There is a clear similarity between the symptoms of anxiety disorders and depression. In addition, these two disorders are very often seen together. We can consider the relationships between these two main psychiatric disorders in two dimensions. The first dimension includes similarities and differences in terms of symptoms, diagnosis and differential diagnosis problems; the other is the diagnostic coexistence of these two different diagnostic groups. In this article, both issues will be discussed and then the way these disorders occur in primary care and basic approaches will be discussed.
SYMPTOMS OF DEPRESSION AND ANXIETY DISORDER
In psychiatry, the term depression is used in three different senses. The first use of the term describes a sad and sad mood as an emotional experience that can occur after a loss in normal individuals as well. In this sense, depressive mood is an appropriate and natural emotional response to adaptation to environmental changes and life events, which can also be seen in normal individuals from time to time. A second use of the term is depression as a mental symptom. The term depression as a symptom is used to describe an abnormal mood (mood) in which daily life is sad and sadness and unhappiness dominate. Depression as a symptom can be seen in many different situations or accompany various mental disorders. In other words, some of the patients presenting with this complaint may not have the characteristics of a complete depressive episode or may be suffering from another mental disorder. In this sense, depressive symptoms can accompany many neurological and medical diseases, especially psychiatric disorders. The third use of depression is to describe a specific mental illness. In this sense, depression is a mental disorder that goes with a certain group of symptoms and sometimes shows a cyclical nature (Klerman 1989).
Depressive disorders are not seen as a single disorder in current classifications and are classified as different entities. Depressive disorders in current psychiatric classification systems include major depressive episode, dysthymic disorder, and depressive disorders not otherwise specified. A major depressive episode requires at least two weeks of depressed mood or loss of interest, as well as the presence of at least four of the depression symptoms listed below. Significant weight loss or weight gain (more than 5% of body weight) or decreased or increased appetite nearly every day, insomnia or excessive sleepiness, psychomotor agitation or retardation, fatigue, exhaustion or Loss of energy, worthlessness, excessive or inappropriate feelings of guilt, decreased ability to think or concentrate on a particular topic or indecision, and recurrent thoughts of death. Dysthymia is a chronic depressive mood that lasts nearly every day for at least two years. For a person to be diagnosed with dysthymia, at least a minimum of symptoms of loss of appetite or overeating, insomnia or excessive sleepiness, low energy level or fatigue, low self-esteem, difficulty concentrating or making decisions, and feelings of hopelessness are required during mood episodes. both must be present.
Anxiety is a feeling of fear and worry that is difficult to define. This feeling may be accompanied by a number of sensations in the body. Feelings of tightness in the chest, heart palpitations, sweating, headache, feeling of emptiness in the stomach and the need to go to the toilet immediately can be given as examples. Restlessness and wanting to wander are also common symptoms of anxiety. The fact that anxiety is experienced without any concrete danger, occurs frequently and severely, and begins to affect the person’s normal life suggests that the individual has an anxiety disorder. The clinical manifestations of anxiety vary greatly from person to person. In some patients, muscle tension predominates and they complain of muscle stiffness or spasm, headache and stiff neck. Anxiety disorders: panic attack, agoraphobia, panic disorder without agoraphobia, panic disorder with agoraphobia, agoraphobia without panic disorder, specific phobia, social phobia, obsessive compulsive disorder, posttraumatic stress disorder, acute stress disorder, generalized anxiety disorder, anxiety disorder due to general medical condition and anxiety disorders caused by substance use. Especially panic disorder and generalized anxiety disorder are important in terms of differential diagnosis.
A panic attack is defined as a period of intense fear or discomfort accompanied by at least four of 13 physical or cognitive symptoms. The attack starts suddenly and quickly reaches its climax. It usually develops in less than ten minutes. Often this is accompanied by the sense that danger is imminent or the end of the person is coming, and the urge to flee. 13 physical or cognitive symptoms; palpitations, sweating, trembling or shaking, shortness of breath or choking sensations, shortness of breath, chest pain or feeling of tightness in the chest, nausea or abdominal pain, dizziness or lightheadedness, feelings of detachment or self-monitoring It consists of fear of losing control or going crazy, fear of death, paresthesias, and chills, chills, or hot flashes. These patients are people who worry about the little things, who are in constant fear and who expect the worst to happen to them.
DIAGNOSTIC COOPERATION IN DEPRESSION AND ANXIETY DISORDERS
When we examine the symptoms seen in depressive disorders and anxiety disorders as a cluster, we can divide them into 3 groups:
Symptoms seen only in depressive disorder (such as depressed mood, lack of pleasure)
Symptoms seen only in anxiety disorders (such as extreme anxiety)
Symptoms seen in both disorders (such as sleep and appetite disorder)
We can liken this relationship to set theory in mathematics. Although the depression cluster and the anxiety disorders cluster are two separate clusters, they show a wide intersection (Figure 1). As it can be understood from this situation, we are faced with two diseases that can show similar symptoms, although they are two separate diagnoses. Beyond these similarities in symptoms, patients presenting with anxiety or depression often have symptoms of both disorders. In terms of diagnostic relationships, we can see patients showing the symptoms of these two groups of disorders in the clinic in 4 groups:
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The group consists of patients diagnosed with depression as well as patients with anxiety symptoms that are not large enough to fully diagnose an anxiety disorder.
