And blood pressure and anxiety-depressive syndrome. How to cope with anxiety and depression on your own? Biochemistry of mechanisms of action

It is known that depression is current problem among people of the 21st century. It develops due to high psycho-emotional stress associated with the accelerated pace of life. Depressive disorders significantly reduce the quality human life, so you need to learn how to maintain personal mental hygiene.

Causes of Anxiety Disorder

Anxiety-depressive syndrome belongs to the group of neuroses (ICD-10), and is accompanied by various kinds of physical and mental disorders. The most common causes of depression are the following:

• hereditary predisposition to depression;
• many stressful situations;
• organic changes in the state of the brain (after bruises, injuries);
• long-term anxiety and depressive symptoms;
• deficiency of serotonin and essential amino acids in the body;
• taking barbiturates, anticonvulsants and estrogen drugs.

Symptoms of nervous system disease

The main symptom of anxiety-depressive disorder is constant groundless anxiety. That is, a person feels an impending catastrophe that threatens him or his loved ones. The danger of anxiety and depression lies in vicious circle: anxiety stimulates the production of adrenaline, which increases negative emotional stress. Patients who have this personality disorder complain of lack of mood, systematic sleep disturbances, decreased concentration, accompanied by chills and muscle pain.

Postpartum depression in women

Many women immediately after childbirth experience anxiety and depressive symptoms, which are called childhood sadness. The condition lasts from several hours to a week. But sometimes depression and anxiety in young mothers takes severe form which can last for months. The etiology of the anxiety state is still not precisely known, but doctors name the main factors: genetics and hormonal changes.

Types of depressive disorders

Anxiety differs from true fear in that it is a product of an internal emotional state, subjective perception. The disorder manifests itself not only at the emotional level, but also by body reactions: increased sweating, rapid heartbeat, and indigestion. There are several types of this disease, differing in symptoms.

Generalized anxiety

With this syndrome, the patient chronically experiences anxiety without knowing the cause of the condition. Anxious depression manifests itself as fatigue, gastrointestinal dysfunction, motor restlessness, and insomnia. Depressive syndrome is often observed in people with panic attacks or alcohol addiction. Generalized anxiety-depressive disorder develops at any age, but women suffer from it more often than men.

Anxious-phobic

It is known that a phobia is the medical name for an exaggerated or unrealistic fear of an object that does not pose a threat. The disorder manifests itself in different ways: fear of spiders, snakes, flying on an airplane, being in a crowd of people, sharp objects, swimming, sexual harassment, etc. With anxiety-phobic syndrome, the patient develops a persistent fear of such a situation.

Mixed

When a person has several symptoms of depression for a month or more, doctors diagnose “mixed anxiety-depressive disorder.” Moreover, the symptoms are not caused by taking any medications, but worsen the quality of the patient’s social, professional or any other area of ​​life. Main features:

• slow thinking;
• tearfulness;
• sleep disturbance;
• low self-esteem;
• irritability;
• difficulty concentrating.

Diagnosis of depressive disorders

The main method for diagnosing depression in a patient remains questioning. Identification of symptoms of depression is facilitated by a trusting atmosphere, a sense of empathy, and the doctor’s ability to listen to the patient. Also in the practice of psychotherapy, a special HADS depression and anxiety scale is used to determine the level of pathology. The test does not cause any difficulties for the patient, does not take much time, but gives the specialist the opportunity to make the correct diagnosis.

Treatment of anxiety-depressive syndrome

General strategy Treatment of anxiety and depressive disorders consists of prescribing a complex of medications, homeopathic remedies, herbal remedies and folk recipes. Behavioral psychotherapy, which greatly enhances the effect of drug therapy, is also important. The complex treatment of anxiety-depressive syndrome also includes physiotherapy.

Drugs

Medication treatment helps to get rid of depressive-anxiety disorder. There are many types of drugs with psychotropic effects, each of which affects its own clinical symptoms:

1. Tranquilizers. Powerful psychotropic medications used when other treatments for depression have not worked. They help get rid of internal tension and panic, reduce aggression and suicidal intentions.
2. Antidepressants. Normalize the emotional state of a person with obsessive-compulsive disorder ( obsessive states), prevent exacerbation.
3. Neuroleptics. Prescribed for inappropriate emotions of the patient. The drugs affect the area of ​​the brain that is responsible for the ability to perceive information and think rationally.
4. Sedatives. Sedatives, which are used to eliminate nervous tension, normalize sleep, and reduce the level of excitability.
5. Nootropics. They affect areas of the brain to increase performance and improve blood circulation.
6. Alpha and beta blockers. Able to turn off receptors that respond to adrenaline. They increase the level of glucose in the blood, sharply narrow the lumen of blood vessels, and regulate vegetative processes.

Psychotherapeutic methods

Not every person with anxiety-depressive disorder needs medication therapy or hospitalization. Many psychiatrists prefer to treat depression in children and adults using psychotherapeutic methods. Experts are developing a variety of techniques, taking into account gender characteristics, adapted to different social groups. Some patients are better suited to one-on-one consultations, while others show excellent results when treated in a group setting.

Cognitive behavioral therapy

Anxiety disorder can be cured with cognitive behavioral therapy. It is used to relieve a wide range of depressive symptoms, including addiction, phobias, and anxiety. During treatment, people identify and change their destructive thinking patterns that influence their behavior. The goal of therapy is that a person can take control of any concept of the world and interact positively with it.

Hypnosis

Sometimes the effect of hypnosis on a patient with a depressive disorder is the most effective therapeutic method. Thanks to modern trance techniques, a person’s negative attitudes and perception of reality. With the help of hypnosis, patients quickly get rid of dark obsessive thoughts and chronic depression. A person’s anxious personality disorder goes away, he receives a powerful charge of energy and a lasting feeling of inner satisfaction.

Video

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Anxiety and depressive disorders in women

Vasyuk Yu.A.

Yuri Aleksandrovich Vasyuk presented an overview report on the topic of anxiety and depressive disorders in women and the possibility of drug correction of depression.

Ivashkin Vladimir Trofimovich, Academician of the Russian Academy of Medical Sciences, Doctor of Medical Sciences:

I will now give the opportunity to make a message to Professor Yuri Aleksandrovich Vasyuk. "Anxiety and depressive disorders in women."

Yuri Alexandrovich Vasyuk,Doctor of Medical Sciences, Professor:

Good afternoon, dear colleagues.

Today we will talk about anxiety and depressive disorders in women and the possibilities of their medical correction.

First of all, we need to remember the definition of depression. As you know, depression is characterized by a state of low mood, depression, sadness, decreased or loss of interest in any activity, and decreased activity.

If current trends continue, by 2020 depressive disorders will take second place (after coronary heart disease) among all diseases in terms of the number of years lost due to disability.

Speaking about the epidemiology of depression, it would probably be very revealing to reflect the situation that has developed in such a rich and prosperous country as the United States.

It is known that 10 million people in this country currently suffer from clinically significant depression. Another 20 million suffer from adjustment disorders. The economic burden of depression in the United States is $83 billion.

Great Britain is also an equally prosperous country. The concept of “iceberg depression phenomenon” has even been introduced. Its essence lies in the fact that only a third of patients with depression turn to doctors. Only a third of those applying are diagnosed with an affective disorder. This part of the patients is prescribed adequate treatment.

The total cost of depression in the UK is more than 15 billion pounds. 65% of patients with depression are a consequence of insufficient diagnosis and untimely correction. 65% of patients with depression have suicidal ideation, 15% of them commit suicide.

Speaking about risk factors for depression, we can recall quite a lot of unfavorable circumstances. History of anxiety disorder, unfavorable heredity, lack of social support, postpartum period, drug or alcohol addiction, severe somatic illnesses, old age, low socioeconomic status. But the female gender occupies a special place in this list.

Risk factors for mental disorders in premenopausal women. In fact, there are quite a lot of disorders. But it is necessary to note the most significant of them. First of all, this:

• - stressful life events:
• - divorce;
• - childlessness;
• - a loss social security;
• - history of mental disorders;
• - low level education;
• - postpartum period, premenopause, oophorectomy, luteal phase of the menstrual cycle.

We will try to discuss in detail all of the listed conditions.

The so-called “female depression”. This is premenstrual syndrome (PMS). Characterized by depression in combination with somatic disorders(vegetative-vascular and neuro-endocrine).

Premenstrual dysphoric disorder is the same, but in combination with pathocharacterological manifestations (up to suicidal thoughts, affective lability).

If we talk about epidemiology, it should be noted that in the population the frequency of PMS is 30 - 70%, depending on age. In mentally ill women, the incidence of PMS is 100%.

Clinical criteria for this syndrome boil down to the following key points:

• - PMS occurs 2-14 days before menstruation and disappears with its onset or in the first days of menstruation;
• - it is a complex of vegetative-vascular, metabolic-endocrine and mental disorders;
• - in the premenstrual period, aggressiveness, suicidal activity, the frequency of offenses and suicide attempts increase.

Postpartum depression is also a fairly common situation.

Manifestation or repeated attack of endogenous depression. Typically, postpartum depression occurs 10 to 12 days after an uncomplicated birth without an external cause. The clinical picture is characterized by classic depressive symptoms, anxiety and an atypical form (tearful).

Neurotic depression is distinguished separately. It manifests itself before childbirth (stress, fear of childbirth) or after childbirth (psychogenies associated with family and child). The clinical picture of neurotic depression is manifested by asthenic-depressive and anxiety-depressive symptoms.

