Depression and Anxiety Treatment

by William Nelson, NMD

Depression and anxiety disorders can be particularly attributed to a chemical imbalance known as Neurotransmitter Deficiency Disorder (NDD). People with NDD cal also suffer from one or more of the following conditions: obesity, depression, bulimia, anorexia, anxiety, fribromyalgia, chronic fatigue, insomnia, attention deficit, learning disorders, panic attacks, migraines, pms, menopausal symptoms, irritable bowel and many more.

Neurotransmitters (NTs) are essential chemical messengers that regulate brain and muscle, nerve and organ function. The most common neurotransmitters are serotonin, dopamine, norepinephrine, epinephrine, GABA, histamine and acetylcholine. Low levels of these important chemicals are extremely common in the general public due to poor lifestyle and diet. This article is intended to help the reader determine whether they may be deficient in neurotransmitters and how evaluation and treatment can help.

Conventional treatment uses selective serotonin re-uptake inhibitor (SSRI) drugs such as Zoloft, Prozac, etc. which can offer patients symptomatic relief. They work by redistributing serotonin from inside the nerve cell to the synapse where it transmits its chemical message. This artificial redistribution allows for chemical messages to be sent even though the total body NT levels are low.

The problem with this approach is that these drugs DO NOT increase serotonin levels and in fact further depletes NTs. SSRI class drugs cause an increase activity of an enzyme called MAO which breaks down serotonin. It is common for people to experience only temporary improvement due to this effect. The increased MAO activity depletes serotonin until there is not enough for the drug to act on. Conventional research supports this model even though most doctors prescribing these drugs are not aware of this fact.

This is a classic example of a conventional medical treatment that helps with the symptoms but makes the true cause of a condition worse. This approach can be compared with smashing a fire alarm with a sledge hammer because the noise hurts your ears. Your ears stop hurting but the fire is smoldering.

A clinical example of this phenomenon is common to patients on anti-depressant medications. They start on a drug and they feel significant improvement. This can last for months or years until the drug loses its effect. The doctor then suggests taking a drug holiday or prescribes a new prescription and the pattern is repeated.

A symptom questionnaire combined with a simple neurotransmitter urine test is the most effective way to detect a NT deficiency. Many well intentioned doctors are prescribing SSRI drugs, but don’t perform this test to monitor or direct proper treatment.

Neurotransmitters levels can be restored using amino acid therapy. Amino acids are obtained from dietary protein, but not in adequate levels to correct even a moderate NT deficiency. Supplements used in treatment may include 5HTP, tyrosine, DMAE, DLPA, Cysteine, GABA, methionine, mucuna (herbal L-dopa), herbals, and vitamin/mineral cofactors. Once a urine test has identified the NT deficiency, and individualized formulation is given to help replenish the low level NTs.

It takes anywhere from 2 to 18 months or more to restore the NT levels using this approach. Patients that have taken amphetamines, SSRIs, or psychotropics Rx drugs or recreational drugs such as crystal meth and Ecstasy have been found to take longer to respond to therapy. The amino acid supplements are safe and have a side effect profile equal to placebo.

The amino acids are safe when used alone or in combination with prescription drugs. Many conventional and alternative doctors tell patients to never combine amino acids with prescriptions because it is dangerous. In thousands of patient visits using this approach, there have been no problems using them concurrently. Patients that weren’t getting good results with their SSRIs get great results using this approach. Once the symptoms resolve, most patients can slowly wean off their prescription.

After measuring the NT levels to establish a baseline, amino acid therapy is broken down into three phases. Phase one or conditioning increases serotonin levels to prepare the body for the therapeutic stage. This usually takes two weeks. Phase two is the actual therapy that rebuilds both serotonin and dopamine, norepinephrine and epinephrine. Therapy can take anywhere from 2 months to 2 years. Phase three is maintenance whereby supplements are reduced to simply replace the daily NT depletion rate. 90% of patients with this condition will need to stay on a low maintenance dose to avoid the return of symptoms.

The recommendation for patients with symptoms of NDD as well as anyone on prescription antidepressants is to have their neurotransmitter levels evaluated and optimized. Current research and clinical work in this area is incredibly exciting and promising for doctors treating these conditions and patients suffering from them.

