Lit review

Treatment Options for Anxiety and Depression: A Review of the Literature HPRO 536 Program Planning and Development Treatment Options for Anxiety and Depression: A Review of the Literature About 14% of the global burden of disease has been attributed to neuropsychiatric disorders (Prince et al., 2007). This burden is likely to be underestimated because the link between physical health and mental health is not valued. Even with this global burden, mental health remains a low priority, especial y in most low-income and middle- income countries (Prince et al., 2007). Developed countries tend to focus on early death diseases like cancer and heart disease. Developing countries tend to focus on eradication of infectious diseases (Prince et al., 2007). Major depressive disorder symptoms can be severe and is prevalent in about 15% to 20% of the population (Blumenthal et al., 2007). Anxiety disorders, a subset of neuropsychiatric disorders and closely related to depression, account for almost one third of the mental health bil in the United States each year (Black, 2006). Table 1 shows the geographical distribution of depression based on information gathered from the Results from the 2004 National Survey on Drug Use and Health: National Findings. As reflected in the table, depression and anxiety spans across al races, al socioeconomic status levels are involved, and al levels of education with the “some col ege” category showing the highest degree of depression, also the most affected gender and ethnicity is white females.
Depression is especial y problematic in the 65 and older populations with 8% to 20% suffering with symptoms, mostly due to physical disease, and up to 37% of this population in primary care settings are symptomatic (Steinman et al., 2007).
The research has yielded inconsistent results with Children who grew up disadvantaged. In some studies, a correlation did not exist while in others there was evidence that those who grew up socioeconomical y disadvantaged are at a higher risk for depression and anxiety (Melchior et al., 2007). Adult socioeconomic status and how the adult views status appear to influence depression and anxiety (Barger, 2006). Overal , adult experiences seem to determine the risk of anxiety and depression How individuals view themselves is more important than gender, status, or even ethnic culture. If a person is living outside of their own standards, beliefs, or values, then they wil typical y have lower self-esteem, which wil affect mood. In fact, cultural ideals act as opposing parts of self-evaluation. Cultural ideals are guides to live by, but set a standard that may be difficult to maintain. In either case, failure may lead to depression and anxiety (Mahalingam & Jackson, 2007). Optimism and social support are factors in the treatment of depression and anxiety. They are also inherent in religious institutions. Individuals who are spiritual employee these factors just by the nature of spirituality. Many studies suggest lower rates of depression and anxiety with those who report greater spirituality (Mofidi et al. 2007). However, spirituality and the relationship to depression and anxiety are complex and needs further study (Mofidi et al. 2007).
Mental health professionals typical y recommend a combination of treatment modalities, which include psychotherapy and medication. Cognitive Behavioral Therapy (CBT) is the standard when treating anxiety and depression. Pharmacological options include tricyclic antidepressants, monoamine oxidase inhibitors, serotonin norephinephrine reuptake inhibitors, selective serotonin reuptake inhibitors (SSRI’s), and anxiolytics (Black, 2006). Despite this standard, the evidence to support this customary treatment is insufficient (Black, 2006). In Black’s (2006) study, Efficacy of combined pharmacotherapy and psychotherapy versus monotherapy in the treatment of anxiety disorders, he reports that a review of the relevant studies could not confirm the superiority of combined treatment over therapy alone (p. 29).
The studies that have been done in evaluating remission with depression and anxiety when using a combination treatment method, reports there is insufficient knowledge of the long-term course of anxiety disorders (Rubio & Lopez-Ibor, 2007). In addition, two main problems arise when treating anxiety with medication, the first is that the anxiety symptoms return when the medication is discontinued, and the second is the lack of knowledge around the long-term course of anxiety disorders (Ferrero et al., 2007). In other studies patients with anxiety disorders respond better to psychological treatment than to pharmacotherapy (Ferrero et al., 2007). In fact, it has been reported that the use of combined treatment modality may actual y lead to a worse outcome when treating panic disorder (Black, 2006). With depression, Stassen (2007) concluded that depressed patients likely have a biological “resilience” that controls recovery from depression and once this “resilience” is activated, then recovery natural y occurs (p. Patients who used a treatment option of only psychotherapy (monotherapy) tend to have reduced symptoms without the use of medications (Ferrero et al., 2007). Monotherapy seems to be effective and sufficient in the treatment of these disorders (Ferrero et al., 2007). It is important that primary care physicians encourage their patients with anxiety disorders to attend therapy (Craske et al. 2005).
This leaves health professionals with a need to reevaluate the effectiveness of a treatment modality that is insufficient and does not lead to remission. There have been few studies that investigate diet and exercise as treatment alternatives to the more traditional modality. One study evaluated different exercise conditions, low frequency aerobic exercise and high frequency aerobic exercise and found that the participants in the high frequency aerobic exercise reported lower depression scores than those participants in the low frequency aerobic exercise group (Legrand & Heuze, 2007).