Another type of depression in women is associated with menopause. Her options:

• - menopausal depression;
• - psychogenic depression;
• - endogenous depression;
• - involutive depression;
• - depression during surgical menopause.

Emotional-affective syndrome is known to be characterized by:

• - decreased mood;
• - loss of interest in one’s own personality and in the environment;
• - unmotivated anxiety;
• - suspiciousness, anxiety;
• - feeling of internal tension;
• - alarming fears for one’s health, etc.

Asthenic syndrome is very well known to all of us. There is probably no need to dwell on it for a long time. It is enough to remember such key manifestations, How increased fatigue, decreased activity, increased vulnerability, touchiness, excessive sensitivity, mood lability, tearfulness and irritability.

Somatovegetative disorders occur in almost every second or third woman at an outpatient appointment. These are palpitations, arrhythmia, discomfort in the left half of the chest, fluctuations blood pressure(BP), feeling of lack of air, dyspeptic disorders, chills, trembling, sweating.

Finally, dissomnia disorders (or sleep disorders). They manifest themselves in women by an increase in the time it takes to fall asleep, frequent awakenings at night, low subjective assessment of sleep quality and the so-called “sleep apnea” syndrome.

A fairly large part of depression in women is occupied by depressive disorders during surgical menopause. The frequency of these disorders (according to some authors) reaches 60 - 80% of cases. But most of the literature indicates the detection of this syndrome in 40 - 45% of patients.

The clinical picture is characterized by a combination of affective (anxious, melancholy, apathetic, dysphoric) and somatovegetative disorders (which we just talked about).

For the treatment of affective disorders of the depressive spectrum, it is optimal combination therapy. It is possible to use small doses of antidepressants in the treatment of these conditions.

Diagnosis of depression with concomitant somatic pathology. This is very important point. I would like to draw your attention to the main clinical manifestations. Targeted search for the most significant symptoms depression:

• - yearning;
• - sleep disturbance;
• - guilt, low self-esteem;
• - suicidal ideas/thoughts about death;
• - frequency of manifestation of painful symptoms.

This makes it possible in most cases to suspect the presence of a depressive syndrome.

Assessing the dynamics of these symptoms (especially improvement while taking antidepressants) is a direct indication of its presence. IN in doubtful cases ex juvantibus treatment is carried out.

It should be noted that, as a rule, depression is masked somatic manifestations. Clinical manifestations of most somatic diseases, which are also characteristic of depression:

• - weakness, fatigue;
• - headache;
• - tachycardia, chest pain;
• - feeling of difficulty breathing, tachypnea;
• - arthralgia, myalgia;
• - loss of appetite;
• - constipation, abdominal pain;
• - urination disorder;
• - decreased libido;
• - menstrual cycle disorders.

Very wide range of clinical manifestations. With such a spectrum of manifestations, it is very difficult to suspect the presence of an anxiety-depressive disorder.

But if the clinician has such suspicions, it is necessary to use widely available, very simple tools to identify depression: subjective and objective scales.

Subjective scales: Beck Depression Inventory (BDI), Zung scale.

Objective scales: Hamilton anxiety and depression scales, Montgomery-Asberg scale.

I will not draw your attention to the technology of using these tools. It is described in sufficient detail in the literature. A list of questions, answer options, each of which has a certain number of points. Their summation allows one to suspect the presence of depression.

(Slide show).

This slide shows a fairly typical appearance of a woman with a depressive disorder. Notice the dull look, the downcast face. Appearance speaks volumes.

The treatment strategy for depressive disorders during menopause is reduced to symptomatic treatment, the use of phytoestrogens, hormone replacement therapy, antidepressant therapy, and psychotherapy.

Cognitive therapy or psychotherapy is a very important component of complex treatment, but is not an alternative pharmacological treatment, but very actively increases its effectiveness. It is aimed at changing self-esteem. The most important thing is to develop emotional self-regulation skills that allow patients to endure difficult stressful situations without falling into depression.

Even in ancient times, philosophers noted: “A reasonable person will never grumble about anything, because he understands well that real grief does not come from what happened to him, but from the fact that he unreasonably thinks about what happened.” About his attitude to this stressful situation, to the possibility of self-regulation.

Of course, antidepressants are the first choice drugs. Their general property- positive impact on emotional sphere, accompanied by an improvement in general and mental state and, in particular, an improvement in mood.

The therapeutic effect of antidepressants (this must be remembered) develops gradually. It usually appears within 2-4 weeks from the start of therapy.

Undesirable effects. Unfortunately, there are quite a lot of them. This:

• - sedative effect(for some medications, especially classic tricyclic antidepressants);
• - orthostatic hypotension;
• - high potential for drug-drug interactions (especially sedatives, hypnotics, antiarrhythmics, antihypertensive drugs. Most of the listed drugs are prescribed to patients with cardiac pathology);
• - weight gain is also an undesirable effect of antidepressants (with long-term use of tri- and tetracyclic antidepressants);
• - slow development of the therapeutic effect, the need for dose titration;
• - the need to gradually reduce the dose of the drug upon completion of treatment.

Anxiety and anxiety disorders are satellites of depressive disorders. Anxiety is a feeling of restlessness, nervousness, tension, nervousness, anticipation of trouble, internal tension. All these components of anxiety are well known not only to doctors, but also to most of our patients.

The severity of anxiety during stressful conditions ranges from mental discomfort without a clear understanding of the causes of anxiety to the appearance of symptoms of psychological maladaptation of the individual.

Anxiety disorder is a group of neuroses associated with unreasonable and destabilizing feelings of fear and tension for no apparent reason.

We often hear the phrase “anxiety-depressive disorder.” They usually accompany each other. If we talk about symptoms of anxiety, they can be divided into mental and somatic.

The former include tension, inability to relax, restless thoughts, bad feelings and fears, irritability and impatience, difficulty concentrating and sleep disturbances.

Somatic symptoms include hot or cold flashes, sweating, palpitations, shortness of breath, “lump in the throat,” dizziness and headache, trembling, “crawling” sensation, disturbances in the gastrointestinal tract, urination problems, and sexual disorders. Very common clinical manifestations.

In developed countries, anxiety disorders are detected in 10-20% of the population.

According to the National Comorbidity Survey, 25% of the world's population will experience some form of anxiety disorder at least once in their lives. Their prevalence among general medical practice is several times higher than in the general population.

I would like to draw your attention to the fact that women suffer from anxiety disorders 2 times more often than men. The cause of these disorders: everyday life, home, husband, child, work.

The medical and social significance of anxiety disorders is very great. They are characterized by a long course and a tendency to recur.

Somatization of psychopathological disorders is a very common phenomenon. Patients with anxiety symptoms turn to a cardiologist 6 times more often, 2.5 to 3 times more often to a rheumatologist, and 2 times more often to a neurologist, urologist, or ENT doctor. According to the literature, people turn to a gastroenterologist 1.5 times more often than in the population.

The worsening prognosis of concomitant somatic pathology is also a very important component of medical and social disorders. A significant decrease in quality of life and ability to work, impairment of social functioning is a very important medical and social aspect of anxiety disorders.

Speaking about drug therapy used to treat anxiety conditions, you must first of all turn to tranquilizers (or anxiolytics - anti-anxiety drugs). They are classified into benzodiazepine and non-benzodiazepine ("Afobazol"). In addition, the use of antidepressants and herbal drugs.

Undesirable effects of benzodiazepines:

• - sedative and hypnotic effects;
• - the phenomenon of “behavioral toxicity”;
• - paradoxical reactions;
• - systemic side effects;
• - formation of mental and physical dependence, development of effect syndrome (rebound effect);
• - high potential for intercellular interaction (especially when combining a class of drugs with beta blockers, adrenergic agonists, calcium antagonists, ACE inhibitors and ethanol).

Contraindicated in serious illnesses cardiovascular system, kidneys and liver.

Herbal preparations are used quite actively nowadays. In particular, "Persen". It is not by chance that I focus on this drug, because one of the questions that came to me is related to the desire of listeners to discuss the issue of the evidence base for Afobazol, Persen and antidepressants.

Weaknesses of herbal preparations:

• - low efficiency - the anxiolytic effect is very weakly expressed, as a rule, only when a pronounced sedative effect is achieved;
• - they (in particular, “Persen”) are characterized by the presence of a hypnosedative effect in daytime;
• - individual sensitivity of patients;
• - a large number of side effects that limit the use of the drug (nausea, epigastric pain, dry mouth, abdominal pain, flatulence, diarrhea or constipation, anorexia, anxiety, fatigue, headache);
• - a large number of herbal components in combination preparations (which are quite popular in our country), unfortunately, significantly increases the risk of allergic reactions.

St. John's wort is highly recommended in wide practical activities. But it affects isoenzymes of the cytochrome P450 system and can interact with many drugs metabolized by this enzyme. Most of us are like that. At least in cardiology.

Weaknesses of barbiturate-containing drugs (Corvalolum, Valocordin, Valoserdin).

High toxicity. It manifests itself as depression of the respiratory and vasomotor centers, a decrease in myocardial contractility and vascular smooth muscle tone.

These drugs can be addictive, require increased doses, and are associated with withdrawal syndrome, which can lead to complete insomnia and the development of physical and mental dependence.

In most countries around the world, these drugs are not available over-the-counter. You simply cannot enter any EU country with this drug. In most countries of the world, phenobarbital has not been used as an anti-anxiety and hypnotic drug for many years.

