GAD, ADD, Depression Flashcards
Dx GAD
Excessive anxiety/worry more days than not x6 months + ≥3:
- Restlessness
- Easily fatigued
- Difficulty concentrating
- Difficulty falling/staying asleep
- Irritability
- Muscle tension
pathophys of GAD
Decreased GABA receptor density. Inc glutamate
Decreased 5-HT
CO2 serum concentration sensitivity (panic)
Increased amygdala activity
tx of acute phase anxiety
Start SSRIs, TCAs
+/-BZD if necessary
pphx anxiety tx
SSRIs, SNRIs
buspirone
pregabalin
name first and second line tx for anxiety
tx timelines
SSRIs for 12 weeks then switch to another for at least 6 mos.
- Fluoxetine may have best response and remission outcomes.
- Sertraline best tolerability outcomes.
Venlafaxine second line (dose 75mg or less)
- Venlafaxine and paroxetine may have worst comparative outcomes.
SSRIs for GAD w/
best response and remission outcomes.
best tolerability outcomes.
may have worst comparative outcomes.
Fluoxetine may have best response and remission outcomes.
Sertraline best tolerability outcomes.
Venlafaxine and paroxetine may have worst comparative outcomes.
Indication & MOI of Buspirone
advantages & disadvantages
indicated for GAD
5HT1A partial agonist
Advantages:
- Almost as effective as benzos for GAD
- No sedation, cognitive impairment, respiratory depression, dependence or withdrawal
- Lacks abuse potential
Disadvantages:
- Onset of effect ~2 weeks, but can take 6 weeks for full effect (similar to the antidepressants)
name an antiepiletic to consider w/ GAD
Pregabalin
Name the atypical antipsychotic you could use in GAD (unlikely)
Quetiapine –> monotherapy may be beneficial in non refractory GAD
greater discontinuations.
define panic attack
Period of intense fear in which 4 of the following symptoms develop abruptly and reached a peak within minutes.
- Palpitations
- Sweating
- Trembling
- Shortness of breath or smothering
- Feeling of choking
- Chest pain
- Nausea
- Dizzy or lightheadedness
- Chills or heat sensations
- Paresthesias
- Derealization or depersonalization
- Fear of losing control
- Fear of dying – peaks at 10-15mins and disappears in 30 mins
define panic disorder
YOU CHANGE YOUR LIFE
At least one of the attacks has been followed by 1 month of one of the following
- Persistent concern about having additional attacks
- Worry about the implication of the attack
- Significant change in behavior related to the attacks
first line for panic disorder
Antidepressants - high dose
how to dose SSRIs for pt with panic disorder
Need to start low and increase dose slowly – takes a while to get to therapeutic dose
- SSRIs can precipitate a panic attack if initially dosed too high.
- Goal dose is at high end of dosing range.
treat for at least 8 weeks (and probably 12).
name drugs to consider for a pt w/ panic attacks
SSRIs and SNRIs
TCAs
BZDs for the first 4-6 weeks of treatment only.
what type of benzos are indicated for panic attacks
Alprazolam
lorazepam
High potency, short acting
type of BZD indicated for GAD vs Panic disorders
GAD - low potency, low acting
Panic - High potency, short acting (Alprazolam, lorazepam.)
what is the most common comorbidity assoc w/ GAD & PD
MDD
At least half of GAD patients will develop MDD.
30-60% of Panic patients will develop MDD.
•Highest risk of admission due to OD in Medicaid patients when compared to other BZDs.
Alprazolam
name fast onset BZDs
- Triazolam
- Alprazolam
- Loprazolam
what drug would you give to a pt who is tapering off BZD and feeling withdrawl si/sx?
Pregabalin
describe how to taper BZDs
Empower patient.
- Most research has been done in median age > 60 yo
- offer to anyone >64 or to anyone prescribed for >4wks
_Slow reduction 3-6 month_s with decreases of 1/8 to 1/4 dose qweek/q2week/monthly dose
Along with initiation of an SSRI/SNRI for anxiety maintenance (if appropriate)
Melatonin for sleep*
Pregabalin with withdrawal/anxiety symptoms**
who should we offer BZD tapering to
over 64 or
anyone prescribed for >4wks
si/sx of protracted BZD withdrawl
May last for up to a year after drug cessation
- Anxiety
- Insomnia
- Depression
Weakness, muscle pain, tremor, irritable bowel
signs of rapid BZD withdrawl
Tremors
Anxiety
Perceptual disturbances
Dysphoria
Psychosis
Seizures
Insomnia
explain role of atypical antipsychotics in GAD and PD
For panic disorder:
- NO monotherapy –> adjunct to SSRIs.
For GAD: NOT RECOMMENDED
- atypicals shown to have more side effects with little benefit when added to SSRIs-
- Quetiapine monotherapy has positive efficacy data but poor tolerability
name other adjuct tx for anxiet & PD
Hydroxyzine
propranolol
clonidine