Characterization Of Depressive And Anxiety Disorders

The primary clinical manifestations of major depression are significant depression of mood and impairment of function. Some features of depressive disorders overlap those of the anxiety disorders, including panic-agoraphobia syndrome, severe phobias, generalized anxiety disorder, social anxiety disorder, posttraumatic stress disorder, and obsessive-compulsive disorder. Extremes of mood also may be associated with psychosis, as manifested by disordered or delusional thinking and perceptions that often are congruent with the predominant mood. Conversely, secondary changes in mood may be associated with psychotic disorders. This overlap of disorders can lead to errors in diagnosis and suboptimal treatment. Mood and anxiety disorders are the most common mental illnesses, each affecting up to 10% of the general population at some time in their lives.

Clinical depression must be distinguished from normal grief, sadness, disappointment, and the dysphoria or demoralization often associated with medical illness. The condition is underdiagnosed and frequently undertreated. Major depression is characterized by feelings of intense sadness and despair, mental slowing and loss of concentration, pessimistic worry, lack of pleasure, self-deprecation, and variable agitation or hostility. Physical changes also occur, particularly in severe depression, including: insomnia or hypersomnia; altered eating patterns, with anorexia and weight loss or sometimes overeating; decreased energy and libido; and disruption of the normal circadian and ultradian rhythms of activity, body temperature, and many endocrine functions. As many as 10-15% of individuals with severe clinical depression, and up to 25% of those with bipolar disorder, display suicidal behavior at some time. Depressed patients usually respond to antidepressant drugs, or, in severe or treatment-resistant cases, to electroconvulsive therapy (ECT). This method remains the most rapid and effective treatment for severe acute depression and sometimes is life-saving for acutely suicidal patients. Efficacy of other forms of biological treatment of depression (e.g., magnetic stimulation of the brain or electrical stimulation of the vagus nerve) is not well established. The decision to treat with an antidepressant is guided by the presenting clinical syndrome, its severity, and by the patient's personal and family history. The lifetime risk for major depression is ~5% in men and 10% in women.

Anxiety disorders may be acute and transient, or more commonly, recurrent or persistent. Symptoms may include mood changes (fear, panic, or dysphoria) or limited abnormalities of thought (obsessions, irrational fears, or phobias) or of behavior (avoidance, rituals or compulsions, "hysterical" conversion signs, or fixation on imagined or exaggerated physical symptoms). Drugs can be beneficial in such disorders, particularly by modifying associated anxiety and depression to facilitate a more comprehensive program of treatment and rehabilitation. Antide-pressants and sedative-antianxiety agents are commonly used to treat anxiety disorder.

Antidepressants

Most antidepressants exert important actions on the metabolism of monoamine neurotransmitters and their receptors, particularly norepinephrine (NE) and serotonin (5-HT) (Table 17-1).

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