2 - Anxiety Disorders Flashcards
non-pharms for anxiety
- therapy or counselling
- stress-reduction techniques
- relaxation
- sleep and exercise
- reduce caffeine and alcohol
- time management
In general, what meds are first line?
Why?
SSRIs or SNRIs
*1st line bc of tolerability and better safety profile as compared to TCAs and MAOIs
Once the target dose is reached, how long may it take to see improvement?
2-8 weeks
*optimal response may take up to 12 weeks
How long should you use pharmacotherapy for?
for at least 12-24 months in most patients
Why are BZD second line?
abuse, sedation, cognitive impairment and withdrawal
*recommend them as short term treatment while starting SSRI or SNRI
What classes are options for second or third line treatment or adjunctive treatment?
- second generation antipsychotics (SGAs)
- anticonvulsants
*they are used as last resort due to side effects and limited number of studies for their efficacy in this setting
Panic Disorder: What are 1st line agents?
SSRIs or venlafaxine (SNRI)
Panic Disorder: What are 2nd line agents?
imipramine or clomipramine (TCAs), or mirtazapine, BZD for short term or PRN
Panic Disorder: What are 3rd line agents?
phenelzine or tranylcypromine (irreversible MAOIs)
*not used much due to s/e and dietary restrictions (need low tyramine diet)
Social Anxiety Disorders: 1st line agents?
SSRIs and venlafaxine (fluoxetine may be less effective)
-Pregabalin high dose ( > 600mg/day)
Social Anxiety Disorders: 2nd line agents?
- phenelzine (irreversible MAOi)
- gabapentin
- clonazepam, bronazepam
Social Anxiety Disorders: 3rd line agents?
SGAs (olanzapine, quetiapine, risperidone)
Social Anxiety Disorders:
What drugs can help if taken 30-60 mins prior to anxiety-provoking event?
low dose propranolol or atenolol (beta blockers)
Specific Phobia Treatment?
exposure therapy and/or BZD prior to exposure
Generalized Anxiety Disorder:
Symptoms have to be present for how long
6 months
Generalized Anxiety Disorder: 1st line?
- SSRIs and SNRIs
- Pregabalin (provides fast relief in approx 1 week)
Generalized Anxiety Disorder: 2nd line?
- quetiapine XR
- imipramine
- buproprion
- BZD
- busprione
- hydroxyzine
Generalized Anxiety Disorder: 3rd line?
- adjuvant pregabalin
- mirtazapine
- SGAs as adjuvant Tx
Anxiety Disorders and Pregnancy:
What is 1st line?
- CBT and interpersonal therapy
- mediation, relaxation
Anxiety Disorders and Pregnancy:
If medication is necessary, which ones are safe?
SSRIs and SNRIs or BZDs
*avoid paroxetine in pregnancy - cardiac abnormalities
SSRIs in 1st trimester may be linked with spontaneous abortions
SSRIs in 3rd trimester may cause behavioural syndrome of newborn (agitation, tremors, increased muscle tone, breathing probs) - fluoxetine and paroxetine are more likely bc they cross placenta more than other SSRIs
Don’t use BZD in 1st trimester
Anxiety Disorders and Breastfeeding:
What are first line after non-pharms? Why?
Paroxetine or sertraline
- low concentration in breast milk
- undetected in plasma of child
Anxiety Disorders and Breastfeeding:
Why do we avoid BZD?
potential accumulation, sedation and impaired temperature regulation in the infant