Why should we worry about anxiety disorder? Perhaps because it is so common; or maybe because it can be so disabling for those that experience it; or even because it is so often the harbinger of another mental health difficulty. Although all of the above would be reason enough perhaps, there is another more pressing reason to take the problem of anxiety disorder very seriously.
It is this; the prevalence of anxiety disorder appears to be increasing, at least in our young people.
Anxiety disorders are already very common. More than four percent of people have generalised anxiety disorder and a similar number have Panic/Agoraphobia or other Phobic disorders, Post-Traumatic Stress disorders (PTSD), Somatoform (Conversion) Disorders and Obsessive Compulsive Disorders (OCD). Taken together the prevalence of these anxious mental health difficulties appears even higher. Common mental health disorders affect at least one in six of the population and this prevalence is even higher amongst users of primary care services. Nearly one third of patients in general practice have a mental health component to their presentation. This primary care component is most commonly with anxiety, depression and/or substance misuse.
Many people have more than one anxiety problem. More than two-thirds have three or more. The presentation of anxiety disorder may be multi-layered and complex. The commonest co-morbidity is with another anxiety disorder.
Secondary problems with depression and substance abuse are also typical. While those presenting with depression are likely to be recognised as such, a person presenting with anxiety symptoms may not be. The evidence suggests that anxiety symptoms are more likely to be dismissed or passed off with some kind of reassurance.
So is the problem of mental health disorder really more common today?
The evidence is not straightforward. For many mental health problems often referred to as major mental health disorders such as Schizophrenia, Bipolar Mood Disorder, Psychosis and even Autism, there is no evidence of change in prevalence. These problems do not appear to be rising in our society or in our time. However, Anxiety Disorders, Post-Traumatic Stress Disorders and substance misuse disorders do appear to be increasing. This increase is likely to be a huge mental health challenge.
These data come from the UK Office of National Statistics and they are taken from the ‘Adult Psychiatric Morbidity Survey’ published in 2016. They have been highlighted recently by Professor Sir Simon Wessley, President of the Royal College of Psychiatrists in London who has described them as ‘worrying trends’. This increasing level is “mainly in anxiety disorders, in young women - 19% in 1993 to 26% in 2014. Compared to the much smaller changes in men (8% in 1993 to 9.1% in 2014), this means the gender gap has widened significantly”.
We could try to ignore these problems by pretending that a different reality exists in Ireland but unfortunately the facts speak for themselves. An impressive data set produced by Mary Cannon and Helen Coughlin and others at the Royal College of Surgeons in Ireland (RCSI) has confirmed that the mental health needs of our young people are some of the highest in Western Europe. It is no use trying to ignore these data any longer.
Let’s start by putting these statistics into more human terms. The real problem is that people experiencing clinically significant degrees of anxiety and other common mental health problems are more likely to persist in distress or at least relapse without treatment unless effective care is offered. Many people wait for years before presenting for effective treatment. The consequences for lives lost through avoidance, depression, substance misuse and suicide are very large.
So what is the answer for us today? Is Ireland’s national mental health strategy ‘A Vision for Change’ (2006) fit to address this challenge? In short ‘A Vision’ proposes a community care model of mental health service with close integration between primary care and secondary mental health care. This Vision anticipates that most common mental health problems will be treated in the community and also that specialised services will be provided to meet such demand. The reality acknowledged by the subsequent implementation group is that the delivery of this vision has been patchy at best. Difficulties with funding are often cited but the problems with ‘A Vision…’ go much further than that.
Today’s mental health challenges are complex and they are in a community; a community that is already over stretched. The problems include increasingly unmet needs for those at the extremes of the life span as well as some unforeseen problems for many in between. Most mental health problems arise before the age of 25 and yet our children’s mental health services still lag far behind service levels proposed by ‘A Vision..’. In today’s 21st century Ireland the mental health needs of our young people are not being adequately addressed. This does not bode well for the future. The increase in anxiety, substance misuse and suicide that has occurred in our country is mostly in the young and this is neither anticipated by our national strategy nor provided for by our current policy.
How could Vision’s authors, (‘the expert group’), have got it so wrong? It seems ironic that a document whose ambition was to see into the future actually failed to anticipate that future by such a margin. Perhaps this failure is understandable. The mindset of ‘A Vision…’ was actually about the major mental health disorders and this mindset was unchanged since its parent document entitled ‘Planning for the future’ was published in the 1980’s. The assumption was that most of the minor disorders would simply be managed more cheaply in the community. To paraphrase George Orwell their ideological position was ‘Community Care Good; Asylum Care Bad’. Unfortunately, nothing in mental healthcare is that simple. There is more to good community care than the relocation of the asylum into the community. A community care service that is disconnected, demoralised and underfunded may also be bad.
No one wishes to be critical of Vision’s authors. They were sincerely dedicated to the completion of the largest 20th century mental health project of all: the closure of our shameful 19th century asylum system. This closure project was necessary, but hasn’t the time has come to acknowledge this project is over? There is a need for a new national mental health project.
21st century Ireland urgently needs a modern mental healthcare system. To be effective this modern system must be data driven, human rights based and integrated right across the community, with appropriate services ranging from primary care, secondary care and onwards if required to tertiary care.
Is this too much to ask? Surely not! A modern mental healthcare system would be a great psychological and economic boost for our country. It could provide Ireland with a stepped response to our current mental health problems; Step One for those at the lower end of complexity would be met entirely in the community, rising to Step Four for those with the most complex and challenging problems whose needs will require more integrated care. Examples of such stepped care models for anxiety disorders (as well as many other common mental health problems) have been described by the National Institute for Clinical Excellence NICE and by others elsewhere.
