anxiety and depression Flashcards
what is anxiety?
mild or severe feeling of unease such as worry or fear
- long term condition
- anxious about certain events
what are the risk factors for anxiety?
genetics
history of stress or traumatic experiences (violence, child abuse, bullying)
painful long term health conditions - limiting (i.e., arthritis)
history of alcohol or drug abuse
- women more affected than men
- more common in 35-55 years
what are the 2 types of symptoms you can get with anxiety?
physiological and physical
what are the symptoms of anxiety?
physiological:
- restlessness/worried
- fearful
- on edge 24/7
- irritable
- difficulty concentrating/sleeping
physical:
- dizziness
- tiredness
- palpitations
- SOB
- insomnia
- headache
- excessive sweating
- dry mouth
what is the diagnosis of anxiety?
there is no single diagnosis
- other conditions w overlapping symptoms (i.e., anaemia) ruled out first
- if ruled out and symptoms for > 6 months then GAD likely
what are the 3 evidence based treatments for anxiety?
- self help
- talking therapies (CBT)
- medication
what are non pharmacological treatments for anxiety?
self help and talking therapies:
- goal of motivating oneself to improve physical health to have a positive impact on mental health
= exercising regularly, smoking cessation, avoiding caffeine, reducing alcohol
NICE recommends CBT:
- aims to change -ve or unhelpful thoughts and behaviours to manage GAD
- support groups available: anxiety UK, mind, rethink mental illness
NHS Long Term Plan –> NHS want to further expand talking therapies
what are the pharmacological treatments? (4)
a) SSRIs;
- first line = sertraline (cost effective)
- then escitalopram, then paroxetine (paroxetine has ACB of 3!)
- start w low dose and gradually increased
- s/e such as n+v, dizziness - should resolve within 2 weeks
- dose adjustments may be needed if not
b) if SSRIs do not work then SNRI (serotonin & noradrenaline reuptake inhibitors);
- venlafaxine (but increased risk of suicide, toxicity, and withdrawal)
- duloxetine
- s/e such as dry mouth, constipation, drowsiness
if not working then Sch 3 and 4 CDs
c) pregabalin (anticonvulsant): schedule 3
d) benzodiazepines: schedule 4
risk of addiction if used for more than 4 weeks
used in severe episodes of anxiety (i.e., diazepam)
What needs to be monitored with the pharmacological treatments?
SSRIs and SNRIs and pregabalin:
- there is an increased risk of suicidal thoughts and self harm in those under 30 = weekly monitoring for 1st month
SSRIs:
- increased risk of bleeding (esp in elderly that take meds which can interfere w GI mucosa such as NSAIDs)
benzodiazepines (sedative):
- avoid abrupt withdrawal - taper dose
what are some measures patients can take to help their anxiety?
exercise
calming breathing techniques (3, 4, 5 method)
mental wellbeing audio guides
healthy diet
set small targets that are achievable
do not focus on what you cannot change
do not avoid situations that make you anxious - try to build up tolerance gradually
what is depression?
serious mental disorder that -vely affects how you feel , the way you think and how you act.
involves depressed mood or loss of pleasure/interest in activities for long periods of time
what are the risk factors for depression?
biochemistry: chemical imbalances in brain
genetics - familial links
personality - those w low self esteem may be easily overwhelmed by stress
life events - trauma, stress, bereavement, unemployment, neglect, abuse, poverty
physical health - may be hard to manage conditions (CVD, cancer, diabetes etc)
can be a mix of all these
what are the symptoms of depression?
depressed mood: feeling sad, irritable, empty with loss of interest/pleasure in activities (may be mild, moderate or severe)
- poor concentration
- disrupted sleep
- guilt, low self esteem
- hopelessness about future
- low energy
- changes in appetite
what is the diagnosis for depression?
if suspected then self administered questionnaires used:
- patient health questionnaire
- hospital anxiety & depression scale
- beck depression inventory
what are the evidence based treatments for depression?
behavioural activation
CBT
interpersonal psychotherapy
antidepressants
what is first line for mild depression?
behavioural activation = use of behaviour to influence emotional state
CBT = helps Pt recognise -ve thinking w goal of changing thoughts/behaviours
interpersonal psychotherapy = focusing on relieving symptoms by improving interpersonal functioning
antidepressants not offered unless Pt requests (then start w SSRI and gradually increase)
what is first line for moderate to severe depression?
antidepressants + individual CBT
OR
monotherapy w antidepressant or psychological Tx
what is the matched care model?
a pyramid published by NICE
describes how choice of Tx is based off:
- severity of the problem
- pt past experiences
- pt preferences
as severity increases, as do the nature of the interventions
acknowledge stigma associated w condition and provide the privacy they need when discussing
what are the pharmacological options?
SSRIs
SNRI
TCAs
what is first line for pharmacological treatment?
SSRIs: sertraline, citalopram, fluoxetine
- well tolerated and better safety profile
- increase serotonin activity by increasing amount of synaptic 5-HT available for neurotransmission
what do you need to consider/monitor with the first line treatment?
- is there history of bleeding?
- risk of hyponatraemia, risk
- increased w concurrent NSAIDs and ACEi
- QT interval prolongation - citalopram contraindicated
- closed angle glaucoma
- renal impairment
if drowsiness/dizziness - dose taken at night.
what is second line pharmacological treatment?
SNRIs: duloxetine, venlafaxine
what do you need to consider/monitor with the second line treatment?
- QT interval prolongation: possible increased risk of QT interval prolongation if
venlafaxine is taken with other drugs known to cause QT interval prolongation - angle closed glaucoma (duloxetine)
- renal impairment (venlafaxine) – dose reduction
- hepatic impairment (venlafaxine) (dose reduction)
- history of bleeding disorders (GI bleeding)
if drowsiness/dizziness - dose taken at night.
what is the third line of pharmacological treatment?
TCAs: amitriptyline (ACB of 3), lofepramine