Dr. William Nelson is a Naturopathic Medical Doctor who specializes in the treatment of Neurotransmitters Deficiency Disorder by combining the latest medical advances with time-honored naturopathic therapies. The Elements of health Clinic, 7500 E. Pinnacle Peak A-207, Scottsdale, AZ 85255 - (480) 563-4256 or go to www.theelementsofhealth.com

Depression and obesity represent two major public health problems in the U.S. today. Depression is one of the most common and serious psychological problems. It is estimated that more than 10 percent of Americans are likely to experience at least one major depression during some point in their lives. Obesity, on the other hand, represents the most common physiological problem in the U.S. population. Roughly one-third of all Americans are overweight and at increased risk for morbidity and mortality. [Editor’s note: As of 2002, it is estimated that close to 80 percent of all American adults are overweight.]

The economic costs of obesity are staggering—estimated at more than $30 billion per year. Even more astounding are the recently estimated annual costs (direct-care, morbidity, and mortality) of depression in the U.S.—more than $40 billion.

Depression and overweight frequently co-occur. This should not be surprising since about a third of the population is overweight. Given this high prevalence of overweight, it should not be surprising that depression (a second prevalent problem) is also frequently present among overweight persons. Depression often goes undetected. In fact, a number of studies have found that more than 50 percent of diagnosable clinically-significant depressions are not detected by primary care physicians. Since depression often coexists with obesity, understanding its characteristics and treatment options is important. This is particularly true for overweight persons and health professionals working in the field of weight management.

The relationship between depression, eating, and weight is both interesting and complex. There are many ways that these factors may be related. In this article, I discuss some of the possible associations between depression, eating, and weight control. I also discuss some of the depression treatment options and their implications for eating and weight. I hope this discussion answers many questions while at the same time raises important issues for clients and health professionals to discuss when planning a treatment program.

Depression
Depression is a general term for a variety of conditions ranging from the lay person’s usage conveying temporary states of “feeling blue” or dips in mood to a professional’s usage signifying a psychiatric problem. Several specific types of clinically-meaningful depressions exist. The most common type of depression is referred to as Major Depressive Disorder. The defining symptoms are summarized in the illustration to the right.

Major depression requires the presence of at least one of the following two symptoms:
 A persistent and prolonged period (i.e., minimum of two weeks)
of significantly depressed mood, and/or
 A sustained loss of interest (inability to derive any pleasure)

Besides these mood symptoms, depression requires the presence of several additional symptoms. Generally, the additional symptoms can be divided into three areas. These include:
1.  Thinking (impaired concentration, indecisiveness, worthlessness,
guilt, suicidal thoughts),
2.  Behavior (psychomotor agitation or slowing, decreased activity,
social withdrawal, suicidal behaviors), and
3.  Physical (appetite change, weight change, sleep problems, fatigue).

Most major depressions are episodic in nature. That is, they tend to be discrete episodes that—in most cases—remit at least partially. Unfortunately, the chances of having additional depressive episodes increase with each major depression. For instance, a person who has experienced two depressive episodes is estimated to have a 50 percent risk of having another depressive episode. If you look closely at the criteria listed in the illustration above you will note that a fairly wide variety of symptoms may characterize different cases of depression.

Depression and Weight
Let’s take another look at the symptoms of depression in the illustration above. Notice that appetite may either increase or decrease with depression or that weight may increase or decrease during a depression episode. The more typical types of depression result in weight loss and a decrease in appetite. Insomnia and physical agitation frequently accompany this pattern. It is generally thought that about 60–65 percent of depressed individuals lose weight during a depression episode. However, some individuals gain weight when they are depressed.

     A significant portion (estimated at one-third) of depressed individuals gains weight during a depression. Often referred to as atypical depressions, weight gain, increased appetite, hypersomnia, fatigue, and sometimes “heavy legs” are the prominent physical symptoms that accompany the sadness or loss of interest. The weight gain experienced by these individuals can be substantial. In studies conducted by Dr. Stunkard and his colleagues at the University of Pennsylvania School of Medicine patients gained an average of 19 pounds during one depressive episode. This pattern of depression and weight gain was more common in women than men. It typically began at an earlier age than the more typical depressions (i.e., weight loss, decreased appetite, etc.) and became chronic with incomplete recovery between successive episodes.

