Depression and Anxiety Treatment

One of the main consequences of bereavement is psychologic
distress, particularly sadness and depression.
Other features include anxiety, insomnia, somatic symptoms
(somatization) and hallucinations. In western culture,
the expression of sadness following bereavement is
expected and its absence seen as pathologic. In addition
to bereavement, a sense of grief can be experienced from
other major losses, such as a terminal diagnosis, losing a
job, a marriage that fails, amputation or radical surgery.
Figures 4.9 and 4.10 show typical physical and psychologic
symptoms experienced during ‘normal grief ’.
Bereavement can also have a negative impact on
health. There is an increased risk of mortality particularly
within the first 6 months after bereavement37–40.
There is also evidence of an increased vulnerability to
physical illness and mortality during the first 2 years of
bereavement, with men at higher risk than women.
Some bereaved people develop health-impairing behaviors
such as increased substance use41, typically alcohol,
tobacco and psychotropic medication42, which can have
negative consequences for mental and physical health.
Marital status has an important influence on the rates
of depressive disorders both in the community and
inpatients and, in general, those who are widowed or
divorced have a greater risk of depression than those
married or single. Bebbington43 analyzed data from
English national statistics to assess the association
between sex, marital status and first admission to psychiatric
hospital. First admission rates (1982–1985) were
estimated per 100 000 for populations over the age of
15 using ICD-9 as the diagnostic criteria. Admission
rates for all depressive disorders were higher in widowed
and divorced patients irrespective of gender. When all
affective disorders were taken together, those widowed
had the highest incidence.
Bereavement also increases the risk of mental health
problems, particularly depression and anxiety44–46.
Symptoms of anxiety and depression are common during
the first months of bereavement and normal grief
reactions persists for 2–6 months, but usually improve
without specific interventions.

Community surveys in industrialized countries estimate
a 1% lifetime risk for bipolar disorder and a 5%
risk for the bipolar spectrum35. In 1990, bipolar disorder
was estimated to be the sixth leading cause of
worldwide disability in people between the ages of 15
and 44 years (see Figure 4.6)36. The mean age of onset is
21 years, which is earlier than for major depression.
Both sexes are affected equally, although women tend
to have proportionately more depressive episodes. The
cyclical pattern of mania and depression was previously
called ‘manic-depressive psychosis’. The current term of
bipolar affective disorder or bipolar illness is more
appropriate, as many patients with marked disturbance
of affect do not ever experience psychotic phenomena,
such as delusions or hallucinations.

Approximately 29% of women after childbirth experience
some mild decline in mood and/or increased anxiety,
thought mainly to be due to psychosocial changes
associated with motherhood34. Most do not require
treatment. However, postpartum depression affects 14%
of women. The features generally fit the DSM-IV criteria
for major depression and the diagnosis is given when
the onset is within 4 weeks postpartum, as defined in
the ‘postpartum onset specifier’. Anxiety is often a
prominent feature with high levels of anxiety, particularly
obsessional ruminations about the health of the
infant.

MIXED ANXIETY AND DEPRESSIVE
DISORDER
The ICD-10 includes a category of mixed anxiety and
depressive disorder (MADD), to be recorded when
symptoms of both anxiety and depression are present,
but neither set of symptoms, considered separately, is sufficiently
severe to justify a diagnosis. The appendix of the
DSM-IV contains a broadly similar description, but neither
ICD-10 nor DSM-IV have specified criteria. The
recent UK Office of Population Censuses and Surveys
(OPCS) Survey of Psychiatric Morbidity found a point
prevalence for MADD (using ICD-10 diagnostic criteria)
of 7.7%, compared to a point prevalence of only
2.1%, for depressive episodes32, rates in women being
almost double those in men (9.9% versus 5.4%, respectively).
The course and treatment outcome of MADD
are largely unknown, but the disorder is likely to be of
particular relevance in primary care settings.

DYSTHYMIA (DYSTHYMIC DISORDER)
Dysthymia was first introduced into the group of affective
disorders in the DSM-III classification in 1980. It overlaps
substantially with major depression, the main differentiation
being that dysthymia is a chronic depressive
disorder with milder symptoms. The chronic features of
dysthymia fluctuate in severity, and most sufferers will
develop supervening comorbid major depressive episodes
(sometimes termed ‘double depression’). See Figure 4.3
for a summary of the DSM-IV criteria.
Estimates of lifetime prevalence of dysthymia are probably
unreliable. A review by Angst28 revealed a lifetime
prevalence ranging from 1.1% to 20.6%. Accurate diagnosis
is often difficult and the reliability low, since it is
largely dependent on the accurate recall of symptoms
spanning 2 years, which may be many years in the
patient’s past. The female:male ratio is approximately 2:1,
and dysthymia appears more common in the elderly than
in younger people. In one study of a Finnish cohort of
elderly subjects the prevalence was 12%29.

