Depression and anxiety are common psychiatric conditions that frequently co-occur and are often underdiagnosed and undertreated. These psychiatric conditions may be accompanied by physical symptoms, and patients often present in primary care offices with physical rather than psychological complaints.

1. Sherif Saad Osman , M.D.
Consultant of Psychiatry
ANXIETY AND DEPRESSION IN PRIMARY
CARE

3. 3
.
MIND
(PSYCH)
BODY
(SOMA)
BODY
(SOMA)
MIND
(PSYCHE)
MIND – BODY INTERACTION

4. 4THE BIO-PSYCHO-SOCIAL MODEL

5. STRESS
 Stress : Experiencing events that are perceived as endangering one’s
physical or psychological well-being.
 The events are known as stressors and the result as the stress response
 The response to stressors is influenced by
 Controllability, predictability and challenge to our limits.
 Holmes Life Events Scale
 Different psychological responses to stress include
 Anxiety
 Anger and aggression
 Apathy and depression
 Cognitive impairment

6. STRESS

7. Yerkes-Dodson law:
Performance improves as a function of anxiety up to a threshold
beyond which there is a fall off in performance
Too little stress is just as bad as too much stress,
we need to get a balance.

8. ANXIETY AND DEPRESSION IN PRIMARY CARE
8
General practitioner who sees 40
patients a day can expect that eight
will require support or treatment for
anxiety or depression (20%) -- and
that's not counting those whose
disorders go unrecognized.
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9. LIFETIME PREVALENCE
OF
COMMON PSYCHIATRIC DISORDERS
Kessler 1994; Kessler 1995; DSM-IV-TR™ 2000.
*In menstruating women. Lifetime prevalence (%)
0 2 4 6 8 10 12 14
7.8%
Posttraumatic stress
disorder (PTSD)
5.1%
Generalized anxiety
disorder (GAD)
3.5%Panic disorder
2.5%
Obsessive-compulsive
disorder (OCD)
16 18
Alcohol dependence 14.1%
Major depressive disorder 17.1%
13.3%Social anxiety disorder
5%*
Premenstrual dysphoric
disorder (PMDD)
9
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10. DEPRESSION—MEDICAL COMORBIDITIES
Kessler 1999; Carney 1987; Frasure-Smith 1993; AHCPR Guidelines 1993; Anderson 2001; Bing 2001; Reifler 1986; Rovner 1989; Breslau 1991; Minden 1987; Joffe
1987.
Prevalence Comments
General population 10% 12-month prevalence
Coronary artery disease 18% Current episode of depression
Myocardial infarction 16% 6-months post-MI
Cancer 20%-25% At some time during illness
Diabetes 25% Meta-analysis of 42 studies
HIV 36% 12-month prevalence
Alzheimer’s disease 17%-31% Current episode of depression
Migraine 22%-32% Lifetime prevalence in young adults
Multiple sclerosis Up to 50% Lifetime prevalence
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11. WORLD PSYCHATRIC DAY,
10-10- 2011
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12. MAJOR DEPRESSION:
5 OF 9 SX:
12
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13. SAD-A FACES: A MNEMONIC FOR
THE CORE SYMPTOMS OF DEPRESSION
 S = Sleep — insomnia/hypersomnia; often the earliest symptom; may be overlooked
if the patient has been given sleeping tablets
 A = Appetite or weight change (increase or decrease)
 D = Dysphoria — “bad mood”, irritability, sadness; the essential abnormality; few
complain of it spontaneously
 A = Anhedonia — loss of interest in work, hobbies, sex
 F = Fatigue—affects almost all; often manifests as difficulty completing tasks
 A = Agitation/retardation—especially in the elderly
 C = Concentration — diminished; difficulty with simple tasks, conversation,
decision-making; may lead to a misdiagnosis of dementia in the elderly
 E = Esteem — low; guilt; events from the past may assume new significance
 S = Suicidal thoughts—present in two-thirds of depressed patients; 10%–15% will
commit suicide.
13
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14. THE CORE SYMPTOMS OF
ANXIETY
 Cognitive:
 Fear of dying or going mad
 Decreased attention and concentration
 Somatic
 Cardiovascular: palpitations, chest pain, tachycardia, flushing
