Anxiety and Depression

Anxiety and depression are extremely common problems addressed by any primary care physician.  I've seen data indicating that by the year 2020 mood disorders will be the number one disabling medical problem in this country (currently arthritis and back pain are the leaders).  Fully a third of all my office visits are directed at the diagnosis and management of anxiety and depression.

Anxiety is much more common than full-fledged depression.  Anxiety is usually manifest by a sense of constant worry--the patient just feels they can't stop thinking about things that stress them.  They'll often awaken in the night and be unable to sleep because their minds "just won't shut off."  They'll find themselves having difficulty relaxing, or finding pleasure in previously pleasurable activities, because they can't let themselves stop processing their worries.

Anxiety can have many forms:  Social anxiety disorder is a variation where the patient becomes very uncomfortable in public situations where the patient might have attention of strangers drawn to them.  They fear being judged or criticized.  Other common forms of anxiety include the various phobias such as fear of flying or claustrophobia--there are many variations on this theme.  I have patients who fear driving in bad weather to the point of being unable to drive if there is even the threat of bad weather.  Of course one of the most intriguing forms of anxiety is Obsessive-Compulsive Disorder, where patients develop ritualistic behaviors that they feel compelled to do often over and over.  Somatoform anxiety disorder is when anxiety morphs itself into recurrent and often unrelated physical symptoms--headaches, abdominal pain, back pain, tingling, numbness, nausea, etc.

Most forms of anxiety, however, are more generalized and "free-floating."  Patients just don't feel like themselves.  They can begin to feel overwhelmed.  They can feel as though they have no tolerance for any further frustrations or stressors.  They are often "fed up!"  Like they are on their "last nerve."  This can some times lead to them blowing up over small issues, or what I call "flying off the handle."  The anxious patient may find themselves feeling unusually over-emotional--"emotional overload."

Of course, many patients develop anxiety due to life and situational stressors--a divorce, the loss of a job, financial stressors, ill family members requiring care.  However, some patients simply are "wired" to be more anxious even without unusual life stressors.

I think of anxiety as the result of being constantly bombarded by perceived threats--whether real or imagined.  Threats of job loss, financial ruin, loved ones in trouble, loss of quality of life.   These constantly-perceived threats sort of soak the brain in adrenaline (epinephrine) and other stress hormones.  Anxiety has an evolutionary benefit--if you were a paleolithic human it served in your best interest to keep a constant guard out for an invading hoard from the next valley, or a marauding saber-toothed cat. We had to keep ready to fight or flee at a moment's notice.  There was a survival advantage to the brain being hyper-vigilant.

Anxiety can certainly be hereditary.  I have several families in my practice where I have three generations of the family and all are treated for anxiety.  However, there is also a sort of classic personality type that is particularly prone to anxiety:  It has been given the acronym of SICK:  S--Sensitive, I--Intelligent, C--Creative, K--Kind.

Patients who are sensitive tend to be empathetic--they feel and are aware of the emotions of others close to them.  They may even sympathetically take on those emotions and can find them overwhelming.

Intelligent people tend to be more analytical--in their life experience, they have found that they can solve problems by teasing them around in their mind and coming up with a solution.  However, with many of the stressors of daily life, there is no "solving the problem" and the person simply keeps thinking about the stressor in a cyclic fashion, getting nowhere closer to solving the problem.

Creative people tend to be imaginative--so when presented with some type of stressor, their imaginations can take them quickly to the worst-case-scenario.  They play out the issues to ridiculous degrees and consequences even if they are not realistic.  So that stress-related headache becomes a brain tumor, and that stress-related stomach ache becomes colon cancer.

Kind people generally don't want to "rock the boat."  That is, they don't like confrontation and don't want to be the center of attention.  They don't want to hurt other people's feelings.  So that means they don't let their emotions out, or discuss how they feel.  They generally just "swallow" their own emotional pain and hope it disappears.  But of course, instead, it usually just festers.

Combining all these personality qualities into one person puts that person at significant risk for anxiety and depression.

Many people find ways to self-treat.  Sometimes self-medicate.  Many males often start to use alcohol more frequently.  Females are more likely to seek help from friends, family or physicians.  When discussing stress, physicians think in terms of systems:   If you have any kind of system--a human being, a family, a business--and apply some type of stress to that system, there are two types of responses that system can make to recover:  Adaptive responses are reactions to stress that reduce the stress and its effects in a way that promotes the well-being of the system (person, family, etc).  A maladaptive response might initially reduce the effects of the stress, but in the long run makes the problems worse.