An interesting question that researchers have tried to answer is, “Does a person’s weight change in the same manner from depression to depression?” Dr. Stunkard and researchers from the University of Pittsburgh found that 85 percent of 53 depressed persons who experienced two major depressions experienced the same weight changes. During two separate depressions, 32 percent of the participants gained weight, 44 percent lost weight, and 9 percent had no change. The amount of weight change each person experienced in the two depressions was also very consistent. This consistency during recurrent depressions is particularly interesting since many aspects of depression are not consistent from one episode to the next. Thus, roughly one-third of persons with recurrent depression are likely to gain weight each time they experience a depression episode. Over time, the total weight gain can be substantial.

Who Gains and Who Loses?
Since it seems that individuals are consistent in their pattern of weight change when depressed, the next question is “who gains weight and who loses weight?” Dr. Stunkard and his colleagues looked at two factors in trying to answer this question:
1.  Body mass index (weight taking into account height) and
2.  Disinhibition (i.e., the tendency to lose control over eating under certain circumstances,
such as when experiencing negative emotions).

In two studies, depressed people who were disinhibited were the most likely to consistently gain weight during repeated depressions. However, it seems that body mass index was responsible for much of the association. In other words, heavier people are most likely to gain weight repeatedly, and lighter people are most likely to consistently lose weight during repeated depressions. Although we do not know why heavier people are likely to gain more during depressions, this finding is useful to alert people to that risk.

Overweight and Depression
Are overweight persons susceptible to depression? Most studies have found that slightly overweight persons do not differ from average-weight persons in rates of depression. The picture seems quite different, however, for persons who are substantially overweight and for overweight persons who binge eat. Dr. Donald Black and his colleagues at the University of Iowa School of Medicine found that 19.3 percent of 88 morbidly obese persons (i.e., more than 100 percent over ideal body weight) had histories of major depression versus just 5.3 percent of 76 average-weight persons. Dr. Susan Yanovski and her colleagues at the National Institute of Diabetes and Digestive and Kidney Diseases found that 14 percent of overweight persons and 51 percent of overweight persons with binge eating disorder suffered from major depression. A recent study at Yale found similar rates of current depression and histories of depression in overweight males (20 and 52 percent respectively) and females (20 and 42 percent respectively) with binge eating disorder.

Specific Depressions and Weight
Different types of depression exist in addition to Major Depressive Disorder, and these may also be linked in complex ways to weight changes. Let’s look at Bipolar Disorder as an example. Bipolar Disorder involves substantial mood swings from mania (i.e., extreme energy) to depression. Aside from the complex associations between different patterns of mood swings and weight, bipolar disorder alerts us to a different and indirect link between depression and weight. The consensus treatment of choice for bipolar disorder involves the use of lithium carbonate. We know long-term treatment with lithium produces weight gain, and this weight gain is most likely to occur in individuals who are already overweight. Unfortunately, some treatments chosen for certain types of depression may contribute to weight gain.

Seasonal Affective Disorder
     In 1984, Dr. Norman Rosenthal and colleagues, in studies performed in the Clinical Psychobiology Branch of the National Institutes of Health, identified a subset of persons who experienced periods of depression. These periods seemed to closely follow seasonal changes. In the original study, the researchers identified 29 patients who regularly developed major depression during the autumn and winter months. The depression would improve dramatically during the summer months. This pattern of depression—termed Seasonal Affective Disorder—is frequently accompanied by substantial weight gain (in as many as 75 percent of cases) and increased appetite, carbohydrate craving, increased sleep, and constant fatigue.

Since Dr. Rosenthal’s 1984 study, several studies in the United States and Europe have verified this specific form of depression. A more recent study by Dr. Krauuchi and his colleagues at the Psychiatric University Clinic in Switzerland found that persons with Seasonal Affective Disorder frequently engaged in emotional eating (i.e., excessive eating in response to negative feelings, depression, irritability, and anxiety) and “external eating” (i.e., eating in response to food stimuli regardless of whether hungry or not). These individuals have a tendency to eat large portions of carbohydrates (sweets) when feeling badly. Persons with Seasonal Affective Disorder also frequently report body image concerns and problematic eating attitudes that are similar to persons with bulimia and binge eating problems.