INTRODUCTION
The ICD-10 and DSM-IV have largely similar
approaches to the classification of the depressive disorders
(see Figures 2.1 and 2.2), with a depressive episode
(ICD-10) and a major depressive episode (DSM-IV)
being the pivotal form of depressive illness, about which
other depressive disorders are described. However, in primary
care, many depressed patients present with depressive
symptoms that do not fulfil the accepted diagnostic
criteria for major depression or depressive episode,
because the depressive syndrome is too mild, too short,
too long or without social consequences. By contrast
patients in secondary care inpatient settings are rather
unrepresentative of the total sample of patients, psychiatrists
being likely to see the most severely ill and those
patients with ‘comorbid’ (coexisting) disorders.
The most recent classificatory schemes include a number
of other depressive disorders, in an attempt to
describe important groups of patients, who otherwise
could not be allocated a diagnosis. For example, both the
DSM-IV classification and the ICD-10 system include
dysthymia (a chronic mild depressive disorder), and the
ICD-10 also incorporates recurrent brief depressive disorder
(RBD) within the group of mood disorders.
UNIPOLAR AND BIPOLAR DEPRESSION
When a person develops an episode of mania they are
conventionally identified as suffering from bipolar disorder,
but those patients with depressive episodes only are
diagnosed as having unipolar depression. This differentiation
is useful from a clinical perspective, as differing
treatment approaches are required for these disorders (see
Figure 4.1). The person who is in a manic phase of the
bipolar disorder will usually require ‘anti-manic’ treatment,
and treatment of any future depressive episodes
must be carefully undertaken, so as not to precipitate a
further manic episode.
Most patients experience multiple depressive episodes
over their lifetime, the episodes varying in length, severity
and impairment, and in the response to treatment.
Approximately 15% of consultations in general practice
are due to ‘recurrent unipolar depression’1. Anxiety
symptoms are a common feature in many people with
depression and may be so prominent that they ‘mask’ the
underlying depressive symptoms, which are found only
after direct questioning.
MAJOR DEPRESSIVE EPISODE
The two key features of major depression are depressed
mood and loss of interest or pleasure.
The prevailing mood is one of persistent misery, which
does not respond to good news. This is often accompanied
by a lack of enthusiasm for previously enjoyable
activities or hobbies. Figure 2.2 shows the DSM-IV diagnostic
criteria for major depressive episode.
The lifetime prevalence rates for major depressive disorder
have been estimated to range between 12% and
17%. However, there is a wide variation in the reported
prevalence rates for major depression (see Figure 4.2).
Table 1 shows the lifetime prevalence rates found across a
variety of locations27. The lowest rates were 0.9% in
Taiwan, and the highest 24% in Oregon (USA).
European rates are closer to those of Oregon, e.g. 15.7%
in Basel18,19, 16% in Zurich27 and 16.4% in Paris21. A key
factor in identifying rates of major depression is the sensitivity
of the questionnaire instrument. The Composite
International Diagnostic Schedule (CIDI) is probably a
more sensitive instrument than the Diagnostic Interview
Schedule (DIS), which generally produces lower rates.

