Question

summarize what you know about anxiety and depression and its courses.. please put a reference and intext citation of where you got your information

Answer 1

Anxiety and depression are major public health issues, affecting a large segment of the general population and responsible for multibillion-dollar spending directly related to health care and hospitalizations and indirectly related to morbidity and mortality.^1,2 However, these conditions are associated with substantial declines in patient well-being and social functioning and may warn.

Initially, anxiety and depression are frequently expressed as physical ailments rather than the conventional symptom of altered mood; therefore, it is not surprising that many of these patients turn to their primary care doctors for care. As a consequence, being well versed in identifying and treating such cases is important for the generalist physician.

Anxiety :

The existence of clinically relevant degrees of persistent anxiety characterises many of the various types of known anxiety disorders. In patients seen by primary care physicians, these disorders are very common. Such less common anxiety disorders include posttraumatic stress disorder ( PTSD), obsessive-compulsive disorder (OCD), and acute stress disorder. With the exception of OCD, anxiety disorders typically occur more often in women than in men.³

When anxiety is encountered during distinct times ( e.g., panic disorder) or in particular circumstances ( e.g., social phobia), some anxiety disorders occur. Acute periods of extreme anxiety and distress associated with symptoms of autonomic arousal, such as tachycardia, sweating, dizziness , shortness of breath, and chest pain, are regularly encountered in patients with panic disorder. As a result of their fear of locations and circumstances, these patients can also suffer from agoraphobia.³

They prefer, therefore, to avoid things like crowds, elevators, buses , trains, and bridges. Social phobic patients are afraid of communicating with and being scrutinised by unknown individuals (or individuals in authority) (e.g. when writing, eating at a group, talking to a supervisor or store clerk). On the other hand, when approached by a particular object or circumstance (e.g., snakes, thunderstorms), patients with serious phobias experience anxiety.

Patients with OCD are plagued with recurring, repetitive thoughts, desires, or images that cause marked distress, and in reaction to these obsessions, they compulsively participate in ritualistic actions or behaviours. GAD patients experience anxiety that is more unfocused than in these other conditions and are overly (daily) anxious with everyday life activities and circumstances. These patients have historically been known as "lifetime worriers. "

Benzodiazepines and buspirone.

Benzodiazepines (BZDs) have a long history of use in the treatment of anxiety disorders. Diazepam has been the most frequently used BZD for many years, however due to its lower risk of sedation, alprazolam is now the most commonly used medication of this class.8 Alprazolam also dramatically decreases panic symptoms within a few days at the recommended daily dose of 1.5 to 10 mg, although dosages as low as 0.25 mg 3 times daily may be beneficial in some patients.^4–7

Typical maintenance dosages of alprazolam are typically smaller (0.75 to 4.0 mg / day) in more chronic cases of anxiety, such as GAD, than those found in panic disorder.

Sedation, ataxia, and problems with attention , memory, and balance are common adverse treatment effects.

It is known that many of the anxiolytic effects of antidepressants are modulated by serotonin reuptake inhibition. Selective serotonin reuptake inhibitors ( SSRIs) have also been extensively studied in anxiety disorders, including panic disorder, OCD, GAD, and social phobia. ^8-12 While these agents have a lag in their initiation of action, they are usually more tolerable than the TCAs, much like that of older tricyclic antidepressants (TCAs) and buspirone. SSRIs are usually considered to be first-choice therapies, definitely for OCD, more recently for panic disorder, and most recently for social phobia. However, in some patients taking several concomitant drugs, complex drug-drug interactions triggered by cytochrome P450 enzyme system inhibition which occur.

The only agent with a dual indication for the treatment of depression and GAD is venlafaxine extended release (XR). Some data indicate that it could be effective in social phobia, panic disorder,and OCD, in addition to demonstrating effectiveness in GAD.

Depression :

Depression is a severe psychiatric condition that is traditionally associated with mood disorders, lack of interest or satisfaction of things previously enjoyed (anhedonia), and feelings of intense sorrow and hopelessness. There may also be improvements in sleep habits, sexual desire and behaviour, appetite and weight, and the capacity to focus in depressed patients.

