Kurier Health Talk: Depression and Anxiety

Society

On 15.3.2017 the Van-Swieten-Saal of the Meduni Vienna was the venue for the Kurier Gesundheitstalk on the topic of “Depression and Angst”. Univ.-Prof. Dr. Gabriele Fischer of the University Clinic for Psychiatry and Psychotherapy of the MedUni Vienna, Univ.-Prof. Dr. Stephan Doering of the University Clinic for Psychoanalysis and Psychotherapy of the MedUni Vienna and Dr. Rudolf Wagner, managing director of pro mente in Vienna took part in the discussion led by Gabriele Kuhn.

Introduction & Definition

Ms. Kuhn began the discussion with some figures: 25% to 30% of the population experience either depression or anxiety states at least once a year. 50% of workplace absenteeism is due to depression or anxiety.

Prof. Fischer turned next to depression which can, according to her statements, have different forms. It is now known that the illness can appear differently in men and women. The symptoms can include not only sadness with tearfulness, but also emotional instability and irritability. Further characteristics of depression are sleep disturbances, which often appear as first precursors, a dysregulation of emotions as well as a malfunction of an individual’s drive. With some forms of depression, an improvement as regards drive is noticeable in the evening.

Prof. Doering then spoke about anxiety, a fundamentally healthy feeling which is necessary to survive life. In the case of real threats, it is healthy to feel anxiety. Anxiety becomes pathological when it leads to psychological stress and appears without an appropriate trigger.

Medicine differentiates four groups of anxiety disorders:

Panic disorders (characterised by panic attacks, with or without agoraphobia)
Phobias (connected to very specific situations or objects, e.g. fear of heights or fear of snakes)
Social phobias (specific fear of social situations in which an evaluation by others could follow)
Generalised anxiety disorder (constant worrying, brooding, thoughts about potential catastrophes)

Anxiety disorders are a very frequently occurring illness. Every year, 15% of the population will suffer from some form of anxiety, which represents almost every sixth person.

Etiology

Prof. Fischer made a comparison with breast cancer which is now known to have a certain genetic component. The daughters of these patients are encouraged to take particular care and to have themselves examined early.

Also in the case of psychiatric disorders is the genetic influence significant but a diversity of other influences can have an effect on the development of depression or an anxiety disorder. These include, among others, childhood experiences as well as trauma.

With females, postpartum mood disorders are also common, but this perimenopausal phase only poses a higher risk if depression had already arisen in the past. In the course of one’s life, there are physical phenomena which can also cause sleeping disorders. However, this is normal and not to be considered as a part of depression.

Prof. Doering complements this explanation with the image of a genetic predisposition, which early unfavourable relationship experiences could “support”, thus making this person particularly vulnerable to disorders. It is, however, almost never assumed that depression or anxiety is purely inherited. Equally, there is almost nobody whose disorders have only been caused by experiences of life or relationships. It is always an interaction of the two factors.

Children and young people

Ms. Kuhn then addressed the topic of the increasing numbers of children and young people affected. Prof. Fischer stressed the importance of prevention and the correct initial recognition of phobias in children (e.g. fear of going to school). This is, in particular, the task of attentive pedagogues. This helps to prevent a manifest anxiety or depression disorder as a consequence. The increase especially concerns the vulnerable population of children and youths who have experienced various traumas.

The attention deficit hyperactivity syndrome (ADHS) commonly accompanies a depressive disorder. Regarding early recognition and treatment, there is an urban-rural gap.Further, she stressed the importance of events like this, which raise awareness in the population for early intervention (medication, psychotherapy, etc). An early recognition of symptoms is always important.

According to Prof. Fischer, as a parent, one should be attentive to the question of causality in the example of the fear of school (e.g. the child does not want to go to school because he/she did not study for a test) and observe the child carefully, in particular if there are other additional symptoms (e.g. insomnia or youths starting to smoke at a very young age). School doctors and psychologists also have a very valuable task in this phase. Prof. Fischer calls for these to be an integral part of the observation and early recognition in the school system which should not only become active if required.

Prof. Doering advises all worried parents to seek help at appropriate places (GP, specialist for child and adolescent psychiatry…). It is ultimately also a great factor for the child when the parents are constantly worried about him/her. Easing this burden by consulting an appropriate specialist is good for both sides. This could possibly also have a preventative effect. He calls for the courage to seek a representative in the mental health system in case of need.

Once cannot begin early enough in the case of an existing need for treatment. The earlier one comes, the quicker one has the situation under control, according to Prof. Doering. Prof. Fischer agrees with him on this point: in the case of illness, there should be no shame in seeking help.

