Comprehensive Notes on Depression and Anxiety Management

Managing Primary Care Conditions: Depression and Anxiety

Depression

  • Depression affects mood, self-care, and physical functioning, exacerbating other chronic conditions.
  • Many cases go undiagnosed due to associated stigma.
  • Clinicians should assess patients for depression without bias.
  • Anyone can develop depression, including children, adolescents, and adults.
  • Risk factors include:
    • Family history of depression
    • Major negative life events
    • Chronic conditions like cancer or Parkinson's disease
  • Focus on Major Depressive Disorder (MDD).
    • According to DSM-5-TR, diagnosis requires one of two key symptoms:
      • Sad, depressed mood
      • Loss of pleasure or interest (anhedonia)
  • Mnemonic for MDD symptoms: SITCAPS
    • S: Sleeplessness
    • I: Decreased Interest
    • G: Guilt
    • E: Decreased Energy
    • C: Decreased Concentration
    • A: Appetite changes
    • P: Psychomotor symptoms
    • S: Suicidal ideation
  • Symptoms must be present for at least two consecutive weeks and interfere with daily living.
  • Screening Tool: PHQ-2 (Two-Item Patient Health Questionnaire)
    • Asks about anhedonia and sad mood over the past two weeks.
    • A score of 3 or higher warrants a full PHQ-9.

Symptoms of Depression

  • PHQ-9: Asks about sleep disturbances, appetite changes, and concentration issues.
    • A score of 5 or greater suggests depression.
    • Important to consider the entire clinical picture and rule out other diagnoses.
  • Assess for harm to self or others.
    • Directly ask about thoughts of harm.
    • If yes, investigate the plan.
    • Detailed plan with current means requires transport to the emergency department.
  • Risk factors for suicide:
    • Male sex
    • Underlying psychiatric disorders (including depression and substance use disorders)
    • Chronic pain or comorbidities
    • Older adults have higher rates.
  • Goal of treatment is remission of symptoms.
  • Treatment options:
    • Combination of pharmacological management and psychotherapy is most effective.
    • Cognitive Behavioral Therapy (CBT) is a common psychotherapy.
    • First-line medications: Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Norepinephrine Reuptake Inhibitors (SNRIs).
    • Start at a lower dose and taper up slowly.
    • Potential for increased risk of suicidal ideation, especially in younger adults.
    • Educate patients about this risk.
    • True effects seen 4-6 weeks after starting medication.
  • Referral indications:
    • Need for multiple medications
    • Suboptimal symptom control despite recommended treatment
    • Changes in symptoms suggesting another mental health condition
    • Coexisting substance use disorder

Seasonal Affective Disorder (SAD)

  • Depression occurs at the same time every year, commonly in winter.
  • Caused by changes in circadian rhythm due to changing seasons.
  • Treatment:
    • Light therapy to reset circadian rhythm.

Generalized Anxiety Disorder

  • Anxiety is a normal fight or flight response.
  • Can be acute or chronic (lifelong).
  • Progression leads to worry, fear, and physical symptoms.
  • Anxiety and depression often coexist.
  • DSM-5-TR criteria:
    • Anxiety on more days than not for at least six months.
    • Excessive anxiety, difficult to control.
    • Causes impairment in functioning.
    • Not caused by other substance or mental health disorders.
  • Mnemonic for GAD symptoms: WATCHERS
    • W: Worry
    • A: Anxiety
    • T: Tension
    • C: Concentration difficulty
    • H: Hyperarousal
    • E: Energy loss
    • R: Restlessness
    • S: Sleep disturbance
  • Screening Tool: GAD-2 (Generalized Anxiety Disorder 2-item scale):
    • Asks if patient felt nervous, anxious, or on edge, and control of worrying over the last two weeks.
    • A total score of 3 or greater warrants further follow-up with GAD-7.
  • GAD-7:
    • Seven questions evaluating frequency of other anxiety symptoms.
    • A score of 5 or higher suggests possible GAD diagnosis.
  • Treatment:
    • Pharmacotherapy and/or psychotherapy (CBT).
    • SSRIs and SNRIs are first-line drug classes.
  • Consult a specialist for any persistent symptoms or changes in symptoms that suggest another psychiatric mental health disorder.