Managing Depression and Anxiety

Disorder in Hospital Setting :

Challenges and Enablers

Andri
Department of Psychiatry, Faculty of Medicine UKRIDA
Omni Hospital Alam Sutera

Optimizing Depression and Anxiety Treatment Seminar, March 25th, 2018, Hotel Westin, JAKARTA
Primary Care Setting

Hospital Setting
Psychiatric Service
in General Hospital
✤ Outpatient

✤ Inpatient

✤ Consultation and
Liaison Service
Recent Situations in Psychiatric Service
in General Hospital

✤ Health National Insurance Coverage (JKN-BPJS)

covers mental health disorder

✤ Primary care - Type C Hospital - Type B Hospital -

Type A Hospital

✤ Most of the patients are treated in Type C dan Type B

Hospitals
Depression and Anxiety

✤ 85 % of patients with depression also experience

significant symptoms of anxiety

✤ Symptoms of depression occur in up to 90 % of

patients with anxiety

✤ Co-morbid anxiety and depression may occur at any

age, from childhood and adolescence to old age

Mollerr HJ, et al. The relevance of ‘mixed anxiety and depression’ as a diagnostic
category in clinical practice. Eur Arch Psychiatry Clin Neurosci. 2016; 266(8): 725–736.
Depression and Anxiety

✤ When anxiety and depression come together :

✤ more disabling
✤ more resistant to treatment
✤ have a greater risk of suicide
✤ unexplained somatic symptoms
✤ associated with more severe psychological, physical, social, and
workplace impairment1
✤ High use of nonpsychiatric medical care
✤ Nearly four times more common than depressive disorder
alone2
✤ In clinical and epidemiological studies, anxiety and depression
have consistently shown considerable symptom overlap
1. Mollerr HJ, et al. The relevance of ‘mixed anxiety and depression’ as a diagnostic
category in clinical practice. Eur Arch Psychiatry Clin Neurosci. 2016; 266(8): 725–736.
2. Walters K, et al. Mixed anxiety and depressive disorder outcomes: prospective cohort study in primary care.
The British Journal of Psychiatry (2011) 198, 472–478.
3. Lydiard RB, Brawman-Mintzer O. Anxious depression. J Clin Psychiatry. 1998;59(suppl 18):10-17
4. Boulenger JP, Fournier M, Rosales D, Lavallee YJ J Clin Psychiatry. 1997;58 Suppl 8:27-34
Symptoms of Anxiety and
Depression Overlap
Social Anxiety Disorder

Fear/avoidance
of social situations
Blushing
Trembling/shaking
Stuttering

Palpitations Low self-

Generalized Difficulty Major
Sweating concentrating esteem
Anxiety Disorder Depressive
GI complaints Disorder
Interpersonal Anhedonia
Worry sensitivity Depressed mood
Anxiety Suicidal ideation
Agitation
Muscle tension Worthlessness
Irritability
Dry mouth Sleep disturbance Appetite
Fatigue disturbance
Pain

DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

Mollerr HJ, et al. The relevance of ‘mixed anxiety and depression’ as a diagnostic category in clini
Mental disorder and medical
condition
The studies on patients entering in a G.P.’s office showed at least
25% of them have a psychiatric problem

Patients are not properly diagnosed, due to :

The general medical examination seldom includes precise
questions about the psychic status of the patient

An estimated percent of 21-46% of the patients hospitalized in

non-psychiatric settings have a psychiatric disorder.

Mental disorders’ prevalence is about 25-50% with chronic

medical conditions and less than 18% in those with medical
conditions
Sorin E. The role of consultation-liaison psychiatry In the general hospital. J Med Life. 2008 Nov 15; 1(4): 429–431.z
Depression is common
in medical conditions

(STAR*D) study : comorbid medical condition was present in 52.8% of the

1500 patients with MDD
Medical condition : chronic heart disease and diabetes mellitus type 2

Prim Care Companion J Clin Psychiatry. 2005; 7(6): 282–295

Consultation and Liaison Psychiatry
CLP : medical specialty concerned with the care of people presenting
with both mental and physical health symptoms regardless of
presumed cause.

