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Mental Health > Clinical Management of Anxiety Disorders > Flashcards

Clinical Management of Anxiety Disorders Flashcards

1
Q

For evaluation of any anxiety disorder, we should…

A

Gather history + review all systems
Rule out anxiety disorders due to other medical conditions or substance use
Suicidal ideation or intention

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2
Q

Classes of medications that are used for anxiety include…

A

Serotonergic agents
Gabapentin/pregabalin
Benzodiazepines
Beta-blockers
Alpha-1 adrenergic antagonist

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3
Q

Goals of therapy for an acute episode of GAD include the following…

These can really be applied to any anxiety disorder

A

Decrease severity + duration of anxiety symptoms
Improve overall function

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4
Q

Long-term goals of therapy for GAD include…

These can really be applied to any anxiety disorder

A

Reach remission - minimal/no anxiety symptoms, no functional impairment, improval of QoL
Treat co-morbid conditions
Minimize AE’s from pharmacotherapy

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5
Q

Benefits of psychotherapy for GAD is that…

A

It is least invasive and safest

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6
Q

Treatment plan of pharmacotherapy depends on…

A

Severity and chronicity of symptoms
Age
Medication history
Comorbid medical/psychiatric conditions

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7
Q

Elimination of contributing factors for GAD include…

A

Reducing/avoiding alcohol, caffeine
Avoidance of stimulants and medications that may induce anxiety

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8
Q

Non-pharm treatment that has the most evidence is…

A

Psychotherapy +/- counselling

CBT = most effective
But overall underused due to cost, time requirements, limited professionals

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9
Q

Other aspects of non-pharm treatment besides psychotherapy include…

A

Exercise
Relaxation techniques
Biofeedback

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10
Q

1st line drugs for GAD treatment include…

A

SSRI - escitalopram, paroxetine, sertraline
SNRI - duloxetine, venlafaxine
Pregabalin

Most studies done, and given approved indication in guidelines

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11
Q

2nd line treatment options for GAD include…

A

BZD’s with short-term use
Bupropion
Buspirone
Hydroxyzine

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12
Q

Can the other SSRI’s be used in GAD?

A

Yes, others are often used in practice. Paroxetine, escitalopram, and sertraline were the ones specifically studied in GAD

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13
Q

Imipramine (TCA) and trazodone are ____ compared to placebo for GAD, but ____

A

More effective compared to placebo, but less tolerable

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14
Q

Open label trials have showed that mirtazpine can be ____ for GAD

A

Effective; low evidence compared to others, but used a lot in practice

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15
Q

Bupropion has been shown to have similar efficacy to escitalopram for GAD, however…

A

Can exacerbate anxiety

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16
Q

BZD’s are most often used for acute anxiety; long-term use is not recommended due to…

A

Physiological/psychological dependence

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17
Q

BZD’s are not effective for…

What kind of symptoms?

A

Depressive symptoms, and may worsen depression

CNS depressant

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18
Q

While pregabalin is 1st line for GAD, it is especially effective when a patient experiences anxiety and ____

A

Neuropathic pain

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19
Q

MOA of buspirone is…

A

5-HT 1A partial agonist

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20
Q

Onset of effect for buspirone is…

A

Delayed; 2 weeks or longer

Not useful for acute anxiety

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21
Q

Buspirone efficacy is…

A

Inconsistent for long term use - not commonly used

Only indicated for GAD or to potentiate AD’s

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22
Q

MOA of hydroxyzine is…

A

5-HT2 and H1 antagonist

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23
Q

Hydroxyzine is uncommonly used in clinical practice because…

A

Lack of tolerability - anticholinergic, sedation

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24
Q

Second generation antipsychotics have anxiolytic effect that is mediated via…

A

5-HT 1A

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25
Q

Second generation antipsychotics are 3rd line for GAD due to…

A

AE’s and limited evidence

Usually used as augmenting agents

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26
Q

In terms of GAD treatment timeframe, onset of symptom relief (for SSRI/SNRI) is usually…

What should we do if no response?

A

2-4 weeks

No response in 2 weeks, increase dose
No response in 4 weeks, unlikely to respond; potentially augment

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27
Q

Maximal response for GAD treatment (for SSRI/SNRI) takes about…

A

12 weeks

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28
Q

Treatment duration for GAD is usually….

