Management of anxiety disorder 1.2.1 (Anxiolytics & Hypnotics) Flashcards
What are the general principles of management?
Step 1: Confirm diagnosis
- hx assessment
- physical examination to exclude underlying medical cause
- identify features to define specific anxiety disorder (&/or co-existing psychiatric disorders)
Step 2: Identify and address factors that may exacerbate the disorder
- Psychological factors
- Lifestyle factors
Step 3: Initiate therapy
- Psychoeducation
- Psychological treatments
- Pharmacological management
Why do anxiety disorders require ongoing management?
Anxiety disorders are usually relapsing and chronic and require ongoing treatment
How do we avoid exacerbating anxiety disorders?
- avoiding exacerbating agents such as…
- financial difficulties
- relationship difficulties
- elcohol, nicotine
- illicit drug use
- excessive caffeine intake
- excessive work
- inadequate sleep
What is the most appropriate psychological intervention for treatment of anxiety?
- psychological treatments
- includes CBT, exposure therapy & lots of others
- self help therapies online–> e therapy
What is a 1st line intervention for anxiety? What does it do?
- CBT
- focuses on changing maladaptive thinking patterns and behaviour
- based on two key principles
- Cognitions may control feelings and behaviour
- Behaviours may affect thought patterns and emotions
- 12-20 weekly sessins
- individual or group therapy or self directed formats
- follow up booster sessions after 3 or 6 months useful
- Benzos can interfere with effectiveness of CBT
What is exposure therapy? What anxiety conditions is it useful for?
- based on the principle of respondent conditioning
- useful for PTSD, OCD, specific phobias
- when people are fearful of something they often avoid what they fear however in the long term this can make fears worse
- exposure therapy= face fears & challenge them in a controlled way
- can be done using virtual reality
What is E-therapy for?
- Generally CBT-based treatment approach
- Can be as effective as face-to-face therapies
- Mood gym
- Mindsport courses
- E-couch programmes
For pharmacotherapy for anxiety- used when psychological interventions are ineffective or not available
A) What is first line?
B) What is used in exceptional circumstances?
C) What are other drugs used in anxiety?
A) SSRIs (for all anxiety disorders) + SNRIs for some disorders
B) Benzodiazepines
C) TCAs, MAOIs, Buspirone, Anticonvulsants, Anttipsychotics, Beta-blockers
What drugs are used for GAD, general anxiety disorder?
- escitalopram, SSRI
- paroxetine, SSRI
- venlafaxine, SNRI
- duloxetine, SSRI
- imipramine
- busprirone
What drugs are used for SAD, social anxiety disorder?
- escitalopram, SSRI
- paroxetine, SSRI
- sertraline, SSRI
- venlafaxine, SNRI
What drugs are used for panic disorder?
- SSRI or venlafaxine
- clomipramine or imipramine
What drugs are used for specific phobias?
- no ongoing pharmacotherapy recommended
What drugs are used for OCD, obsessive compulsive disorder?
- Citalopram, SSRI
- escitalopram, SSRI
- fluoxetine, SSRI
- fluvoxamine, SSRI
- paroxetine, SSRI
- sertraline, SSRI
What drugs are used for PTSD?
- fluoxetine, SSRI
- paroxetine, SSRI
What are some common adverse effects for SSRIs?
- nausea, diarrhoea
- agitation
- insomnia, drowsiness
- tremor
- dry mouth
- dizziness
- headache
- sweating
- weakness
- anxiety
- sexual dysfunction
- rhinitis,
- myalgia
- rash
What are some considerations with SSRIs?
- taper over several weeks to avoid withdrawal effects when ceasing
- Drug interactions: Several are potent inhibitors of CYP enzymes
- QT interval prolongation effects
- Risk of serotonin toxicity with other serotonergic drugs
- Effects on platelet aggregation → ↑ risk of bleeding n Risk of hyponatraemia
How to dose SSRIs in patients who have anxiety? What is seen when starting SSRIS? What is the onset of action?
- Start patients on half the minimum strength tablet available –> continue at that dose for a few days to a week until patient feels confident enough to increase dose
- Increased anxiety when starting SSRIs
- Onset of action is slower for anxiety (4-6 weeks)
How do benzodiazepines (BDZs) work?
- potentiate the inhibitory effects of GABA throughout the CNS, resulting in anxiolytic, sedative, hypnotic, muscle relaxant and antiepileptic effects
Which BZDs are used for the following and why:
A) For anxiety
B) For insomnia
C) For controlled drugs
A) Diazepam, lorazepam, oxazepam
- rapid onset of action and long half life –> less withdrawal symptoms
B) Temazepam
- >rapid onset of action but short half life
C) Alprazolam
Flunitrazepam
What are the indications for BZDs? Provide THREE answers
- Can provide rapid symptomatic relief
- Reserved for short-term (2 to 4 weeks) use or intermittent use as part of a broader treatment plan
- (up to 2 weeks) to manage agitation or insomnia when starting antidepressants
What to consider when prescribing BZD?
