Prevalence of Anxiety, Insomnia, and Depression SECTION I

(1)

Treatment of the Most

Common Behavioral

Disorders: Anxiety,

Insomnia & Depression

P R E S E N T E R : M A R L I N C . H O O V E R , P H D , M S , A B P P

B E H AV I O R A L S C I E N C E FA C U LT Y – S O U T H E R N N E W M E X I C O FA M I LY M E D I C I N E R E S I D E N C Y – L A S C R U C E S

E M A I L : M A R L I N . H O O V E R @ L P N T. N E T

MARLIN C. HOOVER, PHD, MS, ABPP -‐ SOUTHERN NEW MEXICO FAMILY MEDICINE RESIDENCY

Optimum Treatment vs. Usual

Treatment

Ø Most common behavioral (emoMonal/psychological/psychiatric) disorders in primary care and hospital seSngs

Ø Anxiety Ø Insomnia Ø Depression

Ø Behavioral disorders oUen co-‐occur with other medical disorders Ø Contribute to polypharmacy

Ø Complicate other medical treatment

Optimum Treatment vs. Usual

Treatment

Best treatment for these behavioral disorders is oUen non-‐Rx rather than Rx Pharmacotherapy is overused due to

Ø Unavailability of behavioral providers Ø Costs of behavioral intervenMons

Ø Time constraints experienced by busy medical providers

Ø Lack of awareness of evidence base for the eﬀecMveness of opMmal intervenMons

Organization of This Presentation

SecMon I -‐ Prevalence of anxiety, insomnia, and depression SecMon II -‐ Symptoms of anxiety, insomnia, and depression

SecMon III -‐ Some criteria for deciding whether non-‐Rx, Rx, or a combinaMon of non-‐Rx and Rx treatment is opMmum

SecMon IV -‐ Some criteria for deciding which Rx is opMmum when Rx is part of the treatment plan with reference to the half-‐life, eﬀects, and side-‐eﬀects of the Rx SecMon V – Notes on the non-‐Rx treatments

Prevalence of Anxiety,

Insomnia, and

Depression

SECTION I

Anxiety

The most common psychiatric disorders

Ø 15.4% of community samples have an anxiety disorder Ø 5th_{most common clinical diagnosis in primary care (11% of all visits)} Ø OUen precipitated by or coexisMng with somaMc illness

Ø More than half of all paMents in US with a mental disorder receive their sole treatment from a PCP

(2)

Prevalence of Most Common Anxiety

Disorders

12 Months % LifeMme % Social phobia 7.9 13.3 OCD 0.6-‐1.3 2.5 PTSD 2.0-‐3.2 8.0

Agoraphobia without panic disorder 2.8 5.3

Panic disorder 2.3 3.5

GAD 3.1 5.1

Anxiety

Medical condiMons that cause or exacerbate anxiety Ø Hyperthyroidism

Ø Hypoglycemia

Ø Cardiovascular disorders (arrhythmias, MI, CHF, mitral valve prolapse) Ø Audio vesMbular disorder

Ø COPD and other respiratory disorders Ø Substance use or withdrawal Ø Acute pain

Insomnia – Prevalence

Only 5% of paMents with insomnia go to their PCP with the problem Only 16% of paMents who are with PCP will menMon the problem Contributes to a variety of medical condiMons – DysregulaMon of circadian paeerns leads to

Ø Suppressed immune funcMon Ø Retarded healing

Ø DysregulaMon of autonomic nervous system

NEI Audio Education Series

Insomnia – Prevalence

Ø 30 percent of the general populaMon complains of sleep disrupMon Ø 10 percent has associated symptoms of dayMme funcMonal impairment Ø  Unpublished data from a middle-‐aged populaMon followed over 10 years

describe a persistence of symptoms

NIH SOS Conference 2005 June

Prevalence of Depression

Ø LifeMme prevalence: 16.2%

Ø 12-‐month prevalence: 6.6%

Ø 59% had severe or very severe role impairment Ø 51.6% of depressed paMents received some treatment Ø Of these, 41.9% were rated as adequately treated Kessler et al. JAMA 2003 June 18:3095-‐3105