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The opposite group is patients with an anxiety disorder, but also with depressive symptoms that are so intense that they cannot be diagnosed with a complete depressive disorder.
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The group consists of patients with two diagnoses, who show symptoms that are intense enough to be diagnosed with both depression and an anxiety disorder.
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and the last group of patients are those who show mixed symptoms of both depression and anxiety, but both alone cannot cross the threshold in terms of diagnosis (Hirschfeld 2001).
Although it is controversial to recognize a separate diagnosis group in today’s psychiatry, it is advocated to classify this group of patients under a new diagnosis group called mixed anxiety depression disorder (Lydiard and BrawmanMintzer 1998).
Depression and anxiety are frequently seen together, especially in primary care medicine. In the National Comorbidity Survey (NCS), a large-scale study of the epidemiology of mental disorders in the United States, 58% of patients with major depression had a secondary anxiety disorder, and 68% of patients with any anxiety disorder had co-diagnosis. Major depression was found to be the most common (Kessler et al. 1996). In an observation study that followed the course of anxiety and depression in a group of patients over a period of 40 years, it was found that half of the patients with anxiety disorders also had depression (Murphy et al. 2004). The high rates found in these studies conducted in the community were even higher in studies conducted in primary care. For example, it was found that 75% of primary care patients diagnosed with depression also had an anxiety disorder. Based on epidemiological studies conducted in the community, it was calculated that the risk of developing an additional anxiety disorder increased 3.38.2 times in a patient with major depression, while the risk of developing depression in a person with an anxiety disorder increased by 762 times in a year (Hirschfeld 2001). However, these findings should not suggest that anxiety and depression are entities that appear completely together. For example, in a study conducted with 4051 elderly patients, the frequency of pure depression was 12.2%, the frequency of pure generalized anxiety disorder was 2.9%, and the frequency of mixed anxiety depression was 1.8% (Schoevers et al. 2003). In addition to this large patient group in which these two diagnoses can be made together, anxiety or depression symptoms that are not at a level that deserves a second diagnosis, and mixed pictures in which depression and anxiety cannot be distinguished can be encountered.
CLINICAL RECOMMENDATIONS
Although it is reported that the incidence of anxiety and depression is high in primary care, it should be noted that the complaints brought by these patients are physical rather than behavioral and psychological. In primary care, such patients are typically characterized by somatic complaints as well as symptoms of anxiety and depression intertwined with life problems, accompanied by very little psychological insight. Many of these patients are unfamiliar with the idea that their somatic symptoms may be due to mental illness. Studies have reported that chronic pain, easy fatigue, and sleep disorders are predictors of depression in patients admitted to primary care (Montano). Therefore, after an adequate physical examination, patients with unexplained back pain, chest pain, shortness of breath, heart palpitations, sleep and appetite problems and fatigue should be questioned in this respect, considering that they may have depression or anxiety disorder. The main symptoms of these two disorders should be investigated in patient groups with such symptoms. A more detailed interview should be conducted to clarify the diagnosis in patients who have symptoms after this screening.
What screening questions should be asked and when to find out if anxiety and depression are present? One approach in this regard is to fill in the interview form known as Prime MD, which was developed for primary care, and a questionnaire covering the basic psychiatric symptoms by each patient, and then clarify the diagnosis by detailed questioning with the patients who stated that the symptoms were present (Doğan 1996). However, since this approach is not possible for every patient in a busy work environment, it may be more practical to use such questionnaires, at least in suspicious complaints and patient groups. The main symptoms investigated are depressive mood (sad, unhappy, pessimistic mood) and loss of interest (reluctance, not enjoying life), which are the necessary conditions for depression, among the depression and anxiety disorder symptoms we explained in the introduction; In anxiety, there may be a state of unreasonable fear, anxiety, uneasiness and worry. A depression or anxiety disorder may be considered if other additional symptoms required for diagnosis are detected in patients with these symptoms. After these patients are diagnosed, referral of patients who have both diagnoses to specialists and treatment of plain depression and anxiety cases in primary care can be considered. Antidepressant drugs, especially serotonin reuptake inhibitors, are used in the treatment of these patients.
Psychiatrists should be consulted at this initial stage in cases of severe or chronic depression, in cases where there is a risk of suicide, in those with additional substance use or addiction, and in patients with suspected bipolar disorder. It would be appropriate to seek help from psychiatrists in patients whose treatment was initiated in the primary care setting, in whom the response to treatment was insufficient, complete recovery could not be achieved or the clinical picture deteriorated.
In patients with severe anxiety symptoms in addition to depression, medical factors should be investigated, especially in elderly patients. These medical factors include drugs used at that time, endocrine disorders (thyroid pathologies). Since the agitation accompanying hypomania may present itself similar to anxiety, bipolar disorder is a diagnosis that should be considered in such patients. If, at any time in the patient’s life, the presence of extreme joyful or angry mood episodes, which are the main features of bipolar disorder, is detected, it is appropriate to refer these patients to a psychiatrist.
Source: Türkçapar, H. (2004), Diagnostic Relationships of Anxiety Disorder and Depression, Clinical Psychiatry 2004; Appendix 4:12-16