Table 1 Lifetime prevalence rates of major depressive disorder. CIDI, Composite International Diagnostic Schedule; DIS,
Diagnostic Interview Schedule; DSM-III-R, Diagnostic and Statistic Manual III revised; HDS (DPA), Diagnostic and statistic
Manual I revised; NCS, National Comorbidity Survey; SADS-L, schedule for affective disorders and schizophrenia; SADSRDC,
schedule for affective disorders and schizophrenia – research diagnostic criteria. Adapted with permission from
Angst J. The Prevalence of Depression in Antidepressant Therapy at the Dawn of the Third Millennium. Briley M, Montgomery S,
eds. London: Dunitz, 1998:198
Location Reference Instrument n Male Female Male + Female
Taiwan (metropolis) 2 DIS 5005 0.7 1.0+ 0.9
Taiwan (small township) 3 DIS 3004 0.9 2.5+ 1.7
Hong Kong 4 DIS 7229 1.3 2.4 –
Korea 5 DIS 3134 2.4 4.1 3.3
Korea (rural) 6 DIS 2995 2.9 4.1 3.5
Puerto Rico 7 DIS 1513 3.5 5.5 4.6
Iceland 8 DIS/DSM-III 862 2.9 7.8 5.3
ECA, USA 9 DIS 5.2 10.2 4.9
New Haven, USA 9 DIS 5063 – – 5.9
Baltimore, USA 9 DIS 3560 – – 3.0
St Louis, USA 9 DIS 3200 – – 4.5
Durham, USA 9 DIS 4101 – – 3.5
Los Angeles, USA 9 DIS 3436 – – 5.6
Mainz,Germany 10 SADS-L 80 – – 7.7
National Survey, USA 11 8.4
Edmonton, Canada 12 DIS 3258 5.9 11.4 8.6
Munich, Germany 13 DIS 483 – – 9.0
Boston, USA 14 DIS 386 5.1 13.7 9.4
DSM-III-R
Sardinia 15 CIDI 552 11.6 14.8 13.3
Christchurch, New Zealand 16 DIS 1498 8.8 16.3 12.6
St Louis, USA 17 DIS 298 12.8 23.8 14.8
Basel, Switzerland 18,19 CIDI 470 11.0 19.5 15.7
Stirling County, Canada 20 HDS (DPA) 1003 16.0
Paris 21 DIS/CIDI 1787 10.7 22.4 16.4
NCS, USA 22,23 CIDI 8098 F F 17.1
New Haven, USA 24 SADS-RDC 12.3 25.8 18.0
Oregon (T1) 25 SADS-L 1508 11.6 24.8 18.5
Oregon (T2) 25 15.2 31.6 24.0
Iceland 26 DIS 862 2.0 7.8 –

We cannot list complete medication information on this page, due to individual differences, possible misinterpretation, medical complications, and other related problems. A consultation with a medical professional, such as a psychiatrist who specializes in the anxiety disorders, is an important and necessary step when medication is being considered for social anxiety.The following is only a guide to what we have found to be clinically useful. However, empirical research in this area has tended to support these clinical findings.

In the first place, not everyone with social phobia needs to be on medication. There are many factors that need to enter into this judgment, such as severity of the condition, conferring with your anxiety specialist, your psychiatrist, other medications you take and your general medical condition, etc. and the way you know your body responds to medication in general.

When a socially-anxious person faces anxiety problems related to social anxiety every day of their lives we recommend that medication may be very useful. Please keep in mind that while medication can be very helpful in some cases, it is NOT a cure. It will not get you to where you want to be — it will not be the “solution”.

If we recommend medication it is for the purpose of using it as a “tool” or as an “encouragement” while undergoing cognitive-behavioral therapy. If medication allows the individual to practice better and clearer at home on CBT material and if the anxiety is cut somewhat in daily functioning, then medication can be powerful and helpful. It is the CBT however that changes your brain pathways (neural pathways) permanently, NOT the medication. Medication generally works faster (if it works), but permanent results (physiological changes) can only occur by learning to think and beginning to feel differently.  We use CBT to make these permanent changes.

If you are looking for a band-aid, get the medication and ignore CBT therapy.  In a few years, you will not be happy with your decision.

Again, in general, we prefer a combination of the right medication with CBT.  When both work in concert, progress is enhanced.

If you are looking for a permanent solution — a change in your brain’s chemistry and neural pathways –  stick with CBT and practice, practice, practice until it becomes an automatic habit. There is research evidence showing that neural pathways actually change physiologically over time by using cognitive-behavioral therapy.

Medication changes brain chemistry temporarily; CBT has the power to make it permanent.

Each and every person responds individually to medication.  When medication is addressed, what works for one person may not work for another. Here we are only talking in generalities and in approximate percentages. If a medication works for you, as you are under the care of a qualified psychiatrist who specializes in the anxiety disorders, stick with it.

Tri-cyclic antidepressants (TCAs): generally are not much help for social anxiety.

Buspirone: May provide limited help, however empirical research is lacking.  We have had very little success from this medication when it is prescribed for social anxiety.  Not a medication of choice for social anxiety.

SSRIs, such as Prozac, Zoloft, Paxil: Some reports have found a 15-45% success rate in temporarily reducing social anxiety symptoms, a finding that is optimistic compared to our clinical observations. Among our current and past socially-anxious client base, we have seen only a few people who seem to have been helped by one of the SSRI medications.  On the other hand, over 60% of our people who have been prescribed an SSRI have had fairly negative responses.

