health

Anxiety and Depression

Are we all getting more depressed? 

Depression is the third most common reason for people to visit the GP, with anxiety being the most common psychiatric disorder people suffer.  It’s difficult for people to unpick whether they’re anxious or depressed because they often co-exist.  Like with most health problems there’s a scale: some people suffer with mild mood disorders and require a bit of support, but for others anxiety and depression can be severe, life-altering and, in its extreme fatal.  

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How are anxiety and depression defined?

They are officially two separate conditions:

Anxiety usually refers to generalised anxiety disorder (GAD) which is one or a range of anxiety disorders which can also include more specific variants such as obsessive compulsive disorder, social phobia, post-traumatic stress disorder and so on.

  • Someone who suffers which GAD is described as suffering uncontrollable and widespread worry with the presence of physical and psychological symptoms.

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  • These symptoms can include (but are not limited to):
    • fast heart rate
    • awareness of thumping heart beat (palpitations)
    • sweating
    • chest pain
    • dry mouth
    • shakes or tremors
    • rapid breathing
    • dizziness or light-headedness
    • feeling sick (nausea)

Depression is the feeling of low mood or inability to take pleasure in things which is persistent and interferes with your normal life.  It is completely normal to have variations in mood and feel really low from time to time, particularly at times of stress, or as a reaction to a life-event, but if the feeling stays for at least two weeks and is accompanied by other physical and behavioural symptoms it could be depression.

  • Like with anxiety, depression can give a range of symptoms.  These include:
    • Difficulty sleeping: typically waking up early in the morning, but sleeping too much can be an issue.
    • Difficulty concentrating
    • Feeling tired or lethargic
    • Change in appetite: like with sleep this can go either way with people not eating or overeating
    • Thoughts or death and dying: this is not always as extreme as wanting to end your own life but commonly in mild to moderate depression a feeling that other people would be better off without you or that life “isn’t worth living”.  In more severe cases this can develop into thoughts of or even plans for suicide.
    • Feeling agitate or conversely slowing down of movements.

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Who is likely to suffer?

Depression can affect anyone.  Some people seem more likely to suffer from it than others but the mechanism which drives this is not fully understood.  Certain life-situations make people more likely to suffer (such as unemployment, marital breakdowns and money trouble) but undoubtedly genetics, upbringing and personality play a part too.  Having any form of chronic illness such as diabetes or heart trouble increases peoples risk.

It’s a slightly different picture for anxiety.  Although it too is a complex disorder certain characteristics make people more likely to suffer:

  • being female
  • experiencing difficulties in childhood (bullying, abuse etc)
  • having lifestyle stressors such as unemployment or dissatisfaction with work, money troubles, physical or emotional pain (such as from a a traumatic event)
  • Dependence to drugs or alcohol: this can be the cause or can just augment existing anxiety
  • Long term illnesses

Are we more depressed and anxious?

The answer to the question I asked at the beginning of the article is not straight forward.  If we look at the stats the suicide rates these tend to fluctuate year on year with the latest data showing this has fallen in the UK.  But the concerning feature that is often highlighted in the media is the high rate of male suicide which has accounted for 75% of all suicide since the 1990s.  As I said above, this is not because men are more likely to suffer from depression or even severe depression then women but it is thought that men are less likely to seek help about it.  This has prompted lots of campaigning to ensure men recognise the signs of depression, and know where to go for help.

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The other thing we look at is numbers of people seeing their GP about anxiety or depression.  These numbers are high but this may be because we are more willing to recognise it as a problem now than in the past.  There is still a stigma attached and people will wait 6-8 years to seek help for anxiety and depression.

What can we do about it?

There are a number of tests or questionaires you can do on the internet which ask how stressed, anxious or depressed you are but truthfully if you feel you are anxious or depressed and it is interfering with your life you should go an see your GP.  It is important to see a GP if you have any thoughts of suicide.  A lot of people worry that they’re “wasting the GPs time” or that they may just be “fobbed off” with tablets. 

