Interviews of Prof. Iqbal

In an interview with Medical News, Dr Afridi has discussed various aspects of anxiety and depression which are among the most prevalent psychiatric disorders in the country. Excerpts from the interview are as follows. Q: How can psychiatric disorders be prevented? A. There are hardly 360 qualified psychiatrists in Pakistan for a huge population of 160 million, and if we want to defeat psychiatric illness this number is insufficient Therefore, strategies should be developed to prevent psychiatric illnesses. There is lot of room to improve the mental health of the people by prevention. If we adopt a healthy lifestyle where we maintain a good ratio between sleep, work, meal, exercise, pray and recreational activities, we can prevent many illnesses. At the same time, if we encourage our kids, because it has been observed that the kids are not encouraged to express their feelings, they are given punishments in schools and home and are not encouraged: so, most of them have fearfulness and anxiety in examination and public speaking. If we develop a healthy society in which we encourage each other and avoid highlighting the weaknesses of others and appreciate their efforts, most of the anxiety can be prevented. Q Why did you opt for a career in psychiatry? A: I was very good at surgery and wanted to become a surgeon, but when I saw the situation in Pakistan. I realized that the surgeons and physicians are in sufficient number and our country needs psychiatrists, so I opted for this specialty. Q: What would be your advice to the young doctors willing to pursue their career in psychiatry? A In the near future, you would see that the scope of psychiatry would be at the top In our country. most of our talent goes to medicine and surgery: I think it is irrational. Each and every speciality and profession has its own importance. Psychiatry, though it has been stigmatized, is a very good field Psychology and psychiatry help to better understand sell family, friends, organization and society. Q: What would be your advice to the young doctors willing to pursue their career in psychiatry? A: In the near future, you would see that the scope of psychiatry would be at the top. In our country, most of our talent goes to medicine and surgery: I think it is irrational. Each and every speciality and profession has its own importance. Psychiatry, though it has been stigmatized, is a very good field. Psychology and psychiatry help to better understand self, family, friends, organization and society. Q: What would be your advice to the General Practitioners (GPs) regarding diagnosis and management of anxiety and depression? A: The GPs should have some training, or read booklets, as the undergraduate training is not up to the mark. They should at least know few drugs with good profile, their side effects and how to start and how to taper off. They should not be afraid of treating psychiatric patients, treating anxiety and depression is as simple as treating any other common disease. Q: Would you like to give any comment or message apart from this question-answer series? A. Yes, my message is that psychiatric disorders are like any other illnesses of the body and we should not stigmatize these illnesses. Let us join hands in order to detect, prevent, treat and defeat psychiatric disorders in order to achieve good mental health which is the social capital of our country. Psychiatric disorders are like other illnesses of the body and we should not stigmatize these illnesses: Dr Iqbal Afridi Medical News (MN): What is depression? Dr Iqbal Afridi (IA): Depression is a common phenomenon which may occur in any individual; while depressive disorder is an emotional disorder characterized by sadness, pessimistic ideation, loss of interest, lack of enjoyment, disturbance of sleep and appetite; which last for at least 2 weeks. MN: How to differentiate between physiological and pathological depression? IA: There are normal swings of moods; if somebody appreciates one becomes happy; conversely in the case of an adverse life event one gets depressed; it is depression; not a depressive disorder. In depressive disorder, there is persistent sadness, low energy, lack of enjoyment with pessimistic ideation, which lasts for at least 2 weeks accompanied with disturbance of performance. The patient in depressive disorder would lose interest in all the activities he used to enjoy earlier. MN: What is anxiety? IA: Anxiety is a universal phenomenon. It is like pain in surgery, everybody must have experienced pain; similarly, everybody must have experienced anxiety. Anxiety is a normal phenomenon. Normal anxiety is the one in which there is worry about a known danger; for example if someone is appearing in the examinations, he/she may have anxiety i.e. apprehension, worries, tremors and dryness of mouth. These are conditions reflecting anxiety, but it is not pathological anxiety. Pathological anxiety, according to Freud, is worries about a perceived danger yet to be discovered. There are five criteria for pathological anxiety i.e. increased