Availability combination drugs, which I spoke about, often becomes the reason for their uncontrolled use. There are more problems than positive effects.

A few words about Afobazole. Systemic effects the new generation anxiolytic “Afobazole” is associated with a vegetotropic effect. "Afobazole" increases heart rate variability under stress, tone n. vagus, which contributes to better adaptation of the cardiovascular system to stress.

Intravenous administration of Afobazole does not cause changes in blood pressure, cardiac output and contractile function intact heart.

During occlusion and reperfusion of the coronary artery, Afobazol has an antirhythmic and antifibrillatory effect.

The pharmacodynamics of this drug is due to the fact that it has an anxiolytic effect that is not accompanied by a hypnosedative effect. The anxiolytic effect occurs 5-7 days from the start of treatment. The maximum effect is by the end of the 4th week of treatment.

What features does Afobazol have? Not formed drug addiction and withdrawal syndrome does not develop. There are no muscle relaxant properties and no negative impact on memory and attention indicators, or cognitive disorders.

To the question I received: what is the evidence base for antidepressants and Afobazole?

Currently, quite a lot of research has been conducted with this drug. The format of our meeting does not allow me to dwell on many of them in detail. But I'll try to do it.

An open clinical trial was conducted at the Scientific Center for Obstetrics, Gynecology and Perinatology. 56 patients with uterine fibroids and a control group - 32 healthy women. It has been shown that anxiety symptoms are detected in 72% of patients with uterine fibroids and mastopathy. You see what a large percentage of affective disorders there are.

“Afobazole” reduced sympathetic influences, restored compensatory and adaptive response mechanisms, and reduced the frequency of emotional and anxiety symptoms in these patients by 2.5 times. Afobazole was noted to be well tolerated.

Another open non-comparative clinical study was conducted at the First Moscow Medical Institute (Perinatal Center) and City Clinical Hospital No. 29 of Moscow. It studied the effect of Afobazole on PMS in women with autonomic disorders.

Results. The administration of Afobazole was associated with a decrease in the severity of autonomic disorders. The most pronounced effect was noted with sympathicotonia. The maximum effect is by the end of the 4th week. The effect persisted for two weeks after completion of therapy.

Another open-label, non-comparative clinical trial. It included women with psychopathological climacteric disorders. Afobazol was prescribed. Its effect was compared with other psychotropic drugs (Diazepam, Mebicarum).

It was shown that normalization of mood with the use of Afobazole, disappearance of anxiety disorders, emotional lability, and a decrease in depressive symptoms were noted already on the 5-6th day of therapy.

Compared to Diazepam, Afobazol more often stopped or significantly weakened psychopathological manifestations climacteric syndrome within the asthenic variant. More often than Mebicar, it stopped the manifestation of anxiety and depressive disorders.

Also in the group of patients receiving Afobazol, a decrease in vegetative-vascular manifestations was noted already in the second week, the disappearance of lethargy, fatigue, and asthenic manifestations. Normalization of sleep in most patients.

The use of Afobazole in the treatment of anxiety and depressive disorders during surgical menopause. A very important group of patients was studied in an open-label, non-comparative controlled trial. It included women with surgical menopause.

It was shown that treatment with Afobazole (20 mg/day for three weeks) led to improved well-being, mood, a decrease in the frequency of headaches, and a decrease in disorders of the gastrointestinal tract and respiratory system.

No side effects have been reported.

Indications for use are already clear from what I said:

• - anxiety states: generalized disorders, adaptation disorders, such as a predepressive state in patients with various somatic diseases. Also for dermatological and oncological diseases;
• - sleep disorders associated with anxiety;
• - cardiopsychoneurosis;
• - PMS;
• - alcoholic withdrawal syndrome;
• - to alleviate withdrawal symptoms when quitting smoking.

Contraindications:

• - individual intolerance;
• - period of pregnancy or lactation;
• - childhood.

Side effects of Afobazole:

• - increased individual sensitivity;
• - possible allergic reactions;
• - rarely - headache;
• - is not addictive;
• - does not cause drowsiness;
• - does not affect concentration and memory (can be used by people whose activities require increased attention and rapid response).

The regimen for using Afobazole is quite well known. 1 tablet 3 times a day for 2-4 weeks. If necessary, the dose can be increased to six tablets per day, and the course of treatment extended to three months.

Speaking about the advantages, I would once again like to emphasize the very high safety profile. Convenient release form. Low potential for intercellular interaction.

(Slide show).

A completely different face: glowing bright eyes, smile! Full of energy, cheerful woman.

Questions and answers

In the remaining 2 minutes I will try to answer the questions I received.

? Whether there is a non-drug treatment depression?

Undoubtedly. We have already said that non-drug treatment is rational psychotherapy. Quite an effective method. It should be noted that it is used not as an alternative, but as an addition to psychopharmacotherapy. Only then can a sufficiently good effect be achieved.

? Does hormone replacement therapy reduce the risk of depression in menopausal women?

Definitely. I talked about this. The format of our meeting does not allow me to dwell on this in detail. But in consultation with a gynecologist-endocrinologist, it can significantly increase the effectiveness of treatment for these patients. Naturally, the appointment of hormone replacement therapy.

? Is depression in men less important, both socially and economically?

The question is philosophical. But psychiatrists, psychoneurologists, and psychotherapists believe that depression still develops more often in women. In my opinion, there is no need to prove this for a very long time. This is an obvious fact.

? When is the use of antidepressants indicated?

The question is quite difficult. I have already spoken about the use of scales when testing patients. When you score a certain number of points (more than 20), it is advisable to consult a psychiatrist. We must keep in mind that in our country the number of psychiatrists is about 10 thousand people. The number of patients with anxiety and depressive disorders...

45% of all somatic patients at outpatient appointments have anxiety-depressive disorder. In 25% of them, clinical manifestations are detected that require correction. Psychiatrists, therapists, and cardiologists have agreed that when using modern antidepressants in small doses, with a moderate regimen, depression can be treated with antidepressants and not by psychiatrists.

It is difficult to say in a nutshell about the prescription of antidepressants. This is a separate topic.

Thank you for attention.

Vladimir Ivashkin: Thank you very much, Yuri Alexandrovich.

Avedisova A.S., Doctor of Medical Sciences
State Scientific Center for Social
and forensic psychiatry named after. V.P. Serbian
Department of New Means and Methods of Therapy

INTRODUCTION

The terms “depression” and “anxiety” are often used not only in the medical literature, but also in everyday speech. Indeed, these concepts are so diverse that they allow us to describe any feeling of internal discomfort. In some cases, depression takes the form of melancholy - a severe mental disorder that leads to complete loss of ability to work as often as a cerebral stroke; in others, a short-term deterioration in mood may be a consequence of the loss of a favorite football team. When describing their condition, patients may complain of a feeling of anxiety (or restlessness, nervousness) and at the same time a depressed mood (or a feeling of melancholy and sadness). It is not easy to understand these conflicting complaints without knowing the circumstances of the patient’s life, his social status, personality traits, family and personal history.

In addition, depression and anxiety are difficult to separate methodically - there are currently no laboratory or instrumental methods(such as blood tests, ultrasound, computed tomography, etc.) to confirm the diagnosis. Scientific studies have shown that depression may be accompanied by an increase in plasma cortisol levels, and generalized anxiety disorder may be accompanied by an increase in blood flow in the vessels of the forearm, however practical significance of these indicators is small. In addition, a thorough psychiatric examination takes a long time and is often impracticable in routine medical practice. Standardized questionnaires can provide some help in these cases, but in order to “feel” the patient well, it is necessary to talk with him repeatedly and for a long time.

If you suspect any mental disorder, you should carefully question people who know the patient well, his character, and the characteristics of his life. The main question in this case is “Has the person changed?” In other words, it is necessary to find out whether his psychological status has changed, whether he has become socially passive, helpless and dependent on others, whether his interests, topics of conversation, and manner of speaking have changed. If for a therapist a symptom of a disease is an increase in body temperature or blood pressure, then for a psychiatrist such signs as decreased concentration, sleep disturbances, or difficulties in performing usual work are important. Assessing the psychological status requires the specialist to have patience, perseverance and the ability to ask the right questions to the patient.

In addition, it must be remembered that the symptoms of neurotic disorders (both depression and anxiety are typical non-psychotic diseases) change over time. Thus, symptoms of depression observed in a patient last year may be replaced this year by classic signs of an anxiety disorder, and two years later by symptoms of obsessive-compulsive or panic disorder. It is not surprising that expressions such as “depressive person” or “perpetually anxious person” are often found in the literature—it appears that some people are more susceptible to depression or anxiety disorders than others. It is believed that there is a family predisposition to even mild forms of neurosis. Thus, suspicious housewives who are prone to anxious reactions often explain their condition by the “nervousness” of the mother or the alcoholism of the father. It should be remembered that any minimal information can be useful in making a diagnosis.

Finally, in practice, a specialist is always faced with a dilemma: whether depression is a secondary manifestation of an anxiety state (including panic attacks) or vice versa. It is possible that the patient has mixed symptoms - the manifestations of depression and anxiety disorders are largely similar (see below), and indeed, in general practice, patients with anxiety-depressive disorder are more often observed. At the same time, it is much more important not just to establish a diagnosis of depression or anxiety disorder, but to identify as fully as possible all the psychopathological symptoms present in a particular patient. Strict diagnostic criteria listed in the standard classifications ICD-10 or DSM-IV are indispensable when conducting scientific research, but the main task of a practicing physician remains to provide qualified medical care to patients. Practitioners cannot and do not want to waste time on formulations, and if a patient complains of depressed mood or increased anxiety, the first question that an experienced clinician will ask him is “how does being depressed or anxious affect your life?”

