Clinical Management of Anxiety Disorders Flashcards
For evaluation of any anxiety disorder, we should…
Gather history + review all systems
Rule out anxiety disorders due to other medical conditions or substance use
Suicidal ideation or intention
Classes of medications that are used for anxiety include…
Serotonergic agents
Gabapentin/pregabalin
Benzodiazepines
Beta-blockers
Alpha-1 adrenergic antagonist
Goals of therapy for an acute episode of GAD include the following…
These can really be applied to any anxiety disorder
Decrease severity + duration of anxiety symptoms
Improve overall function
Long-term goals of therapy for GAD include…
These can really be applied to any anxiety disorder
Reach remission - minimal/no anxiety symptoms, no functional impairment, improval of QoL
Treat co-morbid conditions
Minimize AE’s from pharmacotherapy
Benefits of psychotherapy for GAD is that…
It is least invasive and safest
Treatment plan of pharmacotherapy depends on…
Severity and chronicity of symptoms
Age
Medication history
Comorbid medical/psychiatric conditions
Elimination of contributing factors for GAD include…
Reducing/avoiding alcohol, caffeine
Avoidance of stimulants and medications that may induce anxiety
Non-pharm treatment that has the most evidence is…
Psychotherapy +/- counselling
CBT = most effective
But overall underused due to cost, time requirements, limited professionals
Other aspects of non-pharm treatment besides psychotherapy include…
Exercise
Relaxation techniques
Biofeedback
1st line drugs for GAD treatment include…
SSRI - escitalopram, paroxetine, sertraline
SNRI - duloxetine, venlafaxine
Pregabalin
Most studies done, and given approved indication in guidelines
2nd line treatment options for GAD include…
BZD’s with short-term use
Bupropion
Buspirone
Hydroxyzine
Can the other SSRI’s be used in GAD?
Yes, others are often used in practice. Paroxetine, escitalopram, and sertraline were the ones specifically studied in GAD
Imipramine (TCA) and trazodone are ____ compared to placebo for GAD, but ____
More effective compared to placebo, but less tolerable
Open label trials have showed that mirtazpine can be ____ for GAD
Effective; low evidence compared to others, but used a lot in practice
Bupropion has been shown to have similar efficacy to escitalopram for GAD, however…
Can exacerbate anxiety
BZD’s are most often used for acute anxiety; long-term use is not recommended due to…
Physiological/psychological dependence
BZD’s are not effective for…
What kind of symptoms?
Depressive symptoms, and may worsen depression
CNS depressant
While pregabalin is 1st line for GAD, it is especially effective when a patient experiences anxiety and ____
Neuropathic pain
MOA of buspirone is…
5-HT 1A partial agonist
Onset of effect for buspirone is…
Delayed; 2 weeks or longer
Not useful for acute anxiety
Buspirone efficacy is…
Inconsistent for long term use - not commonly used
Only indicated for GAD or to potentiate AD’s
MOA of hydroxyzine is…
5-HT2 and H1 antagonist
Hydroxyzine is uncommonly used in clinical practice because…
Lack of tolerability - anticholinergic, sedation
Second generation antipsychotics have anxiolytic effect that is mediated via…
5-HT 1A
Second generation antipsychotics are 3rd line for GAD due to…
AE’s and limited evidence
Usually used as augmenting agents
In terms of GAD treatment timeframe, onset of symptom relief (for SSRI/SNRI) is usually…
What should we do if no response?
2-4 weeks
No response in 2 weeks, increase dose
No response in 4 weeks, unlikely to respond; potentially augment
Maximal response for GAD treatment (for SSRI/SNRI) takes about…
12 weeks
Treatment duration for GAD is usually….