 Respiratory: hyperventilation, shortness of breath
 Neurological: dizziness, headache, paraesthesia, vertigo
 Gastrointestinal: choking, dry mouth, nausea, vomiting, diarrhoea
 Musculoskeletal: muscle ache and tension, restlessness
 Psychological
 Derealisation, depersonalisation, speeding or slowing of thoughts,
distractibility, irritability, insomnia, vivid dreams.
14
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15. A SCREENING TEST FOR
ANXIETY AND DEPRESSION
Score one point for each “Yes”.
 Have you felt keyed up, on edge?
 Have you been worrying a lot?
 Have you been irritable?
 Have you had any difficulty relaxing?
If “Yes” to two of the above, go on to ask:
 Have you been sleeping poorly?
 Have you had headaches or neck aches?
 Have you had any of the following: trembling,
tingling, dizzy spells, sweating, urinary
frequency, diarrhoea?
 Have you been worried about your health?
 Have you had difficulty falling asleep?
A
N
X
I
E
T
y
S
C
A
L
e
15
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16. A SCREENING TEST FOR
ANXIETY AND DEPRESSION
Score one point for each “Yes”.
 Have you had low energy?
 Have you had loss of interests?
 Have you lost confidence in yourself?
 Have you felt hopeless?
If “Yes” to ANY question, go on to ask:
 Have you had difficulty concentrating?
 Have you lost weight (due to poor appetite)?
 Have you been waking early?
 Have you felt slowed up?
 Have you tended to feel worse in the morning?
D
E
P
R
E
S
S
I
O
N
S
C
A
L
e
16
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17. Anxiety Depression
Adaptive Debilitating
Future-oriented Past-oriented
Helplessness Hopelessness
Worse in the p.m. Worse in the a.m.
Blames external factors Blames internal factors (self)
Trouble falling asleep Early morning awakening
Potential suicide risk Definite suicide risk
Differentiating Anxiety and Depression
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18. DIAGNOSTIC CRITERIA FOR MIXED
ANXIETY-DEPRESSIVE DISORDER
 Presence of persistent or recurrent dysphoric mood
lasting 4 weeks and accompanied by 4 of the following
symptoms:
 –concentration or memory difficulties
 –Sleep disturbances
 –Fatigue or low energy
 –Irritability
 –Worry
 –Being easily moved to tears
 –Hypervigilance
 –Anticipating the worst
 –Hopelessness or pessimism about the
future
 –Low self-esteem or feelings of
worthlessness
18
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Symptoms are not due to A medication, drug
abuse, or A medical condition and cause
significant distress or impairment in social,
occupational, or other important areas of
functioning. Symptoms do not meet criteria of
any other mental disorder DSM-IV, diagnostic
and statistical manual of mental disorders,
fourth edition. Adapted from the American
Psychiatric Association.

19. The patient has three or four of the symptoms of
major depression (which must include depressed
mood and/or anhedonia), and they are accompanied
by anxious distress. The symptoms must have lasted
at least 2 weeks, and no other DSM diagnosis of
anxiety or depression must be present, and they are
both occurring at the same time.
Anxious distress is defined as having two or more
of the following symptoms: irrational worry,
preoccupation with unpleasant worries, having
trouble relaxing, motor tension, fear that something
awful may happen.
19
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PROPOSED DIAGNOSTIC CRITERIA FOR
MIXED ANXIETY DEPRESSION IN DSM-V

21. Depression and anxiety in Primary Care
Depressive and anxiety disorders are common,
occurring in up to 25% of primary care patients
Depressive and anxiety disorders are more
disabling, both socially and in terms of physical
functioning, than many chronic physical illnesses,
such as diabetes, hypertension, arthritis and back
pain.
The economic impact is immense, both in direct
costs to health care systems and in indirect costs to
the community.