Symptoms of Anxiety,

Insomnia, and

Depression

SECTION II

(3)

Anxiety

Ø PalpitaMons, pounding heart, chest pain or discomfort Ø SweaMng/trembling/shaking, chills or hot ﬂushes, paresthesias Ø SensaMon of shortness of breath or smothering/choking Ø Nausea or abdominal distress

Ø Feeling dizzy, unsteady, lightheaded, or faint Ø DerealizaMon or depersonalizaMon Ø Fear of dying

Presentations of Anxiety

Ø ExacerbaMng or resulMng from comorbid medical condiMons and treatments Ø Presented in the DiagnosMc and StaMsMcal Manual of the American Medical

AssociaMon (DSM-‐V) as a diagnosable anxiety disorder

Ø Presented as a symptom of other DSM-‐V diagnosable mental disorders

Medications Known to Cause Anxiety

Ø AnMhypertensive and cardiovascular

Ø Calcium channel blockers and digitalis Ø SympathomimeMcs and bronchodilators Ø AnestheMcs

Ø Analgesics

Ø AnMcholinergic and anM-‐Parkinson’s agents Ø Insulin

Ø Thyroid preparaMons

Ø Oral contracepMve and/or hormone replacement Ø AnMhistamines

Ø AnMconvulsants Ø Lithium Ø AnMdepressants Ø AnMpsychoMcs

Iatrogenic Effects of Medication vs.

Primary Symptoms of Disease

Progression

Examples

Ø Akathisia versus anxiety Ø MedicaMon-‐induced tremor Ø Serotonin syndrome

Sleep Disorders – Common Types

Dyssomnias

Ø Insomnia

ü Diﬃculty falling asleep and staying asleep Ø Hypersomnia

ü DayMme sleepiness in a paMent who appears to be “sleeping enough” Ø Circadian rhythm sleep disorders

ü Adolescent “owls” ü Elderly “larks” ü ShiU work

Major Depressive Episode

Depressed mood or anhedonia (loss of the capacity to experience pleasure) for at least 2 weeks

At least 5 of the following

Ø Depressed mood

Ø Decreased interest or pleasure most of the Mme

Ø Insomnia or hypersomnia

Ø Anorexia or hyperphagia or 5% weight gain/loss in month

Ø Psychomotor agitaMon or retardaMon

Ø FaMgue

Ø Decreased concentraMon or thinking, indecisiveness

Ø NegaMve thinking—worthlessness, inappropriate guilt

Ø Recurring thoughts of death or suicide-‐IV-‐TR Criteria

(4)

Depression

Severity

Ø Depressed mood or anhedonia (loss of the capacity to experience pleasure) for at least 2 weeks

Ø Not caused by medical illness

Ø At least 5 of the cardinal symptoms indicaMve of major depression, broadly, insomnia or hypersomnia, anorexia or hyperphagia, psychomotor agitaMon or retardaMon, faMgue, execuMve funcMon impairment, negaMve thinking, suicidal ideaMon or intent

Non-Rx, Rx, or a

Combination of

Non-Rx and Non-Rx Treatment

SECTION III

MARLIN C. HOOVER, PHD, MS, ABPP -‐ SOUTHERN NEW MEXICO FAMILY MEDICINE RESIDENCY MARLIN C. HOOVER, PHD, MS, ABPP -‐ SOUTHERN NEW MEXICO FAMILY MEDICINE RESIDENCY

Behavioral Non-‐Rx Rx Combined

Anxiety disorders Generalized anxiety

disorder XXX X XX

Panic disorder XXX X XX

Social phobia XXX X XX

OCD XX XX XXX

Sleep disorders Sleep onset delay XXX X XX

Sleep maintenance

disorder XXX X XX

Sleep phase disorder XXX X X

Depressive disorders Major depressive disorder XXX XXX XXX

Dysthymic disorder XXX X XX

Postpartum disorder XX XX XXX

Bipolar disorder XX XX XXX

Conditions in which Rx may be

considered essential?