Ms. Kuhn wanted to know from Dr. Wagner whether the current times promote depression and anxiety. According to facts and studies, mental illnesses have not increased in the last decades, according to Dr. Wagner. However, the use of the system has indeed increased, which he believes is the result of successful destigmitisation. In the case of mental illnesses, years normally pass from the first symptoms until help is sought – analogous to physical illnessess – which makes therapy more difficult or extends it. In order to shorten this time, preventative and explanatory work has to be conducted already in the schools. Dr. Wagner reports that the pupils’ interest in this area is already huge.

In the framework of destigmitisation, people such as Robert Hochner (a former televsion presenter) who acknowleged his depression, have contributed significantly.

The path to diagnosis and treatment

According to Dr. Wagner, people notice from their own suffering when treatment is necessary. In the self-help section of pro mente Vienna, the significance of self-help is evident – this is a good point of entry to receive advice. So-called “peer counseling” enables credible transmission of information which helps former affected people. These people are trained especially in order to be able to offer competent self-help. Here, though, it is often necessary that the concerned individual is accompanied by a person whom they trust. As a further possibility to receive initial counselling, Dr. Wagner mentions GPs, therapists as well as out-patient clinics.

It has to become more a matter of course that the appropriate help is sought for mental – in the same way as physical – complaints. These barriers in our heads should be dismantled already in the schools.

“Psychotherapist Jungle”

Prof. Fischer stresses how difficult the choice of the right first point of contact is. She considers the GP to be a significant pillar in this system because going to him/her does not represent such a great hurdle. In our system, however, GPs often do not have the time to comprehensively deal with the symptoms. In this connection, an experienced psychiatrist plays a big role. Prof. Fischer considers it to be a significant task of the Health Minister to simplify the Psychotherapy Act and to make it more consumer-friendly.

Often patients do not know about the various paths let alone which therapy would be the most suitable in the case of certain illnesses.

In Austria there are very many psychotherapists: however, in order to find one’s way in this “jungle”, the system has to be greatly simplified in her eyes.

Patients have likewise to be given more information about the fact that medication can be very effective. A waiting time which is too long, however, leads to an anxiety spiral with depressive symptoms which extends the length of treatment accordingly. Patients’ scepticism of medication is still very high. An already severely depressed person will not be cured with fresh air. Subsequently finding a place with a therapist is a further hurdle.

Reactions of relatives are often nonetheless understandable, according to Prof. Doering. Great fear is often associated with a suspected diagnosis of one’s own partner, child, etc. Thus, this is often repressed and relatives give simple tips (“Get out into the fresh air and things will be better!”).

Relatives are often asked what changes in life would arise as a result of a diagnosis and whether they themselves could cope with this. “Turning a blind eye” is completely normal and further there is the hurdle of how to communicate such a suspicion.

According to Prof. Doering, many people would need support here. That the relatives are somewhat helpless has to be appreciated.

However, it also has to be possible to talk openly about a change in the behaviour of a person close to us, according to Dr. Wagner. This is also very important considering that many psychiatric phenomena can have physical causes. The person could be asked to have their symptoms checked out since, for example, the thyroid could have an influence on this. In this way most people would see their GP at least once.

Therapy

Prof. Doering explains that, in the case of both anxiety and depressive disorders, medication and psychotherapeutic treatment are the methods of choice.

The indications for psychotherapy in the case of both anxiety disorders and every form of depression can be read in the guidelines. In most cases – with the exception of minor illnesses, such as phobias and mild depression – medication should be administered. According to Prof. Doering, a combination of both should be considered from a certain severity of the disorder.

Prof. Doering in discussion — From left to right: Prof. Gabriele Fischer, Dr. Rudolf Wagner, Gabriele Kuhn and Prof. Stephan Doering.

Prof. Fischer considers the lack of a lobby for psychiatry in Austria to be a fundamental problem. In the case of oncological treatment, there have been great advances in therapy and new methods have been gained as a result of research but in comparison the development of psychiatric medication is depressing. In the last few decades there has been worrying little done in this area. This is made more difficult due to the fact that those concerned are often extremely sceptical about medication.

According to Prof. Fischer, there are potent substances even if the correct active substance has often to be found in the beginning. In this connection, she likes the expression of the “chemical imbalance” of the brain. If this imbalance is corrected with medication, the patient would quickly feel better and this would usually enable the first psychotherapeutic sessions. She calls for appropriate medication to be taken quickly – but also mentions that there are not enough specialists for psychiatry and even less for child and adolescent psychiatry. This situation exists in the cities but is an even greater problem in rural areas. For example, in Styria there is not a single child and adolescent psychiatrist who can offer services free of charge in the health system. She asks herself where is the lobby?

It is common that the relatives of patients have also already had massive mood swings.