12-24 months
However, 60% patients don’t achieve remission and may require longer tx
MOA of BZD’s is…
Binding to BZD receptors on GABA neuron
Increases frequency of opening of chloride channels, by increasing binding affinity for GABA
Shift in chloride ions results in hyperpolarization (less excitable state) and stabilization
BZD’s role in GAD is to…
Provide rapid initial relief of anxiety symptoms
BZD effects on anxiety may not be significantly different from placebo after…
4-6 weeks of treatment
However, some refractory patients may need long-term BZD treatment
BZD’s are primarily effective for relieving ____ rather than ____
Somatic symptoms, rather than the key features characteristic of GAD
BZD’s commonly used in GAD include…
Alprazolam, bromazepam, lorazepam, diazepam, clonazepam
Short half life BZD’s include…
Alprazolam
Bromazepam
Lorazepam
Alprazolam: 12-15h
Bromzepam: 8-30h
Lorazepam: 10-20h
Long half-life BZD’s include…
Clonazepam
Diazepam
BZD’s with faster onset of 20-60 minutes include…
Clonazepam
Diazepam
Lorazepam
BZD’s with a slower onset of 1-2 hours include…
Alprazolam
Bromazepam
Common AE’s with BZD include
CNS depressant, GABA blocker
Sedation
Psychomotor impairment
Dizziness, ataxia, lightheadedness
Paradoxical response can occur (agitation, irritability, confusion); variability in how people respond to BZD
More serious AE’s with BZD’s include…
Memory impairment
Depression, confusion, hallucinations
Respiratory depression
Patients may develop ____ to anxiolytic effects of BZD’s, which may necessitate…
Tolerance; may necessitate dosage increases with chronic use
Risk of BZD dependence increases with…
Higher dose +/- longer use
History of AUD, SUD, or personality disorders
A benefit of long-acting BZD’s is…
Less risk of withdrawal, good choice for tapering
A disadvantage of using long-acting BZD’s is…
More daytime sedation
A benefit of short-acting BZD’s is…
Better hypnotic and sedative properties
Disadvantages of short-acting BZD’s include…
More rebound anxiety
Inter-dose withdrawal
Anterograde amnesia (memory impairment)
These BZD drugs are preferred in elderly + liver dysfunction, due to…
Lorazepam, oxazepam, temazepam; no active metabolites
LOT drugs
Withdrawal symptoms of BZD’s include…
Think of excess stimulation
Seizures
Rebound anxiety, sweating
N/V
Agitation, insomnia, tremors + twitching
Increased heart rate
Onset of BZD withdrawal usually starts within ____ after the BZD is stopped
1-2 days
Withdrawal symptoms from BZD can be avoided by…
Tapering
SLOW is ok; too fast of a taper = withdrawal symptoms common
BZD’s should be precautioned with the following medical conditions…
Sleep apnea, COPD, CNS depression, pregnancy
Substance use history
Due to BZD AE’s; respiratory depression
Pregnancy - possible teratogen, can precipitate withdrawal in newborns
BZD’s need to be cautioned with other drugs, such as…
Alcohol, opioids, barbiturates
Clozapine
Significant sedation, profound respiratory depression, coma, death
A BZD antidote is ____, and it reverses…
Flumazenil; reverses hypnotic-sedative effect of BZD
Flumazenil clinical usage is limited, due to risk of…
Causing seizures in BZD dependant patients
Can be used in emergency settings, where respiratory support is available
Initial treatment of panic disorder is with…
Medication or psychotherapy
Evidence doesn’t support superiority of either, or for combination
Augment with CBT if ongoing symptoms despite pharm
1st line pharmacotherapy for panic disorder includes…
SSRI’s
SNRI’s - venlafaxine, duloxetine
2nd line pharmacotherapy for panic disorder includes…
TCA’s - similar efficacy to SSRI/SNRI, but less well tolerated
Augment with SGA or BZD depending on comorbidity
If a patient has not responded to anything else in panic disorder, we can try…
Phenelzine
These are the most studied TCA’s for panic disorder…
Clomipramine
Imipramine
BZD’s are not an effective strategy to treat an acute panic attack because…
Onset of BZD will typically occur after the panic attack
BZD’s may be helpful in panic disorder, if a patient…
Circumstance?
