ANXIOUS AND SAD PATIENTS
| ANXIETY DISORDERS —Shirah Vollmer, MD, Associate Clinical Professor of Psychiatry and Family Medicine, David
Geffen School of Medicine at the University of California, Los Angeles
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| Anxiety: primary care physicians see more patients with anxiety disorders than do psychiatrists; most patients anxious
during even routine visit; difficult to distinguish anxiety disorder from normal anxiety during office visit; definitions—
good anxiety defined as mild anxiety that mobilizes people to action; bad anxiety defined as unpleasant and overriding
mental tension that leads to avoidance and impairment; ask patients what happens when they are anxious to determine
whether patient has good or bad anxiety (ie, do they work harder at task or avoid task); fear different from anxiety; fear
involves cognitive functions (eg, worries about terrorism), while anxiety creates tense emotional state marked by physical
symptoms; symptoms of anxiety include substernal chest pain, diarrhea, constipation, and joint pain; conceptual
model of anxiety as exaggerated reflexes—designed to ward off potential hazards; patients may exhibit eye blinking,
gagging, coughing, trouble breathing, vomiting, and diarrhea; consider patients with irritable bowel syndrome (IBS) as
having anxiety disorder until proven otherwise
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| Classification of anxiety disorders: spectrum includes social anxiety disorder (SAD; also called social phobia),
posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), and
panic disorder; anxiety disorder not otherwise specified (NOS) used if symptoms do not fit these categories;
prevalence—SAD most common; PTSD second most common, then GAD, and panic disorder least common; anxiety
and depression—2 aspects of same disorder; depression can develop in patient with untreated anxiety disorder; anxiety
can develop in patient with untreated depressive disorder; treatment involves same therapeutic agents; prescribing
antidepressant for anxiety disorder may confuse patients
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 | SAD: fear of what other people think leads to impaired functioning; symptoms include stuttering, palpitations, “butterflies,”
blushing, sweating, and trembling; consider using propranolol (Inderal) to treat patient with performance anxiety;
referring patient to another physician for treatment may prove difficult because of patient’s social anxiety
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| Posttraumatic stress disorder (PTSD): reimbursable diagnosis; involves severe trauma resulting from experiencing unusual
event in which person could do nothing, and as result, feels complete helplessness (helplessness key to diagnosis); patient
re-experiences event through nightmares and flashbacks (dissociative-like experience); avoidance or numbing occurs
in order to prevent re-experiencing traumatic event; hyperarousal to stimuli can result in inappropriate reactions and
dissociation (eg, loud noises associated with gunshot fired during event)
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| OCD: associated with very specific symptoms that respond well to treatment with medication; obsessive component involves
repetitive and intrusive thoughts (eg, “I have to wash my hands”); obsessive thoughts lead to compulsive and
ritualistic behavior (eg, repetitive washing of hands); usually arises in childhood or adolescence, suggesting lifelong
disorder
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| GAD: excessive anxiety and worry that involves various issues; associated with symptoms of restlessness and irritability;
patients feel on edge or “keyed up”; treatment can improve symptoms
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| Panic disorder: mistaken for myocardial infarction by some patients because symptoms include substernal chest pain
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| Etiology: psychoanalytic theory—anxiety arises from unconscious Oedipal conflict; learning theory—anxiety is a
learned behavior; children learn anxiety from anxious parents; chemical imbalance concept—some people genetically
predisposed to anxiety through imbalance of neurotransmitters; involves biologic susceptibility, but early environment
plays role in development; panic disorder associated with reduction in 5-hydroxytryptamine 1A (5-HT1A ) type of serotonin
receptor in 3 areas of brain
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| Diagnostic evaluation: functional impairment—key to evaluation; assess patient for avoidance behavior involving
driving, restaurants, shopping malls, and elevators; avoidance of anxiety-provoking stimuli can lead to agoraphobia; in
children—anxiety expressed through crying, tantrums, or clinging behavior; most anxiety disorders begin in childhood or
adolescence and result in lifelong condition; medication history—assess use of medications, caffeine, marijuana, bronchodilators,
and anticholinergic agents; screening questions—useful in evaluating patient for each anxiety disorder
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| Behavioral: breathing retraining—involves teaching patients rhythmic abdominal breathing; helps to make patients feel
more in control of their anxiety; cognitive restructuring—patients get anxious because they engage in catastrophic
thinking and overestimate probability of occurrence of event; need to restructure thought processes to ease anxiety
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| Pharmacotherapy: selective serotonin reuptake inhibitors (SSRIs)—start with lower dose than usually recommended
and slowly titrate up; starting doses cause increased anxiety in patient with anxiety disorder; patients more sensitive to
side effects from medications; start patient on one-half of smallest dose available; recommend treating patient for 1 yr;
studies show SSRIs can increase risk for suicidal behavior in children and adolescents with psychiatric disorders; consider
risk for suicide when treating children or adolescents with any antidepressant; antidepressants can cause behavioral
