(Focus - Singapore)
In this issue, we turn our focus to one of the most prevalent mental health conditions - Anxiety Disorder.
While it is normal to feel anxious in certain situations, anxiety disorders involve persistent and uncontrollable feelings that can interfere with day-to-day functioning. According to the World Health Organization (WHO), although highly effective treatments for anxiety disorders exist, only about 1 in 4 people in need (27.6%) receive any treatment. This highlights the need for increased awareness, accessibility, and destigmatization of anxiety disorders.
To learn more about the barriers hindering care for anxiety disorders, we have interviewed Dr. Jacob Rajesh a renowned psychiatrist from Singapore who discussed about the challenges associated with managing anxiety disorders across diverse age groups. Dr Rajesh highlighted the role of online supportive communities, along with the impact that family and caregivers can have on positively influencing the mental health of patients.
Dr. Jacob Rajesh is a Senior Consultant Psychiatrist currently serving at Promises Healthcare Pte Ltd, Singapore.
Previously, patients would go to the hospitals in large numbers, queue up to see doctors, and then return home. But with the availability of telemedicine, getting access to healthcare has become easier. This was one of the benefits of the pandemic from a telehealth perspective. So, people are more tech-savvy, and then they are open to talking to doctors online as well, especially for psychiatric conditions when you do not really have to get a medical examination done because a psychiatric assessment is done mainly by talking. They need not be physically present to get help.
What is the common story that you may get from someone who might have an anxiety disorder?
Dr. Rajesh - Anxiety disorder is also known as Generalized Anxiety Disorder (GAD). It is a long-term condition, and the symptoms will be there for at least six months. It starts with anxiety or worry about small things. They find it very difficult to relax and may have muscle tension. Their muscles are always very tight, and they might have difficulty falling asleep because they constantly think a lot and cannot relax their mind. These symptoms will happen for at least six months before we call it an anxiety disorder. Most importantly, it results in functional impairment, and they might find it hard to function at work. Some of them may even become addicted to alcohol to try and reduce their symptoms.
The causes are multifactorial, and usually, they can be genetic factors. If there is a family history of anxiety, the children are at a slightly higher risk of developing it, but there can be other triggers as well, which can be environmental factors or highly stressful situations. The use of alcohol can also be a predisposition to anxiety disorder. So, there are multiple factors, not just one.
We understand that there is a growing interest in complementary and alternative medicine (CAM) therapies for anxiety, such as mindfulness and yoga. Can you comment more on this approach?
Dr. Rajesh - For mild cases of GAD, we usually recommend psychological therapies. From a professional point of view, we ask the patients to see a psychologist who can do some therapies, such as Cognitive Behavioral Therapies (CBT). Regarding mindfulness-based meditation or yoga, we sometimes tell them to download mindfulness-based apps like Headspace or Calm to help them learn some meditation techniques. So, it does help in mild cases, but once the symptoms are quite severe, this may not be enough. They would need to take medication as well and seek professional advice. However, there is no harm in doing mindfulness-based meditation or yoga. It does help for mild cases.
The COVID-19 pandemic has had a profound impact on mental health worldwide [1]. What are the challenges that you encountered while managing anxiety disorder patients during the pandemic?
Dr. Rajesh - The prevalence of anxiety disorders has increased during the COVID pandemic because of multiple reasons, such as the lockdowns, loss of employment, loss of financial income, separation from family members in different countries, fear of getting the virus, and fear of dying. Firstly, all these factors contributed to an increased prevalence of anxiety disorders. Secondly, because of the pandemic, getting access to medical care was also limited, especially during the first few months of the pandemic in 2020, and during the lockdowns, telemedicine was used more often. So, the fear of not getting medical care or the lack of access also contributed to it.
However, it helped us improve telemedicine or telehealth. Previously, patients would go to the hospitals in large numbers, queue up to see doctors, and then return home. But with the availability of telemedicine, getting access to healthcare has become easier. This was one of the benefits of the pandemic from a telehealth perspective. So, people are more tech-savvy, and then they are open to talking to doctors online as well, especially for psychiatric conditions when you do not really have to get a medical examination done because a psychiatric assessment is done mainly by talking. They need not be physically present to get help.
To what extent did online supportive communities play a role during the pandemic?
Dr. Rajesh - Yes, online supportive communities have increased quite a bit over the last few years. We do find that youths generally tend to use more online supportive communities, like Reddit forums, online media, and online support groups. With the pandemic, internet usage and people spending time online have definitely increased. Since the prevalence of these conditions has increased, the number of support groups has also gone up. This is a good outcome because people can seek support.
However, the support that you get online needs to be proper because sometimes we do not want people to get into online support groups and then come up with the negative viewpoint that their condition is very severe and cannot be treated. So, the support needs to be proper and positive.
In practice, I do not see children below the age of 16. So, I cannot comment more on that. Generally, we do not tend to use medication in very young children. But, once they are 11 or 12 years old and their symptoms are quite severe, and if we feel that the medications will be useful, we prescribe them. However, the main treatment goal for children is psychological therapy.