Ø Major depressive disorder – severe Ø Bipolar disorder

Ø PsychoMc disorders

Optimum Treatment of Depression

Ø Time

Ø Aerobic exercise Ø Proper nutriMon Ø ReducMon in stressors Ø CogniMve behavioral therapy Ø Psychotropic medicaMon

Antidepressants Work Best If

PaMents show “vegetaMve signs” of depression including Ø Anergy (low energy – gross faMgue)

Ø Anhedonia (absence of drive for and pleasure in insMnctual graMﬁcaMon – ﬂuid, food, sex)

Ø CogniMve slowing

Ø Sleep disturbance – especially early morning waking without a return to sleep

(5)

Antidepressants Work Less Well For

Ø Persons whose depression is secondary to a physical cause

ü Medical illness

ü Substance use, dependence, abuse Ø Persons whose depression is “characterological”

ü Based on lifestyle ü Based on habitual ways of thinking

ü Based on the ideas commonly held in their social milieu Ø Persons with a bipolar disorder or schizophrenia

Considering Effects,

Side-Effects, and

Half-Life

SECTION IV

Rx Treatment – Anxiety, Insomnia,

Depression

NEUROTRANSMITTER TARGETS

CONDITION + 5HT + NE + DA Ø ACH Ø H1 +GABAMEDICATIONS

Depression

With Low Energy xx xx xx Bupropion, Venlafaxine, Selegiline

With Anxiety xx xx Fluoxetine, Trazodone

Anxiety xx x x Citalopram, Buspirone, Hydoxyzine, Diazepam Insomnia

With Depression xx xx xx Trazodone, Mirtazapine, Amitriptyline

Without Depression x Zolpidem

Physical Pain x x Duloxetine

Ø = Blockade + = Increase

Pharmacotherapy of Anxiety

Ø Acute vs. chronic

Ø Chronic

ü Rely on ADs rather than BZs unless AD is counter-‐indicated ü May start AD along with a limited course of BZ to treat anxiety unMl AD

begins working

ü Try buspirone rather than BZ for chronic anxiolyMc

Medication Choices – Anxiety

Disorders

Panic Disorder GAD Social Anxiety

Disorder OCD

SSRIs SSRIs SSRIs SSRIs

SNRI SNRI SNRI

TCAs TCAs TCAs TCAs

Trazodone Beta Blockers

Buspirone

SSRIs: Treatment of Choice

Ø Depression

Ø Panic aeacks

Ø Obsessive compulsive disorder (OCD) Ø Social anxiety disorder Ø Post-‐traumaMc stress disorder (PTSD) Ø Used in generalized anxiety disorder (GAD) REMEMBER

SSRIs are oUen acMvaMng in the ﬁrst two weeks to one month with increased anxiety, agitaMon, GI complaints, suicidal ideaMon

(6)

Relative Risk of Suicidal Behavior

Drug Half-‐Life RR for SB Half-‐Life Rank RR Rank

Venlafaxine 5.2 4.97 1 2 Fluvoxamine 15.6 5.52 2 1 ParoxeMne 21 2.65 3 3 Sertraline 26 1.45 4 6 Mirtazapine 30.5 1.58 5 4 Citalopram 35 1.37 6 7 FluoxeMne 96-‐144 1.52 7 5

Relative risk is the risk of condition in exposed versus non-exposed group. Smith, E. Association between antidepressant half-life and the risk of suicidal ideation or

behavior among children and adolescents. Journal of Affective Disorders. Published

Online August 2008.

Pharmacotherapy of Sleep Disorders

Treatment algorithm – 3 quesMons

Ø Difficulty falling asleep (sleep onset delay = SOD) Ø Difficulty staying asleep (difficulty maintaining sleep – DMS) Ø How much Mme available to be in bed sleeping (Mme for bed – TFB)

Pharmacotherapy

SOD DMS TFB Treatment AcQon DuraQon

yes no 8 hrs Short or speciﬁc to SOD

no yes 8 hrs Longer acMng without dayMme sedaMon at bedMme

OR

Short acMng at Mme of early waking

yes yes 8 hrs Longer acMng without dayMme sedaMon

yes yes 4 hrs Short acMng

no yes 4 hrs Short acMng

yes no 2 hrs Shortest acMng (Zaleplon – Sonata)