EPIDEMIOLOGY

Neurotic disorders are widespread in the population, and it is these diseases that doctors most often encounter general practice. Current estimates place the lifetime risk of developing depression, anxiety, or a mixed disorder at 15–20%. A survey conducted in the UK in 1995 showed that the prevalence of anxiety disorders (including panic disorder, phobias and obsessive-compulsive disorder) reached 10%, and mixed anxiety-depressive disorder - 8%. It is believed that patients with increased anxiety make up about one third of all consultations in general practice. Anxiety states (along with cultural and personal characteristics) are typical for a certain category of patients who regularly come to see a doctor with numerous health complaints - when such a patient appears at the door of the office, the doctor’s heart “freezes” (“heartsink” patients).

The results of studies of depression are equally disappointing: the prevalence of “pure” depression in the population reaches 2-5% (of course, the partial overlap of symptoms of depression and mixed disorder, the prevalence of which is 8%, plays a role here). Women get sick 3-4 times more often than men, but in practice, depression remains undiagnosed in 50% of cases. Men often experience so-called “masked” (somatized) depression, manifested mainly by somatic symptoms. Patients in this category often abuse alcohol, but avoid seeking help from psychiatrists, including due to certain prejudices that are widespread even in modern society.

In addition, 10-15% of women develop postpartum depression, and 50% experience premenstrual syndrome, characterized by a combination of somatic symptoms with manifestations of anxiety (or irritability) and depression. The prevalence of depression among patients with alcoholism is significantly higher in women (20% compared to 5-10% in men). Finally, there is a direct correlation between the severity of social phobia, anxiety or panic symptoms and the use of alcohol (or tranquilizers) as a pleasant and effective means of self-soothing.

The prevalence of depression increases with age. Thus, according to research, symptoms of depression are observed in 25-30% of people over 65 years of age, and women in this age group (up to 85 years of age) suffer from it twice as often as men. Moreover, in older people with several somatic diseases (4 or more), the prevalence of depression is significantly higher (30% compared to 5% among people without comorbidities). For example, the prevalence of depression in patients who have suffered a cerebral stroke is 30-50%.

Given these data, as well as the fact that patients in this category are often observed by general practitioners, the question of why depression and mixed anxiety-depressive disorder often remain undiagnosed becomes important. According to the results of most studies, identifying symptoms of depression depends on the qualifications of the doctor and his ability to interview the patient. As a rule, diagnosing depression in older people is not difficult. A certain role in the diagnosis of depression and anxiety is played by the doctor’s attitude towards the possibility of treating mental disorders - often general practitioners believe that treatment of such patients is ineffective, since it does not improve their condition. However, this point of view is incorrect, and special training programs can significantly increase the effectiveness of treatment of patients, which is accompanied by a decrease in the frequency of suicides. At the same time, in order to maintain acquired skills, general practitioners must undergo training courses regularly: once every few years.

DIAGNOSTICS

When examining patients with signs of depression, anxiety or a mixed disorder, the specialist must identify which of the psychopathological symptoms are the main ones. The patient comes to the doctor with his own ideas about the nature and causes of his problems, most often associating them with an unfavorable life event or chain of events. Neurotic and affective disorders lasts not one or two days (like some acute inflammatory diseases), but several weeks, months and years, and the causes of their occurrence may indeed be hidden in the past. For example, sleep disturbances or persistent headaches are often the result of routine occupational or family problems, which does not at all detract from the pathogenetic importance of these “life events,” since it has been shown that many of them are factors that provoke the onset of a depressive state. At the same time, attempts to detect such provoking factors in the patient’s past life are based, as a rule, on a very common point of view, according to which any mental disorder is considered as a consequence of stressful and traumatic situations (including those not realized by the patient), and not as a disease brain, as unpredictable as ischemic heart disease or gallstone disease.

One of the most difficult tasks in diagnosing mental disorders is the need to distinguish between cause and effect of diseases. Obviously, low mood or depression can be caused by the loss of a regular job, but depressed people are bad workers, which in itself is grounds for their dismissal. In the same way, patients with agoraphobia associate their fear of crowded places (and not just a fear of open spaces) with a certain stressful event, shyness, etc. In fact, this stressful event could be the first panic attack, after which the patient seeks to stay at home and thereby reduce , the likelihood of another attack. A panic attack is often accompanied by severe somatic symptoms (difficulty breathing, profuse sweating), which forces patients to seek help from doctors of various specialties (cardiologists, gastroenterologists, etc.) in a vain attempt to establish a diagnosis of the disease. Of course, most of all they want to get rid of painful symptoms and receive effective treatment, but they avoid contacting a specialist doctor.

Currently, no one doubts the fact that the causes of many psychological problems in adulthood lie in childhood and upbringing. Thus, in people who lost their parents before the age of 10 years, the risk of developing depression (or a depressive reaction in response to a stressful situation) is 2-3 times higher than in people who have not experienced such a loss. There is convincing evidence that adults who have suffered abuse in childhood (violence, indecent assault, etc.) are more likely to have difficulty communicating with others, are more susceptible to emotional stress, and have a higher risk of developing mental and physical illnesses. Of course, these factors must be taken into account, but their correction (in the form of conversations, courses of psychoanalysis or psychotherapy) does not always eliminate the symptoms of a depressive or anxiety disorder. It has been shown that cognitive behavioral psychotherapy is effective in a large number of patients, but it is specific and momentary in nature and, as a rule, is not aimed at solving complex problems, the roots of which lie in the past life and upbringing of the patient.

SYMPTOMS OF DEPRESSION

Table 1 lists the psychopathological and somatic symptoms of depression. Patients with depression may experience any combination of symptoms, and their number plays a decisive role in determining the severity of the disease. How more symptoms the patient has, the greater the impact depression has on his daily life, but the easier it is for the doctor to establish a final diagnosis. When turning to specialists, patients often describe their condition as “depressive,” but true depression is characterized by a depressed mood, a pessimistic assessment of the future, a lack of life interests, decreased concentration, a feeling of inferiority and guilt. On the contrary, if, when asked “how does depression affect your life,” the patient answers that he has become more irritable, more often feels worried or anxious, then the most likely diagnosis will not be depression, but an anxiety disorder. In psychiatry, as in other areas of medicine, diagnosis largely depends on the experience and qualifications of the doctor.

Since many patients cannot explain their psychological condition, during the first examination it is better to use analogies with somatic diseases. For example, a patient’s poor health and depressed state can be compared to a chronic cold. In addition, it is important to distinguish between an understandable reaction of loss (for example, after a divorce) and a feeling of despair that arose in the patient for no apparent reason. In psychiatry, it is customary to distinguish between “reactive”, “endogenous” and “organic” depression, the first being considered a consequence of mental trauma, the others developing as a result of biological and organic disorders. In fact, most patients have a combination of precipitating factors (or factors that can be considered precipitating factors) as well as a combination of symptoms characteristic of these forms of depression. The severity and duration of symptoms, as well as their impact on the patient’s daily life, play a decisive role in establishing the diagnosis. It is important to remember that a depressed mood or crying during an examination are not typical symptoms of depression. Thus, patients may insist that their depressed mood is different from the usual feeling of sadness, that it is more pronounced and painful, and tearfulness may generally be a character trait. In addition, this symptom is more often observed in patients with a predominance of anxiety symptoms.

Patients with depression are characterized by depressed mood, despondency, and a negative perception of the world around them. Such patients lose interest in life, and things or events that previously made them happy no longer give them pleasure, for example, they stop laughing while watching their favorite TV show and cannot concentrate even to read the newspaper. Typical symptoms of depression include feelings of hopelessness and inferiority, often developing into unfounded ideas of guilt. In fact, self-blame (as opposed to blaming other people or society as a whole for your problems) is a hallmark of true depression. Self-blame is the most important symptom for diagnosing depression.

When conducting an examination, it is advisable not to try to remember the entire list of symptoms of depression, but to ask the patient to briefly describe one day of his life. For example, when does the patient wake up? Early awakening (at 3-5 am) is typical for patients with depression, while difficulty falling asleep is usually observed in anxiety states. Of course, in practice, patients with mixed symptoms are more often encountered, who may feel tired, overwhelmed, and irritable in the morning. In any case, you can ask about the patient’s appetite. If appetite is reduced, has the patient lost weight? When asked about daily activity and communication with other people, patients usually answer that they experience a loss of strength, that they are tired and cannot “jump up and run” as before. Irritability or depressed mood prevents them from communicating with other people during the day or evening; many patients note a decrease in sexual desire. It’s good if the examination was able to identify such a classic symptom of depression as “changes in mood during the day” - in the morning patients experience difficulties communicating with other people, but in the evening their condition improves. It should be emphasized again that although most patients have mixed symptoms and their mood may not improve during the day, identifying differences in the patient's mood in the morning and in the evening clearly indicates a depressive disorder.