intensity, duration, irrational, disturbance of performance, and if the person is unable to get rid of it despite efforts. Everybody must have experienced anxiety. For example while appearing in interview. An optimal level of anxiety is useful and leads to good performance but pathological anxiety leads to poor performance. MN: What are the different types of anxiety? IA: Anxiety is manifestation of disorders that are classified into Generalized Anxiety Disorder (GAD), Panic Disorder, Obsessive Compulsive Disorder (OCD), Post Traumatic Stress Disorder (PTSD) and Phobias; others include Acute Stress Disorder and Adjustment Disorder. In Generalized Anxiety Disorder, there are pointless worries about various domains of life; and to be classified as GAD, the symptoms should be persistent and lasting for at least 6 months. In Phobic Anxiety, there is irrational fear. Lizard phobia is very common in our society. Agoraphobia is intense fear in closed space or crowd. Panic Disorder is characterized by intense episodic anxiety which lasts for few minutes to half an hour and the person may feel that he is having heart attack, respiratory failure or he will become mad or die. In Obsessive Compulsive Disorder (OCD), the patient has repeated ideas coming to his mind that he can not get rid of despite efforts. Post-Traumatic Stress Disorder is the anxiety that starts after catastrophic stressful event which is beyond the experience of a normal human being, e.g. earth quake, rape, severe road traffic accident, robbery, bomb explosion, genocide etc. MN: What are the different types of depression? IA: Depression may be classified in a number of ways, according to severity, like mild, moderate and severe; according to the course and time, for example Unipolar, Biopolar, Seasonal, Affective, Involutional and Senile Depression; and according to the etiology, for example Exogenous (reactive) and Endogenous, Primary and Secondary Depression. In exogenous or reactive depression, the patient would have stressful and adverse circumstances that would lead to depression, for example death of spouse, separation etc; while in endogenous depression, there is no obvious external factor; rather the decrease in the serotonin level in brain is responsible. In unipolar depression there is no episode of mania, while in bipolar depression the patient has episodes of depression and mania and the person would exhibit symptoms opposite to depression (mania), like elation, happiness, talkativeness that would last for at least a week; and, on the other hand, he would have symptoms of depression. MN: What are the signs and symptoms of anxiety and depression? IA: The signs and symptoms may be divided into psychological and physical. Psychological signs and symptoms in anxiety include apprehension, worry and lack of concentration while the physical signs and symptoms include tremors, piloerection, sweating, tachypnia, shortness of breath, hypotension, excessive urination and dryness of mouth. The signs and symptoms of depression include persistent sadness, low mood, decreased energy level, loss of interested and enjoyment, pessimistic ideation, disturbance of sleep and appetite and loss of concentration. Vague bodily symptoms like indigestion etc may also be there. MN: Tell us about the pathophysiology of anxiety and depression. IA: If we look at the pathophysiology of anxiety, the activity of adrenalin system and hypothalamic-pituitary-adrenal axis (HPA) is increased resulting in increased ketecholamin from suprarenal gland and the serotonin is also involved. The availability of serotonin, dopamine and norepinephrine are directly linked with depression. Decreased availability of norepinephrine is more related to anxiety and that of serotonin to depression. The activity of the neurotransmitters is interlinked and individual neurotransmitter cannot be pointed out, however, the decreased availability of serotonin at the synaptic cleft has been associated with depressive disorders. MN: What are the different types of drugs used for the treatment of anxiety and depression and what is the rationale behind their selection? IA: There are various classifications of psychotropic drugs, for example anxiolytic, antidepressants, antipsychotics, mood stabilizers etc. Antidepressants are neither minor tranquilizers nor major tranquilizers despite the fact that they may have sedative properties; therefore they are not habit-forming drugs. Anxiolytic drugs primarily act on the GABA system, GABA is the break system of the brain. Anxiolytic can be divided into benzodiazepine, beta blockers and minor dose of antipsychotics and antidepressants can also act as an anxiolytic. There are also non-benzodiazepine anxiolytics like buspirone which are non-tranquilizer and non habit forming. The commonly used drugs for anxiety are lorazepam, bromazepam, oxazepam, chlorodiapoxide, propranolol and paroxetine. Antidepressants are classified into tricyclic, tetracyclic, SSRI, SnRI. Monoamine Oxidase Inhibitors (MOA) were used previously but are obsolete now. Anxiety and depression are common conditions and some authors