Anti-anxiety agents, such as Ativan and Klonopin: These are the agents of choice for starting anxiety management.   The most positive research is available on these two anti-anxiety agents.  (Note: these are anti-anxiety agents and will have no effect on dysthymia and depression.  If a person has strong depression, this medication may not be the agent of choice.)

Many “primary care” physicians (GPs) have not been trained in the anxiety disorders and see these medications as being “addictive”. However, these medications are NOT addictive for people with clinical anxiety disorders. Over three dozen research studies report that people with clinical anxiety disorders do not become drug addicts as a result of temporary anti-anxiety use. These medications can be very helpful for people with social phobia. Find a psychiatrist who understands this.  These medications are tolerated well and almost always help. There are few side effects (e.g., tiredness at first) and they work quickly.  There seems to be more research support for the use of Ativan (lorazepam) and Klonopin (clonazepam) in the treatment of social anxiety than the other anti-anxiety medications.

If a professional tells a person with a definable, DSM-IV anxiety disorder that the anti-anxiety agents may prove addictive to them, the professional (a) is not aware of research in the area of anxiety, and (b) should probably not be treating you.  The anti-anxiety agents work, they are safe, and people with anxiety disorders stay on a low dosage when going through CBT.  These medications are nothing to worry about.

When stopping anti-anxiety use, it is necessary to taper off the medication very slowly, by reducing the dose gradually over a period of 3 to 4 weeks.

MAOIs: These medications, in general, have been shown to work effectively approximately 60-85% of the time for people with clinical social anxiety. Most people with social anxiety do not need this medication, however.

If a medication is needed in addition to the anti-anxiety agents, these medications have been shown to work best for social anxiety disorder. Although most of our generalized social anxiety people do NOT need to be on these medications, people with more avoidant behaviors DO need the added benefits of an MAOI.

We have found that, in general, Parnate, as opposed to Nardil, is more effective with (generalized) social anxiety disorder, provided there are no other anxiety or mental health care complications. (Nardil has been shown by research to be effective, also, although we have yet to see anyone tolerate this medication.  If an MAOI is considered, we recommend Parnate over Nardil, due to Parnate’s added noradrenergic and dopaminergic effects).  People with avoidant personality disorder are usually greatly helped by this medication.  Although these medications require slight food restrictions, the current restriction list (even as far back as of 1998) is quite small.  No responsible adult who needs to be on an MAOI, and is receiving help from the medication, has ever complained about the food restrictions.

Our more severely socially-anxious individuals (currently being termed “avoidant personality disorder”) may need to use these medications, under proper psychiatric care. Again, Parnate works faster, has less side effects, is uplifting and motivating for people with social anxiety and is preferred over Nardil.  Talk with your social anxiety therapist about this first, and get a recommendation to a psychiatrist who understands social anxiety and this particular medication in general. You will not typically be able to obtain one of the MAOIs from your general practitioner, as they are usually unaware of the positive effects these medications can play in helping people with social anxiety.

RIMAs:  The reversible MAOIs or RIMAs are available almost everywhere else in the world except the United States.  Currently, it is possible to have your psychiatrist write a prescription for a RIMA  and have it filled at a pharmacy in Australia, New Zealand, or in Europe.  It will then be mailed to you.   In general, moclobemide appears from the early data to be much less effective for social phobia than Parnate or Nardil.  We do not recommend its use based on the available data.

NOTE: If you are given any type of medication for psychosis, you have been misdiagnosed. Social anxiety is an anxiety disorder and is therefore the “opposite” of psychosis. If this happens to you, please seek another therapeutic source. (We have received e-mails about antipsychotic medication, such as zyprexa.  Zyprexa, or any of the other antipsychotics, generally has no place in the treatment of DSM-IV defined social anxiety disorder.)

ADDITIONAL NOTE:  Research has demonstrated that “avoidant personality disorder” is simply a severe case of social phobia/social anxiety.  Avoidant personality disorder is NOT a psychotic condition, and the administration of anti-psychotic medication is therefore inappropriate.   These medications should not be used with uncomplicated social phobia/social anxiety.

IMPORTANT NOTICE: This information is intended as a general guide only. It is essential you consult with your psychiatrist about any medication, due to individual and/or interaction effects, and additional medical complications. It is also essential that you work with a psychiatrist that FULLY understands social anxiety and has kept up with the latest research on medical treatment for social anxiety.