Anxiety OCD PTSD therapeutics Flashcards
GAD
PT and non-PT
SSRIs *
Venlafaxine XR *
TCAs
Others: e.g. beta-blockers, hydroxyzine, buspirone
Cognitive behavioral therapy (CBT)*
Psychotherapy
Relaxation
Anxiety Management
Panic Disorder
PT and non PT
SSRIs *
TCAs
CBT*
Social Anxiety Disorder
PT and non PT
SSRIs *
MAOIs/RIMAs
MAOIs + Benzodiazepines
Behavioural Therapy
OCD
PT and Non PT
SSRIs *
Clomipramine *
CBT *
Exposure & Response Prevention (ERP)
PTSD
PT and non PT
SSRIs *
TCAs
CBT (important 1st line tx)*
Psychotherapy Counselling
Cognitive Behavioural Therapy (CBT): used in combination with medications
Cognitive Behavioural Therapy (CBT): used in combination with medications
All Serotonergic Antidepressants can be useful for long-term management of Anxiety Disorders, OCD, PTSD
eg __________
– SSRIs, SNRIs (1st line)
– Clomipramine (3rd line)
Approach to Dosing (antidepressant in anxiety)
– Starting Dose must be LOW: (“start low go slow”)
• Transient jitteriness in the initial 1-2 weeks of starting antidepressant.
• Start antidepressant at with low dose; consider Benzodiazepine as adjunct
– Maintenance Dose are usually HIGH:
• Effective maintenance dosing of antidepressants for treatment of Anxiety Disorders are on the high end of the dose range (e.g. Fluoxetine 60-80mg/day)
– Discontinuation (SSRI SNRI):
• Gradual taper recommended to avoid discontinuation symptoms
• E.g. ↓dose by 10-25% every 1-2 weeks
Serotonergic Antidepressant: – Effective for________
Onset
Full response generally ____
Duration of treatment
– Effective for “excessive worrying” type of symptoms in anxiety
• Onset at least 1-2 months
• Full response generally 3 months
– Duration of treatment at least 1-2 years, typically long-term.
Adjunctive
Benzodiazepines
BZD
Effective for Onset Aim for \_\_\_\_\_\_\_ tx PD properties Tolerance Dependence
High potency agents usually preferred in _____
example
Caution
Therapeutic action:
– Effective for physical symptoms of anxiety (e.g. muscle tension)
» Fast Onset of Action: can be within 30min (e.g. Lorazepam)
– Aim for short term (3-4 months) of treatment, PRN dosing, then taper.
– PD properties same:
» Anxiolytic, Hypnotic, Muscle relaxation, Anticonvulsant, Amnesic properties
Tolerance
– Tolerance to hypnotic actions common, develops within days.
– Tolerance to anxiolytic action is uncommon
Dependence
– Avoid abrupt cessation after weeks of continued use (withdrawal)
– Gradual taper required (DECREASE in steps of Diazepam 2mg, q2-3 wks)
High potency agents usually preferred in Anxiety disorders
– Alprazolam XR, Clonazepam, Lorazepam
Cautions
– Paradoxical excitement Esp. in children and elderly
– Dependence and withdrawal symptoms can occur especially in patients with history of drug dependence.
NOT recommended:
Kava (risks of hepatotoxicity),
Chamomile (avoid in pregnancy),
Valerian (INCREASE GABA)
NOT recommended:
Kava (risks of hepatotoxicity),
Chamomile (avoid in pregnancy),
Valerian (INCREASE GABA)
2nd line
PREGABALIN
Alcohol and other CNS depressants increases CNS depressant side effects of benzodiazepines and antidepressants
Alcohol and other CNS depressants increases CNS depressant side effects of benzodiazepines and antidepressants
MAOIs and SSRIs/TCAs combinations: =====???
• Serotonin syndrome:
– restlessness, diaphoresis, tremor, shivering, myoclonus, confusion, convulsions, death.