The multidisciplinary liaison psychiatry team will typically include :

1. CL-Psychiatrist as a team leader
2. specialist mental health nurses
3. clinical psychologists
4. occupational therapist
Dr Peter Aitken, Dr Sarah Robens, Tobit Emmens .An Evidence Base for Liaison Psychiatry - Guidance. 1st edition. February 2014
Liaison Psychiatry Team
Problems referred to
liaison psychiatry

• Psychological reactions to physical

illness
• Deliberate self-harm
• Organic mental disorders,
ie: delirium and dementia
• Alcohol and substance misuse
• Mental illness related to childbirth
• Behavioural disturbance
• Medically unexplained symptoms

https://www.hsj.co.uk/efficiency/liaison-psychiatry-can-bridge-the-gap/5051771.article#
 Andri. Challenge of CLP Service in Indonesia.
Slide presented in Asian College of Psychosomatic Medicine, Fukuoka, 2015
 Treatment Issues in MDD

Untreated MDD ▪ Up to 50% are untreated1,2

▪ Overall non-adherence up to 70%3
▪ 60% of patients stop antidepressant therapy before 6 months4
Non-adherence in MDD ▪ 28% of primary care patients stop antidepressant therapy at 1
month4

Treatment Failures in MDD ▪ 40% to 60%5

Recurrence/Relapse in MDD ▪ Up to 80%5
▪ After 1 MDD episode, there is a 50% probability of a 2nd
episode5
▪ After 2 MDD episodes, there is an 80% to 90% probability of a
Subsequent Episodes of MDD 3rd episode5
▪ Residual symptoms are associated with risk of relapse and
recurrence6,7

1. Patten. Can J Psychiatry. 2006;51:84-90; 2. Lecrubier. J Clin Psychiatry. 2007; 68 Suppl 2: 36-41; 3. Cassano Ann Clin Psychiatry. 2004;16(1):15-25; 4. Lin. Med Care. 1995;33(1):67-74; 5.
Masand. Clin Ther. 2003;25(8):2289-2304; 6. McIntyre. Can J Psychiatry. 2004;49(3Suppl 1):10S-16S; 7. Zajecka. J Clin Psychiatry. 2013;75(4):407-414.
Challenges to optimal patient care of MDD
across Asia (1)

✤ Psychiatric
stigma associated with lack of awareness and
understanding mental illness

✤ Widespread under-recognition of depression and their

associated unmet need

✤ Delay in help-seeking, diagnosis and treatment

✤ Primary care has low capacity in screening and treatment

✤ Wide variation in psychiatric system, referral paths, practice and

policies
Slide Deck presentation from Prof Chee Ng in APAC CNS Speaker Bureau Masterclass, 17-18 March 2018, Bangkok
Challenges to optimal patient care of MDD across Asia (2)

✤ Lackof measurement-based care due to lack of time

and cultural validity

✤ Treatments often not optimal or appropriate

✤ Varying acceptability of treatment (eg psychotherapy,

fear of psychotropics)

✤ Unrealistic
expectations and understanding of
treatment effects

Slide Deck presentation from Prof Chee Ng in APAC CNS Speaker Bureau Masterclass, 17-18 March 2018, Bangkok
Challenges to optimal patient care of MDD across Asia (3)

✤ Drug availability and cost restraints

✤ Poor treatment adherence and follow-up

✤ Concurrent alternative medicines

✤ Family/carer
support is strong but lack
psychoeducation/capability

✤ Lack of self-help groups, NGOs and community supports

Slide Deck presentation from Prof Chee Ng in APAC CNS Speaker Bureau Masterclass, 17-18 March 2018, Bangkok
 Guidelines in Asia

Review of antidepressant use for MDD

in six Asian countries showed:

▪ No remarkable differences between China, Korea, Malaysia,

Philippines, Taiwan and
guidelines from Asian and Thailand

international groups/countries

▪ Adapted from western guidelines

▪ A lack of country-level evidence may

be the main barrier to developing
guidelines for Asia

Treuer et al. Asia Pac Psychiatry 2013;5:219-30. Slide Deck presentation from Prof Chee Ng in APAC CNS Speaker Bureau Masterclass, 17-18 March 2018, Bangkok
Practical Management Hints
Managing MDD may include

✤ therapeutic engagement

✤ patient education

✤ appropriate selection of biopsychosocial therapies

✤ relapse prevention

Slide Deck presentation from Prof Chee Ng in APAC CNS Speaker Bureau Masterclass, 17-18 March 2018, Bangkok
Take home messages

✤ Prevalence of anxiety and depression in patients with

medical condition is high

✤ CLP team is needed in general hospital

✤ Management approach must be tailor made for each

patients
Thank You