Anxiety/Depression

Anxiety

Episodic

Social Anxiety Disorder

  • Anxiety correlated with specific social and/or cultural interactions

  • Refer for cognitive behavioral therapy and/or graded desensitization

  • Start escitalopram 10 mg qd and propranolol 40 mg PRN 60 minutes prior to anxiety-provoking events

  • Buspirone is not effective

Panic Disorder

  • Acute onset anxiety presenting with lightheadedness, shortness of breath

  • Hyperventilation, diaphoresis, and tremors on exam

  • Treatment

    • Start escitalopram 10 mg qd and hydroxyzine 25 mg TID PRN

      • Continue escitalopram for at least 1 year before trial of discontinuation

      • Increase escitalopram by 10 mg every 4 weeks until symptoms are controlled (maximum daily dose 30 mg qd)

    • Buspirone is not effective

Chronic

Generalized Anxiety Disorder

  • More common in females (2:1 prevalence)

  • Patients often perseverate on personal failures and imperfections

  • Often comorbid with major depressive disorder

  • Diagnosis

    • Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months

    • The individual finds it difficult to control the worry

    • The anxiety and worry are associated with three (or more) of the following six symptoms

      • Restlessness, feeling keyed up or on edge

      • Being easily fatigued

      • Difficulty concentrating or mind going blank

      • Irritability

      • Muscle tension

      • Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)

    • The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

    • The disturbance is not attributable to the physiological effects of a substance (e.g. substance abuse) or another medical condition (e.g. hyperthyroidism)

    • The disturbance is not better explained by another medical disorder (e.g. panic disorder)

  • Treatment

    • Maintenance medications: Start one of the following

      • Escitalopram 10 mg qd and increase by 10 mg every 4 weeks until symptoms are controlled (maximum daily dose 30 mg qd)

      • Buspirone 5 mg BID and increase 5 mg BID every week until symptoms are controlled (maximum daily dose 20 mg TID)

    • Consider hydroxyzine 25 mg TID PRN for comorbid panic attacks

    • Beta-blockers (e.g. propranolol) are not effective

Due to a medical condition: Hyperthyroidism

Major and Persistent Depression Disorders

Overview

  • Screen all patients ≥ 12 years old

  • Organic etiologies

    • Associated medical conditions commonly associated with fatigue

    • Review social history and medications for central nervous system depressants, e.g.

      • Alcohol and/or recreational drug use

      • Prescription anxiolytics, sedatives, narcotics

      • Corticosteroids

    • Consider CBC, CMP, TSH, RPR, urine drug screen prior to starting treatment

Diagnosis per DSM-5

Major Depressive Disorder

  • Diagnosis (PHQ-9) requires ≥ 5 of the following symptoms and symptoms 1 or 2 (below) must be present:

  1. Anhedonia (diminished interest or pleasure)

  2. Depressed mood most of the day, nearly every day

  3. Insomnia or hypersomnia

  4. Fatigue and/or decreased energy

  5. Poor appetite or overeating

  6. Feelings of worthlessness or excessive guilt

  7. Diminished concentration and/or decisiveness

  8. Slowing in thought or movement noticeable to others

  9. Recurrent thoughts of death or suicidal ideation without a plan

Persistent Depressive Disorder (Dysthymia)

  • Depressed mood for ≥ 2 years with no symptom free period for > 2 months and 2 of the following

    • Changes in sleep or appetite

    • Decreased energy or concentration

    • Slowing in thought or movement noticeable to others

    • Excessive guilt or thoughts of death

    • Hopelessness

Pseudodementia

  • Major depressive disorder in elderly patients leading to significant memory/concentration deficits patients

  • Resolves with treatment of depression

Treatment: Psychotherapy and/or Pharmacotherapy

  • Medications

    • First line: SSRI

      • Start escitalopram 10 mg qd and increase by 10 mg every 4 weeks until symptoms are controlled (maximum daily dose 30 mg qd)

      • Use caution in patients with a h/o mania, hyponatremia

    • Second line: SNRIs

      • Venlafaxine 75 mg qd

      • History of chronic pain: Duloxetine 40 mg qd

    • Sexual side effects with SSRI/SNRI and/or current smoker: Bupropion 150 mg qd (verify no h/o seizure)

    • Insomnia and

      • Decreased appetite: Mirtazapine 15 mg qhs

      • Chronic pain: Nortriptyline 50 mg qd

    • Refractory to multiple medications: Consider electroconvulsive therapy (ECT)

  • Schedule follow-up in 4-6 weeks

    • If repeat PHQ-9 shows improvement, continue current medication and consider increasing the dose