toxicity, resulting in increased anxiety; side effects include sexual dysfunction (eg, decreased libido, difficulty
achieving orgasm), headaches, irritability, nausea, and insomnia (mild and transient); benzodiazepines—enhance action
of neurotransmitter γ-aminobutyric acid (GABA); produce sense of calm in patients within minutes; potential for
abuse, especially in patients who abuse other drugs (eg, methamphetamine, cocaine) or alcohol; can help patients understand
connection between anxiety and experiences; dualaction reuptake inhibitors—venlafaxine (Effexor) and duloxetine
(Cymbalta); mechanism of action involves serotonin and norepinephrine; effective in treating anxiety, but not
more effective than SSRI; can cause hypertension (monitor blood pressure); other psychotropics— β-blockers useful
in treating performance anxiety; mood stabilizers second- or third-line treatment of anxiety disorders; clonidine used to
treat children with anxiety (associated with rebound hypertension); buspirone (BuSpar) safe and effective in treating
GAD; mirtazapine (Remeron) effective in reducing anxiety but associated with somnolence and weight gain
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| DEPRESSION —A. Evan Eyler, MD, MPH, Associate Professor, Family Medicine and Psychiatry, Associate Residency
Director, and Director, Behavioral Sciences, Department of Family Medicine, University of Vermont College of Medicine,
Burlington
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| Outpatient evaluation: initial evaluation—determine whether patient depressed or going through life turmoil (not necessarily
depression); determine when depressive symptoms started; check whether patient had previous episode of depression
and outcome of that episode; consider using diagnostic criteria of specific instrument to diagnose depression (eg,
Patient Health Questionnaire-9 [PHQ-9]); consider other diagnoses, eg, adjustment disorder; discuss with patient risks and
benefits of treatment with antidepressants (Food and Drug Administration [FDA] currently more focused on antidepressant
risks); document diagnosis and reasons for diagnosis, and indicate risks and benefits of antidepressant medications discussed
with patient; differential diagnosis—determine type of depression; need to distinguish unipolar depression from bipolar
disorder or depression with psychotic features; look for evidence of mood elevation now or in past; determine whether patient
has or has had psychotic symptoms; determine whether substances contribute to presentation; consider whether patient
chronically dysregulated (eg, personality disorder present); questions to ask patients include “has there ever been a time
when you felt just the opposite of the way you do now?” and “have you ever been so depressed that it caused a perceptual
distortion and made you see or hear things that weren’t there?”; if considering diagnosis of bipolar disorder, document history
and consider consultation; mood swings not necessarily suggestive of bipolar disorder; antidepressant treatment can
cause hypomania or manic episode to occur in patient with bipolar disorder; consider prescribing bupropion if possibility of
cycling; general medical evaluation—document illnesses, medication use, use of illicit substances, and use of herbs; consider
use of stimulant medication along with antidepressant in patient who has severe medical illness with depressive symptoms;
history—ask about previous suicide attempts or near-suicide attempts, past substance abuse treatment (or if treatment
needed), past psychiatric treatment (check for medications and response or problems, psychotherapy or programs, or hospitalizations);
safety evaluation—assess patient for suicidal or violent ideation, intent, or plans; determine whether patient
has access to means to commit suicide, especially guns; check for presence of psychotic symptoms, command hallucinations,
and severe anxiety; ask patient about substance use and past attempts or near attempts at suicide; determine whether
family history of suicide or recent exposure to suicide present; determine whether crisis evaluation needed; evaluation of
functional status—criteria for involuntary hospitalization in most states involve inability to meet basic needs or determination
that person danger to themselves or others; “basic needs” not well defined; assess patient for ability to work, care for
children, meet medical needs, and whether support available
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| Treatment: choices—consider medication or therapy (alone or combined) in mild depression; consider medication and
therapy (if patient able to participate) in patients with moderate to severe depression; if patient has severe depression with
psychotic features or bipolar disorder, consider medication, electroconvulsive therapy (ECT), and psychotherapy when
patient able; therapy as primary modality—consider if patient preference, if previous response positive, significant psychosocial
stressors, interpersonal difficulties, intrapsychic conflict, comorbid personality disorder, or if patient pregnant,
lactating, plans pregnancy, or has high chance of pregnancy; medication as primary modality—consider patient preference,
previous positive response, lack of available alternative modalities, significant sleep or appetite disturbance or agitation,
severe symptoms present, or if need for maintenance therapy anticipated; improving medication response—
once-daily or bid regimen; low cost; optimism on part of patient that medication effective in relieving symptoms and if
reasonably tolerant of side effects; warn patient that response may take up to 1 mo, and to keep taking medications even
when feeling better; ask patient to notify physician before stopping medication, especially if patient taking selective serotonin/norepinephrine
reuptake inhibitor (SNRI); also inform patient where and how to call if he or she experiences problems;
unipolar depression—SSRIs, SNRIs (venlafaxine and duloxetine), norepinephrine and dopamine reuptake
inhibitors (NDRI; bupropion), and noradrenergic and specific serotonergic antidepressants (NaSSA; mirtazapine); consider