Several studies have found that Seasonal Affective Disorder can be effectively treated with a specific form of light therapy. Using bright artificial light produces rapid and substantial reduction in the depression and appetite symptoms. An intriguing finding from these studies is that persons who frequently eat high amounts of sweets late in the day are most likely to benefit from light therapy for the Seasonal Affective Disorder.

Depression Treatment
Although depression is a serious problem, effective treatments are readily available. Several medication and therapy options are available. A mental health professional can help determine the best treatment option.

Medication Treatments
A number of antidepressant medications are available. The antidepressant medications can be divided into three classes:
1.  Tricyclics,
2.  Monoamine oxidase inhibitors (MAOI), and
3.  Serotonin reuptake inhibitors (SRI)

Although there is some variability, treatment studies have generally found that approximately 60 to 75 percent of depressed patients derive some benefit from antidepressant medications.

The choice of a specific antidepressant for a particular individual is a complex decision best made by a psychiatrist. In general, the type of depressive symptoms and experience with antidepressant medications may influence the psychiatrist’s decision. Increasingly, psychiatrists view the newer class of SRIs as the starting point for treatment since their rates of success are slightly higher than the older antidepressants. They also tend to have more benign side-effect patterns. This may be especially relevant for overweight persons since SRI antidepressants (e.g., fluoxetine) have been reported in some studies to produce weight loss (Editor’s Note: See Dhurandhar NV, Atkinson RL. Recent advances in the treatment of obesity. The Weight Control Digest. March/April 1997). At a minimum, the SRIs are much less likely to produce the weight gain sometimes observed with the tricylic antidepressants.

In the July/August 1997 issue of The Weight Control Digest, Dr. Devlin and I reviewed the preliminary status and support for tricyclic and SRI antidepressants for Binge Eating Disorder. These two classes of medication used at similar or slightly higher doses than used for depression, produced substantial short-term reductions in binge eating but little or no change in weight.

Psychotherapy Treatments
In cases of depression, two psychological treatments have consistently received support in carefully conducted studies—cognitive behavioral therapy and interpersonal psychotherapy. Cognitive behavioral therapy is an active and collaborative therapy in which the client learns about maladaptive behaviors and ways of thinking. Clients learn to replace these behaviors with healthier coping and problem-solving skills and more objective ways of thinking. In interpersonal psychotherapy, the focus is on current interpersonal problems associated with the onset or maintenance of the depression. Clients focus on improving their social skills, handling interpersonal disputes, transitions, and grief.

Cognitive behavioral therapy and interpersonal psychotherapy (adapted for the specific needs of persons with eating disorders) are considered the “treatments of choice” for bulimia. Both treatments have also received impressive preliminary support for Binge Eating Disorder. For overweight persons with Binge Eating Disorder, studies have shown both treatment options reduce or eliminate binge eating in roughly 75 percent of cases. However, for reasons not yet understood, they do not seem to result in weight loss. Although many clinicians claim to incorporate certain elements of these treatments into their therapy approaches, many are not qualified or specifically trained in these approaches. If you are seeking treatment, be sure to ask.

What Treatments are Best?
Too often, professionals offer their patients treatments that they are most familiar with or that they have had the most experience. In the case of depression and certain eating-related problems (e.g., Binge Eating Disorder and bulimia nervosa) the available scientific evidence suggests that specific treatments should be considered first. These treatments are suggested as the first course of treatment because they have received scientific support from controlled studies. Scientists call such treatments “empirically-validated” approaches. It is my recommendation also that these treatments should be the first line of treatment. If a professional is not trained in the use of a particular treatment, the patient should be referred to a health profession with appropriate training and experience.