Knows their triggers - can take one to help prevent occurrence of panic attack
BZD may also be helpful in panic disorder if an individual is starting an antidepressant and…
Needs help with residual anxiety symptoms that are physical
NOT treating underlying mood/anxiety disorder
Most patients with panic disorder are ____ to medication AE’s, which can lead to…
Hypersensitive; lead to activation (early worsening of anxiety, agitation, irritability)
Therefore, start low and titrate slow
Acute treatment duration with panic disorder is about…
We should alter treatment if no response in…
1-3 months
Alter treatment if no response after 6-8 weeks
Maintenance treatment duration with panic disorder is usually ____, however…
12 months; but if residual symptoms continue, continue treatment
Longer than 12 months is very common
If we want to discontinue pharmacotherapy for panic disorder, we need to consider some factors such as…
Duration of stability
Presence of psychosocial stressors
Patient’s motivation to stop treatment
If we are discontinuing pharmacotherapy for panic disorder, we should taper over ____ to…
4-6 months, to reduce the risk of relapse
Important non-pharm treatment for SAD includes…
CBT
Is a 1st line option
1st line pharmacotherapy for SAD includes…
SSRI’s (escitalopram, fluvoxamine, paroxetine, sertraline)
Venlafaxine
Pregabalin
Venlafaxine for SAD is shown to be effective, specifically for patients who…
Fail to respond to SSRI’s
For performace related SAD, this could be given…
Propranolol 10-80mg
Atenolol 25-50mg
1-2 hours before performance
Consider CI’s for beta-blockers
Onset of symptom relief using pharmacotherapy for SAD is usually…
6 to 8 weeks
Venlafaxine is sometimes as early as week 3
Pharmacotherapy treatment duration for SAD is usually…
1 year or longer, after response is attained
If a patient wants to discontinue pharmacotherapy for SAD, tapering usually needs to be done for ____
3-4 months
Relapse common after discontinuation
Key non-pharm treatment for PTSD is…
Trauma-focused psychotherapy
Reorganization of traumatic memory into an inactive, consolidated memory
1st line pharmacotherapy for PTSD includes…
SSRI’s - Fluoxetine, paroxetine, sertraline
Venlafaxine
For trauma-related nightmares in PTSD, this is 1st line pharmacotherapy…
Prazosin
Benzodiazepines in PTSD are…
Contraindicated - lack of efficacy, and likely to worsen severity and outcomes
Interfere with memory consolidation process, and not helping with underlying symptoms
Mean doses of prazosin are usually…
Men: 15-16mg/night
Women: 7mg/night
A lot of people are usually not on this high dose, so would be ineffective.
Mean dose for daytime is lower; men: 4mg, women: 1.7mg
Onset of symptom relief with pharmacotherapy in PTSD is usually…
2-8 weeks
Maximal response with pharmacotherapy in PTSD is usually achieved within…
12+ weeks
Treatment with pharmacotherapy for PTSD is usually ____, but…
Duration?
12-24 months, but most patients are on lifelong treatment unless they undergo intensive CBT
Non-pharmacological 1st line treatment for OCD is…
CBT
1st line pharmacotherapy for OCD includes…
SSRI’s
Venlafaxine
Aripiprazole, risperidone for adjunctive treatment
If an OCD patient gets little/no response to 1st line treatment, they should try…
An alternate SSRI, or venlafaxine if not tried yet
For OCD, if 2 SSRI’s fail, this drug is recommended…
Clomipramine (TCA)
Equally/slightly more efficacious than SSRI, but less tolerable and more DI’s
Augmentation for OCD pharmacotherapy should be considered in patients…
With a partial response to 1st line treatment (40% decrease in OCD rating scale)
Something that may really help OCD patients is to…
Keep a symptom diary - data + content of obsessions and compulsions, and time spent in carrying out compulsion
Onset of symptom relief with pharmacotherapy for OCD is usually…
2-4 weeks
Maximal response with pharmacotherapy for OCD is usually obtained within…
10-12 weeks
Treatment duration of pharmacotherapy in OCD is…
1-2 years, but experts recommend indefinite treatment for most patients
Relapse rates are extremely high