combining bupropion with SSRI when patient not getting enough benefit from SSRI alone; bupropion somewhat
activating, and all 3 of major neurotransmitters stimulated with combination of bupropion and SSRI; consider switching
between groups if patient not experiencing enough symptom relief; consider combining SSRIs in some patient; recommend
SSRI if patient has comorbid anxiety disorder, if patient medically ill (eg, myocardial infarction, stroke), has
chronic fatigue, or experiences premature ejaculation; avoid using SSRI with tricyclic antidepressant (TCA);
bupropion—consider if minor cycling risk, if patient has attention-deficit/hyperactivity disorder (ADHD), or if patient
discontinued SSRI because of sexual dysfunction; avoid in patient with eating disorder, seizure disorder, history of traumatic
brain injury, agitation, withdrawal, or hepatic disease; mirtazapine—not associated with sexual dysfunction; consider
use if SSRI becomes ineffective over time, if psychotic symptoms present, or if patient has no appetite or insomnia;
avoid in patient with bipolar disorder, or hepatic or renal risks; neutropenia rare side effect; venlafaxine—consider if patient
needs energy boost or fast onset; use with caution in patients with hypertension, bipolar disorder, cardiac history, or
history of unreliable use or discontinuation of medication; duloxetine—avoid in patient with history of abrupt discontinuation
of medication; consider in patient with erratic use of medication; watch for interactions between medications, especially
SSRI and TCA, and fluoxetine with other drugs metabolized via cytochrome P450 2D6 pathway; risk factors for
recurrence—recommend keeping patient with persistent dysthymia or who had multiple prior major depressive episodes
on medication longer
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| Warnings and cautions: suicide risks—discuss with patients those antidepressant medications associated with increased
risk for suicide, and advise them to seek help immediately if thoughts of suicide occur; document discussion; document that
patient evaluated for bipolar disorder and warned about activation with medication use; discuss risks with responsible caregiver
if patient young or infirm and document discussion; atypical antipsychotics—record baseline weight, body mass index,
blood pressure, blood glucose, and lipid profile in patients given (or who may require) atypical antipsychotics, and follow
these patients closely for changes in these levels; discuss with patient possibility of metabolic syndrome, appetite stimulation,
weight gain, and diabetes and document this discussion; paroxetine—FDA determined exposure in first trimester of pregnancy
may increase risk for congenital malformations; changed from category C to category D; duloxetine—FDA increased
precautions about potential for hepatotoxicity; ask patients about previous liver disease and alcohol use before prescribing this
drug; check transaminase levels in patients taking duloxetine; prostaglandin E2 (PGE2) inhibitors—uncommon but documented
association with rare cases of nonarteric anterior ischemic optic neuropathy (NAION); advise patients who experience
sudden or decreased vision loss to seek help; dextromethorphan—serious threat to adolescents because of potential for
abuse; ask about over-the-counter (OTC) medications during substance histories
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Educational Objectives
| The goal of this activity is to provide a greater understanding of anxiety disorders and depression. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Describe the types of anxiety disorders and their characteristics.
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| 2. Evaluate a patient for an anxiety disorder during an office visit.
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| 3. Enumerate the treatment options for a patient with an anxiety disorder.
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| 4. Appraise a patient for depression.
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| 5. Explain the treatment options for a patient with depression.
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Suggested Reading
Barrett JE et al: Treatment of dysthymia and minor depression in primary care: a randomized trial in patients aged 18 to
59 years. J Fam Pract 50:405, 2001; Beaudin CL et al: Clinical practice guidelines for treating depression in primary
care. Manag Care 13:17-24, 2004; Clark MS et al: FPIN's clinical inquiries. Psychosocial interventions delivered by
primary care physicians to patients with depression. Am Fam Physician 74:1580, 2006; Gao K et al: Efficacy of typical
and atypical antipsychotics for primary and comorbid anxiety symptoms or disorders: a review. J Clin Psychiatry 67:1327,
2006; Halverson J et al: Screening for psychiatric disorders in primary care. WMJ 103:46, 2004; Ham P et al: Treatment
of panic disorder. Am Fam Physician 71:733, 2005; Jacob KS: The diagnosis and management of depression and
anxiety in primary care: the need for a different framework. Postgrad Med J 82:836, 2006; Karasz A et al: Conceptual
models of treatment in depressed Hispanic patients. Ann Fam Med 4:527, 2006; Robinson WD et al: Depression treatment
in primary care. J Am Board Fam Pract 18:79, 2005; Roy-Byrne PP et al: Primary care perspectives on generalized
anxiety disorder. J Clin Psychiatry 65:20, 2004; Stein RE et al: Interventions for adolescent depression in primary
care. Pediatrics 118:669, 2006; Weilburg JB: An overview of SSRI and SNRI therapies for depression. Manag Care.
13:25, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty
reported nothing to disclose.
Dr. Vollmer was recorded at the UCLA Family Practice Refresher Course, sponsored by the David Geffen School of
Medicine at University of California, Los Angeles, and held June 5-9, 2006, in Los Angeles, CA. Dr. Eyler was recorded
at the Vermont Family Medicine Review, sponsored by the University of Vermont College of Medicine, and
held June 13-16, 2006, in Burlington, VT. The Audio-Digest Foundation thanks the speakers and the sponsors for
their cooperation in the production of this program.
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