Sometimes, these symptoms of depression are so extreme that they substantially interfere with the social, family, and occupational functioning of the depressed person and cause substantial distress. It is not unusual for patients with depression, such as those with comorbid anxiety, to have a variety of physical disorders that resemble other medical diseases or conditions in the primary care environment, rather than the classic signs.

In the primary care community, aggressive and appropriate treatment of depression is important, not just from a therapeutic viewpoint, but also from a viewpoint of health economics.¹³

Drug treatment for depression was limited to TCAs and inhibitors of monoamine oxidase (MAOIs) until recently. Unfortunately, both of these agent groups are associated with substantial adverse effects and toxicity that limit their effectiveness in primary care patients, and in this population, they have been relegated to second- and third-line choices for the most part.¹⁴ TCAs are associated with anticholinergic side effects, such as dry mouth, blurred vision, constipation, and urinary retention, and antihistaminergic effects, such as sedation and weight gain.The narrow therapeutic index of these agents, however, is more deleterious, making even small quantities (e.g. a 1-week supply) potentially lethal.

The primary care clinician has an ever-wider variety of therapies to choose from with the advent of second-generation antidepressants (i.e., SSRIs, serotonin-norepinephrine reuptake inhibitors [SNRIs], and others) and their enhanced safety profiles. Thanks to their broad therapeutic index, relative protection from overdosing, and more favourable adverse effect profiles, these newer medications are obviously more appropriate than older antidepressants for use by generalists. Once-daily dosing is an added feature of these newer agents—the SSRIs, venlafaxine XR, and mirtazapine—that makes them convenient to use and may help increase patients' compliance with the regimen.

An additional advantage of these newer agents, SSRIs, venlafaxine XR, and mirtazapine, is once-daily dosing, which makes them easier to use and can help improve the compliance of patients with the regimen.

Nausea, headache, sleep disruption, and sexual dysfunction are some of the adverse effects associated with SSRIs.¹⁵ Nausea is also the most prominent adverse effect associated with venlafaxine XR, but occurs more often at higher dosages and usually resolves to the levels seen with placebo within 2 weeks of continued treatment. Bupropion, which is free of serotonergic effects, has placebo levels. Nefazodone also seems to lack the other antidepressants' sexual side effects. Owing to their lower occurrence of these side effects, these last 2 agents are also used often after sexual side effects arise with other antidepressants.

References :

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2. Greenberg PE, Sisitsky T, Kessler RC, et al. The economic burden of anxiety disorders in the 1990s. J Clin Psychiatry. 1999;60:427–435.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. Washington, DC: American Psychiatric Association. 1994
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5. Burke WJ, Folks DG, McNeilly DP. Effective use of anxiolytics in older adults. Clin Geriatr Med. 1998;14:47–65.
6. Goldberg RJ. Diagnostic dilemmas presented by patients with anxiety and depression. Am J Med. 1995;98:278–284.
7. Ballenger JC, Burrows GD, DuPont RLJ, et al. Alprazolam in panic disorder and agoraphobia: results from a multicenter trial, 1: efficacy in short-term treatment. Arch Gen Psychiatry. 1988;45:413–422.
8. Ballenger J. Treatment of panic disorder with serotonin reuptake inhibitors (SSRIs). In: den Boer JA, Montgomery SA, eds. SSRIs in Depression and Anxiety. Chichester, NY: John Wiley & Sons. 1998 115–134.
9. Katzelnick DJ, Kobak KA, Greist JH, et al. Sertraline for social phobia: a double-blind, placebo-controlled crossover study. Am J Psychiatry. 1995;152:1368–1371.
10. Stein MB, Liebowitz MR, Lydiard RB, et al. Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial. JAMA. 1998;280:708–713.
11. Ballenger JC, Wheadon DE, Steiner M, et al. Double-blind, fixed-dose, placebo-controlled study of paroxetine in the treatment of panic disorder. Am J Psychiatry. 1998;155:36–42.
12. Ballenger JC. Current treatments of the anxiety disorders in adults. Biol Psychiatry. 1999;46:1579–1594.
13. Cohen LJ. Rational drug use in the treatment of depression. Pharmacotherapy. 1997;17:45–61.
14. Montano CB. Recognition and treatment of depression in a primary care setting. J Clin Psychiatry. 1994;55(12, suppl):18–34.
15. Frazer A. Antidepressant drugs. Depression. 1994;2:1–19.