A 21st century response to the management of anxiety disorder, substance misuse and other common mental health difficulties in Ireland could meet the needs of the whole community by developing better integrated multidisciplinary care. Creating this new better connected health service will require more than a new vision; it will require a renewed desire to make it a reality. Isn’t it time for us to acknowledge that the service we need today has not been achieved by simply relocating the asylum? Providing a meaningful modern and effective mental health service is about more than the closure of the discredited system of the past. It is about responding meaningfully to the changing needs of the present day.
Prof. Jim Lucey, Medical Director
If you wish to have more information about mental health services in your locality, why not talk to our dedicated staff at our free information and support line at www.stpatricks.ie or call (01) 2493 333.
Some references for this blog are found below:
UK Statistics 2016 quoted by Professor Wessley http://www.huffingtonpost.co.uk/professor-sir-simon-wessely/
The Mental Health of Young People in Ireland: a report of the Psychiatric Epidemiology Research across the Lifespan (PERL) Group Dublin: (2013) Cannon M, Coughlan H, Clarke M, Harley M & Kelleher I. Royal College of Surgeons in Ireland
A stepped programme for the management of generalised anxiety disorders https://www.nice.org.uk/guidance/cg113/chapter/1-Guidance#stepped-care-for-people-with-gad
Anxiety is a normal phenomenon
No species can survive without a warning system which anticipates and helps to respond to hazards and threats. When we are anxious we become more alert, we prepare and get ready. We anticipate danger. This anticipatory anxiety is associated with increased heart rate, increased breathing and increased sweating.
When do Anxiety Disorders occur?
Anxiety Disorders occur when our anxiety is disproportionate. Anticipation disables us; because of anxiety disorder we lose the ability to live independently, to work productively or to relate to others socially.
What are the symptoms of panic attacks?
Symptoms of Panic attacks include:
- Pounding heart and Chest pain
- Sweating /Chills or hot flushes
- Dizziness, light-headedness
- Paraesthesias Trembling or shaking
- Abdominal distress
- Derealization or depersonalization
- Fear of losing control / Fear of going crazy or dying
- Shortness of breath or smothering /Choking feelings
Disabling crescendos of anxiety are called Panic attacks. Anxiety symptoms leading to avoidance of situations are called Phobias. Unwelcome intrusive anxiety provoking ideas thoughts and images are called obsessions; and repetitive behaviours carried out in a ritual fashion in response to stress of obsessive anxiety are called compulsions.
Anxiety Disorder Facts
The age at onset of anxiety disorder is between 25-35; the Female : Male ratio is 3: 1.
10% people have had occasional panic attacks and 2% have Panic Disorder.
50% of Panic Disorder sufferers have at least one other anxiety disorder and 50% of Panic Disorder sufferers develop depressive disorder. Up to 40% of Relatives of Panic Disorder develop Panic Disorder.
Women with Panic Disorder are more likely to experience breathing difficulties and faintness with panic attacks. Women report more symptoms of panic disorder than men and they are three times more likely to relapse in the long term than men.
The majority of women with Panic disorder have panic with agoraphobia whereas men are more likely to have isolated Panic Disorder. Alcohol misuse is more common in men with Panic Disorder Agoraphobia than in women. The causes of anxiety disorder are multi-factorial. Childhood trauma is a significant risk factor.
In panic disorder 24% of people will develop a major depression within 5 years and 50% in a lifetime. People with Panic Disorder are 20 times more likely to die by suicide than the healthy population
Less than 40% of people with an anxiety disorder receive professional treatment. For anxiety disorders, there is a delay in presentation ranging from nine to 23 years. Along the way many people with phobic anxiety or panic disorder can become depressed or develop alcoholism.
Unfortunately, stigmatic beliefs about people with anxiety disorders are common. These say people with anxiety disorders are just worriers who should pull themselves together. The reality is very different.
Anxiety Disorders are the commonest mental health problems presenting to general practice. They are the most treatable of mental health disorders and none of the treatments requires rare expertise or extremely costly interventions.
Recovery requires brain change; this means new learning, new thinking and new behaviours. The great psychiatrist (Nobel Prize winner) Eric Kandel teaches us that all recovery involves the person and the brain. This is because all mental processes derive from operations of the brain.
Anxiety symptoms and depression arise from both genetic and environmental factors. Roughly 30% of the contributing factors for the development of anxiety disorder come from genetic pathways, while the remaining factors come from environmental pathways.
Our genes determine the pattern of neuron (brain) interconnections. Learning of functional or dysfunctional behaviours alters gene expression. Gene expression promotes the production of proteins which control our behaviour by building the pattern of brain connections and strengthening them.
Effective psychotherapy changes behaviour through learning; and learning changes gene expression leading to renewed strength of synaptic brain connections.
Our genes have the capacity to facilitate recovery, by making and strengthening the connections our brains need to promote positive behaviours. Far from being a fixed bar code which only limits our hope of recovery, genes are the source of our best hope. All that is necessary is that we learn the recovery behaviours which switch our genes on.
Prof Jim Lucey
Prof. Jim Lucey was Medical Director of St Patrick’s Mental Health Services, Dublin, from 2008 to 2019. He is Clinical Professor of Psychiatry at Trinity College Dublin. He has been working for more than 30 years with patients suffering from mental health problems. In addition to medical management, he maintains his clinical practice at St Patrick`s, where he specialises in the assessment, diagnosis and management of Obsessive Compulsive Disorder (OCD) and other anxiety disorders. He gives public lectures and is a regular broadcaster on mental health matters on RTÉ radio, featuring on ‘Today with Sean O’Rourke’.