Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Basic Pathophysiology Depression and anxiety are among the most common disorders seen in medical practice. The pathophysiology and etiology of these illnesses are diverse and complex. A combination of environmental factors and genetic predispositions is believed to contribute to both anxiety and depressive disorders. Traumatic or stressful life events can also trigger episodes. It is common for someone with an anxiety disorder to also suffer from depression and vice versa. Altered levels of neurotransmitters (including norepinephrine , serotonin, dopamine, and gamma-aminobutyric acid [GABA]) have long been implicated and are the primary target of pharmaceutical treatments for both conditions. However, it is not clear if neurotransmitter imbalances are a fundamental cause or instead a consequence of these conditions.

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Basic Pathophysiology Just as depression and anxiety are associated with increased risk of chronic diseases, numerous chronic diseases increase the risk of depression or anxiety Clinical and epidemiological studies suggest that physical inactivity may even be associated with the development of a variety of mental disorders, including depression and anxiety. Depressive Disorders Major depressive disorder (Video) Bipolar disorder ( Video ) Disruptive mood dysregulation disorder [DMDD] (for minors <18 years of age) Persistent depressive disorder (formerly called dysthymia)

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Basic Pathophysiology Major Depressive Disorder (MDD) Also known as clinical or major depression, major depressive disorder (MDD) Leading cause of disability among adults in the United States and throughout the world. Diagnosis of MDD is characterized by at least five of the following symptoms, occurring on most days, for at least two weeks.

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Basic Pathophysiology Bipolar Disorder Also referred to as manic–depressive illness, bipolar disorder causes atypical shifts in mood, energy, and behavior. Extreme euphoria, hyperactivity, and impulsivity may accompany a manic episode, whereas intense sadness and a feeling of hopelessness characterize a depressive episode. These cycles of mood state may last anywhere from a few days to several months and correspond to extreme changes in energy, activity, sleep, and behavior. Between episodes, people may be symptom free, but episodes of mania and depression typically come back over time. Some minors (under the age of 18) have symptoms consistent with bipolar disorder, and under DSM V these have been reclassified as disruptive mood dysregulation disorder (DMDD)

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Basic Pathophysiology Persistent Depressive Disorder Persistent depressive disorder (PDD, formerly known as dysthymia) is a chronic type of depression characterized by a consistently low mood, though symptoms are not as severe as with MDD. People present with many of the same symptoms as with MDD: low energy, sleep disturbances, changes in appetite, etc.,. Individuals may be more irritable, stress easily, or experience anhedonia, which is the inability to derive pleasure from activities once found enjoyable. There is no clear factor differentiating the disorder from MDD other than intensity or severity of symptoms, but the clinical impact of this change remains to be seen. PDD is common in people with chronic conditions.

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Basic Pathophysiology Anxiety Disorders - (General Overview – Video) Anxiety disorders encompass a group of illnesses that include social phobias, panic disorder, obsessive–compulsive disorder (OCD), (Video) posttraumatic stress disorder (PTSD), and generalized anxiety disorder (GAD). (VIDEO ) There is considerable individual variability in both the severity and type of symptoms exhibited with these conditions. Symptoms typically include excessive worry, apprehension, fear, and uneasiness, and physiological symptoms of heightened (fight-or-flight response):

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Basic Pathophysiology Anxiety Disorders Symptoms of Anxiety Chronic stimulation of the physiological stress response exacerbates and even causes chronic conditions such as cardiovascular disease, immunosuppression, and MDD.

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Management and Medications Treatments for depression and anxiety are diverse and have varying degrees of effectiveness. Management traditionally consists of pharmacological intervention, cognitive behavioral therapy, dialectical behavior therapy, or a combination of pharmacological and behavioral therapies. Treatment for depression can help not only manage symptoms but also prevent recurrence. Antidepressants Most classes of antidepressants work by changing the level of one or more neurotransmitters in the brain, mostly serotonin and norepinephrine. By blocking their absorption (reuptake) from the synaptic cleft—the space between neural cell synapses—more of the transmitter is available for stimulation.