    • If no improvement, transition to another antidepressant

  • Duration of antidepressant treatment

    • First depressive episode: At least 6 months

    • Recurrent episode: At least 2 years

Depression-Associated Disorders

General Population

Seasonal Affective Disorder

  • Sub-category of other depressive disorders, e.g. MDD, bipolar

  • Diagnosis

    • Seasonal onset and remission of depressive, manic, or hypomanic episodes with

      • At least two seasonal depressive episodes within the last two years

      • More seasonal than non-seasonal depressive episodes

    • Not due to

      • Psychosocial stressors associated with a season, e.g. financial stress during the holidays

      • Another medical issue, e.g. hypothyroidism, substance abuse

  • Effective treatments: Light therapy (remain 12-18 inches from 10,000 lux lamp for 30 minutes/day), SSRI, CBT

Bipolar I and II

  • Diagnosis

    • Bipolar I: One manic episode lasting ≥ 1 week

    • Bipolar II: One hypomanic episode lasting ≥ 4 days and one major depressive episode (no history of manic episodes)

    • Manic episode (DIG FAST): Distractibility, indiscretion, grandiosity, flight of ideas, activity increase, sleep deficit, talkativeness (pressured speech)

    • Hypomanic episode: Less severe than a manic episode (socially appropriate, no long-lasting self harm, no need for hospitalization)

  • Treatment

    • Lithium (salt that adversely affects pregnancy, renal function)

      • Obtain initial baseline BMP, TSH, T4, and EKG and repeat q6 months

      • 300 mg TID and obtain lithium level within 5 days of starting mediation; goal 1.0 +/- 0.2 mEq/L

    • Valproic acid (anti-convulsant)

      • Obtain CMP (hepatotoxicity) and start 30 mg/kg/day

      • Adjust every 3 days (maximum daily dose 60 mg/kg/day) with goal serum level 50-100 mcg/mL

    • Quetiapine (Seroquel)

      • Start 100 mg BID and increase by 100 mg daily (maximum daily dose 800 mg)

      • Obtain yearly lipid panel, HbA1c

OBGYN-Related Conditions

  • Premenstrual syndrome and dysphoric disorder

  • Major depression disorder during pregnancy

    • Diagnosed per MDD criteria (see above)

    • Start or continue SSRI after shared decision making concerning medication safety

      • Safe: Escitalopram, sertraline

      • Possibly safe: Fluoxetine, venlafaxine, duloxetine, bupropion, amitriptyline

      • Contraindicated: Paroxetine, nortriptyline

  • Postpartum major depression (PMD)

    • Onset within 3 months of delivery with most cases (67%) starting within 6 weeks postpartum

    • Affects 10-15% of women

    • Risk factors

      • H/o major depressive disorder

      • Perinatal stress/trauma

      • Inadequate social support

    • Screen using Edinburgh Postnatal Depression Scale, if positive (score > 10):

      • Obtain TSH to rule out hypothyroidism

      • Start psychotherapy and/or fluoxetine 20 mg qd

Pediatric

  • Depression

    • Screen children 12 years and older using PHQ-9

    • Fluoxetine is the only FDA approved medication

  • Bipolar disorder: Common in children of patients with bipolar disorder

Depression and Anxiety Assessment

PHQ-2 for Depression

  • Over the last 2 weeks, how often have you been bothered by the following problems?

    • Little interest or pleasure in doing things?

    • Feeling down, depressed, or hopeless?

  • Responses

    • 0: Not at all

    • 1: Several days

    • 2: More than half of the days

    • 3: Nearly every day

  • Administer PHQ-9 for total score ≥ 3

Additional Questions Included in PHQ-9 for Depression

  • Trouble falling or staying asleep, or sleeping too much?

  • Feeling tired or having little energy?

  • Poor appetite or overeating?

  • Feeling bad about yourself — or that you are a failure or have let yourself or your family down?

  • Trouble concentrating on things, such as reading the newspaper or watching television?

  • Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?

  • Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?

GAD-7 for Anxiety

  • Over the last 2 weeks, how often have you been bothered by the following problems?

    • Feeling nervous, anxious or on edge

    • Not being able to stop or control worrying

    • Worrying too much about different things

    • Trouble relaxing

    • Being so restless that it is hard to sit still

    • Becoming easily annoyed or irritable

    • Feeling afraid as if something awful might happen

  • Responses

    • 0: Not at all

    • 1: Several days

    • 2: More than half of the days

    • 3: Nearly every day

  • Scoring

    • ≥ 5: Mild

    • ≥ 10: Moderate (probable GAD)

    • ≥ 15: Severe