22. 5/13/2017
22
Major Depression
Hypertension
Diabetes
Arthritis
Back Pain
Disability ScoreDisability Days
0 0 5 10 205 15 2515 10
WHO Collaborated project
Greater disability level than other chronic diseases
1. Ustun TB et al, eds, John Willy & Sons 1995

23.  Despite this, there is considerable evidence that the
medical profession deals poorly with these disorders.
 In up to half of patients presenting with anxiety or
depression, the diagnosis is missed, and in those who
are recognized a significant proportion are not
treated.
 Most patients with the depressive and
anxiety disorders present and are managed
in primary care settings
23
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 Depression and anxiety in Primary Care

24. PREVALENCE OF DEPRESSION AND ANXIETY IN PRIMARY CARE
World Health Organization [WHO] study on psychological
disorders in primary care:
 --25 000 consecutive adults were screened at 15 sites in 14 countries. Over 5 000 were
further assessed with detailed psychiatric interviews.
 -- A quarter had a recognizable mental disorder.
 -- The commonest being a depressive disorder (11.7%) or an anxiety disorder (10.5%),
with 4.6% having both.
 Only half of the mental disorders were recognised by the primary care physician; among
those patients with a recognised mental disorder, half were offered drug treatment.
 National Comorbidity Study in the United States: A 12-month
prevalence of 11.3% for depressive disorders and 17.2% for anxiety
disorders.
24
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25. DEPRESSION & ANXIETY

26. 26
Depression & Anxiety
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 Depression and anxiety in Primary Care

