. 3. Wonca Mental Health: http://www.WWPOMH.ning.com
    4. 4. Mental Health in Family Medicine Journal: http://www.radcliffe-oxford.com/journals/J20_Mental_Health_in_Family_Medicine/default.htm</li></li></ul><li>objectives<br />Learn about: Anxiety Disorders<br />Definitions<br />Recognition<br />treatment<br />
    5. 5. The Role of Mind & Body Separation<br />Since Hippocrates, conditions currently regarded as mental illness were treated by general physicians for 2000 years<br />The idea of insanity as a disease of the mind, different from other illnesses, emerged in the 18th century from Cartesian dualism <br />4<br />
    6. 6. Public Attitudes<br />‘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) <br />5<br />
    7. 7. Mind and Body: dump Descartes !<br />
    8. 8. Mind – Body“The only way to separate the mind from the bodyis with an axe.”<br />
    9. 9. Primary Care Mental Health<br />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<br />up to 60% of people attending primary care clinics have a diagnosable mental disorder.<br />
    10. 10. Primary Care Mental Health<br />effective treatments exist for mental health disorders and can be successfully delivered in primary care<br />
    11. 11. The Size Of The Problem<br />Disability days by diagnosis<br />(Andrews et al, J Ment Health Policy Econ, 2000 Dec 1;3(4):175-186)<br />
    12. 12. depression<br />WHO predicts that by the year 2020 depression will be the second most important cause of disability after ischaemic heart disease<br />Murray & Lopez 1997 <br />
    13. 13. Excess Consultation Rate UK Anti-Depressants (Centre for Innovation in Primary Care 2001)<br />12<br />
    14. 14. Extra Consultations (Centre for Innovation in Primary Care 2001)<br />13<br />
    15. 15. Cause or effect?<br /> Depression<br /> Cardiovascular<br /> disease<br />Depression has been associated with <br />increased risks of MI and mortality<br />(Barefoot & Schroll 1996)<br />Major depressive disorder occurs in between<br />15% and 23% of patients with acute coronary<br />syndromes and constitutes an independent<br />risk factor for both morbidity and mortality<br /> (Glassman et al. 2002)<br />Many patients who are free of depression<br /> following an acute MI experience an episode<br />of depression within a year. <br />(Ranga KR et al 2002)<br />
    16. 16. Depression and Cardiovasular Mortality Post-MI:<br />6 and 18 month outcome<br />Frasure-Smith N, et al. JAMA 1993;270:18191825. <br />Frasure-Smith N, et al. Circulation 1995;91:9991005.<br />
    17. 17. Previously Identified Risk Factors for Coronary Artery Disease<br />Genetic Factors<br />Diabetes<br />Hypertension<br />ThrombocyteDysfunction<br />Hyperlipidemia<br />Smoking<br />Obesity<br />
    18. 18. Major depression – CV risk<br />
    19. 19. Depressionindependent risk factor for myocardial infarction<br />Platelets:<br />upregulation of platelet imidazoline and serotonin receptors and enhanced intraplatelet calcium mobilization seen in patients with depression resulting in increased platelets activation<br />Sauer,Berlin,Kimmel:Selective serotonin reuptake inhibitors and myocardial infarction:Circulation. 2001 Oct 16;104(16):1894-8<br />
    20. 20.