Benzodiazepine Receptor Agonists (Z –

Drugs)

Nonbenzodiazepines Ø Zaleplon (Sonata) ST use – SOD

Ø ½ life = 1 Hour

Ø Zolpidem (Ambien) ST use – SOD

Ø ½ life = 2.5 – 3.1 Hours

Ø Zolpidem sustained release (Ambien CR) – SOD and DMS

Ø ½ life = 4.5

Ø Eszopiclone (Lunesta) – SOD and DMS

Ø ½ life = 6 Hours

Psychopharmacology for Insomnia:

Melatonin Receptor Agonists

Nonbenzodiazepines Ø Ramelteon (Rozerem) – SOD Ø Melatonin supplements – SOD See also

Ø GabapenMn Ø Gabatril

Psychopharmacology for Insomnia:

Sedating Antidepressants

Trazodone (Desyrel)

Ø The most commonly prescribed medicaMon for the treatment of insomnia in the United States

Ø Short-‐term use – Trazodone is sedaMng and improves several sleep parameters

Ø No studies of long-‐term use of Trazodone for treatment of chronic insomnia

(7)

Psychopharmacology for Insomnia:

Sedating Antidepressants

(Continued)

Doxepin

Ø Beneﬁcial eﬀects on sleep for up to 4 weeks Ø Most common SE is sedaMon

Signiﬁcant adverse eﬀects of sedaMng ADs Ø AnMcholinergic

Ø Arryhthmic

Psychopharmacology for Insomnia:

Sedating Antipsychotics

Seroquel (queMapine) Ø Low doses (25 – 50 mg QHS) Ø Signiﬁcant adverse eﬀects

ü Severe hypotension ü Syncope ü Tardive dyskinesia ü NMS ü Hypothyroidism ü Hyperglycemia ü Diabetes mellitus ü Agranulocytosis ü QT prolongaMon ü Worsening depression

Psychopharmacology for Insomnia:

OTCs

Ø Diphenhydramine most common

Ø H1 receptor antagonists are the most commonly used OTC treatments for chronic insomnia

Ø M1 receptor antagonists (producing unwanted SEs) Ø Adverse eﬀects

ü Residual dayMme sedaMon ü Diminished cogniMve funcMon ü Delirium

Pharmacotherapy for Daytime

Sleepiness

Ø Modaﬁnil (Provigil) (long acMng – half-‐life 15 hrs) Ø Selegiline (MAO B inhibitor) (PO and TD – long acMng) Ø SMmulant medicaMon

ü Methylphenidate (Ritalin) (short acMng – half-‐life 2-‐3 hrs) ü Pemoline (Cylert) (longer acMng – half-‐life 12 hrs)

Psychopharmacology for Depression

MedicaMon choice – most important factors Ø How anxious is the paMent? –> SSRI Ø How much pain is the paMent experiencing? –> SNRI Ø How low energy is the paMent? –> NDRI

Ø How much trouble is the paMent having in sleeping? –> SARI, Tricyclic AD Ø How hypersensiMve is the paMent to side eﬀects? –> SSRI with long half-‐life

and “start low and go slow”

SNRI: Venlafaxine

Ø SSRI acMvity essenMally at 75-‐100 mg, when SNRI acMvity begins to dominate

Ø Broad-‐spectrum anMdepressant eﬃcacy (GAD-‐approved also—may need higher doses than for depression)

Ø May lead to hypertension, sedaMon, and sexual dysfuncMon, parMcularly in higher doses

(8)

SNRI: Duloxetine

Ø SSRI/SNRI acMvity ﬁxed at all dosages, with SNRI acMvity dominaMng

Ø Broad-‐spectrum anMdepressant eﬃcacy (approved for GAD and pain associated with peripheral neuropathy of diabetes mellitus)

Ø Nausea the most common reason for disconMnuaMon

ASCP CURRICULUM

Antidepressant Adverse Effects

Serotonin (5HT)

Ø GI disturbances, increase or decrease in anxiety, sexual dysfuncMon, suicidal ideaMon