For example, a business in financial dire straits might have its accountant "fix the books," which might temporarily help, but in the long run screws things up in a major way.  Similarly, if an anxious person starts drinking, they may temporarily reduce their anxiety in a haze of alcohol, but as they become addicted, an entirely new set of problems arises.  Other frequently-encountered maladaptive responses to stress can be verbal abuse--"exploding" at others which can get others to back off and leave the stressed person alone, or isolation--shutting one's self off from society so that interaction is prevented.  Bullying is also a maladaptive response to stress--the bullier is anxious or stressed and finds that by attacking others, they gain some temporary power and attention that reduces the effects of their own stress.

Adaptive responses to stress are many:  Obviously, addressing the stressor and dealing with it to fix it or  "make it go away" is an appropriate response.  A supervisor is making life difficult for a worker.  The worker seeks redress through their union or through Human Resources and gets relocated to a new position and the problem goes away.

Other adaptive responses to stress can be exercise--exercise burns off excessive adrenaline that builds up from persistent stress, and releases "feel good" neurotransmitter chemicals like endorphins and dopamine that can fight the effects of stress.  I really cannot over-emphasize how effective exercise is in the treatment of anxiety.   

Counseling is an exceptionally good adaptive response to stress.  It allows the patient to learn new coping strategies, relaxation techniques, new ways to think about stressful issues in a more positive light, and ways of reducing the tendency toward "worst-case-scenario" thinking.  The wonderful thing about counseling is that it teaches the patient new skills they can use for the rest of their life to counter anxiety-provoking vicious cycles of thinking.  Unfortunately, counseling is somewhat cumbersome in that it requires moderately frequent office visits, and sometimes one patient may not "hit it off" with a specific counselor just due to personality quirks.  Not uncommonly, the phenomenon of "projection" can be a problem--the counselor may remind the patient of their troublesome supervisor at work, so that a healing/trusting relationship is simply impossible.   However, counseling in general is probably one of the most effective interventions for most types of anxiety.

The last resort in the management of anxiety is medication.  There are two basic groups of medications for anxiety.  For intermittent, occasional anxiety episodes such as acute anxiety or panic attacks, medications such as alprazolam or lorazepam can be prescribed.  These belong to a family of medications called benzodiazepines (BENzo-die-AZ-uh-peens).  They have been around for several decades.  Unfortunately, they are potentially habit-forming and patients can develop a tolerance to their effects over time.  I'm sure you have heard of Xanax (alprazolam) and Ativan (lorazepam) and Valium (diazepam).

The ideal use of alprazolam, a fairly short-acting benzodiazepine, would be when a patient uses it only during times of an impending anxiety attack or panic attack, to get quick relief from the attack--using it only once in awhile, no more than every few days.  It is unlikely to become habit-forming when used rarely and intermittently like this.   Benzodiazepines become potentially more worrisome if used regularly on a daily basis.  They can sometimes cause confusion (more likely in older patients), increase the risk of falls, cause drowsiness, and can dramatically amplify the effects of alcohol.

I never use benzodiazepines as a first-line choice for the medication management of anxiety EXCEPT for situations that clearly indicate a rapid-response medication for only occasional use.  For example, the patient who starts to get very anxious while flying, who will only rarely use it.  I also warn patients who might be given a prescription for "as-needed" alprazolam to NEVER use it as a sleeping medication, as it can quickly become habituating if used frequently for sleep.

Our mainstay of medication management for anxiety is the family of medications called SSRIs--Selective Serotonin Reuptake Inhibitors.  There is good scientific evidence that at least a large percentage of patients with anxiety have lower than normal amounts of serotonin in key parts of the brain.  In parts of the brain that help dictate emotional responses, serotonin is a neurotransmitter--that is, it is a chemical that is essential to maintain the communication between brain nerves (neurons).  Without adequate levels of serotonin in the physiologic gaps between neurons, the electrical signals that help people feel calm and relaxed and "warm and fuzzy" simply die out--the signals fade away and don't continue.  Therefore, using medication that increases the amount of serotonin in those gaps--SSRIs--helps keep the signals strong and ongoing.