    21. 21. Prevalence of unexplained symptoms in consecutive new attendees to medical clinics at a UK Teaching Hospital<br />Nimnuan and Wessely, 2000<br />
    22. 22. Unexplained symptoms<br />Kroenke et al, Arch Fam Med, 1994<br />
    23. 23. Stress is normal<br />
    24. 24. Primary care for mental health<br />Mental health care<br />Primary care<br />General health care<br />Primary care for mental health<br />Primary care for mental health forms an essential part of both:<br /><ul><li>comprehensive mental health care
    25. 25. general primary care. </li></li></ul><li>WHO pyramid of care for mental health<br /> Primary care for mental health must be supported by other levels of care including :<br /><ul><li>community-based and hospital services,
    26. 26. informal community care services,
    27. 27. and self-care.</li></li></ul><li>
    28. 28. Generalized Anxiety Disorder: DSM-IV Diagnostic Criteria<br />Excessive anxiety and worry present most of the time for > 6 months<br />Difficult to control worry<br />Associated with (at least 3 items):<br />Restlessness <br />Being easily fatigued <br />Concentration difficulties<br />Irritability<br />Muscle tension<br />Sleep disturbance<br />Focus of anxiety and worry not confined to features of an Axis I disorder<br />Causes clinically significant distress or functional impairment<br />Not due to medication, illness, or substance abuse<br />DSM-IV-TR. APA 2000<br />
    29. 29. Generalized Anxiety Disorder: ICD-10 Summary<br />Anxiety is generalized and persistent and not associated with a particular environmental circumstance (i.e. it is free-floating) <br />Anxiety present most days for at least several weeks at a time and usually for several months<br />Symptoms should involve elements of:<br />Apprehension<br />E.g. Worry about future, feeling “on edge”, difficulty concentrating<br />Motor tension<br />E.g. Restlessness, fidgeting, tension headaches, trembling<br />Autonomic overactivity<br />E.g. Light-headedness, sweating, tachycardia, epigastric discomfort<br />Must not meet full criteria for depressive episode, phobic anxiety disorder, panic disorder, or obsessive-compulsive disorder<br />ICD-10, WHO 1992<br />
    30. 30. DSM-IV and ICD-10 GAD Diagnostic Criteria: Some Differences<br />Rickels & Rynn. J Clin Psychiatry. 2001;62(suppl 11):4-12<br />Starcevic. Anxiety Disorder in Adults. Oxford University Press. 2005:102-140<br />
    31. 31. The epidemiology of generalized anxiety disorder in Europe.<br />Lieb R, Becker E, Altamura C.<br />Eur Neuropsychopharmacol. 2005 Aug;15(4):445-52.<br />Max-Planck-Institute of Psychiatry, Unit Clinical Psychology and Epidemiology, München, Germany. <br />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 <br />(a) about 2% of the adult population in the community is affected (12-month prevalence), <br />(b) GAD is one of the most frequent (up to 10%) of all mental disorders seen in primary care, <br />(c) GAD is a highly impairing condition often comorbid with other mental disorders, <br />(d) GAD patients are high utilizers of healthcare resources, and <br />(e) despite the high prevalence of GAD in primary care, its recognition in general practice is relatively low. <br />
    32. 32. Anxiety: dictionary<br />Feeling anxious<br />Full of mental distress because of fear of danger or misfortune; greatly worried<br />
    33. 33. Anxiety: symptom<br />Anxiety disorders<br />affective disorders<br />anxiety<br />
    34. 34. Acute Illness<br />Gender<br />&<br />sexuality<br />Financial worries<br />Chronic Illness<br />Side effects<br />medication<br />Relationship worries<br />Illness<br />Anxiety<br />&<br />Depression<br />Illness in family<br />Personality<br />disorders<br />Bereavement<br />Work<br />Housing<br />Terminal Illness<br />Pain syndromes<br />Alcohol<br />&<br />drugs<br />The law<br />
    35. 35. Finding GAD in the Symptom “SOUP”<br />Sweaty<br />Cramps<br />Worry<br />Can’t think<br />Headaches<br />Loner<br />Useless<br />Tense<br />No energy<br />Sad<br />Stress<br />Suicidal<br />Depressed<br />Jumpy<br />Irritable<br />Need a drink<br />Angry<br />Crying<br />Weight<br />Insomnia<br />Restless<br />Sad<br />Wake up<br />Appetite<br />Antisocial<br />Off sex<br />IBS<br />Feel Bad<br />Frightened<br />Nervy<br />Worthless<br />Breathless<br />Heart Race<br />Fatigue<br />Guilty<br />Worried<br />Forget<br />Anxious<br />GI pain<br />Panicky<br />Pain<br />Shy<br />Buzzy<br />Shaky<br />Dizzy<br />Flat<br />Etc…..<br />Hot flashes<br />Edgy<br />Always<br />Most of the time<br />Sometimes<br />Most of my life<br />Since I lost my job<br />