When analyzing the classic symptoms of depression, it is necessary to remember that patients in this category often present with a variety of somatic complaints, among which headaches (especially compressive pain), chest or back pain, palpitations, poor health, constipation, and muscle weakness predominate. All these manifestations are typical for a depressive disorder (an analogy can be drawn with a “chronic cold”). A thorough survey and attentive attention to the somatic complaints presented will allow you to maintain trusting relationship between the patient and the doctor (depression is only one of the possible diagnoses, and somatic complaints may not be related to a mental disorder). By refusing to discuss with the patient the causes of chronic headaches, which usually occur during mental stress, the doctor thereby pushes him to reject the diagnosis. At the same time, when communicating with a patient with hypochondria, such openness is not always justified - often the refusal to discuss or investigate the causes of the ailment is the initial stage of adequate treatment for this category of patients.

SYMPTOMS OF ANXIETY DISORDER

When examining patients with anxiety disorders, it is also advisable to separate psychopathological symptoms and associated somatic disorders. Symptoms of an anxiety disorder do not occur in any particular order, and upon first examination, patients often present only somatic complaints, since it is the physical ailment that prompts them to seek help from a doctor. Anxiety disorder, like depression, develops over several weeks or months, and the symptoms of the disease gradually progress, adversely affecting the daily life of patients. Patients prone to anxious reactions, to one degree or another, exaggerate not only their failures and failures in life, but also their symptoms of the disease. The increased alertness or “hypervigilance” of these patients is explained by the fact that, unlike other people, they see the world as if through a magnifying glass, paying attention to the slightest changes in their internal state and external environment.

Patients with anxiety disorders often complain of depressed mood, but when asked how the condition affects their daily life, they say that they have become more irritable, restless, or even overactive. Typically, such patients are extremely restless and must constantly do something to calm themselves.

During the survey, they note that they always experienced anxious fears. Their relatives or parents recall that patients had the habit of biting their nails, had difficulty calming down and preferred to stay at home. Finally, some patients are characterized by a pathological desire for perfection (perfectionism), and the presence of obsessive thoughts and actions, especially if they take the form of a ritual, may indicate obsessive-compulsive disorder.

The diagnosis of an anxiety disorder is based on a recent history, symptoms of the disease, and an analysis of one typical day in the life of the patient. However, no less revealing can be the study of the patient’s personality characteristics, his habits and lifestyle. For example, special attention should be paid to the use of alcohol, tranquilizers or drugs. People prone to anxious reactions often consider the effects of alcohol and drugs to be pleasant and positive. how they allow you to relax, feel relaxed in a situation that previously caused anxiety, and temporarily “get rid” of the symptoms of the disease. Surprisingly, many patients who drink more than 8 cups of tea or 6 coffee a day do not understand that excess caffeine increases headaches, irritability, sweating, and prevents falling asleep.

Typical symptoms of an anxiety disorder are listed in Table 2. Table 3 lists similar symptoms encountered in patients with depression, anxiety, or mixed anxiety-depressive disorder. It is important to note that anxiety itself (as a state of tension and expressed anxious expectations that do not correspond to the degree of real threat) is often combined with depressive manifestations, somatic, autonomic disorders (due to overexcitation of the sympathetic nervous system, for example during a panic attack), alcohol abuse. These accompanying phenomena are difficult for patients to tolerate and often lead to social maladjustment and loss of ability to work.

Anxiety is a natural human reaction. Any student medical institute It is well known that with typical reactions to danger (for example, fight and flight), the efficiency of the body’s functioning increases, senses become more acute, the supply of oxygen to the muscles increases, and reactions and thinking accelerate. Trained athletes know how to manage anxiety by focusing their energy before major competitions. A cigarette or a cup of coffee before starting the work day is another well-known way to lightly stimulate this adaptive response. The only difference between normal and pathological anxiety is that in the latter case the anxiety is longer and more pronounced, leading to suppression rather than enhancement of the body's adaptive capabilities. Pathological anxiety can take the form of a panic attack, often the patient has a feeling of powerlessness/fatigue, and he has difficulty completing complex tasks.

It is for this reason that patients with anxiety disorders (as well as depression) often complain of " constant feeling fatigue" - prolonged psychological stress, sleep disturbance and overexcitation can really completely deplete the patient’s strength.

PANIC ATTACKS

A panic attack, like epilepsy, occurs in those predisposed or most sensitive to provoking factors. It is possible that a panic attack is a form of the fight and flight response designed to enhance psychological and physical abilities body and avoid or cope with a dangerous situation. It is believed that the formation of an appropriate protective reaction of the body about half a million years ago was of great evolutionary significance and contributed to the preservation of species. Currently, the main problem that patients with panic disorder face is that they perceive a normal physiological stimulus as a symptom of a serious illness.

Unfortunately, this disorder often remains undiagnosed, primarily due to the fact that general practitioners do not pay due attention to the panic attacks observed in the patient. A panic attack occurs spontaneously, often in a crowded place (shop, train, metro, bus, elevator), but patients tend to discuss not the attack itself, but its consequences, for example: deterioration in general condition, without presenting specific complaints. On the other hand, when asked directly, the patient usually confirms what he felt at that moment palpitations, lack of air, sweating, weakness in the legs, abdominal cramps, chest pain, tremor, trembling. Patients often note dizziness and lightheadedness, and in some cases cannot describe their condition at all. Depersonalization and derealization (a feeling of the unreality of the world around us or alienation from oneself) - typical symptoms of panic disorder - only intensify the panic attack.

In addition to these physical symptoms, patients may describe a state close to panic. Usually they have a feeling of approaching danger, confusion and powerlessness to the point of fainting. Patients think they are having a myocardial infarction or stroke and ask to be taken to the nearest emergency room. Many patients experience a feeling of imminent death, memories of which persist for a long time and negatively affect their mental state. Typically, patients remember well the first panic attack, which leaves them with the most painful and lasting memories. The attack itself lasts no more than a few minutes, but the feeling of anxiety and powerlessness can persist for 1-2 hours.

In modern psychiatry, panic attacks are considered a manifestation of “panic disorder”; they are typical for most patients with agoraphobia, but are often observed in patients with anxious depression. The presence of panic attacks may indicate a primary anxiety disorder, and patients in this category should receive adequate treatment after a thorough psychiatric examination. In order to choose the right treatment, it is necessary to find out the frequency of panic attacks, provoking factors, the nature and effectiveness of previous therapy. When examining patients in this category, it is advisable to avoid numerous instrumental studies. On the other hand, at the insistence of patients or in order to resolve doubts and their own concerns, some studies can be carried out - patients often believe that this expresses the doctor’s serious attitude towards their disease. In addition, there are cases when panic attacks occur against the background of a primary somatic or endocrine disease.

DIFFERENTIAL DIAGNOSIS

It is well known that the older the patient with mixed anxiety-depressive disorder, the more attention he requires and the more thorough the examination should be. However, in psychiatric practice it is advisable to limit oneself only to truly necessary instrumental studies.

Concomitant diseases are common, therefore, when examining a patient, one should exclude anemia, conduct a laboratory analysis of liver enzymes (primarily the activity of serum gamma-glutamyltransferase, as an indicator of possible alcoholism) and ESR (to identify a concomitant chronic infection or metabolic disease). For smokers and patients with severe palpitations, a chest x-ray and an ECG study are indicated, but are additional studies necessary? In everyday practice, additional research is not justified, except in cases where the patient has obvious symptoms of a physical illness (for example, external signs of dysfunction thyroid gland, skin rashes, impaired reflexes). X-ray of the skull and tomography of the brain are indicated only in the presence of specific neurological symptoms. On the other hand, in a certain category of patients, especially young people, it is advisable to do a urine and blood test for drug content. Cocaine, marijuana, opioids and benzodiazepines are easily detected. The use of these drugs and medications is widespread in modern society, and while taking them, symptoms of the disease can change, increase or decrease.

When making a differential diagnosis, it is necessary to keep in mind the following categories of patients.

• Patients with organic damage to the central nervous system [show]

  The possibility of organic damage to the central nervous system should always be taken into account, but the diagnosis should be based on anamnestic data, the results of a brain examination and the clinical picture of the disease. Particular attention should be paid to patients with depression with severe cognitive impairment. Symptoms of depression and/or anxiety may occur in patients with cancer, cerebrovascular disease, or after head trauma. Patients with post-concussion syndrome could be unconscious (or in a “stunned” state) for several seconds or minutes. Even several years after the injury, they may be plagued by severe headaches, they often have decreased concentration, mood disturbances, personality changes and severe irritability. It is extremely important to carefully question the patient's relatives and friends, as they can provide additional information that helps in establishing the final diagnosis.

• Patients with alcohol (or tranquilizer) abuse [show]

  To exclude the diagnosis alcohol addiction Medical history and results of a standardized survey (eg, the CAGE Questionnaire) provide significant assistance (Fig. 1). Often, in patients with alcoholism, the activity of serum gamma-glutamyl transferase is increased and the average erythrocyte volume is increased. However, in every third case, there are no obvious biochemical disorders, and external signs of the disease appear much later, when treatment of patients in this category is difficult. A simple and practical method is to detect ethyl alcohol vapor in exhaled air using an indicator tube or by smell. Alcoholism is often combined with dependence on benzodiazepines or barbiturates, and such patients often urgently ask the doctor to write them appropriate prescriptions.

• Patients with psychosis [show]

  Psychotic conditions (schizophrenia, manic-depressive psychosis, paranoid disorders) in the early stages can be manifested by depressive symptoms, ideas of attitude (outwardly sometimes manifested by excessive shyness). In turn, people with anxiety/panic disorder often feel like everyone around them is paying special attention to them, and this behavior can be mistakenly perceived as a manifestation of psychosis. If the clinical picture is complicated by alcohol abuse, then identify primary disease difficult. In these cases, a thorough analysis of the medical history and long-term observation of the patient is necessary.