Combination Treatments
Does combining medication and psychological therapy for depression produce greater benefit than either alone? The evidence is mixed. Some studies show greater benefit from the combination approach, while other studies show cognitive behavioral therapy roughly equal to the combination of cognitive behavioral plus medication. The weight change implications of combination treatments has not been well studied. The focus of these studies has been on the elimination of the debilitating (and even life-threatening) depression.

Does combining medication and psychological therapy for binge eating in overweight persons produce an added benefit for the binge eating, the weight, or level of depression? To date, three studies have tested whether adding antidepressants to either cognitive behavioral therapy or to behavioral weight loss treatments produced any added benefit with overweight binge eaters. Two types of SRI antidepressants (fluvoxamine and fluoxetine) and one type of tricyclic antidepressant (desipramine) have been studied. The addition of the SRI fluvoxamine to these treatments was associated with a greater reduction in depressive symptoms, but no added improvement in eating or weight. Fluoxetine, in contrast, when combined with individual behavioral therapy resulted in added weight loss and probable improvement in binge eating, but had no added benefit as regards depressive symptoms. The tricyclic antidepressant desipramine did not seem to improve the response to behavioral weight loss treatment.

If the depression completely interferes with daily functioning and is coupled with thoughts of suicide, inpatient hospitalization may be warranted. We can successfully treat most cases of depression, however, without hospitalization. Although earlier studies suggested that antidepressant medications might be preferable, the most recent studies have shown that interpersonal therapy and especially cognitive behavioral therapy are quite effective even with moderate to severe depressions.

Future Trends
Many interesting questions remain about the complex relationships between depression and overweight. Currently, researchers are conducting a variety of studies that may address these important questions. For instance, my colleagues and I at the Yale University School of Medicine are directly comparing the effectiveness of antidepressant treatments and cognitive behavioral therapies both—singly and in combination. We are paying particular attention to whether a history or presence of depression influences who benefits from the treatments and what kinds of weight changes occur in persons with depression.

Concluding Thoughts
Depression and weight are related in complex ways and different relationship may exist in different people. Depression is a serious problem that often goes undetected. I hope that the information contained here about depression (symptoms, relationship to overweight, and treatments) is useful to clients and professionals alike. The good news is that there are effective treatments for depression. Perhaps greater attention to special needs of overweight persons during periods of depression may forestall the process of additional weight gain. How to do this safely and effectively represents a daunting challenge. For now, the best advice might be to reestablish lifestyle balance and activity as quickly as emotionally possible.

About the Author
Carlos M. Grilo, Ph.D., is the Director of Psychology and Director of the Eating Disorder Program at the Yale Psychiatric Institute and Assistant Professor of Psychiatry at the Yale University School of Medicine. Dr. Grilo’s major research and clinical emphasis is on eating and weight disorders. Dr. Grilo is currently the Principal Investigator on two research studies funded by the National Institutes of Health testing treatments for eating disorders. In addition, Dr. Grilo is the co-Principal Investigator on a research study examining the course of personality and depression over time in adults. This study will provide information about the nature of depression and its symptoms over time and how these symptoms influence psychological and social functioning.

Mother’s Depression Treatment

Remission of a mother’s depression within the first three months of treatment decreases the likelihood of her children having psychiatric disorders, such as mood or disruptive behavior disorders, within the same time period. Mothers who remain depressed increase the risk of her children having these disorders, according to a study in the March 22/29 issue of JAMA, a theme issue on women’s health.

Lead author Myrna M. Weissman, Ph.D., of Columbia University Medical Center and the New York State Psychiatric Institute, New York, presented the findings of the study today at a JAMA media briefing on women’s health in New York.

Parental depression is among the most consistent risk factors for childhood anxiety and disruptive behavior disorders and for major depression, with more than a 2- to 3-fold increased risk in offspring of depressed parents compared with controls, according to background information in the article. These offspring problems often begin before puberty, continue into adolescence and adulthood, and can be transmitted to the next generation. The long-term affects include impaired social and occupational functioning and increased risk of medical problems. Although early onset major depression is highly familial and has a strong genetic component, environmental factors, such as disrupted parent-child attachment and poor parent-child bonding may affect the impact of parental depression on children’s symptoms.