    36. 36. Overlap Between Anxiety Disorders and Depression Can Make Diagnosis Difficult<br />Comorbidity of depression and anxiety disorders can also confound diagnosis<br />Stahl's Essential Psychopharmacology Online © 2009 Cambridge University Press.<br />
    37. 37. Anxiety Continuum<br />Cardiovascular symptoms<br />Respiratory symptoms<br />Gastro-Intestinal / Genito-urinary symptoms<br />How GAD usually presents to PCPs….<br />Mysterious pains<br />Worried / anxious but NO somatic symptoms<br />Worried / anxious but WITH somatic symptoms<br />
    38. 38. Unexplained Medical Symptoms & Misdiagnosis of GAD… a Viscous Cycle <br />Investigations<br />-ve findings<br />Unexplained medical <br />symptoms<br />Misdiagnosed, untreated <br />Persistent<br />GAD<br />Medical consequences<br />HPA, cytokines<br />Exacerbation of <br />Existing chronic illness<br />Development of new <br />illnesses<br />
    39. 39. Screening Tools<br />Alert the physician to the possibility a disorder might exist<br />Trigger further investigation using diagnostic criteria and instruments<br />Examples<br />GAD-7<br />ASQ-15<br />
    40. 40. GAD 7<br />†Score >10 indicates possibility of GAD<br />
    41. 41.
    42. 42.
    43. 43.
    44. 44. 42<br />Anxiety-causing medicinal substances<br /><ul><li>Levodopa
    45. 45. Neuroleptics (akathisia)
    46. 46. Bronchodilators
    47. 47. Thyroid hormones
    48. 48. Anti-inflammators
    49. 49. SSRI’s
    50. 50. Withdrawal from alcohol and benzodiazepine use</li></ul>Anticholinergics<br />Some blood pressure medicine<br />Caffeine<br />Digitalis (toxic doses)<br />Sympathomimetic drugs (ephedrine)<br />
    51. 51. hyperventilation<br />
    52. 52. Hyperventilation (over-breathing) <br />About 60% of attacks are accompanied by hyperventilation and many panickers overbreathe even whilst relaxed.<br />
    53. 53. hyperventilation<br />The most important thing to understand about hyperventilation:<br /> it can feel as if you don’t have enough oxygen, the opposite is true. It is a symptom of too much oxygen.<br />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). <br />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.<br />
    54. 54. hyperventilation and panic attack symptoms<br />Light headiness <br />Giddiness <br />Dizziness <br />Shortness of breath <br />Heart palpitations <br />Numbness <br />Chest pains <br />Dry mouth <br />Clammy hands <br />Difficulty swallowing <br />Tremors <br />Sweating <br />Weakness <br />Fatigue<br />
    55. 55. Breathing exercises<br />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. <br />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. <br />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. <br />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.<br />
    56. 56. Management and Treatment of GAD<br />Treatment Guidelines<br />
    57. 57. 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<br />
    58. 58.
    59. 59. Nice anxiety<br />A&E<br />Presentation in A&E or other settings with a panic attack<br /><ul><li>If a patient presents with a panic attack, he or she should:
    60. 60. Be asked if they are already receiving treatment for panic disorder
    61. 61. undergo the minimum investigations necessary to exclude acute physical problems
    62. 62. not usually be admitted to a medical or psychiatric bed
    63. 63. be referred to primary care for subsequent care, even if assessment has been undertaken in A&E
    64. 64. be given appropriate written information about panic attacks and why they are being referred to primary care
    65. 65. be offered appropriate written information about sources of support, including local and national voluntary and self-help groups.</li></li></ul><li>Treatments for Anxiety Disorders – Evidence From Controlled Studies<br />Insufficient Proof<br /><ul><li>Typical Neuroleptics</li></ul>Lack of Evidence or Negative Studies<br /><ul><li>Beta blockers
    66. 66. Herbal preparations
    67. 67. Other psychological treatments
    68. 68. Hypnosis </li></ul>Effective<br /><ul><li>SSRIs (escitalopram etc.)