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Management and Medications Listing of Antidepressant Medications - FYI

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Management and Medications Electroconvulsive Therapy Electroconvulsive therapy (ECT) is typically used for people with severe MDD who are unresponsive to all other antidepressant treatments, may be at high risk of suicide, or may not be able to take pharmaceuticals for health reasons or pregnancy. The mechanisms of action are unclear, but the electric currents that pass through the brain are hypothesized to reduce depressive symptoms by affecting neurotransmitter levels. Mood Stabilizers Bipolar disorder can be difficult to manage and is commonly treated with mood-stabilizing drugs. Lithium is usually one of the first medicines prescribed for bipolar disorder.

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Management and Medications Anxiety Disorders First Line - Most selective serotonin reuptake inhibitor (SSRI) and selective serotonin–norepinephrine reuptake inhibitor (SNRI) antidepressants also have anxiolytic properties. Second Line - Benzodiazepines are the other main anxiolytic class of medications and are believed to diminish neural hyperactivity by increasing the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). Benzodiazepines have more side effects than SSRIs or SNRIs and thus are usually second-line agents Common side effects are related to the sedating and muscle-relaxing action of these drugs: drowsiness, dizziness, and decreased alertness and concentration. Such side effects may impair coordination and increase risk of falls and injuries, especially in persons who are elderly or frail.

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Management and Medications - FYI Exercise also appears to be an effective alternative treatment for certain anxiety disorders. However, exercise alone does not reduce anxiety to the same extent as pharmaceuticals.

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Effects on the Exercise Response Depression and anxiety disorders do not typically alter physiological changes to exercise. However, psychomotor retardation, most commonly seen with depression, can cause a visible slowing of motor movements and reaction times. This may be exacerbated with  anxiolytic medications. Other concurrent pharmacological interventions may affect the exercise response. Thus, gathering a thorough medical history and listing of current medications is important. Several drug classes used for treatment in these populations may reduce functional aerobic capacity, affect perception and coordination, or reduce the desire to be physically active

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Effects of Exercise Training The efficacy of exercise compares favorably with that of antidepressant medications for mild to moderate depression, and depressive symptoms are further improved when exercise is used as an adjunct treatment to antidepressant medications. The psychological and physical benefits of exercise can help reduce anxiety and alleviate symptoms of depression. Depression Exercise and physical activity are effective in significantly reducing symptoms of depression, and regular aerobic exercise is equal in effectiveness to some pharmacotherapy treatments in mild to moderate depression. Relapse of depression is less likely with exercise as compared to antidepressant treatment As an adjunct to antidepressant medicines, exercise appears to further improve symptoms compared to medication alone.

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Effects of Exercise Training Depression The mechanisms underlying exercise-related improvements in depression are not known. Proposed psychological factors include : increased self-efficacy, gaining a sense of mastery, distraction from negative thoughts, and enhanced self-concept. Exercise-related improvements in sleep quality and the circadian sleep cycle may also reduce symptoms.

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Effects of Exercise Training Anxiety Exercise training significantly reduces symptoms of anxiety when compared to no treatment or cognitive behavioral therapy. Unlike the situation with depression, exercise alone does not appear to reduce anxiety to the same extent as pharmaceuticals. Recommendations for Exercise Testing Exercise testing recommendations for people with depressive or anxiety disorders depend on the impact of the condition on the patient’s daily functioning: High functioning without comorbid conditions: follow the ACSM Guidelines. Low functioning due to comorbid conditions: use the Basic CDD4 Recommendations

Depression and Anxiety Disorders HESS 509 CHAPTER T HIRTY TWO Recommendations for Exercise Programming Just as with the recommendations for exercise testing, the recommendations for exercise programming when working with people who have depressive and anxiety disorders depend on the individual’s level of functioning: High functioning without comorbid conditions: follow the ACSM Guidelines. Low functioning due to comorbid conditions: use the Basic CDD4 Recommendations. People should be encouraged to achieve at least the minimum recommended levels of 150 min/week or more of moderate-intensity physical activity. For mild to moderate depression, total energy expenditure appears to be a key consideration, with activity levels below 150 min/week having no significant effect. END