Dr. Weissman and colleagues examined whether effective treatment of a mother’s depression with medication is associated with reduction of psychopathological symptoms and disorders in their children. The study included 151 mother-child pairs in 8 primary care and 11 psychiatric outpatient clinics who were part of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, which was conducted between December 2001 and April 2004. The mothers in the trial were treated with medication for depression. The children, aged 7 to 17 years, were assessed by a team of evaluators not involved in maternal treatment and unaware of maternal outcomes.

The researchers found that after 3 months of medication treatment there was an overall 11 percent decrease in rates of diagnoses (from 35 percent to 24 percent) in children of mothers in remission vs. an 8 percent increase (from 35 percent to 43 percent) in children of mothers with continuing depression. Of the offspring who had psychiatric diagnoses at baseline and whose mother’s depression remitted, 33 percent of the children’s own diagnoses had remitted, whereas only 12 percent of the children of women whose depression remained lost their diagnosis. Of the children who had no psychiatric disorder at baseline, all remained free of psychiatric disorders at the 3-month follow-up if the maternal depression remitted, whereas 17 percent of children of mothers who remained depressed had an onset or relapse over this period

“To our knowledge, this is the first published study to document prospectively the relation between remission of a mother’s depression and her child’s clinical state. These findings are intriguing because they suggest that an environmental influence (i.e., the impact of maternal depression remission) had a measurable impact on the child’s psychopathology,” the authors write. “Our studies suggest that a reduction in stress associated with maternal remission may reverse the long-standing symptoms in children who are likely to be genetically vulnerable, although we have not genotyped the children in the study.”

“From a clinical vantage point, our findings suggest that vigorous treatment of depressed mothers to achieve remission is associated with positive outcomes in their children as well, whereas failure to treat depressed mothers may increase the burden of illness in their children. At a time when there are many questions about the appropriate and safe treatment of psychiatric disorders in children, these findings suggest that it is important to provide vigorous treatment to mothers if they are depressed,” the researchers conclude. (JAMA. 2006;295:1389-1398)

• Depressive and anxiety disorders are common in primary care settings, yet up to half the patients who present with these disorders may not be diagnosed and others may not be treated.
• The cornerstone of detection is an understanding of the common presenting symptoms and syndromes.
• Patients with depression or anxiety frequently present complaining of physical symptoms, which may obscure the psychiatric diagnosis.
• The doctor’s consultation technique is important: an empathic style, open questions and a willingness to hear the patient out will help reveal the diagnosis.
• Clinical depression is diagnosed when there are at least three or four symptoms (low mood, loss of interest, sleep disturbance, lost concentration, fatigue, disturbed appetite, agitation or retardation, feelings of worthlessness or guilt, suicidal thoughts)
  present every day for at least two weeks.
• Anxiety disorders include panic disorder, phobias, obsessive-compulsive disorder, post-traumatic stress disorder and generalised anxiety disorder.
• Screening tools (simple questionnaires designed to identify signs and symptoms of anxiety and depression) can be effective.
• Once a depressive or anxiety disorder is detected, possible causes to be explored include underlying medical conditions, psychiatric conditions, and drug or alcohol use.

The high prevalence rates in primary care patients are not surprising in view of large community surveys, such as the National Comorbidity Study in the United States,⁸ which reported a 12-month prevalence of 11.3% for depressive disorders and 17.2% for anxiety disorders.

1. The patient recognising that he or she is unwell. Often patients consider their psychiatric problems as “their lot in life”, and something that cannot change.
2. The patient recognising that a doctor can help. Often patients will present with problems associated with anxiety or depression, without thinking the doctor can help with the anxiety or depression itself. This is especially common with depression, where the sufferer may feel hopeless and beyond help.
3. The doctor recognising the mental illness.
4. The doctor recognising the need to treat and enlist specialist services where necessary.

The barriers at the third hurdle have been best studied and are generally divided into those related to the doctor, the patient, or the consultation.

Finally, personal issues for the doctor may also hinder recognition: some feel uncomfortable dealing with emotions and the interpersonal issues that are associated with anxiety and depression.

1. improving the interview technique of primary carers
2. the use of screening tools, and
3. bringing mental health services into primary care settings.

