anxiety and depression, quito 2005
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ANXIETY AND DEPRESSION:SHARED SYMPTOMS,
COMMON TREATMENTS,SIMILAR CAUSES?
Roger M.Pinder
Secretary ISAD, Treasurer CINPEditor, Neuropsychiatric Disease and
TreatmentPharma Consultant, ‘s-Hertogenbosch,
The Netherlands
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DECLARATION OF INTEREST
• Until June 2004, I was a full-time employee of Organon. Since then I have received honorariaand/or travel support from Organon for chairingand speaking at symposia.
• I am non-executive Chairman of NeuroCure Ltd(Dublin).
• I am a consultant to Cypress Bioscience Inc
(San Diego), Daniolabs Ltd (Cambridge, UK),Nomura Phase4 Ventures (London) andOrganon International Inc (New Jersey, USA).
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Anxiety and Depression:Anxiety and Depression:
The FactsThe Facts
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Comorbidity of majorComorbidity of majordepression with anxietydepression with anxiety
disorders in the communitydisorders in the community• National Comorbidity Survey: 12 months
• Major depression comorbid with: – Any anxiety disorder 53.7%
– Panic disorder 9.9%
– Social phobia 31.3%
– Simple phobia 26.2%
– GAD 16.9%
Kessler et al 1994
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Impact of Depression
• 340 million patients worldwide
• Lifetime risk exceeds 17%
• Women have twice the risk of men• Direct and indirect medical costs in USA in
1990 were $44 billion
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Anxiety and Depression:
Shared Symptoms?
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Symptoms common to majorSymptoms common to major
depression and anxietydepression and anxiety
disordersdisordersMajor
depression
Anxiety
disorder
•Depressedmood•Anhedonia•Weight
gain/loss•Loss of
interest
•Hypervigilance•Agoraphobia•Compulsive
rituals
• Fear • Panic
• Apprehension• Panic attacks• Chronic pain• GI complaints• Excessive worry• Agitation• Difficulty
concentrating• Sleep
disturbances
APA 1994Keller 1995
Clayton et al 1991Coplan et al 1990
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Consequences of anxietyConsequences of anxiety
symptoms in depressionsymptoms in depression
• More severe illness at baseline
• More psychosocial impairment
• Greater likelihood of chronic illness• Poorer, slower response to treatment
• Increased use of health care
resources• Greater likelihood of committing
suicide
Keller et al 1995
Fawcett 1988
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Anxiety and Depression:Common Treatments?
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Antidepressant drugs are effectivein anxiety disorders
• SSRIs (GAD, SAD, PTSD, OCD, PanicDisorder)
• SNRIs (GAD)• Mirtazapine (PTSD, Panic Disorder)
• Clomipramine (OCD)
• MAOIs (SAD)
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But efficacy in anxiety disorders isconfined to those antidepressantswith a serotonergic component in
their pharmacology
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And anxiolytics are generally noteffective in depressive disorders
• Benzodiazepines (used for insomnia andanxiety symptoms in depression, but may
worsen response to antidepressants)• Buspirone (only effective as augmentation
to antidepressants)
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Anxiety and Depression:Similar Causes?