SSRIs came on the scene in the late 1980s--I'm sure everyone old enough remembers the "Prozac Revolution."  Prozac (fluoxetine) was the first, and became a household name, and the subject of a lot of controversy. Prior to this time, we didn't have many good, safe medications for anxiety.  So Prozac prescriptions were being written right and left.  Despite the nay-sayers and the jokers, Prozac and its subsequent siblings have been just short of miraculous in helping reduce the burden of suffering from anxiety.

After Prozac came Zoloft (sertraline), then Paxil (paroxetine), then Luvox (fluvoxamine), then Celexa (citalopram), and then Lexapro (escitalopram).  These all fell into the category of SSRIs.  They all had some relative differences in side effects, which gave us physicians a nice array of options to select from to try to custom-tailor medication to our patients situations.  The nice thing about SSRIs is that they are NOT habit forming, and they are not prone to significant overdose risk.

Common side effects of the SSRI family include initial low-grade headaches, sometimes mild nausea or dizziness, vivid dreams, increased sweating, looser bowel movements, and sometimes sexual side effects such as a lowering of sex drive and sometimes a change in the sensation of orgasm.  Most of these side effects are very minimal and tend to improve with time as the patient adapts to the medication.  There is a "Black Box" warning on all SSRIs mandated by the FDA:  When used in persons under the age of 25, there can be an increased risk of suicidal thoughts.  This is very very rare, but we take it very seriously and I always warn my younger patients about this issue.

Each of the various SSRIs tend to have some variations in side effects--sometimes predictable, but often  not.  I find that fluoxetine (Prozac) tends to be a little more stimulating and less likely to cause fatigue than say, citalopram (Celexa) or escitalopram (Lexapro).   I tend NOT to use paroxetine (Paxil) very often as it can be harder to "wean" patients off of it if they want to come off.   I also have found that many patients I've seen on paroxetine seem to just be overly complacent and "too laid back."

If I do start a patient on an SSRI, I always start with half the long-term maintenance dose, to sort of "break it in."  That is, for example, if I intend for the patient to be on 50 mg of sertraline (Zoloft), then I'll start them on 1/2 tab (25 mg) each morning for 7-10 days to minimize side effects and let them get used to the medication before increasing to the full treatment dose.  If they do experience side effects on the 1/2 dose, usually they are minor and settle down and go away over the break-in period, so that when we move to the full treatment dose, the patient does not experience excessive side effects (hopefully).  I always ask my patients to call if they experience any problem side effects, especially if they feel they are not tolerable or settling down with time.

The positive effects of the SSRIs should become evident within a week or two of getting up on the maintenance dose.  Most commonly, patients report that they are just handling stressful issues better.  They often indicate they are not entering into "cyclic worrying" patterns of thinking.  They say they "bounce back" after major stressors without feeling overwhelmed.  I've heard patients use the analogy of "water off a duck's back" relating their ability to shed stressors and keep functioning.

Of course, I always want to make sure that the positive effects of the medication outweigh any negative side effects.  I always schedule follow up visits pretty frequently at first when a patient is starting out on an SSRI so that we can keep tabs on side effects and positive effects, and make sure we are moving toward our goal.  Sometimes I'll find that the patient is not responding as we'd like, or is having too many side effects.  In that case, we'll discuss a change of medication--possibly to a different SSRI.  But I will ALWAYS mention the other nonpharmacologic interventions:  life-stressor adjustments, exercise, and counseling.

Other medications:
There is another family of prescriptions medications we will consider in the management of anxiety:  the SnRIs.  These medications work not only on increasing serotonin levels, but also increase norepinephrine levels.  Norepinephrine is another but different neurotransmitter in the brain associated with anxiety and depression.

Examples of SnRIs are venlafaxine (Effexor), Cymbalta, Pristique, and Savella.  Venlafaxine is, as far as I know, the only SnRI that is available generically.  SnRIs have a slightly different side effect profile from the SSRIs:  they can sometimes cause a little more dizziness or nausea, dry mouth or eyes, slower bowels, and more interrupted sleep.  However, they tend to have fewer sexual side effects and less tendency toward fatigue when compared to SSRIs.

I always tell my patient that "they are in charge."  That is, THEY are the one to decide if the medication  is helping or not.  THEY are the one to determine if side effects are tolerable or not.  THEY are the ones who determine if they are going to remain on the medication.  I point out that eventually, if things are going well and symptoms are well controlled and stressors are resolving, we can consider trying to reduce the dose and even come off the medication slowly.  Once off the medication, if symptoms remain gone or controlled, then it is completely acceptable to remain off the medication.   We know we can always consider it as an option again "down the road" if need be.