Generally speaking there is no “one-size fits all” approach to anxiety and depression and discussing your problems with your GP can help to identify which treatment route would be best.  There are some avenues you can explore yourself:

  • Mindfullness: this essentially means being more aware of our surroundings and our own thoughts and feelings.  It’s the basis behind a lot of meditation and can help to treat anxiety and depression as well as being more aware of developing symptoms.  Some people use apps such as headspace or calm or more information can be accessed here.

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  • Exercise is also helpful in treating anxiety and depression.  This is due to the chemicals released during exercise (endorphins).  There is also emerging evidence that exercising regularly reduces the risk of future anxiety and depression at any age and although there was no specific “dose” suggested they advised a minimum of 150 hours of moderate to vigorous activity per week can reduce the risk of developing depression in the future by 10%.

The mainstay of treatment is counselling usually “talking therapy” using a method called cognitive behavioural therapy (CBT).  This type of therapy is useful for changing patterns of behaviour and thus reduces the symptoms of anxiety or depression.  CBT can be given as part of a group or individually, via computer programmes or, in some areas via Skype.  Most GP practices will have information on how to access this type, or other forms of counselling.

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Medication is still used, particularly for moderate to severe anxiety or depression.  It is important to realise that this is not a “magic bullet” but can help to stabilise things in order for people to be able to access therapy or other treatments.  There are lots of different types of medications used and there is a lot of overlap between the tablets used for both anxiety and depression (for example selective serotonin re-uptake inhibitors or SSRIs are commonly used for both anxiety and depression).  Generally speaking we expect people to be on these tablets in the short-term (6-12 months) but obviously some people will need longer term treatment.

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There are also tablets which can help with the symptoms of anxiety such as palpitations, nausea, sweating and chest pain.  Often beta-blockers such as propranolol are used.  These can be taken as and when to help with symptoms. There are not many side-effects but some people can experience dizziness, fatigue and vivid dreams   They are not suitable for asthmatics.

Suggested Links

If you need further advice please see:

Mind www.mind.org.uk 

The Calm Zone for men aged 18-35 http://www.thecalmzone.net/ 

Anxiety UK http://www.anxietyuk.org.uk/ 

Samaritans www.samaritans.org.uk 

Young Minds: support for young people and parents of those struggling with mental health issues https://youngminds.org.uk 

health

Irritable Bowel Syndrome

Cramping abdominal pains, bloating, diarrhoea or conversely bouts of constipation: these are all common symptoms of Irritable Bowel Syndrome (IBS).  It’s a pretty common problem thought to affect 10-15% of the population with only 10-20% of sufferers ever going to see their GP.  It’s far more likely to occur in women than men (2:1 ratio female to male sufferers) and commonly affects people in their 20s and 30s.

I’ve been driven to write about it because these are symptoms I see every day in General Practice and have personally suffered with and I’ve found that once it’s been diagnosed it can almost be… dismissed.

“It’s just IBS.  No need to worry”.

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Unfortunately there are studies which show that, although IBS doesn’t limit the length of peoples lives, the quality of the lives sufferers lead can be impaired causing psychological issues and financial losses through missed time at work.

Case: Laura

Last month my friend Laura started to develop severe cramps in her stomach.  She felt sick, bloated and she started having bouts of diarrhoea.  This was unusual for her: she’s very healthy and is rarely off work.  She’s also self-employed so any time she does need to take off is unpaid.  So she took some antacids and just powered through it.  Her pain continued.  It was so bad one night that she called 111 and was advised to go to A&E.  It was December and we were in the grips of yet another winter crisis for the NHS: the hospitals were full to the brim and the staff overworked.  They assessed her and told her it was probably gastritis.  Take some Omeprazole and see your GP.

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The pain continued.  She could barely eat over Christmas.  The pain was intermittent: she’d have periods of time where she thought she was better and go into work only for the pain to come on quickly and be so severe she’d have to return home.  She went to her GP who was very thorough.  She’d been diagnosed with IBS in her early 20s but never had any advice or testing for other things.  He wasn’t particularly happy about this “we should really make sure it isn’t any thing else”.  He arranged for a blood test (including a test for Coeliac’s Disease which is a gluten-allergy) and stool tests to check for a bug called H Pylori which can cause gastritis and another called a faecal calprotectin (to check for inflammation).