27. DEPRESSION ANXIETY27
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 Depression and anxiety in Primary Care

28. ANXIETY IS A COMMON
SYMPTOM OF DEPRESSION
Sadock and Sadock 2003.
Depression With
Anxiety Symptoms
90%
Depression
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29. MDD AND ANXIETY DISORDERS
Anxiety
Disorders
59%
Major
Depression
29
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30. *Anxiety disorders included panic disorder, agoraphobia without panic
disorder, social phobia, simple phobia, and GAD.
Kessler RC, et al. Arch Gen Psychiatry. 1 994 ;5 1 :8- 1 9.
Comorbidity
Majority with AD develop
lifetime MDD;
>50 % with MDD
develop lifetime AD
Anxiety
Disorders*
25 %
lifetime
prevalence
Major
Depression
1 7 %
lifetime
prevalence
ANXIETY-DEPRESSION COMORBIDITY
30
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31. Posttraumatic
stress disorder Panic disorder
OCD
Depression
48% of patients with PTSD Up to 65% of patients
with panic disorder*
67% of patients with
obsessive-compulsive disorder
GAD
Social anxiety
disorder
42% of
patients with
generalized
anxiety
disorder
34% to 70% of patients
with social anxiety
disorder
DEPRESSION—ANXIETY COMORBIDITIES
*Figures for panic disorder and depression not specified as lifetime in DSM-IV-TR™.
Kessler 1995; DSM-IV-TR™ 2000; Brawman-Mintzer 1993; Rasmussen 1992; Stein 2000; Van Ameringen 1991; Wittchen 1999.
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32. DEPRESSION AND ANXIETY IN
PRIMARY CARE
32
Mr. Nasser 28 years old
Chief manger presented to
primary care clinic complaining
of muscular ache, abdominal
discomfort, dry mouth,
palpitation.
He has excessive worry and
sense of impending disaster
without evidence of
appropriate real danger,
started 9 month ago.
He had history frequent
attack of shortness of breath,
cold extremities and wet palm
during the last 7 month.
HOW YOU WILL APPROACH NASSER?
Mrs Z. 40 years old nurse
presented to primary care
clinic complaining of insomnia,
decreased appetite, easy
fatigability, dull headache and
irregular menstrual cycles.
She has depressed mood
most of the day, loss of
interest,, hopelessness, and
pessimistic and guilty thought.
HOW YOU WILL PROCEED DURING THIS
CONSULTATION?
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33. *Symptoms of GAD and SAD.
DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.
SYMPTOM OVERLAP OF
ANXIETY AND DEPRESSION
Depressed mood
Loss of interest or pleasure
Appetite
disturbance
Worthlessness
Suicidal ideation
Low self-esteem
Agitation
Irritability
Fatigue
Difficulty concentrating
Sleep disturbance
Muscle tension
GI complaints
Pain
Anxiety
Worry
Dry mouth
Palpitations
Sweating
Trembling
Blushing
Stuttering
33
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34. DEPRESSION—IMPLICATIONS
OF ANXIETY COMORBIDITIES
 Increased severity of symptoms
 Increased impairment of mental and physical
functioning
 Delayed recovery
In patients with comorbid panic disorder and
depression,
 Increased prevalence of suicide attempts
 Decreased work productivity and attendance
 Increased service use (medical, mental health, social
services)
Brown 1996; Coryell 1988; Roy-Byrne 2000.
34
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35. Impaired occupational functioning=6 or more lost workdays or days spent being less productive;
Impaired social functioning=low rates of social support and high rates of negative
social interactions.
Kessler RC, et al. Am J Psychiatry. 1999;1 56:1 91 5-1 923.
Kessler RC, et al. Arch Gen Psychiatry. 1994;5 1 :8- 1 9.
IMPACT OF ANXIETY
ON FUNCTIONING & HEALTH:-
0
5
10
15
20
25
30
35
40
45
50
Impaired social
functioning
Impaired occupational
functioning
Fair/poor perceived
mental health
Patients(%)
Controls (n=5,217)
Pure GAD (n=92)
Comorbid GAD + MDD (n=99)
35
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36. ETIOLOGY OF MAD
 Depression and anxiety may occur as primary disorders
or secondary to a range of medical conditions, drug use
or other psychiatric disorders.
 The causes of primary depression and anxiety are
include:-
 biological factors such as genetics, neurotransmitter
abnormalities, neuroendocrine abnormalities and
 psychosocial factors (life events, environmental stress,
and premorbid personality).
 In the primary care setting it is the secondary causes
that need to be excluded.
36
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37. ETIOLOGY OF MAD
SECONDARY DEPRESSION
The more common conditions associated with depression
include:
Endocrine disorders (hypothyroidism, hyperthyroidism,
Cushing’s disease and Addison’s disease),
Infections (infectious mononucleosis, influenza, tertiary
syphilis and AIDS),
Neurological disorders (multiple sclerosis, Parkinson’s disease)
and cerebrovascular disorders.
Underlying malignancies should also be considered.
Drugs commonly associated with depression are
antihypertensive agents, corticosteroids, oral contraceptives and
antineoplastic agents.
Recreational drugs such as alcohol and amphetamines can
cause depression either during intoxication or withdrawal.
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38. ETIOLOGY OF MAD
SECONDARY ANXIETY
 anxiety disorders, consider endocrine disorders such
as thyroid, parathyroid, and adrenal dysfunction
(phaeochromocytoma), seizure disorders and cardiac
conditions such as arrhythmias, supraventricular
tachycardia, and mitral-valve prolapse.
Drugs commonly associated with anxiety are
sympathomimetics such as amphetamines, cocaine and
caffeine. Drugs that increase serotonin release, such as LSD and
MDMA (“ecstasy”), can cause acute and chronic anxiety.
Prescription medications to consider include
sympathomimetics, antihypertensives (especially captopril), and
non-steroidal anti-inflammatory drugs.
38
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39. Why it is under-recognized?
Depression
&
Anxiety
39
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 Depression and anxiety in Primary Care

40. Why it is under-recognized?
1. Patient Issues.
2. Physician Issues
3. Health System Issues
4. Societal Issues
40
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 Depression and anxiety in Primary Care