Norepinephrine (NE)

Ø Tremors, tachycardia, augmentaMon of pressor eﬀects of sympathomimeMc amines, sexual dysfuncMon

ASCP CURRICULUM

Antidepressant Adverse Effects

Histamine (H1)

Ø PotenMaMon of central depressant drugs, drowsiness, sedaMon, weight gain, hypotension

Cholinergic

Ø Blurred vision, dry mouth, sinus tachycardia, consMpaMon,

urinary retenMon, memory dysfuncMon Alpha 1 and 2

Ø Postural hypotension, dizziness, reﬂex tachycardia

ASCP CURRICULUM

Effect of ADs on Sleep Architecture

AnQdepressant Sleep Latency Sleep

ConQnuity Delta REM Rem Latency

SSRI /\ \/ \/ \/ \/ \/ /\ Trazodone \/ \/ /\ /\ /\ /\ \/ /\ Mirtazapine \/ \/ /\ /\ /\ /\ \/ /\ Buproprion /\ NE NE NE NE Venlafaxine /\ \/ \/ \/ /\ TCAs \/ \/ /\ /\ /\ /\ \/ \/ /\ MAOIs NE NE NE \/ \/ \/ /\ /\

Jenkins, S., Tinsley, J., and Van Loon, J. A Pocket Reference for Psychiatrists,

3rd Ed. American Psychiatric Press, (2001).

Antidepressants: Risk in Overdose

Drug RelaQve Toxicity Index Scores

Doxepin 2.7 Clomipramine/Anafranil 1.4 Trimipramine/SurmonMl 1.7 Impramine/Tofranil 1.5 Nortriptytline/Pamelor 1.3 Venlafaxine/Eﬀexor 0.29 Mirtazapine/Remeron 0.22 Citalopram/Cylexa 0.12 Sertraline/ZoloU 0.05 FluoxeMne/Prozac 0.03 ParoxeMne/Paxil 0.03

Behavioral Treatment

of Anxiety, Insomnia,

and Depression

SECTION V

(9)

Lifestyle Changes – Anxiety,

Insomnia, Depression

UMlize moMvaMonal interviewing Promote behavioral acMvaMon Begin aerobic exercise (walking program)

Ø Start slowly

Ø Hoover rule – Never Hurt Yourself

ü RaMo of posiMve to negaMve associaMons to exercise must be heavily weighted in the direcMon of the posiMve

ü Goal is to become “addicted” to exercise

Lifestyle Changes – Anxiety,

Insomnia, Depression

DisconMnue/reduce use of sMmulants Reduce/disconMnue alcohol consumpMon Aeend to sleep hygiene

Ø Regularize Mming of sleep-‐wake cycle Ø Reduce late-‐day food consumpMon Ø Sound screen – white noise generator Ø Sleep environment

Behavioral Changes – Anxiety,

Insomnia, Depression

Behavioral intervenMons

Ø Challenge anxiety-‐provoking “cogniMve distorMons” Ø Progressive muscle relaxaMon and breathing exercises Ø Aerobic exercise

Ø Biofeedback Ø Sleep hygiene

Behavioral Treatments: Anxiety,

Insomnia, Depression

Biofeedback

Ø Peripheral temperature (ﬁnger Mp) increase due to peripheral vasodilataMon

Ø Promotes parasympatheMc arousal Exposure

Ø Graded exposure to anxiety-‐triggering sMmulus Ø Flooding to “learn relaxaMon in response to sMmulus”

Behavioral Treatments: Anxiety,

Insomnia, Depression

Progressive muscle relaxaMon Ø  Oﬀer CD to paMent Ø  Explain the importance of pracMce Aerobic exercise

Ø  Increase paMent’s aerobic capacity ü Reduces anoxic trigger of anxiety ü Reduces circulaMng catecholamine Breathing exercises

Ø  Inhale slowly through nose Ø  “Belly breathing”

Cognitive Changes: Anxiety,

Insomnia, Depression

Ø SystemaMcally challenge distorted thinking

Ø SubsMtute nondistorted and realisMc interpretaMons and explanaMons

(10)

Thank you!

QUESTIONS?