  In the case histories of patients with schizophrenia, one can often find records indicating the difficulties that doctors encountered in establishing a final diagnosis (“anxiety disorder/depression?”, “drug use disorder?”, etc.), and, as a result, many Patients in this category had previously received antidepressant therapy. Thinking disorders in such patients are often misdiagnosed as decreased concentration.

• Patients with PTSD [show]

  After emergency situations, 10-15% of victims develop post-traumatic stress disorder (PTSD). Patients with PTSD cannot get rid of intrusive memories of a traumatic event, they unreasonably fear for their lives, they experience nightmares, hallucinations, and mood disorders. At the same time, they always manage to identify obvious provoking factors, and at the time of the traumatic event they do not lose consciousness.

• Patients with other mental disorders [show]

  Symptoms of depression/anxiety are typical for patients with bulimia nervosa, anorexia nervosa, obsessive-compulsive disorder, body dysmorphomania (a disorder in which patients exaggerate a certain defect), as well as people with sexual dysfunction. Typically, patients are worried, confused and unable to explain the cause of anxiety or depressed mood; often, to clarify the primary disorder, it is necessary to talk for a long time and repeatedly with the patient. On the other hand, one well-formulated question asked at the right moment allows you to completely clarify the picture of the disease (for example, “have you ever deliberately tried to harm yourself?” or “are you squeamish, do you often think about what you might get infected?").

Social factors. It is well known that the development of depression/anxiety is often preceded by a stressful life situation (divorce, job loss). In foreign literature, the typical reaction of people to a stressful event is described as an “acute situational crisis.” Some authors believe that such a reaction is natural and understandable, especially in socially isolated or easily vulnerable people. There has been debate for many years about whether this condition should be considered a 'disorder', but GPs need to do something when they encounter these patients. In practice, it is extremely difficult to differentiate such reactions from a real disease, however, an “acute situational crisis” is usually short-lived and provoked by obvious negative social factors that are understandable to the patients themselves.

There are no specific symptoms of a situational crisis. Typically, this condition is accompanied by sleep disturbances (difficulty falling asleep is typical), there is no history of depressive/anxiety disorders before the traumatic event, and patients remain completely critical of their condition. In order to provide effective assistance to a patient, a general practitioner must have a good understanding of his social situation and family problems.

FACTORS DETERMINING PROGNOSIS IN DEPRESSIVE/ANXIETY DISORDERS

It was previously noted that patients with similar or largely overlapping symptoms of depression and anxiety disorders often turn to general practitioners. The clinical picture of a mixed disorder can be very diverse, due to changes in symptoms or living conditions of patients. In addition, the doctor must take into account the suspiciousness of patients in this category. It is well known that the prognosis of the disease is largely determined by the age, gender, level of education of the patient, as well as some more specific factors listed in Table 4. The presence of such factors seems obvious, given the complex relationship of somatic diseases, psychological reactions and social conditions life.

• Age [show]

  Elderly people (for example, over 65-75 years old) have more life experience, have suffered many losses, and are physically weakened. Depression in patients of this age group is more severe, with a predominance of agitation or psychomotor retardation, which is not typical for patients under 40. It is easy to succumb to the temptation and, without a thorough analysis of all the symptoms and signs of the disease, decide that the patient’s problems are a consequence of old age and associated with it deterioration of physical and mental health. In addition, older patients are at higher risk of drug overdose, which can lead to serious consequences. Elderly patients often forget to take medications, but they always try to follow the “rules of the game” and usually follow the doctor’s instructions quite strictly.

• Floor [show]

  Because women are more likely than men to have symptoms of depression/anxiety in general practice, there is a belief that there is a sex difference in the prevalence of these conditions. In addition, women are more likely to recognize that they have a mental disorder and are more compliant with treatment. However, the prognosis of the disease in men and women is generally the same. Of course, in men, unfavorable factors such as alcohol abuse or a high risk of drug addiction play a big role.

  In this regard, it is advisable to consider the features of menopause in women. The physiology of menopause in women is well studied. This condition occurs at a certain age; moreover, effective correction methods have now been developed, for example, the use of hormone replacement therapy. During menopause, most women experience unpleasant physical symptoms, including increased body temperature, profuse sweating, and hot flashes (which may or may not be accompanied by facial flushing). Whether similar physiological changes occur in men (eg, decreased testosterone secretion) is controversial. Men aged 50-60 years actually often experience decreased libido and impotence. Men, regardless of their cultural background, find it difficult to seek help from a doctor due to sexual dysfunction.

  However, as in the case of anxiety disorders, impotence and depression are not only often combined in one patient, but can also be interrelated.

• Etiology [show]

  The first chapters of textbooks are always devoted to the etiology of diseases. However, with the exception of hereditary forms (10-30% of cases depending on study criteria), the causes of depression and anxiety remain unknown. It is not always possible to identify one or two obvious provoking factors in patients with panic disorder, depression or mixed anxiety-depressive disorder. Endless examinations only increase the anxiety of patients and strengthen their confidence that they have an undetected somatic disease. Such digging through a heap of possible tests and studies can worsen the prognosis of the disease.

  Apparently, the family situation is the only information that the general practitioner should become familiar with in as much detail as possible. The death of a loved one (especially if it happens unexpectedly) is usually accompanied by the development of normal loss reactions, which are characterized by denial, emotional shock, numbness, anger and alienation. A worker who loses his job for the first time will feel confused, humiliated and insulted. A classic example of this comes from a study conducted by a general practitioner. If previously the author of the study saw mainly women and children, then after the closure of the factory, which was the only place of work in this region, men with a variety of complaints began to increasingly come to see him with a variety of complaints (headache, back pain, somatic diseases ). However, the real reason for their malaise was unemployment.

  The presence of obvious social causes does not negate the need for adequate treatment of patients with mental disorders. For sleep disturbances in patients with anxiety, traditional medications or conventional measures aimed at restoring sleep are often effective. In addition, the prognosis improves significantly if the patient manages to return to work or comes to terms with and survive the loss.

• Social status [show]

  It is well known that the prevalence of any disease is higher in individuals with low socioeconomic status. Often these people are poorly educated, unemployed, smoke a lot and do not always understand what the doctor tells them. Such patients should be communicated in a language they understand, otherwise they may refuse or stop treatment. Often it seems that these individuals are “pretending to be sick.” It is not a doctor's job to decide whether a patient who has lost his job and is not receiving family or professional help is a "malingerer." On the other hand, continuing to treat a person who does not want to recover is often a very difficult task.

  In reality, social status should not have a significant impact on the prognosis of the disease. If the clinical picture of the disease is clear and the final diagnosis has been established, it is often much easier to treat a secretary or worker than a professor of physiology or an impatient and energetic businessman, who, as a rule, have their own and uncorrectable ideas about the nature of everything that is happening.

• "The role of the patient" and "the behavior of the patient" [show]

  Although these concepts are well known to most practitioners, it is useful to consider them in more detail. They are important for understanding the characteristics of the course of chronic mental disorders, including mixed anxiety-depressive disorder, which is characterized by a periodic increase and decrease in symptoms. The “role” that the patient will play depends on how he understands the existing “rules”. For example, it is assumed that the patient should stop going to work, strictly follow the doctor’s instructions (the disease cannot be dealt with only by “force of will”) and really want to get well. Most doctors proceed from this, but the patient may have completely different ideas. If a lonely elderly woman feels better, her daughter will visit her much less often. The “workaholic” strives to return to work as soon as possible, as he feels guilty for his illness. The concept of “role” is also closely related to the conscientiousness of patients’ compliance with doctor’s orders. It is well known that about 50% of patients do not comply with the treatment regimen and, as a result, do not receive adequate drug therapy. It is believed that the fascination of some patients with homeopathic remedies or alternative medicine is due to the fact that such an approach is perceived as more “holistic”, especially if the “healer” devotes more time to the patient than the always busy general practitioner.

  All these factors have a significant impact on “patient behavior.” During the examination, a phlegmatic middle-aged “northerner” will be silent and calm, and a “hot southern” woman will be anxious, excited, actively gesticulating and demanding everyone’s attention. In these cases, it is extremely dangerous to be at the mercy of cultural, ethnic, age or gender stereotypes, since both patients may indeed have a severe (or mild) mental disorder that requires appropriate diagnosis and adequate treatment.

The factors listed in Table 4 allow us to distinguish two subtypes of patients - those with a favorable or unfavorable prognosis, which will be discussed below. Unfortunately, the majority of patients whom a general practitioner encounters do not belong to one or the other, however, the characteristics of these conditional subtypes will help the doctor both in choosing a treatment method and in strengthening the patient’s faith in recovery.

• Favorable prognosis [show]

  The patient undergoes regular medical examination; the first symptoms of the disease appeared 1-2 months ago. The symptoms are clearly demarcated (sleep disturbances, fatigue, decreased concentration, mood disturbances), and the cause of their occurrence is more or less obvious. The patient has a job and receives family support. These patients could read specialized or popular literature and have a general understanding of the causes and nature of their disease, which helps to establish a trusting relationship with the doctor. Patients in this category do not abuse alcohol, generally understand the doctor’s tasks, and the nature of the upcoming treatment can be discussed with them.

  A treatment plan can be drawn up if the cause of the anxiety is clear (for example, the patient has recently changed jobs), the symptoms of depression are clear, and the patient has the opportunity to undergo a course of mental relaxation or drug therapy. After 3-6 months, the patient will feel better and learn to cope with residual or transient symptoms.

