I’m writing up the discussion of my dissertation and one of the things that has popped up (in a couple of the highest quality studies) is that in people with OA of the knee, clinical levels of anxiety are much more prevalent than clinical levels of depression. Yet for some reason the vast majority of the academic literature focuses on depression.

So my question is – how difficult it is to differentiate between the two conditions when making a diagnosis?

I’m thinking about going down the lines of – focus on integrating anxiety management into the physio rehab of oa knees and ensure that what appears to be depression is in fact depression.

So my question is – how difficult it is to differentiate between the two conditions when making a diagnosis?

Back to the literature I guess.

I know what the literature says, but i was wanting an insight into what the real world thinks.

i was wanting an insight into what the real world thinks.

…and your first thought was to post on STW… 😯

🙂

Yes – because it has proved to be very helpful in the past few weeks with questions like this.

you could start by explaining what OA is 🙂

are we talking true diagnosis or ‘he’s a bit anxious/depressed’? as a true mental health diagnosis should be based on the fact the depression or anxiety is stopping the patient from leading a ‘normal’ life IME

I was wanting an insight into what the real world thinks

I’d be taking my lead from the peer reviewed literature.

Edit: Or for the informed amateur view I’d be contacting TJ and SFB.

True diagnosis.

Having suffered anxiety and depression they are clearly two separate conditions… For me treating the anxiety was the main issue as that was controlling/destroying my life more and causing the depression to get worse

ok, in that case its not very difficult to differentiate between the two conditions, although in the real world its pretty normal to find patients suffering with a mix of the two. depression seems to naturally lead onto various anxiety problems, and anxiety when not managed tends to lead to depression.

depression is quite often misdiagnosed by GP’s and other doctors, the way it is assessed it pretty poor IMHO and its very frustrating for the mental health services to be stuck with clients who aren’t depressed but because the GP said they might be and threw some antidepressants at them…. they then moulded their life around their new diagnosis and adopted the life of an unwell person… usually pushing them slowly towards true depression.

anxiety is harder to misdiagnose i think but its often thrown in to the mix with depression, i think its because a lot of the symptoms of depression can be mistaken for anxiety (not wanting to leave the house , be in busy places with friends etc)…. once you’re on anxiolytics they’re hard to get off and reducing them can sometimes cause anxiety.

sorry for rambling

Anxiety and depression not infrequently coexist and feed each other.

It’s more complex than this, but to my mind the defining features of depression are loss of interest in usual activities and feeling you have nothing to look forward to (another way to put these two is as a profound loss of motivation). The defining features of anxiety are apprehension (panic) and consequent avoidance of usual activities. So they are different.

If a GP prescribes an antidepressant (SSRI, etc), whether for anxiety or depression, they have to use the PHQ-9 or they don’t get paid. I wonder if this is why it’s always “there’s an association between depression and condition of interest”, rather than anxiety and condition of interest. The PHQ-9 is used to assess depression severity and isn’t great for that in my experience. As a tool for assessing anxiety it is useless.

depression is quite often misdiagnosed by GP’s and other doctors, the way it is assessed it pretty poor IMHO and its very frustrating for the mental health services to be stuck with clients who aren’t depressed but because the GP said they might be and threw some antidepressants at them…. they then moulded their life around their new diagnosis and adopted the life of an unwell person… usually pushing them slowly towards true depression.

Agreed (as alluded to above), but this is mostly about extremely poor access to other treatment options + a patient who feels desperate + varying opinions over what “depression” actually means.

good post bonjye 🙂

it’d help if GP’s made the clear point that taking antidepressants is meant to be an everyday thing, not (and it never fails to annoy me) like when i overhear people day ‘having a bit of a blue day today so i popped a couple of those tablets the doctor gave me, feeling better already’

i’m probably making a wild assumption here but is OA osteoarthritis?

if so could you explain a little more as to what sort of anxiety you’re discussing glumpton? 🙂

Thanks philconsequence!

it’d help if GP’s made the clear point that taking antidepressants is meant to be an everyday thing, not (and it never fails to annoy me) like when i overhear people day ‘having a bit of a blue day today so i popped a couple of those tablets the doctor gave me, feeling better already’

I am a GP and I always stress that point. Nevertheless, it is amazing just how many patients completely ignore what I say 🙂

I’m also presuming OA is osteoarthritis, don’t know it as an abbreviation for anything else.

if so could you explain a little more as to what sort of anxiety you’re discussing glumpton?

Yes, are we talking generalised or situational (fear-avoidance)?

OA is indeed osteoarthritis.

There is a body of research that shows a link between depression and poor outcomes with OA knees. But what I think I’m seeing is a lot of misdiagnosed anxiety. The factors that are being classified as depressive symptoms are low exercise, activity avoidance, pain avoidance, low adherance to medication, etc etc etc. Yes they could all be signs of depressive illness, but equally they could be related to anxiety – thinking that exercise will make things worse so avoiding it, worried about becoming addicted to medication, worried that they wont cope with pain, fear avoidance behaviour etc etc etc. It’s a subtle difference, but I think it could have a fairly big implication.

the general public eh?!

doesn’t matter what the demographic.. patients, especially when armed with second hand info from a neighbour, mate or the internet always know better than the people trained in helping them 🙄

reactive depression is something that might be worth looking into glumpton as the loss of good use of a knee, even though its not the loss of a loved one can still be traumatic. reactive depression is usually transitional and the treatment is in an ideal world, short term.