Suggestions to improve interviewing have included the use of video feedback techniques,¹⁰ restructuring consultations to allow extended and repeated interviews, and education about situations in which to be particularly vigilant (e.g., women in the postnatal period).

Other authors have suggested educational efforts need to be broadened to decrease the burden on doctors.⁹ Community campaigns to raise awareness about mental illness are under way in Australia and elsewhere. Information in surgeries, such as posters and videos, can help patients recognise their problems and help them feel comfortable discussing these issues with their doctor. Finally, other staff members, such as nurses, can be better trained to recognise mental illness.

Mental state examination
The mental state examination can be quite variable depending on the severity of the depression. Generalised psychomotor retardation is the commonest sign, although agitation can also occur. Lack of attention to personal grooming and hygiene may also be evident. The speech may be slow and monotonous. The affect is usually, but not always, depressed, and often anxious or irritable, with the patient easily moved to tears (although in more severe depression the patient often describes being emotionally blunted and “beyond tears”). The thought content reveals themes of hopelessness and helplessness, with a negative view of the self, world and future. Suicidal ideas and plans may be evident. In severe depression delusions may occur, and these are usually mood-congruent, with themes such as poverty, failure, guilt, or terminal somatic illnesses (such as “rotting” internal organs). Perceptual disturbances such as hallucinations are less common, but can occur in severe depression.

Cognitive function is intact, although in severe depression the patient may not have the interest or energy to answer, making cognitive assessment difficult.

The depressive syndromes
The Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV)¹³ classifies the mood disorders into the depressive disorders and the bipolar disorders (previously called manic-depressive illness).

The depressive disorders are:

Major depressive disorder:
Five or more symptoms present for at least two weeks, with a significant impairment in occupational or social functioning.

Dysthymic disorder:
Chronic but mild depression. There are more than two (but fewer than five) symptoms present most of the time for at least two years. The symptoms must cause significant distress or impairment.

Depressive disorder not otherwise specified:
Depression is the central feature, but the pattern does not fit the above disorders, or adjustment disorder (see below). It includes premenstrual depression, recurrent brief depression and other, less established, syndromes.

Adjustment disorders:
These are classified separately to depressive disorders, and refer to clinically significant emotional or behavioural symptoms related to depression, anxiety, or both, occurring in response to identifiable psychosocial stressors. They develop within three months of the stressor, and resolve within six months, and are not severe enough to meet criteria for major depressive disorder.

If patients report significant anxiety symptoms, specific questions about the various syndromes should follow.

The anxiety syndromes
DSM-IV¹³ classifies the anxiety disorders as follows:

Panic disorder
is characterised by recurrent, unexpected panic attacks, at least one of which has been followed by one or more months of persistent concern about having additional attacks, worry about the implication of the attack (e.g., fear of going crazy or having a heart attack), or a significant change in behaviour. Panic attacks are sudden, unexpected attacks of anxiety that are not necessarily linked to any cue. Agoraphobia often develops, which is essentially a fear of being in places or situations from which escape may be difficult should a panic attack occur, leading to avoidance of many activities.

Phobias
are more circumscribed forms of anxiety. Simple phobia involves persistent, excessive or unreasonable fear of specific objects or situations, with subsequent avoidance of such objects or situations. Social phobia is the fear of any situation where public scrutiny may be possible, usually with the fear of having a panic attack, or behaving in a way that is embarrassing or humiliating.

Obsessive-compulsive disorder (OCD)
involves specific cognitive and behavioural symptoms accompanying the feelings of anxiety. These include obsessional thoughts (recurrent thoughts, impulses or images that are experienced as intrusive and inappropriate and that cause marked anxiety), and compulsions (repetitive behaviours or mental acts that the person feels driven to perform in response to an obsession in order to reduce anxiety).

OCD is usually a chronic lifelong illness, with a waxing-and-waning course. The most frequent presenting obsessions are those related to contamination, pathological doubt (e.g., “Did I turn off the stove?”), somatisation and a need for symmetry. Frequent compulsions include the need to wash, check and count. The diagnosis of OCD should be made when the symptoms are severe, persistent and distressing.