A

12-24 months

However, 60% patients don’t achieve remission and may require longer tx

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29
Q

MOA of BZD’s is…

A

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

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30
Q

BZD’s role in GAD is to…

A

Provide rapid initial relief of anxiety symptoms

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31
Q

BZD effects on anxiety may not be significantly different from placebo after…

A

4-6 weeks of treatment

However, some refractory patients may need long-term BZD treatment

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32
Q

BZD’s are primarily effective for relieving ____ rather than ____

A

Somatic symptoms, rather than the key features characteristic of GAD

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33
Q

BZD’s commonly used in GAD include…

A

Alprazolam, bromazepam, lorazepam, diazepam, clonazepam

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34
Q

Short half life BZD’s include…

A

Alprazolam
Bromazepam
Lorazepam

Alprazolam: 12-15h
Bromzepam: 8-30h
Lorazepam: 10-20h

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35
Q

Long half-life BZD’s include…

A

Clonazepam
Diazepam

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36
Q

BZD’s with faster onset of 20-60 minutes include…

A

Clonazepam
Diazepam
Lorazepam

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37
Q

BZD’s with a slower onset of 1-2 hours include…

A

Alprazolam
Bromazepam

38
Q

Common AE’s with BZD include

CNS depressant, GABA blocker

A

Sedation
Psychomotor impairment
Dizziness, ataxia, lightheadedness

Paradoxical response can occur (agitation, irritability, confusion); variability in how people respond to BZD

39
Q

More serious AE’s with BZD’s include…

A

Memory impairment
Depression, confusion, hallucinations
Respiratory depression

40
Q

Patients may develop ____ to anxiolytic effects of BZD’s, which may necessitate…

A

Tolerance; may necessitate dosage increases with chronic use

41
Q

Risk of BZD dependence increases with…

A

Higher dose +/- longer use
History of AUD, SUD, or personality disorders

42
Q

A benefit of long-acting BZD’s is…

A

Less risk of withdrawal, good choice for tapering

43
Q

A disadvantage of using long-acting BZD’s is…

A

More daytime sedation

44
Q

A benefit of short-acting BZD’s is…

A

Better hypnotic and sedative properties

45
Q

Disadvantages of short-acting BZD’s include…

A

More rebound anxiety
Inter-dose withdrawal
Anterograde amnesia (memory impairment)

46
Q

These BZD drugs are preferred in elderly + liver dysfunction, due to…

A

Lorazepam, oxazepam, temazepam; no active metabolites

LOT drugs

47
Q

Withdrawal symptoms of BZD’s include…

Think of excess stimulation

A

Seizures
Rebound anxiety, sweating
N/V
Agitation, insomnia, tremors + twitching
Increased heart rate

48
Q

Onset of BZD withdrawal usually starts within ____ after the BZD is stopped

A

1-2 days

49
Q

Withdrawal symptoms from BZD can be avoided by…

A

Tapering

SLOW is ok; too fast of a taper = withdrawal symptoms common

50
Q

BZD’s should be precautioned with the following medical conditions…

A

Sleep apnea, COPD, CNS depression, pregnancy

Substance use history

Due to BZD AE’s; respiratory depression

Pregnancy - possible teratogen, can precipitate withdrawal in newborns

51
Q

BZD’s need to be cautioned with other drugs, such as…

A

Alcohol, opioids, barbiturates
Clozapine

Significant sedation, profound respiratory depression, coma, death

52
Q

A BZD antidote is ____, and it reverses…

A

Flumazenil; reverses hypnotic-sedative effect of BZD

53
Q

Flumazenil clinical usage is limited, due to risk of…

A

Causing seizures in BZD dependant patients

Can be used in emergency settings, where respiratory support is available

54
Q

Initial treatment of panic disorder is with…

A

Medication or psychotherapy

Evidence doesn’t support superiority of either, or for combination

Augment with CBT if ongoing symptoms despite pharm

55
Q

1st line pharmacotherapy for panic disorder includes…

A

SSRI’s
SNRI’s - venlafaxine, duloxetine

56
Q

2nd line pharmacotherapy for panic disorder includes…

A

TCA’s - similar efficacy to SSRI/SNRI, but less well tolerated
Augment with SGA or BZD depending on comorbidity

57
Q

If a patient has not responded to anything else in panic disorder, we can try…

A

Phenelzine

58
Q

These are the most studied TCA’s for panic disorder…

A

Clomipramine
Imipramine

59
Q

BZD’s are not an effective strategy to treat an acute panic attack because…

A

Onset of BZD will typically occur after the panic attack

60
Q

BZD’s may be helpful in panic disorder, if a patient…

Circumstance?