Off she went again, waiting for the results of the tests.  On my advice she’d started trying to track her symptoms to see if they were associated with any specific foods.  The blood tests and stool tests were all normal and she’d realised that her symptoms were worse every time she ate anything containing dairy.

What causes IBS?

Ok this is another syndrome where we don’t fully understand the processes involved but it is likely to be linked to a number of factors.

  • Genetics: no specific gene has been identified but twin studies suggest this has a role.

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  • Diet: this includes intolerances and sensitivity to certain foods and up to 90% of people suffering with IBS report certain food triggers
  • Infection: some people seem to develop IBS after gastroenteritis due to changes in the normal constituents of the gut due to the immune-response and normal bacteria which make up the gut flora.
  • Psychological factors: psychological stress due to anxiety or depression can alter the functioning of the bowel.  This is due to the presence of the “brain” around the gut (a complex neurological system which exists around the gastrointestinal system).

  • Medications: such as antibiotics

How is IBS diagnosed?

This is tricky.  There is no definitive test to confirm the presence of IBS: it’s made by looking at the pattern of symptoms and, if necessary, ruling out other causes.  Laura’s GP was correct: her symptoms were quite severe so it was worth making sure that she was tested appropriately.  But to be honest, this may not always be appropriate and it does depend on the pattern of symptoms and how certain the doctor seeing the patient is about the diagnosis.

I personally think a symptom diary can be invaluable.  Cutting out whole food groups at random always seems to be en vogue but it can lead to deficiencies which can endanger health and wellbeing.  Keeping a diary can help to identify any patterns of symptoms and make it easier to see if certain food groups trigger them.

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If testing is recommended I would always advise being checked for a gluten allergy (Coeliacs Disease) because it can cause similar symptoms.  Before this blood test is carried out you should make sure you’ve been eating wheat for at least 2 weeks otherwise it may be negative even if the disease exists.

Diet and lifestyle

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The most popular treatment option for sufferers of IBS (according to the BMJ) is the low FODMAP diet.  The term FODMAP relates to a new dietary class comprising of fermentable oligosaccharides, disaccharides, monosaccharides and polyols: a list of foods which ferment and thus are poorly absorbed.  This includes common foods such as:

  • Fruits (apples, cherries, peaches and nectarines)
  • Artificial sweeteners (sorbitol, xylitol and mannitol)
  • Vegetables and legumes (including broccoli, Brussels sprouts, cabbage and peas)
  • Most lactose-containing products

This diet is restrictive which can make it difficult to stick to.  Evidence from the trials shows that even short term adherence to the diet can lead to better gut health.  The longest duration of the diet in these trials seemed to be 6 weeks but even sticking to it for as little as 3 can be beneficial.

Ideally this diet should be adopted under the guidance of a dietician but there is a good factsheet from the IBS Network.

The NICE guidance also advises that probiotics purchased over the counter may have some benefit but the evidence from trials is limited and the probiotic should be tried for between 4-6 weeks.

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Exercise and regular physical activity are also advised in the management of IBS.  Theoretically, regular activity reduces bloating and gas retention and it is known that regular exercise reduces stress levels.  There have been some small trials which show that there was a significant reduction in IBS symptoms in patients who undertook a regular exercise programme compared to those who did no exercise.

Medications

There are no specific medications for IBS at present but the choice of medications should be based on the nature and severity of the symptoms.  The different medications can either be used in isolation or combination:

  • Antispasmodics such as Meberverine Hydrochloride or Peppermint Oil for abdominal cramps as required
  • Laxatives (but not Lactulose) for constipation symptoms.  The specific laxative Linaclotide can be prescribed for moderate-severe constipation in IBS if:
    • constipation has persisted for more than 1 year
    • all the other types of laxatives have been tried and failed
  • Anti-motility agents such as Loperamide for diarrhoea-type symptoms
  • Antidepressant medication can be tried if laxatives, antispasmodics or anti-motility agents have not worked.
    • Tricyclic Antidepressants (TCAs) such as Amitriptyline.  As with its use in migraine this would not be used to treat a suspected depression but for its neuropathic painkilling effects.
    • Selective Serotonin Re-uptake inhibitors (SSRIs) such as Citalopram or Fluoxetine if treatment with a TCA has been ineffective or poorly tolerated.