Post-traumatic stress disorder (PTSD)
occurs after an acutely distressing or catastrophic event. Symptoms include re-experiencing the trauma (e.g., recurrent dreams of the event, flashbacks), persistent avoidance of stimuli associated with the event, and persistent symptoms of increased arousal (hypervigilance, irritability, exaggerated startle response). A diagnosis of PTSD is made if the symptoms are present for at least one month and cause clinically significant distress or impairment in functioning.

Generalised anxiety disorder
is excessive anxiety and worry, occurring most days for more than six months. It refers to excessive anxiety in a range of situations that does not fit into any of the more common syndromes.

Other situations in which to be particularly vigilant for depressive and anxiety disorders are:

• patients with chronic physical illness, especially involving the neurological system (e.g., Parkinson’s disease, strokes, multiple sclerosis)
• patients with chronic pain
• the elderly, especially the bereaved and those living alone or in nursing homes
• women in the postnatal period
• adolescents with behaviour problems.

Doctor-rated screening tests are a more structured way of interviewing and rating the severity of the illness. Patient-rated screening tests have the advantage of being completed in the patient’s own time, and hence allowing more widespread and time-efficient screening. PRIME-MD (primary care evaluation of mental disorders) combines a patient questionnaire to screen for common mental disorders and a clinician evaluation guide to gain further diagnostic information in areas which drew affirmative responses from the patient.

A more simple doctor-rated screening test, developed using latent trait analysis by Goldberg et al.,²² is shown in Box 3.

Screening questionnaires can be used routinely in all new patients, or used selectively in high risk groups. Disadvantages include the time needed for training, concerns about their usefulness, and the time taken for completion.

Depression may arise as a psychological response to physical illness, especially if the illness is life-threatening, chronic, or associated with pain. As many as one-fifth of general medical inpatients show some evidence of depression.²³ Alternatively, depression may be a direct consequence of the physical illness. Both Cushing’s disease and hypothyroidism are well known examples of endocrinopathies for which depression may be the first manifestation. The same is true for anxiety, where hyperthyroidism and vitamin B₁₂ deficiency are frequently associated with anxiety symptoms.

Drugs commonly associated with anxiety are sympathomimetics such as amphetamines, cocaine and caffeine. Drugs that increase serotonin release, such as LSD and MDMA (”ecstasy”), can cause acute and chronic anxiety. Prescription medications to consider include sympathomimetics, antihypertensives (especially captopril), and non-steroidal anti-inflammatory drugs.²⁵

Careful questioning about the timing of the drug dose in relation to the symptoms is important. If suspected, the drug should be withdrawn and the patient monitored for a correlation between relief of symptoms and washout (about five half-lives) to confirm or refute the diagnosis.

Comorbidity between anxiety disorders is common (e.g., 30% of patients with OCD report simple or social phobias, and 15% report panic disorder).²⁹

Comorbidity with other psychiatric disorders is also common. Depression can be a feature of virtually any psychiatric disorder. Particularly high rates of depression are found in alcohol-related disorders, eating disorders, schizophrenia and somatoform disorders.³⁰

The key comorbid psychiatric disorders to explore in anxiety disorders (apart from depression) are substance-related disorders (especially alcohol), schizophrenia and dementia.

Determining which disorder is primary and which secondary is difficult. For example, an anxious patient may become alcohol dependent through years of self-medication, or alcohol dependence may result in chronic anxiety. Finally, some independent factor, such as a genetic predisposition or tumultuous life events, may have led to both. Careful history-taking to determine the temporal relationship, with corroborative information from friends or relatives, helps in some cases. In others, unravelling which disorder came first is impossible.

• severe depression or anxiety
• high suicide risk
• failure to respond to treatment
• uncertainty about the diagnosis
• possible organic brain disease or dementia
• the need for greater resources
• adolescent patients
• comorbidity with drugs or alcohol
• patients not accepting recommended advice or treatment.

1. Sartorius N, Ustun TB, Lecrubier Y, Wittchen HV. Depression comorbid with anxiety: Results from the WHO study on psychological disorders in primary health care. Br J Psychiatry 1996; 168 Suppl 30: S38-S43.
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6. G