A

Knows their triggers - can take one to help prevent occurrence of panic attack

61
Q

BZD may also be helpful in panic disorder if an individual is starting an antidepressant and…

A

Needs help with residual anxiety symptoms that are physical

NOT treating underlying mood/anxiety disorder

62
Q

Most patients with panic disorder are ____ to medication AE’s, which can lead to…

A

Hypersensitive; lead to activation (early worsening of anxiety, agitation, irritability)

Therefore, start low and titrate slow

63
Q

Acute treatment duration with panic disorder is about…

We should alter treatment if no response in…

A

1-3 months

Alter treatment if no response after 6-8 weeks

64
Q

Maintenance treatment duration with panic disorder is usually ____, however…

A

12 months; but if residual symptoms continue, continue treatment

Longer than 12 months is very common

65
Q

If we want to discontinue pharmacotherapy for panic disorder, we need to consider some factors such as…

A

Duration of stability
Presence of psychosocial stressors
Patient’s motivation to stop treatment

66
Q

If we are discontinuing pharmacotherapy for panic disorder, we should taper over ____ to…

A

4-6 months, to reduce the risk of relapse

67
Q

Important non-pharm treatment for SAD includes…

A

CBT

Is a 1st line option

68
Q

1st line pharmacotherapy for SAD includes…

A

SSRI’s (escitalopram, fluvoxamine, paroxetine, sertraline)
Venlafaxine
Pregabalin

69
Q

Venlafaxine for SAD is shown to be effective, specifically for patients who…

A

Fail to respond to SSRI’s

70
Q

For performace related SAD, this could be given…

A

Propranolol 10-80mg
Atenolol 25-50mg
1-2 hours before performance

Consider CI’s for beta-blockers

71
Q

Onset of symptom relief using pharmacotherapy for SAD is usually…

A

6 to 8 weeks

Venlafaxine is sometimes as early as week 3

72
Q

Pharmacotherapy treatment duration for SAD is usually…

A

1 year or longer, after response is attained

73
Q

If a patient wants to discontinue pharmacotherapy for SAD, tapering usually needs to be done for ____

A

3-4 months

Relapse common after discontinuation

74
Q

Key non-pharm treatment for PTSD is…

A

Trauma-focused psychotherapy

Reorganization of traumatic memory into an inactive, consolidated memory

75
Q

1st line pharmacotherapy for PTSD includes…

A

SSRI’s - Fluoxetine, paroxetine, sertraline
Venlafaxine

76
Q

For trauma-related nightmares in PTSD, this is 1st line pharmacotherapy…

A

Prazosin

77
Q

Benzodiazepines in PTSD are…

A

Contraindicated - lack of efficacy, and likely to worsen severity and outcomes

Interfere with memory consolidation process, and not helping with underlying symptoms

78
Q

Mean doses of prazosin are usually…

A

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

79
Q

Onset of symptom relief with pharmacotherapy in PTSD is usually…

A

2-8 weeks

80
Q

Maximal response with pharmacotherapy in PTSD is usually achieved within…

A

12+ weeks

81
Q

Treatment with pharmacotherapy for PTSD is usually ____, but…

Duration?

A

12-24 months, but most patients are on lifelong treatment unless they undergo intensive CBT

82
Q

Non-pharmacological 1st line treatment for OCD is…

A

CBT

83
Q

1st line pharmacotherapy for OCD includes…

A

SSRI’s
Venlafaxine
Aripiprazole, risperidone for adjunctive treatment

84
Q

If an OCD patient gets little/no response to 1st line treatment, they should try…

A

An alternate SSRI, or venlafaxine if not tried yet

85
Q

For OCD, if 2 SSRI’s fail, this drug is recommended…

A

Clomipramine (TCA)

Equally/slightly more efficacious than SSRI, but less tolerable and more DI’s

86
Q

Augmentation for OCD pharmacotherapy should be considered in patients…

A

With a partial response to 1st line treatment (40% decrease in OCD rating scale)

87
Q

Something that may really help OCD patients is to…

A

Keep a symptom diary - data + content of obsessions and compulsions, and time spent in carrying out compulsion

88
Q

Onset of symptom relief with pharmacotherapy for OCD is usually…

A

2-4 weeks

89
Q

Maximal response with pharmacotherapy for OCD is usually obtained within…

A

10-12 weeks

90
Q

Treatment duration of pharmacotherapy in OCD is…

A

1-2 years, but experts recommend indefinite treatment for most patients

Relapse rates are extremely high

Mental Health (11 decks)

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