41. 1- Stigma.
2- Ignorance of Depression and Anxiety.
3- Self-blame as one of the elements of depression can
prevent the patient from seeking help.
4- Failure to complete a course of adequate treatment.
5- Presentation (by focusing on somatic symptoms, pain or
discomfort) and ignoring the depressive and anxiety
symptoms.
Patient Issues:
41
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42. 1- Knowledge about depression and anxiety.
a) in the US it is not included in most training programs
for primary care physicians.
b) 40% judged their psychiatric placements to have no
relevance to their practice.
2- Skills development. (Diagnosis and Treatment)
3- Lack of Time.
Physician Issues:
42
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43. -Insurance Covering.
-Structure (liaison, screening scales, depression
clinics …….etc ).
-Training skills.
-Need for educational programs.
-Cost to society (awareness of work days lost or
work impairment).
Health System Issues:
Social Issues:
43
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44. MANAGEMENT OF
DEPRESSION AND ANXIETY
PHARMACHOTHERAPY
TCA
SSRI
SNRI
MOI
OTHERS
PSYCHOTHERAPY
PSYCHOEDUCATION
CBT
44
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45. 5/13/2017 1:43:21 PM
45
SEVEN PRINCIPLES OF TREATMENT
 Diagnosis
 Discontinuation
 Psychotherapy
 Side-effects
 Dose
 Drugs of choice
 Duration

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46 OLD ANTIDEPRESSANTS
TCA
• desipramine
• nortriptyline
• imipramine
Tetracyclics/others
• maprotiline
• mianserin
• trazodone
Dual action
• amitriptyline
• clomipramine
• dothiepin
MAOIs
• phenelzine
• isocarboxazid
• tranylcypromine
Old
antidepressants
Selective TCA
• lofepramine
TCA-related
• amoxapine
• doxepin

47. 5/13/2017 1:43:21 PM
47 NEW ANTIDEPRESSANTS
SSRI
• citalopram
• escitalopram
• fluoxetine
• fluvoxamine
• paroxetine
• sertraline
New
antidepressants
5-HT re-uptake
inhibitors and receptor
antagonists
• nefazodone
NaSSA
• mirtazapine
NDRI
• bupropion
SNRI
• venlafaxine
• milnacipran
RIMA
• moclobemide
NARI
• reboxetine

48. 48
3A4 2D6 1A2 2C19 2C9
Escitalopram* 0 + 0 0 0
Citalopram 0 + + 0 0
Fluoxetine ++ +++ + ++ ++
Paroxetine + +++ + + +
Sertraline + + + ++ +
0 = Negligible
+ = Very weak interaction
Inhibitory effects of SSRIs on drug metabolising
CYP450 isoenzymes
++ = Moderate interaction
+++ = Strong interaction
•Anti-Arrhythmic
•B-blockers
•Haloperidol
•Neuroleptics
•Caffeine
•Ciprofloxacin
•Theophylline
•Verapamil
•Diazepam
•Propranolol
•Moclobemide
•Imipramine
•Miconazole
•Phenytoin
•S-warfarin
•NSAIDs

49. ANXIETY AND DEPRESSION IN
PRIMARY CARE
 Depressive and anxiety disorders are common in primary care settings,
yet up to half the patients who present with these disorders may not
be diagnosed and others may not be treated.
 The cornerstone of detection is an understanding of the common
presenting symptoms and syndromes.
 Patients with depression or anxiety frequently present complaining of
physical symptoms, which may obscure the psychiatric diagnosis.
 The doctor's consultation technique is important: an empathic style,
open questions and a willingness to hear the patient out will help
reveal the diagnosis.
49
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50. ANXIETY AND DEPRESSION IN
PRIMARY CARE
 Clinical depression is diagnosed when there are at least three or
four symptoms (low mood, loss of interest, sleep disturbance,
lost concentration, fatigue, disturbed appetite, agitation or
retardation, feelings of worthlessness or guilt, suicidal thoughts)
present every day for at least two weeks.
 Anxiety disorders include panic disorder, phobias, obsessive-
compulsive disorder, post-traumatic stress disorder and
generalized anxiety disorder.
 Screening tools (simple questionnaires designed to identify signs
and symptoms of anxiety and depression) can be effective.
 Once a depressive or anxiety disorder is detected, possible
causes to be explored include underlying medical conditions,
psychiatric conditions, and drug or alcohol use.
50
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