Depression:  

Depression and anxiety are often, but not always, related.  Depression is often described as a feeling of dark, negative mood.  Patients who are depressed often do not want to do ANYTHING.  They don't want to socialize.  They don't want to work.  They don't want to exercise.  They can't concentrate. They often don't even want to get out of bed.  They may cry a lot, but not necessarily.  They often have thoughts of suicide--maybe not a particular plan, but may just think that if they were dead, at least they wouldn't be as miserable as they are now.  Nothing has any positive value.  They become a "shadow" of themselves.

I view depression as a state of brain "burn-out."  Often depression comes on as anxiety burns itself out and the brain just cannot process anything anymore.  The mind can no longer face the challenge of coming up with "mental energy" to make it through the day.  It is a chronic mental energy crisis.  Depressed patients are often apathetic, ambivalent, sometimes emotionless.  They can see nothing positive, even if positive things are all around them.  A. A. Milne, in his Winnie the Pooh characters, created a perfect example in Eeyore, the blue donkey.   No matter how nice a day it was, Eeyore could see nothing but negatives everywhere.

The mental anguish and pain of the depressed patient can never be overestimated.  Unfortunately, to most people who have never suffered from depression, the day-to-day agony of the depressed patient is hard to understand.  You really have to imagine how severe the suffering of someone can get when they actually start to favor death or non-existence to carrying on the same way day after day.

Depression is treated in somewhat the same way as anxiety.  However, there is an even greater urgency to treating severe depression.  Most patients, fortunately, have only what we call mild-to-moderate depression.  We start with the same interventions:  exercise, counseling, and medications.  It is very hard to get a depressed patient motivated to exercise, however.  Counseling can be very helpful, but takes time.  I will almost always move forward with initiating medication for a depressed patient.

The SSRIs and SnRIs listed above are all excellent first line options in treating depression.  There is also another medication that can be very useful for depression, called bupropion (trade name Wellbutrin).  Bupropion is the only member of its class--it helps restore norepinephrine neurotransmitter levels in the brain.  It can, within 2-3 weeks, help elevate mood and improve motivation and "mental energy."

Bupropion's side effects can be dry mouth and dry eyes, changes in sleep quality, excessive stimulation, tremulousness, slower bowel activity, headaches, and nausea.  It generally does NOT cause sexual side effects or weight gain.  If a patient has a history of seizures, they cannot take bupropion as it can lower seizure "thresholds" and make them more prone to have a seizure.

Other medications are also effective against depression.  Since the 1970s, medications called "TCAs" or "tricyclics" have been used.  These are medications such as amitriptyline, nortriptyline, doxepin, and others.  Trazodone is a closely-related medication. TCAs can be just as effective as SSRIs, SnRIs, and bupropion; however, the TCAs tend to have perhaps more side effects and are more hazardous in overdose situations.

If after several weeks of trials and adjustments of the above medications are not working, then we have a major challenge.  I will sometimes consider the addition of certain types of stimulants if a person is not improving adequately on a "first-line" antidepressant.  Sometimes adding a mood-stabilizer such as lamotrigine (Lamictal) or Depakote will help stabilize mood or improve it.

The other important point is to make sure that the patient is not doing anything to subvert our efforts:  recreational drug use and alcohol can virtually render prescription medication powerless to treat depression.  Chronic sleep deprivation due to other problems such as sleep apnea can aggravate depression.  Hypothyroidism and other metabolic dysfunction can aggravate depression.  I try hard to rule those problems out at the very early evaluation of a patient presenting with depression, but sometimes patients are less than forthcoming about certain things, especially alcohol and drug use.

If these further efforts are not working, and we've exhausted all our other options such as counseling, then it is time for a referral to a Psychiatrist.  There are other medications available such as Abilify and others, but I don't feel comfortable as a Family Practitioner managing them.

I always explain to the patient that if, despite our best efforts, depression symptoms are worsening and the patient is starting to seriously contemplate ending their life, then they MUST seek care through the Emergency Department.  (In McLean County, IL, that number is 211 or 1-800-570-PATH (7284)).

I feel that the vast majority of patients coming in to see me or my partners for anxiety or depression see significant improvement within a matter of a couple of months, if not sooner.  However, it takes honesty on the part of the patient when explaining symptoms, life issues, and health history for the physician to try to come up with a "best-fit" plan for treatment.  It may take a few trials of medication adjustments to fine tune things, but usually we can custom-craft a plan that works.