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Brain Structure in Mood andAnxiety Disorders
• Volumetrics
– Increasing evidence that specific structuresdemonstrate cellular loss as a function of duration of depression and PTSD
– Growing evidence that all antidepressant
treatments and some anticonvulsants may“regrow the brain” (synaptic plasticity or neurogenesis)
Hi l V l i M d
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Hippocampal Volume in Moodand Anxiety Disorders
• Excessive glucocorticoid exposure(hypercortisolemia) may result inhippocampal atrophy in depression andPTSD; 5-10% loss of volume
• Smaller hippocampal volume in
depression depends upon duration of episodes; also found in PTSD
• Reduced volume linked to verbal
memory deficits in both disorders
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H i p
p o c a m p a l v o l u
m e ( m m 3 )
Episode Duration (days)
5800
5300
4800
4300
3800
3300
2800
500 1000 1500 2000 2500 3000 3500 40000
Sheline et al. J. Neuroscience 1999
R 2 = 0.36
p = 0.002
Depression and neurodegenerationHippocampal volume and duration of
depressive episode
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Structural Brain Abnormalitiesin Anxiety and Depression
• Sufficient evidence to conclude that brain
structure is abnormal
• Also appears likely that some structural
abnormalities are distinct in depression and
in PTSD
• Progression of illness results in hippocampalvolume loss; effective treatments may modify
brain structure, resulting in growth of new
neurons and new patterns of connectivity
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Long-term Health Consequencesof Undertreatment
• Depression and PTSD linked with brainchanges:
– Volume of the hippocampus reduced
– Correlated with number and duration of previous episodes
• Do brain changes may persist after resolution of symptoms?
Consequences of Chronic
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Consequences of ChronicStress
STRESS
Glucocorticoids
BDNF
Normal survivaland growth
Atrophy/death of neurons
Antidepressants
BDNF
Increased survivaland growth
5-HT and NE
Glucocorticoids
Duman et al. 2000
HPA AXIS AS DIRECT
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HPA AXIS AS DIRECTTARGET FOR
ANTIDEPRESSANT ACTION
• Non-specific antiglucocorticoids such assteroid synthesis inhibitors
• CRH1 receptor antagonists
• Type II glucocorticoid receptor (GR)antagonists
• Vasopressin antagonists
GLUCOCORTICOID
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GLUCOCORTICOIDRECEPTOR ANTAGONISTS
• RU 486 (mifepristone) and ORG 34517are steroidal central GR antagonists
• Both also have antiprogestagenic
activity - mifepristone is abortifacient
• Mifepristone is effective in psychoticdepression and bipolar disorder, ORG
34517 in melancholia• No studies in PTSD
• No studies on hippocampal volume
ORG 34517 P f f P i i l
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ORG 34517, Proof of Principle:Mean decrease in HAMD-21 at
10 days
0
2
4
6
8
1012
14
All
(n=142)
high
cortisol
(n=48)
DST NS
(n=22)
Paroxetine
Org 34517, 150-300mg
Org 34517, 450-600mg
Hoyberg et al. 2002
Mifepristone in psychotic
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Mifepristone in psychoticdepression: Open label, 7 days,
n=30, % responders
0
10
20
30
40
5060
70
HAMD-21 BPRS BPRS
Positive
Symptoms
50mg
600mg
1200mg
Belanoff et al. 2002
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DOES TREATMENT REVERSE
BRAIN CHANGES IN MOOD ANDANXIETY DISORDERS?
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We do not know (yet)
• No data available in depression for anytreatment modality including drugs, ECT
and psychotherapy. But:
• Paroxetine (1) and phenytoin (2) increasehippocampal volume in PTSD and also
improve verbal declarative memory
(1)Vermetten et al, Biol Psychiatry 2003, 54:693-702
(2) Bremner et al, J Psychopharmacol 2005, 19:159-165
Phenytoin and Brain Volume in
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Phenytoin and Brain Volume inPTSD Patients
% Increase after 300-400mg daily for 3 months
(n=9); *p<0.05
0
1
2
3
4
5
6
Left Brain
Right Brain
Left Hippocampus
Right Hippocampus
Bremner et al, J Psychopharmacol 2005,19:159-165
*
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CONCLUSIONS
• Symptoms of anxiety and depressive disorders overlapto a major extent
• Anxiety and depression commonly occur together
• Anxiety symptoms are frequent in, and a poor prognostic
criteria for, depression• Treatments for anxiety and depressive disorders are
similar
• Structural brain changes occur in depression and PTSD
• There may be some commonality between depressionand PTSD
• Other anxiety disorders are probably distinct fromdepression