EDIT, posted that in reply to bonvye.

unfortunately i’m not going to be much help with the OA side of things, but i can relate to the anxiety type symptoms you mention with regards to ankylosing spondylitis. being reflective it’d be easy to see them as anxieties, but i think with me its trying to slow the deterioration. granted thats a sample of 1 but what others see as anxieties I see as a long term management plan.

One of the problems I have is that if I pipe up with “sod the depression it’s anxiety we should be treating” line i’m going to be pissing on a lot of people’s chips.

There is a body of research that shows a link between depression and poor outcomes with OA knees. But what I think I’m seeing is a lot of misdiagnosed anxiety.

Suspect the devil may be found in the detail – how exactly has “depression” been diagnosed in the research? Does it say? Can you find any further research that links the test that has been used to the diagnosis of anxiety?

the general public eh?!

I know, but then healthcare professionals are the worst patients of all! 🙂

One of the problems I have is that if I pipe up with “sod the depression it’s anxiety we should be treating” line i’m going to be pissing on a lot of people’s chips.

Not necessarily a bad thing. Whose chips?

piss on their chips then 😀

treat the anxiety and associated depression tends to lift a bit IME.

ummm, a bit left field but is it worth looking into the work the army does with injured soldiers getting them going again with physio etc, i’d hazard a guess they were scared of doing stuff to begin with and probably/understandably a bit depressed?

Supervisors chips, their bosses chips, their research groups chips. Lots of chips.

word it in such a way that doesn’t say the chips are being pissed on, but that there might be new chips to consider?

now i’m hungry for chips.

When I had anxiety disorder my mind and body used to way overreact to what you’d now call normal stressors.

Anxiety for me was a fear of these feelings (bodily and mentally) and I would do everything I could to not experience them. Avoidance, meditation, CBT, docs, deep breathing, researching, chat forums support. But this fearful behaviour only fuelled the fear and only by stopping the behaviour and letting the anxiety run its course did I recover.

Although my GP was very nice to me she didn’t help me rid of the anxiety. I luckily came across a couple of books that exsufferers had written.

xcracer… interesting experience! know somebody going through some pretty intensive psychosexual counselling and she had to ride out the anxiety (pun not intended!), been a very successful approach apparently.

Many people who are depressed have some anxiety and vice versa. It’s a Venn diagram thing really.

The PHQ9 and the GAD7 (the anxiety equivalent) are blunt tools and most of us GPs don’t like being forced to use them. Blame NICE and the DoH.

There is a huge body of work on depression in Chronic Illnesses of all sorts. For many it seems about hopelessness and loss of control, and this feeds the perception of pain and disability.

I am guessing you are the man who was SBZ etc etc. A therapist might be initially confronted by an immediate fear reaction to being asked to do things, but I’d guess it is the negative depressive cognitive mindset which has more effects on the OA sufferer’s life. May well be wrong. Anxiety may be more common, but that doesn’t mean it is more disabling…

And in any case – how does the treatment really differ where there is not a specific phobic element…?

SSRIs and/or CBT for depression and…. SSRIs and/or CBT for anxiety….

Questioning of orthodoxy is good, but isn’t a bit premature to be thinking that, a) your theory is correct, b) you are going to do quality work in a dissertation which will alter everyone’s view and cause such a paradigm shift that everyone has a urine/potato interface problem? 😉

There is a huge body of work on depression and chronic illness, there is however an emerging body of work which is finding that there are avoidance models of behaviour and that anxiety alone is between 2 and 6 times more prevalent than depression alone, and that anxiety and depression together is smaller than anxiety alone. This is from fairly big cohorts 10000 and 6000 respectively.

Prevalence doesn’t mean impact. There are more ingrowing toenails than heart attacks.

You need to show that, beyond an academic model, anxiety does alter pain/behaviour as much as depression, and that treatment of it alters the outcome.

Care to address the other points? 😉

My wife has just passed her PHD in “a clinical study of osteoarthritis pain transmission using cerebral spinal fluid” she covered off anxiety and depression – if you think she could help let me know

This is what I’ve come up with as “findings”:
Evidence suggests:
A link between knee instability and fear, and levels of pain and function,
An inverse relationship between depression scores and daily step count,
Depression contributes as much as physical damage to measures of self assessed disability, pain and function,
Depression leads to decreased muscle strength via avoidance,
OA pain determines depressed mood via fatigue and disability,
Increased anxiety leads to poorer function,
Anxiety has a greater impact on function than depression
and
Depression has no apparent link to functional ability in people with OA of the knee.

Just need to discuss that lot now.

I have had anxiety since I was a teen, and had at breakdown at 27 with a diagnosis saying I also had depression. I treated it with CBT and medication, group sessions and exercise. This year (now 31) I came off my bike and messed my leg up, I couldn’t ride or box for a month or so and I felt like absolute shit, doctor sent me for counselling again and I recognised the signs I was becoming depressed as a result of not exercising. My anxiety levels were getting high and I wasn’t leaving the house, just lying in bed waiting for the constant fear to pass or I got so worried I passed out. Built myself back up mentally and keep that anxiety locked away with my cycling and boxing. I don’t know if that info is of any help but think there may be some relevance so posted.

Good luck with your studies OP.