Dr. Wagner mentions the third pillar – sociotherapy – to supplement medication and psychotherapy.

Cost factor

As regards cost, Prof. Fischer points to the ongoing imaging debate (in particular that concerning MRI) and speaks of “two-class medicine”. It is also difficult to get an appointment with a specialist in psychiatry within the free medical health care service. For years psychiatry has been a field of expertise with deficiencies. She would desire a similar public discussion as that relating to the fact that something has to change in the field of imaging techniques for the field of psychiatry.

Prof. Doering stresses this as an area which he also considers unsettling. There is not only “two-class medicine” between the rich and the poor but also between mentally and physically sick. It is unacceptable that only a very small portion of patients are fully reimbursed for the costs of a psychotherapist in Austria (approx. 50€/hour). Everyone else has to contribute from 2/3 to 3/4 of the costs for an hour of therapy as the health insurance only reimburse 23€/hour. Prof. Doering wonders if anyone would entertain the idea of proposing similar models for patients with heart problems or diabetics…

That those who find it the hardest to earn money have to pay the greatest part of their therapy costs is a total failure of the government. It is a scandal that no contract has been reached between psychotherapists and social insurers since the early 1990s. The weakest are being discriminated against.

Dr. Wagner argues that there are not enough medical specialists in Vienna but Prof. Fischer vehemently refuted this. In reality the waiting time for an appointment with a psychiatrist who is not private amounts to weeks.

Medication

According to Prof. Fischer, it is undisputed in evidence-based medicine that anti-depressants are effective in the treatment of depression. However, new super-effective substances do not exist due to a lack of financial resources. The medication, however, which is available, would make one addictive in a manner similar to an antihypertensive or insulin.

However, patients often cease to take their medication when they are feeling better. This, if at all, should only be gradually reduced under medical supervision. Often it is necessary to take medication for a long time or even for a lifetime.

Medication has to be be taken for 1-2 weeks until an improvement can be noticed. There are of course substances which have an immediate effect but caution is called for with these. In acute cases these are very important but should always be taken under the supervision of a doctor.

The danger in the treatment of anxiety, according to Prof. Doering, does not lie in anti-depressants ,which are likewise used as the main medication, but rather in the benzodiazepines. These tranquilizers have a wonderful effect but have a great addictive potential (also physically). They should only be taken in case of emergency or for a very short period of time. Psychotherapy also shows its significance here – ultimately medication cannot cure the trigerring conflicts, experiences and patterns.

In this context, Dr. Wagner calls for open patient-doctor communication. Patients should be honest in informing their doctors of what bothers them about a medication in order to find the right class of active substances. This is bound to fail without honest feedback.

Ms. Kuhn wanted to know from the plenum what the the benefits of psychotherapy could be in the case of such an illness.

Prof. Doering explained that it is the basis of any form of psychotherapy to offer help to those concerned to understand themselves better and to deal with difficulties in another manner. Sometimes it is also necessary to turn to one’s childhood.

The focus of behavioural therapy is to practise and act in the present in order to experience something new. In psychoanalytical therapy, the focus is on previous relationships, the reliving of events, whereby the aim is to change behaviour.

According to Prof. Fischer there are various types of suitable psychotherapy for various indicators.

Tips for relatives

Ms. Kuhn points out a society, HPE – “Hilfe für die Angehörigen psychisch Erkrankter” (Help for relatives of those mentally ill), which specifically supports relatives.

According to Dr. Wagner, relatives of those who are ill carry a great burden, at times alone with dramatic situations. He recommends that everyone seek help in HPE. This is an external point of contact which is outwith the family. Relatives continue for too long alone but it is important that they come into contact with others who are not so strongly involved.

seien Angehörige Erkrankter schwer belastet, teilweise mit dramatischen Situationen alleine. Er empfiehlt jedem, sich im Verein HPE Hilfe zu suchen. Dies sei eine „Außenanspielstelle“, die außerhalb der Familie läge. Angehörige würden zu lange in sich bleiben; es sei aber wichtig, mit Personen in Kontakt zu kommen, die nicht so stark involviert seien.

According to Prof. Fischer, the issues are often apportioning blame and helplessness. Parents, in particular, often become exhausted. If the system of care in Austria were improved, this would ease the pressure felt by relatives.

This fascinating talk with the plenum of informed experts was met with very great interest. The Van-Swieten-Saal was filled to the last seat and some even stood during the one and a half hour discussion. Afterwards many took the opportunity to ask the experts questions. The evening ended with some refreshments.

Credits

Image	Title	Author	License
	Kurier Gesundheitstalk: Depression und Angst	Johanna Bickel	CC BY-SA 4.0
	Prof. Doering in discussion	Johanna Bickel	CC BY-SA 4.0