consider them as two sides of a single coin. Anxiety and depression co-existence is very common and is found in more than 67% of the patients. Paroxetine is a good drug for the situation where anxiety and depression coexist, while other options include chlomipramine from tricyclic group, and venlafaxine from the SnRI group. The selection of drug is based upon its properties and the signs and symptoms of the patient. If the patient is having sleep disturbance, we would opt for such drug which has sedative property; conversely if the patient is having excessive sleep we would select a drug with stimulating property. For example if we talk about antidepressants, fluoxetine is always given in the morning because it disturbs sleeps and has a stimulant effect, while fluvoxamine has sedative property. Similarly, among the anxiolytics, the most sedative is diazepam and has a long life and bromazepam is less sedative, lorazepam is also very sedative. In the case of obsessive compulsive disorder (OCD) we select such a drug which primarily has a serotonin effect, like among tricyclic clomipramine is the drug of choice, while among SSRI, fluoxetine, paroxetine, fluvoxamine and sertralin can be given. If sedation is required, fluvoxamine can be given; if there is anxiety predominant with obsessions, paroxetine is a good choice; if someone is having cardiac problem and increased weight we will prefer sertralin (as it decreases weight). In panic disorder, paroxetine is a very good choice; tricyclic antidepressants are very useful; and among anxiolytics, chlonazepam and alprazolam are the drugs of choice. But anxiolytics should not be given beyond six weeks. Apart from the medication, the people should be advised about exercise, balanced diet, and psychotherapy should also be considered. In case of depression, the general practitioner should always start with a tricyclic unless there is a contraindication, if the patient is young has no cardiac or prostatic problem and glaucoma, then they should be given imipramine or amitriptyline. But these should be avoided if the patient has to take exam or drive. Although, tricyclic antidepressants has good efficacy but the side-effect profile is poor and that is why SSRIs are preferred. MN: What is the prognosis of anxiety and depression? IA: The prognosis of anxiety and depression is very good and is comparable with any other medical disorder. MN: How can psychiatric disorders be prevented? IA: There are hardly 360 qualified psychiatrists in Pakistan for a huge population of 160 million, and if we want to defeat psychiatric illness this number is insufficient. Therefore, strategies should be developed to prevent psychiatric illnesses. There is lot of room to improve the mental health of the people by prevention. If we adopt a healthy lifestyle where we maintain a good ratio between sleep, work, meal, exercise, pray and recreational activities, we can prevent many illnesses. At the same time, if we encourage our kids, because it has been observed that the kids are not encouraged to express their feelings, they are given punishments in schools and home and are not encouraged; so, most of them have fearfulness and anxiety in examination and public speaking. If we develop a healthy society in which we encourage each other and avoid highlighting the weaknesses of others and appreciate their efforts, most of the anxiety can be prevented. MN: Why did you opt for a career in psychiatry? IA: I was very good at surgery and wanted to become a surgeon, but when I saw the situation in Pakistan , I realized that the surgeons and physicians are in sufficient number and our country needs psychiatrists, so I opted for this specialty. MN: What would be your advice to the young doctors willing to pursue their career in psychiatry? IA: In the near future, you would see that the scope of psychiatry would be at the top. In our country, most of our talent goes to medicine and surgery; I think it is irrational. Each and every speciality and profession has its own importance. Psychiatry, though it has been stigmatized, is a very good field. Psychology and psychiatry help to better understand self, family, friends, organization and society. MN: What would be your advice to the General Practitioners (GPs) regarding diagnosis and management of anxiety and depression? IA: The GPs should have some training, or read booklets, as the undergraduate training is not up to the mark. They should at least know few drugs with good profile, their side effects and how to start and how to taper off. They should not be afraid of treating psychiatric patients; treating anxiety and depression is as simple as treating any other common disease. MN: Would you like to give any comment or message apart from this question-answer series? IA: Yes, my message is that psychiatric disorders are like any other illnesses of the body and we should not stigmatize these illnesses. Let us join hands in order to detect, prevent, treat and defeat psychiatric disorders in order to achieve good mental health which is the social capital of our country. RetweetShare