Treatment for Anxiety Flashcards
What is the main treatment for anxiety?
SSRIs are first line in all anxiety disorders
When may benzodiazepines be used for anxiety?
Benzodiazepines may be used alongside anti-psychotics in situations where rapid tranquilisation is required as there is an acute harm to self or others.
If benzodiazepines are used for short term for the initation of symptomatic relief they do not have the dependence risk associated.
Which TCAs are used and in which specific anxiety conditions?
Clomipramine and Imipramine
Used first line for panic disorder when SSRI is unsuitable - also used in OCD
In practice why are TCAs less widely used for anxiety?
Rarely used due to side effects, toxicity in overdose and difficulty reaching the therapeutic level required.
How long do SSRIs take to work in anxiety disorder?
Response is up to 12 weeks which is remarkably longer than when SSRIs are used in the treatment of depression.
Why is extensive monitoring required at the beginning of SSRI therapy for anxiety?
Patients are likely to experience an initial worsening of symptoms which an increased risk of suicidal thinking and self-harm.
The risk should be monitored weekly and the dose slowly up-titrated in response to the patients tolerability usually every 2 weeks.
If SSRIs are to be discontinued how long should it be done over?
Normally over 4 weeks to prevent discontinuation symptoms occurring.
How should the discontinuation of Diazepam be managed?
Diazepam in particular has a long half life and therefore the discontinuation effects of the medication will not become apparent until four weeks after the medication has been stopped.
The last few mg of Diazepam is normally the hardest to stop due to psychological dependence - can use syrup and add 5mL of diluent to wean off, however this is unlicensed.
What are some of the SSRIs used as first-line treatment for anxiety?
Escitalopram
Fluoxetine
Paroxetine
Sertraline
Citalopram
How effective are medications used in anxiety?
No medicine provides a cure for anxiety however they can help with symptomatic relief.
For example in PTSD symptoms are controlled by treatment and they can help recovery however they do not erase the memories.
OCD symptoms can be reduced by adequate treatment and can help psychological therapies be effective which in severe OCD wouldn’t allow.
What are some non-pharmacological interventions for anxiety?
Counselling
CBT
Anxiety management - group or individual
Self help - avoiding caffeine
Relaxation techniques
Self-help groups/books
Lifestyle changes
What is Step 1 of the stepped care approach for anxiety?
Recognise, asses and diagnose the patient with generalised anxiety
Educate them on the condition, treatment options or monitor
What is Step 2 of the stepped care approach for anxiety?
Diagnosed GAD that has not improved after education and active monitoring in primary care
Low intensity psychological interventions
Self-help psychoeducation groups for mild anxiety
What is Step 3 of the stepped care approach for anxiety?
GAD with an inadequate response to Step 2 interventions or marked functional impairment
High intensity psychological interventions are required (CBT/applied relaxation) or drug treatment
What is Step 4 of the stepped care approach for anxiety?
Complex treatment - refractory GAD, marked functional impairment with a high risk of neglect
Specialist treatment, inpatient stay, crisis service, day hospital
Complex drug and/or psychological treatment interventions
Outline the main treatments for generalised anxiety disorders.
Firstline:
SSRIs
Second line:
Venlafaxine
Pregabalin
Mirtazapine
Short term relief:
Benzodiazepines
Antihistamines
Antipsychotics
Treatment resistant:
Beta blockers - Propranolol
Buspirone
Which SSRIs are first line for GAD?
Fluoxetine, Sertraline (although off licensed)
Usually taken at half the normal dose and can be up-titrated to the BNF max.
What is the dosing regimen for SSRIs for GAD?
Need to wait for a response 8-12 weeks after treatment dose is reached
12 months before withdrawing which should be done gradually over weeks to months
What activity does Venlafaxine have?
At low dose it has SSRI activity and at higher dose it has SNRI activity
What is the dosing regimen for Venlafaxine for GAD?
Initially 75mg per day which can be increased if necessary up to 225mg per day
Wait at least 8 weeks for a response and 12 months before discontinuation
When can Pregabalin be initiated?
Following the failure of 2 SSRIs and 1 SNRIs and it is only licensed for GAD.
What is the dosing regimen for Pregabalin?
Initially 150mg per day in 2-3 divided doses and if required up to 600mg per day.
May see some responses within a week and again should wait 12 months before withdrawing.
Is Mirtazapine licensed for GAD?
No its use is off licensed - but may be used if the patient also has depression and sleep issues due to the marked antihistaminic effect especially at lower doses
When is Propranolol used?
Relief of somatic symptoms - tachycardia, sweating etc.
Why is Buspirone not used frequently?
Delayed onset of response
However there is no rebound or withdrawal effects.
Which antihistamines may be used short term for GAD?
Promethazine, Hydroxyzine
What is the main pharmacological management of OCD?
Central serotonin enhancers - high dose SSRIs and Clomipramine:
Clomipramine
Fluoxetine
Sertraline
Although efficient may have low tolerability
How long should the management meds of OCD last?
Need to be on maximum dose to assess response - 25%
Relapse prevention is usually 1-2 years
Which meds are used for social anxiety?
Escitalopram and Venlafaxine are licensed. Need to wait at least 12 weeks to assess response to treatment
Which medications are used for social anxiety?
SSRIs and then need to weigh up the risks vs benefits of using benzodiazepines (dependence) as people with social anxiety if symptoms are uncontrolled are more likely to have substance misuse and dependence so could prescribe PRN.
What is the mainstream treatment for panic disorder?
Self help and CBT should be encouraged.
Which drugs are licensed in the treatment of moderate to severe panic disorder?
Escitalopram
Sertraline
Citalopram
Paroxetine
Venlafaxine
Second line: if SSRIs are not suitable or there is no improvement after a 12 week course
Imipramine
Clomipramine
Are benzodiazepines used in panic disorder?
Not routinely recommended however in practice they may be used for emergency treatment.