• Poor prognosis [show]

  A 40-year-old patient who came to see you for the first time (he recently moved to this area for no apparent reason) asks for a prescription for tranquilizers, antidepressants or painkillers. According to him, he has been ill for several years, but it is difficult to isolate the main symptoms of the disease (with the exception of sleep disturbances and headaches). Establishing a trusting relationship with a patient is extremely difficult. According to the results of laboratory analysis, the activity of serum gamma-glutamyltransferase is increased, the medical history is several tens of centimeters thick, full of notes from psychiatrists. In these cases, a restrained approach is recommended - sometimes it is enough to “keep” the patient away from the hospital. Nobody knows effective ways to treat this category of patients. The prognosis, in general, is unfavorable: mature age, a sudden and successful change in life, everyday experience, alone or all together, sometimes do much more for the patient’s recovery than a general practitioner.

TREATMENT

Principles of treatment. The main problem in treating patients with depression and anxiety disorders is that neither general practitioners nor mental health professionals have time to understand what was and was not done. Frequent relapses of the disease, variability in the clinical picture and active promotion of new drugs encourage the doctor to “try” other treatment methods. A simple listing of records in the medical history of a typical patient with mixed anxiety-depressive disorder will be very revealing (not only for medical students, but also for researchers and specialists). Some of these patients received ten different drugs(antidepressants, tranquilizers, beta-blockers), they underwent several courses of psychotherapy, numerous instrumental studies, consultations with a gastroenterologist, neurologist and cardiologist at the same time.

Regardless of whether the doctor sees the patient for the first time or observes him for a long time, he must always remember that effective treatment for depression and anxiety requires integrated approach. Drug therapy is the most accessible method of treating this category of patients; it can be started immediately, and practitioners are usually well versed in the properties of the prescribed drugs. However, drug therapy must be combined with psychotherapy and programs social assistance.

It is extremely important to help the patient get rid of the symptoms that bother him, and to identify the full clinical picture sometimes requires long and repeated conversations with him. In some cases, it is useful to postpone treatment by asking the patient to record mood changes, the frequency and location of panic attacks in a diary, take notes on the content of previous conversations and bring all previously taken medications to the next examination. You should not prescribe new drugs to a patient without thoroughly understanding the nature of previous treatment, the biological and psychological characteristics of his personality, social status and living conditions. A conversation with the patient’s relatives or a visit to the house where he lives sometimes allows us to completely clarify the picture and reasons for the development of the disease. Once you have received all the necessary data, identified all the symptoms, and established a diagnosis of anxiety depression or anxiety disorder with depressive symptoms, you should begin drug therapy.

Drug treatment. There are five classes of drugs that are effective in treating patients in these categories. These include

1. tranquilizers (mainly long-acting or short-acting benzodiazepine drugs) [show]

   Benzodiazepines. This series of drugs is easy to use and allows you to quickly eliminate anxiety. An overdose of benzodiazepines does not usually lead to death; drugs are prescribed for a short period, gradually selecting the optimal dose. Benzodiazepine therapy is one of the most effective treatments for patients with anxiety disorders. These drugs can be used in combination with most other medications. Benzodiazepines have pronounced anti-anxiety and sedative effects and can be used by patients as a means of preventing a panic attack. It is possible that the risk of developing physical and psychological dependence on benzodiazepines is somewhat exaggerated, but in any case, the course of their use should be limited to 1-2 months.

   The simpler the drug therapy, the easier it is to use in practice. Short-acting benzodiazepines, such as lorazepam, can be prescribed as a sedative in crisis situations, including patients with acute myocardial infarction or patients with psychomotor agitation, the diagnosis of which is completely unknown. These drugs are convenient for continuous oral administration, for example: diazepam is available in the form of 5 and 10 mg tablets, which makes it easier to select the dose.

   Benzodiazepines are prescribed to patients of various categories. A patient with sleep disorders will feel better if he gets enough sleep after taking benzodiazepines. Benzodiazepines can reduce the agitation that occurs in some patients when starting therapy with selective serotonin reuptake inhibitors. A single dose of drugs of this series eliminates anxious expectations, for example, before flying on an airplane. These drugs can be prescribed in minimal doses and, if necessary, gradually reduce the dose and discontinue it.

   However, monotherapy with diazepam (or other tranquilizers) does not eliminate the symptoms of the underlying disease in patients with anxious depression. Externally, the patients' condition improves, but when interviewed, symptoms of depression often appear more clearly. On the other hand, the prescription of benzodiazepines to patients in this category may be justified, since while taking diazepam the patient calms down, is able to more accurately describe his condition, and more easily agrees with the need for treatment.

2. selective serotonin reuptake inhibitors (SSRIs) [show]

   SSRIs. There are many drugs in this class available today - fluoxetine, citalopram, paroxetine, sertraline and fluvoxamine. According to the manufacturers, each of them has certain advantages in terms of side effect profile, half-life, drug interactions, and indications for use. It must be borne in mind that individual reactions of patients to these drugs really differ: in some patients, SSRIs have a sedative effect, in others they increase feelings of anxiety or irritation (especially in 1-2 weeks of therapy), in others they have no effect.

   When prescribing drugs of this class, it is necessary to tell the patient about possible side effects and explain that, depending on individual sensitivity, SSRIs should be taken in the morning or at night. During fluoxetine therapy, most patients experience mild agitation, so the drug is recommended to be taken in the morning. The other two drugs, citalopram and paroxetine, have mild anxiolytic and sedative effects and should be prescribed in the afternoon or at night. Side effects during therapy with SSRIs are rare (especially typical for tricyclic antidepressants - dry mouth, orthostatic hypotension, drowsiness, urinary retention or constipation).

   However, the side effects of drugs in this class should not be ignored. Thus, in 10-20% of patients, SSRI therapy is accompanied by nausea, vomiting or other gastrointestinal disorders. These side effects usually go away on their own after a few weeks. Otherwise, the SSRI must be discontinued and the patient prescribed another treatment. SSRI therapy may be accompanied by psychomotor agitation and headache, especially in patients prone to anxiety reactions who are hypervigilant about their physical condition. Another side effect of drugs in this class is sexual dysfunction, primarily in men. In addition, SSRIs are more expensive but are not more effective than traditional tricyclic antidepressants.

3. selective serotonin reuptake stimulants (SSREs) [show]

   SSOZS is a selective serotonin reuptake stimulator. The main mechanism of action of the drug is unique: unlike most antidepressants, CVDs do not block, but rather stimulate the reuptake of serotonin. It has been shown that SSOD increases the number and length of apical dendrites of hippocampal pyramidal cells, and also reduces the reactivity of the hypothalamic-pituitary-adrenal system in response to stress. It is assumed that such a mechanism underlies the quickly onset antidepressant effect, the original anti-anxiety and anti-stress effect. Unlike SSRIs, SSRIs have not only antidepressant, but also tranquilizing properties, which explains their high efficiency for mixed anxiety-depressive disorders, as well as for depression combined with anxiety disorders. In terms of antidepressant effectiveness, SSRIs are not inferior to traditional tricyclic antidepressants, but unlike them, they are well tolerated by patients, even the elderly. In addition, they are safe in overdose and combine well with other medications (including those prescribed for the treatment of somatic diseases). These properties of SSRIs are highly desirable, which has allowed them to become one of the most frequently prescribed drugs in patients with depressive and anxiety symptoms observed by general practitioners.

4. tricyclic antidepressants [show]

   Tricyclic antidepressants (traditional and new). Since the 50s of the last century, drugs of this class have formed the basis of drug therapy for patients with depression and/or anxiety disorders. The main disadvantage of TCAs is their pronounced side effects, so therapy is always started with a low dose, which is gradually increased at intervals of 2-3 days. Patients are most concerned about symptoms such as weight gain, dry mouth, constipation, sedation, or a feeling of “zombie” (for example, if therapy is started with high doses of drugs). Patients receiving TCAs should undergo regular medical examinations (weekly in the first month of treatment). During the examination, it is necessary to assess the effectiveness of drug therapy, the nature and severity of side effects, and also remind patients, who often forget the content of the first conversation, the rules of use and the TCA therapy regimen.

5. other drugs (monoamine oxidase inhibitors, lithium drugs) [show]

   Monoamine oxidase inhibitors. In the 50-60s, drugs of this class were widely used in clinical practice, especially in the treatment of patients with atypical depression. Indeed, MAO inhibitors are one of the most effective medications (if not the most effective) in the treatment of patients who have symptoms of depression along with panic attacks, increased anxiety and phobias.

   However, unfortunately, the high toxicity of these drugs and numerous drug interactions, including with other psychotropic drugs, have led to the fact that MAO inhibitors are practically not used in medical practice today. Many experts believed that the reversible MAO inhibitor moclobemide would be safer (less risk of overdose, side effects), but in practice these expectations were only partially justified.

   Other drugs and their combinations. When treating patients with treatment-refractory depression, lithium preparations are often added to antidepressants.

   Therapy with lithium preparations requires careful monitoring, the dose is gradually increased until the therapeutic concentration of lithium in the blood serum is 0.5-1.0 mmol/l. Typically, lithium preparations are prescribed at a dose of 600-800 mg/day; Therapy with lithium salts, as a rule, is not accompanied by significant side effects, with the exception of gastrointestinal disorders and skin irritation (mainly in patients with psoriasis). In addition to regularly measuring the concentration of lithium ions in the blood (every 3-6 months), during treatment it is necessary to monitor the function of the kidneys and thyroid gland (taking lithium salts may be accompanied by a decrease in thyroxine levels). Any complications that arise in patients during lithium therapy require specialist consultation and qualified medical care.