Cognitive Behavioural Therapy (CBT)

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Use of psychological therapies such as CBT has been advised for many years now, but uptake of such treatment is low, possibly because of the stigma associated with suffering with a “mental health disorder”.  The studies show that there can be some benefit from CBT in the initial stages following treatment but the benefits are vary according to the practitioner providing the treatment, the patients adherence to the treatment and the number of sessions which are provided.  This is still advised in the NICE guidance for IBS which does not respond to lifestyle changes or medications.

What next?

If none of the above is beneficial a referral to a gastroenterologist should be made to confirm whether or not IBS is indeed the diagnosis and for guidance on further management.

For more information please see:

The gut and liver disease charity CORE

The IBS Network

The Association of UK Dieticians factsheet on IBS and diet

Headache

Medication Overuse Headache (MOH) – detoxing

In the article about acute treatment, I briefly discussed the problem of medication overuse headache (MOH).  This can be a problem in patients who suffer with migraine, tension-type headache, cluster headache and other headache disorders but is much more common in migraineurs.

It happens when people take pain-killers for too many days over a 3 month period: this ends up causing the headache instead of treating it.  The resulting headache can be more severe and unrelenting causing the sufferer to take more medication and… the problem continues.

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It’s a frustrating paradox for the sufferer and can be difficult to get your head around (pardon the pun).

It can happen with any headache medication but for guidance I have made a list of the common ones and how often you have to take them to cause this problem:

  • NSAID medications such as ibuprofen, naproxen or aspirin and other simple pain-killers such as paracetamol are taken on more than 14 days a month
  • Triptans are taken on more than 8 days a month
  • Codeine and other opioids are taken on more than 6 days a month
  • Ergots (an old fashioned migraine treatment) more than 10 days a month

The key point to remember is it’s the number of days not the number of doses that counts.

How do I work out if I have MOH?

I do keep bleating on about migraine diaries but I find them invaluable for teasing out a pattern or helping to work out what’s causing migraine or headache.  If a diary is kept it quickly becomes obvious if someone is using too many pain-killers: you only need to take a triptan 2 days a week or paracetamol for more than 4 days on a weekly basis to cause MOH.  It’s difficult to keep track of this without noting it down.

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What do I do?

This is the difficult part.  You have to stop taking pain-killers.  It’s tough… really tough.  I liken it to a detox: initially when the medication in question is stopped the headache gets worse.  It’s really important to be aware of this because the temptation is to reach into your purse and grab the ibuprofen to make the pain go away.  But that would be a mistake because you’d just be delaying the inevitable and your frequent headaches would continue.

The amount of time it takes to detox is dependent on which medication is causing the issue.  If the problem is a triptan, NSAID the withdrawal headache will last for 7-10 days.  If it is a simple pain-killer it’s 2-3 weeks and if codeine or an opiod is the problem it’s 2-4 weeks.

How long do I need to “detox” for.

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We advise 12 weeks to allow the medication to wash out of the system.  If there is more than one medication that is being overused it is sometimes better to stop one medication at a time.

Can anything be done to help?

There are a few options:

  1. Naproxen: this is only a possibility if you have not taken this medication much before.  This can ease the withdrawal headache.  We often start a 6 week course starting
    • 3 times a day for two weeks
    • 2 times a day for two weeks
    • 1 time a day for two weeks
  1. Greater Occipital Nerve Block: injection of steroid with local anaesthetic at the back over the head around the nerves that supply the scalp.  It works by blocking the abnormal pain signals that fire during MOH.  Typically it gives relief for up to 6 weeks: just long enough to detox from the medication.
  2. Preventative medication: see full article but often we use Amitriptyline to dampen the withdrawal headaches.

For more information please see:

The National Migraine Centre factsheet.