depression, anxiety and stress

1. DEPRESSION, ANXIETY & STRESS

2. DEPRESSION
• Depression is a mental disorder that affects a person’s:
– Thoughts, moods, feelings, behavior & physical health.
– Many thought it was just in ones head (misconceptions of
‘you can snap out of it’, or ‘just get over it’, would cure
someone)
• It is a medical disorder with a biological and chemical
basis
– Genetics/ family interaction styles
– Stressful life event
– Spontaneously with no specific identifiable cause
• May occur only once, sporadically or chronically

3. Core symptoms of depression
• Persistent depressed mood.
• Markedly diminished interest in or pleasure of
activities.

4. Common presentations of depression
• Multiple persistent
physical symptoms with
no clear cause
• Low energy
• Fatigue
• Sleep problems
(sleeping too much/ too
little)
• Anxiety
• Significant change in
appetite/ weight
(weight gain/ loss)
• Beliefs of worthlessness
• Excessive guilt
• Indecisiveness
• Restlessness/ agitation
• Hopelessness
• Suicidal thoughts & acts

5. Assessment in primary care

7. Depression in primary care
• 2 simple screening questions:
– “During the past 2 weeks, have you felt down,
depressed or hopeless?”
– “During the past 2 weeks, have you felt little
interest or pleasure in doing things?”

8. Screening tools
• DASS (Depression Anxiety Stress scale)

9. Cannot be missed
• Anemia
• Hypo/ hyperthyroid
• Anxiety disorder
• PMS
• Psychotic disorder
(schizophrenia)
• Cancer (pancreatic,
bronchogenic, renal,
ovarian)
Commonly missed
• Chronic fatigue syndrome
• SLE
• Anorexia nervosa
• Sleep disorders
• Hypoglycemia
• Hypercalcemia
• Porphyria
• Addison’s disease
• Cushing syndrome
• Lyme disease

10. Masquerade
• IVDU
• HIV
• Marital problem
• Psychosocial problem
• Medication use
(antiphyschotics, beta
blockers, contraceptives,
corticosteroids & isotretoin)
Want to tell you something
• Abuse
• Bully

11. Management in primary care
Suicide assessment
Rule of 7:
● 1 in 7 people with recurrent depression die by suicide
● 70% of suicides have depression
● 70% of patients who suicide have seen a GP within the
last 7 weeks
● Suicide is the 7th leading cause of death
If the symptoms are major and the patient appears in
poor health or is a suicide risk, referral is appropriate.

12. To clarify the risk of suicide and
appropriate response, ask about:
● Suicide thought
● Plan
● Lethality
● Means
● Past history
● Suicide of family member or peer

13. Low risk - thought of self-harm or suicide
but no current plan or means
● Discuss availability of support and
treatment options
● Arrange follow up
● Provide contact details
Medium risk - suicidal thought and intent
but no current plan or immediate means
● Discuss availability of support and
treatment
● Organise reassessment within 1
week
● Develop safety plan
High risk - continual/specific suicidal
thought, intent plan and means
● Ensure that person is in
appropriately safe and secure
environment
● Organise reassessment within 24
hours and monitor
● Follow up outcome of assessment

15. ANXIETY
• Anxiety is defined as an individual’s emotional & physical fear
response to a perceived threat.
• Anxiety becomes a disorder when out of proportion or when it
significantly interferes with life.
• Anxiety disorders are caused by a combination of:
– Genetic
– Biological
– Environmental
– Psychosocial factors
• Major neurotransmitter systems implicated:
– Norepinephrine (NE)
– Serotonin (5-HT)
– Gamma-aminobutyric acid (GABA)
• More frequently seen in women compared to men (2:1)

16. Signs & symptoms of anxiety
Constitutional Fatigue, diaphoresis, shivering
Cardiac Chest pain, palpitations, tachycardia,
hypertension
Pulmonary SOB, hyperventilation
Neurologic/
musculoskeletal
Vertigo, lightheadedness, paresthesias,
tremors, insomnia, muscle tension
Gastrointestinal Abdominal discomfort, anorexia,
nausea, emesis, diarrhea, constipation

17. Assessment in primary care

18. Cant be missed
• Myocardial infarction/
ischemia
• Pericarditis
• Pneumothorax
• Pregnancy
• Foreign body aspiration
• Rib fracture/ injury
Commonly missed
• Cardiac arryhtmias (ventricular
tachycardia)
• Supraventricular tachycardia
• Atrioventricular tachycardia
• Asthma
• Thyrotoxicosis
• Menopause
• Herpes zoster
• Peptic ulcers
• Dyspepsia
• GERD

19. Masquerade
• Cholecystitis
• Pancreatitis
• Hiatal hernia
• Marital problem
• Psychosocial problem
Want to tell you something
• Abuse
• Bully

20. Management in primary care

21. STRESS
• Stress is a simply a reaction to a stimulus that disturbs
our physical or mental equilibrium.
• The difference between “stress” and “a stressor”- a
stressor is an agent or stimulus that causes stress.
Stress is the feeling we have when under pressure,
while stressors are the things we respond to in our
environment.
• Source of stress :
– Environment : weather, noise, crowded
– Social stressor : love, divorce, financial problem
– Physiological : menopause, illness
– Thoughts : our brain interprets & perceives situations as
stressful, difficult, painful or pleasant

22. Types of stress
Eustress
• Positive – also called as
useful stress.
• Motivator :
– Rollercoaster ride
– Buying things
– Game
Distress
• Negative – also called as
bad or unhealthy.
• Demotivator :
– Test
– Money problems
– Relationship issues

23. Signs & symptoms of stress
Congenital symptoms
• Memory problems
• Inability to concentrate
• Poor judgment
• Seeing only the negative
• Anxious or racing thoughts
• Constant worrying
Emotional symptoms
• Moodiness
• Irritability or short temper
• Agitation, inability to relax
• Feeling overwhelmed
• Sense of loneliness &
isolation
• Depression or general
unhappiness

24. Physical symptoms
• Aches & pains
• Diarrhea/ constipation
• Nausea, dizziness
• Chest pain, tachycardia
• Decreased libido
• Frequent colds
Behavioural symptoms
• Increase/ loss of appetite
• Hypersomnia/ insomnia
• Isolating yourself from
others
• Procrastinating/ neglecting
responsibility
• Using alcohol, cigarettes or
drugs related
• Nervous habits

25. Consequences of long term stress
• Long term stress can lead to many chronic
diseases which effect our body.
• Such as :
– Hypertension
– Infertility
– Obesity
– Diabetes

26. Assessment in primary care

28. Cant be missed
• Depression
• ADHD (eg, schizo)
• Anxiety disorder
• OCD
• PMS
• Pregnancy
• Obstructive sleep apnea
• Narcolepsy
Commonly missed
• Intusseption
• Hyperthyroidism
• Grave’s disease
• Hypoglycemia
• DM
• Irritable bowel syndrome
• Crohn disease
• Addison’s disease

29. Masquerade
• Substance abuse disorder
• Marital problem
• Social problem
• Personal problem
• Psychososial problem
• MC
Want to tell you something
• Abuse
• Bully

30. Management primary care