   In practice, when treating patients with anxiety, propranolol (a beta-blocker) is often successfully used. Propranolol is indicated for situational anxiety (for example, internal tension and tremors that occur in crowded places); It is advisable to use the drug during attacks. Regular use of propranolol has no practical meaning; moreover, during therapy with propranolol, the risk of developing depressive episodes increases (10% of patients) and the effectiveness of the drug decreases with a single dose (for example, during an attack).

The effectiveness of these drugs varies; standard algorithms are usually of little help in choosing the optimal drug therapy, and the result of treatment largely depends on the conscientious implementation of the doctor’s instructions, the severity of side effects, the nature of the symptoms and the characteristics of the course of the disease.

Psychotherapy. Psychotherapy methods, widely used in the treatment of patients with anxiety, panic attacks, depression or anxiety-depressive disorder, are not included in the arsenal of the general practitioner's tools. Obviously, only psychiatrists have enough time to identify and assess the severity of symptoms of the disease, long and regular conversations with patients, and individual selection of an adequate method of psychotherapy. GPs should actively collaborate with services psychiatric care, since psychotherapeutic methods are highly effective and well accepted by patients.

At the core behavioral psychotherapy lies in the deliberate presentation of a conditioned stimulus to the patient, which, for example, reminds him of the first panic attack (crowded place, loud noise). Over time, this reaction (panic fear, desire to hide in the house) becomes habitual, and then weakens or completely disappears. Thus, the goal of the therapist is to achieve psychological desensitization by staying with the patient during the panic attack, calming the patient, helping him relax, and assessing the severity of anxiety before and after each psychotherapy session.

Cognitive behavioral (rational) psychotherapy is a more subtle method, but based on the same principles. For example, when treating patients with depression, the doctor must identify individual factors that characterize the patient’s depressive state. When conducting a course of cognitive psychotherapy, the doctor must explain to the patient the reasons for his negative attitude towards the world around him, himself and his future. Any event (for example, a work colleague not talking to a sick person) can lead to increased symptoms of depression and decreased self-esteem.

The goal of cognitive psychotherapy is to eliminate “negative thinking” and low self-esteem (the patient believes that he is incompetent, stupid, ugly). The patient is asked to remember the event that provoked the depressed mood (for this, the patient is recommended to keep a diary). After this, the doctor explains to the patient that his colleagues do not talk to him because he is doing everything right, he looks good, everything is fine with him. In other words, cognitive psychotherapy is designed to teach the patient to look at the world around him in a new way, to restore and strengthen his self-confidence.

Social factors. A general practitioner is not able to influence the situation in the patient’s family and home. Moving an agoraphobic single mother to a cozy house with a garden, in a quiet suburb, with friendly neighbors and a well-functioning social assistance system, is a pipe dream. However, it is often these aspects of the patient’s life that determine the choice of an adequate treatment method.

SUMMARY

Diagnosis and treatment of depression and anxiety disorders is not difficult if the doctor is able to identify and analyze the patient’s symptoms. In general practice, it is not the final diagnosis that is decisive, but a clear understanding of the clinical picture of the disease, which is often possible only after lengthy conversations and repeated examinations of the patient. In most cases, you can be quite open with people with depression/anxiety disorders. Thus, one should not refer the patient for consultation to a “specialist” without specifying that this is a psychiatrist, it is undesirable to stop one and prescribe drugs too quickly (it takes months, not weeks, to evaluate the effectiveness of therapy), or try to involve numerous members of the patient’s family. In complex cases, as a rule, a consultation is held with other specialists, and this issue was not discussed in this guide. At the same time, after the consultation, not all patients feel better (especially emotionally labile individuals).

There is no convincing evidence that patients who have suffered a traumatic event are advised to consult or talk with a psychiatrist. Moreover, such interference is often counterproductive. So, for a driver who experiences panic attacks and sleep disturbances after a car accident, it is advisable to prescribe therapy with benzodiazepines (improves sleep, reduces muscle tension, reduces anxiety), but does not refer him to a specialized center where a stranger will remind him of this terrible event. In these cases, more formal methods of psychotherapy, which most general practitioners should be proficient in, can be successfully used.

It is well known that depression/anxiety disorders are often combined with somatic diseases (cerebral stroke, chronic intestinal diseases, cardiovascular or pulmonary diseases), moreover, effective therapy one disease can alleviate the course of another. The author hopes that this guide will help to properly distribute the burden on modern health services.

CASES FROM PRACTICE

Next, two anamnesis of one of the many patients who seek help from general practitioners will be presented. First, the history will be given as presented by a general practitioner who has not read this book. A repeated history of the same patient was written by a doctor who has mastered the basic principles of recognizing depressive and anxiety disorders. When you read both anamnesis, you will clearly see errors in the diagnosis of somatic conditions (highlighted) in this patient.

And now we can present a discussion of two clinical cases by a general practitioner (B) and a psychiatrist (P), which, unfortunately, most often occurs only in textbooks.

Depressive disorder of the anxiety type is more common in women; it manifests itself in causeless anxiety for any reason, depression, lack of positive emotions, apathy, lack of will and other negative symptoms. The help of a qualified psychiatrist is needed. To eliminate symptoms of anxiety, tranquilizers are prescribed in combination with antidepressants. latest generation, which soon gives positive results.

IsraClinic consultants will be happy to answer any questions on this topic.

According to WHO statistics, the prevalence of the disease is 5%, while the diagnosis of mixed anxiety-depressive disorder is almost twice as common among representatives of the fair sex.

Among the symptoms of mixed anxiety-depressive disorder, doctors note the following:

• The appearance of anxiety and worry for various reasons
• Aggression and irritability
• Fatigue, excessive weakness
• Depressed mood or sudden change in mood with a predominance of depressed mood
• Absent-mindedness, inability to concentrate
• Sleep problems
• Emotional lability, tearfulness
• Pessimism, feeling of hopelessness
• Low self-esteem, feeling of uselessness, worthlessness

Causes of mixed anxiety-depressive disorder

Causes of mixed anxiety-depressive disorder can be different, among the most common are the following factors:

• Sudden change in life status quo (change of job, change in marital status, etc.)
• Long-term stress
• Difficulties in family relationships, conflicts at work
• Negative events (death, illness)
• Genetic predisposition
• Personal characteristics of a person

Difficulties in diagnosing STDD

The combination of both anxious and depressive components at once introduces certain difficulties into the diagnosis of mixed anxiety-depressive disorder, since there are difficulties in differential diagnosis between anxiety and depressive disorder. Doctors note that with STDR, the patient’s quality of Everyday life in everyday life, work and interpersonal terms. In particular, people with a diagnosis of mixed anxiety-depressive disorder had twice as many days spent on sick leave or personal leave as people with an anxiety disorder or only a depressive disorder.

For patients with ADHD, in contrast to patients with single disorders (depression or anxiety), the following manifestations are characteristic:

• The first episode of the disease appears at an earlier age
• Greater severity of symptoms
• Occurs more often chronic form illness or exacerbation of a disorder
• Greater decline in functioning
• Pronounced psychosomatic manifestations
• Acute psychosomatic disorders
• Increased risk of suicidality
• Time-delayed response to pharmacotherapy and psychotherapy

The prognosis in the treatment of ADHD is somewhat worse than in the treatment of anxiety disorder or depressive disorder separately. Therefore, when mixed anxiety-depressive disorder diagnosis plays a big role.

Treatment of mixed anxiety-depressive disorder

When choosing medications, the doctor must take into account the symptoms and changes in the patient’s condition for timely correction of treatment and optimal effective therapy.

In Israel, when diagnosed with mixed anxiety-depressive disorder, treatment is carried out with effective antidepressants, and often this is monodrug therapy. However, STDR uses higher dosages and longer treatment times. In combination with drug therapy, psychotherapy is actively pursued, often also on a tighter schedule than with a diagnosis of anxiety or depression. Cognitive behavioral therapy has shown the greatest effectiveness, during which the patient not only gets rid of the symptoms of the disease, but also learns to correctly respond to life events to prevent the development of psychological disorders further.

In addition to those listed, among the methods of the IsraClinic clinic, hypnotherapy and yoga nidra techniques are used for relaxation. Clinical practice has shown that teaching the patient relaxation skills - muscle relaxation, even breathing, switching attention - helps relieve anxiety. Moreover, relaxation skills help the patient cope with stressful situations in the future, in other words, this is an excellent means of prevention and mental hygiene.

In addition to relaxation sessions, the patient may be recommended sports therapy, the purpose of which is to improve physical and mental well-being. The IsraClinic uses the techniques of Moshe Feldenkrais, the main meaning of which can be conveyed by the phrase “awareness through movement.” These are motor practices that allow a person to be aware of himself in the process of performing exercises, to approach classes through an understanding of the relationship between body and mind. Hippotherapy also shows excellent results in the treatment of mixed anxiety-depressive disorder, since through interaction with horses a person gets rid of fear and anxiety, his mood and self-confidence improve. Hippotherapists offer patients with ADHD a set of tasks that must be completed while riding, or teach the horse certain commands. The main task is to learn to act in tandem with the animal, trust the horse and listen to it.