2 - Anxiety Disorders

Question 1

non-pharms for anxiety

Answer 1

• therapy or counselling
• stress-reduction techniques
• relaxation
• sleep and exercise
• reduce caffeine and alcohol
• time management

Question 2

In general, what meds are first line?

Why?

Answer 2

SSRIs or SNRIs

*1st line bc of tolerability and better safety profile as compared to TCAs and MAOIs

Question 3

Once the target dose is reached, how long may it take to see improvement?

Answer 3

2-8 weeks

*optimal response may take up to 12 weeks

Question 4

How long should you use pharmacotherapy for?

Answer 4

for at least 12-24 months in most patients

Question 5

Why are BZD second line?

Answer 5

abuse, sedation, cognitive impairment and withdrawal

*recommend them as short term treatment while starting SSRI or SNRI

Question 6

What classes are options for second or third line treatment or adjunctive treatment?

Answer 6

• 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

Question 7

Panic Disorder: What are 1st line agents?

Answer 7

SSRIs or venlafaxine (SNRI)

Question 8

Panic Disorder: What are 2nd line agents?

Answer 8

imipramine or clomipramine (TCAs), or mirtazapine, BZD for short term or PRN

Question 9

Panic Disorder: What are 3rd line agents?

Answer 9

phenelzine or tranylcypromine (irreversible MAOIs)

*not used much due to s/e and dietary restrictions (need low tyramine diet)

Question 10

Social Anxiety Disorders: 1st line agents?

Answer 10

SSRIs and venlafaxine (fluoxetine may be less effective)

-Pregabalin high dose ( > 600mg/day)

Question 11

Social Anxiety Disorders: 2nd line agents?

Answer 11

• phenelzine (irreversible MAOi)
• gabapentin
• clonazepam, bronazepam

Question 12

Social Anxiety Disorders: 3rd line agents?

Answer 12

SGAs (olanzapine, quetiapine, risperidone)

Question 13

Social Anxiety Disorders:

What drugs can help if taken 30-60 mins prior to anxiety-provoking event?

Answer 13

low dose propranolol or atenolol (beta blockers)

Question 14

Specific Phobia Treatment?

Answer 14

exposure therapy and/or BZD prior to exposure

Question 15

Generalized Anxiety Disorder:

Symptoms have to be present for how long

Answer 15

6 months

Question 16

Generalized Anxiety Disorder: 1st line?

Answer 16

• SSRIs and SNRIs

- Pregabalin (provides fast relief in approx 1 week)

Question 17

Generalized Anxiety Disorder: 2nd line?

Answer 17

• quetiapine XR
• imipramine
• buproprion
• BZD
• busprione
• hydroxyzine

Question 18

Generalized Anxiety Disorder: 3rd line?

Answer 18

• adjuvant pregabalin
• mirtazapine
• SGAs as adjuvant Tx

Question 19

Anxiety Disorders and Pregnancy:

What is 1st line?

Answer 19

• CBT and interpersonal therapy

- mediation, relaxation

Question 20

Anxiety Disorders and Pregnancy:

If medication is necessary, which ones are safe?

Answer 20

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

Question 21

Anxiety Disorders and Breastfeeding:

What are first line after non-pharms? Why?

Answer 21

Paroxetine or sertraline

• low concentration in breast milk
• undetected in plasma of child

Question 22

Anxiety Disorders and Breastfeeding:

Why do we avoid BZD?

Answer 22

potential accumulation, sedation and impaired temperature regulation in the infant