    69. 69. SNRIs venlafaxine, duloxetine
    70. 70. Tricyclic antidepressants
    71. 71. Benzodiazepines
    72. 72. Pregabalin (only GAD)
    73. 73. Buspirone (only GAD)
    74. 74. Irreversible MAOIs
    75. 75. Moclobemide (only SAD)
    76. 76. Quetiapine (only GAD)</li></ul>--------------------------<br /><ul><li>Cognitive/behavior therapy
    77. 77. Psychoanalysis -1 study</li></ul>In God we trust.<br />Everybody else needs to provide evidence.<br />Anon<br />Bandelow et al. World J Biol Psychiatry.<br />2008;9(4):248-312.<br />
    78. 78. Bandelow et al. World J Biol Psychiatry. 2008;9(4):248-312.<br />
    79. 79. Bandelow et al. World J Biol Psychiatry. 2008;9(4):248-312.<br />
    80. 80. WFSBP Recommendations: Generalized Anxiety Disorder<br />Bandelow et al. World J Biol Psychiatry. 2008;9(4):248-312.<br />
    81. 81. WFSBP 2008 GAD Treatment Guidelines<br />Yes<br />Continue<br />FIRST-LINE<br />Pregabalin<br />SSRIs <br />SNRIs<br />4-6 <br />Weeks<br />Further<br />4-6 weeks<br />Partial<br />Response?<br />Change dose <br />or<br />switch<br />No<br /><ul><li>Benzodiazepines (2nd line because of abuse potential)
    82. 82. Treatment-resistant patients with no history of dependence
    83. 83. Add-on to SSRIs/SNRIs in first few weeks until onset of efficacy of antidepressant
    84. 84. TCAs
    85. 85. Imipramine effective, but potentially lethal in overdose and tolerability less than first-line</li></ul>Second line<br />World Federation of Societies of Biological Psychiatry <br />Bandelow B, et al. The World Journal of Biological Psychiatry. 2008; 9(4): 248-312<br />
    86. 86.
    87. 87.
    88. 88.
    89. 89.
    90. 90.
    91. 91.
    92. 92.
    93. 93.
    94. 94.
    95. 95.
    96. 96. QOF<br />Bibliotherapy<br />Preferred reading list<br />CBT<br />Local “primary care counselling service”<br />CBT online<br />www.livinglifetothefull.com<br />
    97. 97. Finding GAD in the Symptom “SOUP”<br />Sweaty<br />Cramps<br />Worry<br />Can’t think<br />Headaches<br />Loner<br />Useless<br />Tense<br />No energy<br />Sad<br />Stress<br />Suicidal<br />Depressed<br />Jumpy<br />Irritable<br />Need a drink<br />Angry<br />Crying<br />Weight<br />Insomnia<br />Restless<br />Sad<br />Wake up<br />Appetite<br />Antisocial<br />Off sex<br />IBS<br />Feel Bad<br />Frightened<br />Nervy<br />Worthless<br />Breathless<br />Heart Race<br />Fatigue<br />Guilty<br />Worried<br />Forget<br />Anxious<br />GI pain<br />Panicky<br />Pain<br />Shy<br />Buzzy<br />Shaky<br />Dizzy<br />Flat<br />Etc…..<br />Hot flashes<br />Edgy<br />Always<br />Most of the time<br />Sometimes<br />Most of my life<br />Since I lost my job<br />
    98. 98. Thank you<br />Henk.parmentier@gmail.com<br />

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