Anxiety disorders can manifest differently across the lifespan [2]. Can you please tell us your treatment approach for patients across different age groups?
Dr. Rajesh - In children, it can manifest as a refusal to go to school. The child can be very anxious. It can also manifest as physical symptoms like aches and pains since they cannot express their symptoms psychologically, so it can manifest physically. So, we do not usually give medications to children. We provide counseling services and get the family, teachers, and the school involved in the treatment plan for young kids. For adults, depending upon the symptoms, severity, and impairment in function, they will require medication as well as psychological therapy.
In the elderly, we tend to use lower doses of medication because they are more prone to side effects, and they also may have underlying medical conditions. So, we have to be cautious about using psychiatric drugs in them. But again, depending on the severity of symptoms, the impairment, and functioning, we may prescribe them medications at a lower dose.
How do you perceive the evolving landscape of anxiety treatment in pediatric and geriatric populations?
Dr. Rajesh - Some of the medications that we use are vortioxetine, which is a new antidepressant and has good effects on anxiety disorder as well. We also have medications like pregabalin and buspirone.
In practice, I do not see children below the age of 16. So, I cannot comment more on that. Generally, we do not tend to use medication in very young children. But, once they are 11 or 12 years old and their symptoms are quite severe, and if we feel that the medications will be useful, we prescribe them. However, the main treatment goal for children is psychological therapy.
For the geriatric population, yes, we do use medications. But as I said, we need to use medications at a lower dose because they are more prone to side effects, and they also have underlying medical conditions for which they will be on multiple medications. So, psychiatric drugs and other medicines can interact and can cause more side effects. Hence, we are cautious. We do have new antidepressants or anti-anxiety medications that we use in the elderly.
Anxiety and depression are highly comorbid with each other [3]. What are the challenges in differentiating between symptoms of anxiety and depression, especially when they overlap?
Dr. Rajesh - If you go back 20 to 30 years, people used to think that anxiety and depression are two separate disorders. But in fact, there is a lot of overlap. So, you may find somebody with major depression having a lot of anxiety symptoms. You may find people with anxiety disorders having depressive symptoms. There is a category which is known as mixed anxiety depressive disorder in ICD 11, which is the WHO classification system for mental disorders. The condition is well defined, and people can suffer from both.
We are now trying not to delineate each separately. We assess the symptoms of both anxiety and depression, and the treatments or medications that we use commonly address both depression and anxiety. So, it works for both because the mechanism of action is similar that they usually work on serotonin.
Most of the psychiatric medications for depression also help in addressing anxiety. Newer medications, like vortioxetine and escitalopram, especially help address both conditions. We have selective medications, just to help with anxiety, like benzodiazepines, but we do not use them long term because there is a risk of addiction and tolerance, but they work very well. Since they work very well, people tend to overuse them, and they can become addicted. So, we go for medications that have the least risk of addiction.
Does this overlap impact the diagnosis and treatment decision of the doctor?
Dr. Rajesh - If the patient primarily has major depression with not a lot of anxiety, then the treatments can last for a year. But if they have frequent episodes, we must treat them long-term. If somebody predominantly has anxiety and not much depression, then we give medication depending on the severity and psychological therapy. We also provide psychological therapy for depression. However, treatment duration is generally similar for both unless the episodes are very severe or they have multiple episodes over the lifespan.
Could you elaborate more on the integrated or specialized treatment approaches designed to address both anxiety and depression simultaneously?
Dr. Rajesh - Most of the psychiatric medications for depression also help in addressing anxiety. Newer medications, like vortioxetine and escitalopram, especially help address both conditions.
We have selective medications, just to help with anxiety, like benzodiazepines, but we do not use them long term because there is a risk of addiction and tolerance, but they work very well. Since they work very well, people tend to overuse them, and they can become addicted. So, we go for medications that have the least risk of addiction.
What research or development in the field of anxiety disorder treatment is on the horizon?
Dr. Rajesh - Scientists are trying to find specific receptors or neurotransmitters in the brain that are linked to the presence of anxiety. Therefore, they are also looking at specific drugs or medications targeting these specific receptors or neurotransmitters. But again, it's not an easy task. It is very complex because the brain is a complex body part. Different pathways and different transmitters are working in different ways. They are also looking into genetic factors like specific genes or locations of genes, but it's a work in progress. There is no solution or answer so far.
With regards to brain stimulation methods, we generally do not use them for anxiety disorders. We use it for other conditions like major depression, where the patient doesn't respond to antidepressants. We don't usually use brain stimulation like TMS for anxiety.
How can individuals with anxiety disorders effectively manage their condition, and what advice or guidance would you offer them?
Dr. Rajesh - Somebody who has severe symptoms causing impairment in functioning will need to see a professional psychiatrist who can prescribe medications after making a diagnosis, and they also need to receive psychological therapy to address their symptoms. Family support and family therapy is also quite important. The family members need to understand what the patient is going through. We all work together: the psychiatrist, psychologist, the families, and the patients who are going through this condition.
Thank you for sharing your valuable insights!
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