In Blumenthal’s (2007) study, Exercise and pharmacotherapy in the treatment of major depressive disorder, patients with major depressive disorder were randomized into 16-week placebo control ed trial of supervised and home based exercise group and a sertraline, (Lexapro) treatment group. The participants were measured for changes in aerobic capacity at the beginning and end of the study. This study found that there was no difference in remission when comparing the medication group to the exercise group and concluded that exercise alone may be an effective treatment for depression (pp Even fewer studies were available for inclusion in this report in the effective treatment of anxiety and depression utilizing diet and nutrition. Chandler-Laney (2007) found that in individuals with eating disorders, depression and mood disturbances are comorbid. The study investigated the effects of caloric restriction on rats. The rats were subject to a series of food restriction and food abundance over time. The result of the study was that caloric restriction produced behavioral and neurochemical changes. The neurochemical brain changes were markers for depression caused by eating practices Diets that are deficient in zinc resulted in anxiety like symptoms in rats (Takeda et al., 2007). This relationship needs further studies and clarification. However, the researcher has concluded that anxiety-like behavior increases with zinc deficiencies The data regarding anxiety and depression are abundant. The current treatment models using a combination of medication and therapy are not successful to remission. The viewpoint that anxiety disorder is a chronic and recurring il ness and that few are cured maintains a system of prescribing medication for its treatment and yet the studies that were reviewed stated that there was insufficient knowledge of the long-term course of the disease (Rubio & Lopez-Ibor, 2007). In an additional study, it showed that people suffering with anxiety and depression preferred more natural remedies for the treatment of the disorders (Badger & Nolan, 2007). When exercise was introduced as a treatment option, the results were positive. This suggests that these disorders have a lifestyle component inherent in the nature of the disease. This literature review functioned as a needs assessment for the development of a program where healthy lifestyles in combination with psychotherapy are, with the exclusion of a medication program for situational depression and anxiety, are introduced into the treatment of anxiety and depression. Lifestyle changes would include exercise programs, nutrition and diet evaluations, and education as to the physiological nature of It is clear from the literature that when people, in any ethnic group, socioeconomic group, religious affiliation, educational level, or gender, feel a high self-esteem that they are less depressed or anxious. Which is why medication has limited value for the long- term treatment of these disorders and psychotherapy is much more effective. The focus of any treatment wil need to incorporate self-esteem building and when people move their bodies, when they eat healthy, and when they are connected with their spirituality Table 1 – Had at least one MDE in lifetime aged 18 years or older by gender, geographic, SES, and health Office of Applied Studies (2005) Badger, F., & Nolan, P. (2007). Use of self-chosen therapies by depressed people in primary care. Journal of Clinical Nursing, 16(7), 1343-1352. Baldwin, D., et al. (2005). Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for psychopharmacology. Journal of Psychopharmacology, 19(6), 567-596. Barger, S. (2006). Do psychological characteristics explain socioeconomic stratification of self-rated health? Journal of Health Psychology, 11(1), 21-35. Black, D. W. (2006). Efficacy of combined pharmacotherapy and psychotherapy versus monotherapy in the treatment of anxiety disorders. CNS Spectrums, 11(12), Blumenthal, J., et al. (2007). Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosomatic Medicine, 69(7), 587-596.
Chandler-Laney, P. C., et al. (2007). A history of caloric restriction induces neurochemical and behavioral changes in rats consistent with models of depression. Pharmacology Biochemistry and Behavior, 87(1), 104-114. Craske, M., Golinel i, D., Stein, M., Roy-Byrne, P., Bystritsky, A., & Sherbourne, C. (2005). Does the addition of cognitive behavioral therapy improve panic disorder treatment outcome relative to medication alone in the primary-care setting? Psychological Medicine, 35, 1645-1654. Ferrero, A., et al. (2007). A 12-month comparison of brief psychodynamic psychotherapy and pharmacotherapy treatment in subjects with generalized anxiety disorders in a community setting. European Psychiatry, , . doi:http://0- Legrand, F., & Heuze, J. P. (2007). Antidepressant effects associated with different exercise conditions in participants with depression: a pilot study. Journal of Sport and Exercise Psychology, 29(3), 348-364. Mahalingam, R., & Jackson, B. (2007). Idealized culture beliefs about gender: implications for mental health. Social Psychiatry and Psychiatric Epidemiology, , . Melchior, M., Moffitt, T., Milne, B., Poulton, R., & Caspi, A. (2007). Why do children from socioeconomical y disadvantaged families suffer from poor health when they reach adulthood? A life-course study. American Journal of Epidemiology, 166(8), Mofidi, M., Devel is, R. F., Devel is, B. M., Blazer, D. G., Panter, A. T., & Jordan, J. M. (2007). The relationship between spirituality and depressive symptoms. The Journal of Nervous and Mental Disease, 195, 681-688. Prince, M., et al. (2007). No health without mental health. The Lancet, 370(9590), Rubio, G., & Lopez-Ibor, J. J. (2007). What can be learnt from the natural history of anxiety disorders? European Psychiatry, 22(2), 80-86. Stassen, H. H., Angst, J., Scharfetter, C., & Szegedi, A. (2007). Is there a common resilience mechanism underlying antidepressant drug response? Evidence from 2848 patients. Journal of Clinical Psychiatry, 68(8), 1195-1205. Steinman, L., et al. (2007). Recommendations for treating depression in community- based older adults. American Journal of Preventive Medicine, 33(3), 175-181. Takeda, A., Tamano, H., Kan, F., Itoh, H., & Oku, N. (2007). Anxiety-like behaviors of young rats after 2-week zinc deprivation. Behavioral Brain Research, 177(1), 1-6. U.S. Department Of Health And Human Services. (2005). Major Depressive Episode Among Adults. Retrieved from


The medical letter issue 1137

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