- Always check for a history of problem alcohol or drug use
- Be wary of prescribing to unfamiliar patients, especially if asking for a particular drug by name (may indicate drug-seeking behaviour)
- Carefully discuss the potential for addiction with the patient
- Avoid using short-acting drugs as they are the most highly addictive
- Only prescribe small quantities of medication at a time
- Use only as short-term treatment
- Ensure regular review of the patient and continuity of care.
Which BZD used for GAD?
- diazepam
- 2mg to 5mg as a single dose repeated up to twice daily
- Short term measure only during a crisis for severe or disabling anxiety
- Up to 2 weeks treatment then reduce dose to zero by 6 weeks
- Long term use only in rare instances where other therapies have failed.
Which BZD used for SAD?
- A short-acting BDZ can be used just before a performance in instances of specific performance anxiety
- alprazolam
- However, side effects may inhibit the performance
What conditions is there evidence of benefit/no benefit in for the use of BDZs?
- benzodiazepines have evidence of benefit in GAD, SAD and panic disorder, but not OCD or PSTD
What are the common ADV of BZDs?
- drowsiness
- over-sedation
- light-headedness
- hypersalivation
- ataxia
- slurred speech
- dependence
- effects on vision
What are the symptoms of BZD withdrawal syndrome?
- Anxiety
- insomnia
- irritability
- myoclonic jerks
- palpitations
- sensory disturbances
- occasionally seizures
How to do dose reduction for BZDs? What are the peak effects at weak 2 of withdrawal?
- Dose reduction at a rate of 15% per week is usually tolerated
- Titrate dose decrease depending on symptoms
- Higher dose preparations – stabilise on equivalent dose (ddd) of diazepam before reducing dose (not > 80mg/day)
- e.g. 5mg of diazepam = 0.5 mg of alaprozalam
- May need to withdraw in inpatient setting
- Peak effects at week 2- anxiety, panic, insomnia, muscle spasms, vomitting, diarrhoea, seizures
For other drugs used for anxiety, when should TCAS be avoided?
- need to be avoided with any patient at risk of suicide or those with underlying cardiac disease
- Second line after SSRIs (prolong QT interval and increase arrythmias)
- Cardiotoxicity in overdosage
- Efficacious but more side effects than SSRIs – anticholinergic effects, hypotension and weight gain
- Sedation can sometimes be useful in anxiety disorders
- doses of TCA’s for treating panic are often higher than those for depression
MAOIs used for anxiety…
- occasionally used by specialists in social phobia following failure of SSRIs
- phenelzine also used rarely in PTSD
- phenelzine → tyramine interactions, less interactions with moclobemide
When may mirtazapine be used for anxiety? Side effects?
- option in PTSD
- less N, V and sexual dysfunction than SSRIs but more weight gain and sedation
Which antipsychotics are used for anxiety? Why are they used?
- risperidone, quetiapine, olanzapine- SGA, atypical
- evidence limited and side effect risk is high
- most evidence of effect in OCD when used in combination with an SSRI
- olanzapine with SSRI has been used for PTSD and social phobia
When may buspirone used for anxiety? MOA and when is it appropriate to use?
- Partial agonist of serotonin 5HT1A receptors
- Not currently available but may be obtained as an SAS drug
- May be preferable to BDZs for management of GAD in patients with a history of substance misuse – less potential for dependence
- May take 2 weeks for optimal benefit
- Avoid use with MAOIs = increases BP
- avoid eating graepfruit
- causes drowsiness
When is pregabalin used for anxiety? What is the MOA? ADV?
- GAD
- pre-synaptic inhibitor of the release of excitatory neurotransmitters
- somnolence, nausea, dizziness, dry mouth
- expensive
- no rebound anxiety when discontinued but need to withdraw slowly to avoid precipitating a seizure
When are beta blockers used for anxiety? Which patient is it not appropriate in?
- used for physical symptoms (manifestations of sympathetic overactivity) including tremor, palpitations and sweating which can be distressing and unpleasant
- does not relieve the mental aspects of social phobia
- little evidence to support their use even in SAD
- avoid use in patients with asthma, severe peripheral vascular disease and some patients with heart failure
- caution in patients with diabetes
What are some complementary medicines that can be used for anxiety?
Kava Kava may cause liver failure = not recommended
St John’s Wort for depression
Passionflower* GAD
Inositol* panic disorder & OCD
Valerian root
Melatonin
Omega-3-fatty acids
5-Adenosyl-L-Methionine
When to consider an antidepressant for anxiety disorder?
- consider an antidepressant for those who do not respond to non-drug therapy, selecting on the basis of evidence of efficacy in the diagnosed anxiety disorder
