Week 6 - Anxiety and Insomnia therapeutics Flashcards
Anxiety disorders background
Inc. cause, key n.transmitters
- Up to 1 in 3 adults suffer from anxiety
- Affects women more than men
- ONSET: young adulthood
- Anxiety is a risk factor for CV problems
- Anxiety is associated with other comorbidities + physical illness
CAUSE:
- genetic
- environmental
- development
IMPORTANT:
Key transporters = noradrenaline and serotnin
List the 3 major types of anxiety
- Gerneralised anxiety disorder (GAD)
- Panic disorder
- Social anxiety disroder
What are the signs and symptoms of anxiety
Physical and Psychological
Physical:
- tremor
- fatigue
- palipitations
- dizziness, headache
- poor swallowing, dry mouth
- sexual difficulties
- loose bowels
Psychological:
- worrying thoughts
- insomnia
- poor memory
- poor concentration
- irritability
- avoidance behaviours (avoiding things that may trigger anxiety)
What are the 2 diagnostic tools for anxiety
- GAD-2
When patient presents with symptoms of anxiety GAD-2 is used to perfrom screening- if score 3 or more = referred for GAD-7
GAD-2 asks 2 questions based on the last 2 weeks:
1. how often have you expreinced feeling nervous / anxious / on edge?
2. how often have you had uncontrollable worry?
- if score 3 or more = referred for GAD-7
- DSM-5
NOTE: rule out other possible diagnosis for anxiery e.g. BDZs, stopping smoking, heart conditions, thyroid issues etc.
What is the DSM-5 diagnostic criteria for Generalised Anxiety Disorder (GAD)
SYMPTOMS:
- excessive worry about many issues (not specific)
- constantly seeking reassurance for symptoms or health problems
- insomnia
- poor concentration
- irritability
DURATION: ≥ 6 months
What is the DSM-5 diagnostic criteria for Panic Disorder
SYMPTOMS:
- panic attacks (intense fear = can’t function)
- worrying thoughts
- fearful amticipation
- poor memory
DURATION:
- have 1 panic attack AND persistent worry about its reoccurence for 1 month
What is the DSM-5 diagnostic criteria for Social Anxiety Disorder (GAD)
SYMPTOMS:
- persistent + overwhelming fear about social situations
- panic attacks
- excessive worry before, during and after social situations
DURATION: ≥ 6 months
Treating Anxiety basics
- Rule out other causes of anxiety e.g. SE of meds, substamce misuse
- ALWAYS START with physcological treatment (e.g. CBT, therapy)
- may have long waiting lists
- ALWAYS START with physcological treatment (e.g. CBT, therapy)
- If unresponsive, dont want the above or severe disorder then START with pharmacological treatment
- Treatment should be indiviualised + shared decsion making with patient should occur
- Offer lifestyle advice e.g. find time to relax, ↓ alcohol
KEY INFO:
- Anti-depressant treatment may take 2 weeks to see effect
- Can use BDZ in GAD for SHORT term
- ADRs for antidepressants = anxiety, insomnia, suicidal thoughts = monitor
- Monitoir suicude risk
- Medicines optimisation
NICE Guidelines: for treating Generalised Anxiety Disorder (GAD)
Psychological and Pharmacological
Psychological:
1. Self help and group education = 1st line
- with self help may have a therapist reaching out weekly
2. If above is ineffective use high intensity interventions e.g. CBT, applied relaxation
- CBT develops coping stratergies
- applied relaxation teaches techniques to remain physically + psychologically relaxed
Pharmacological:
(ONLY offered if have MARKED functional impairment OR psychological therapy failed)
1. SSRIs = 1st line
- look at depression flashcard for SE of antidepressants
2. SNRIs
3. Pregablin
- dangerous if overdose
- causes euphoric effects
4. BDZs (short term use ONLY ~ MAX. 4 weeks)
NOTE: NEVER USE antipsychotics
NICE Guidelines: for treating Panic Disorders
Psychological and Pharmacological
Psychological:
1. CBT
- 1 to 2 hour weekly sessions
- treatment 4 months max.
2. Self help and group eductaion
Pharmacological:
1. SSRIs
2. Tricyclic antidepressants
If treatment successful taper dose after 6 months then stop
NOTE: do NOT USE BDZs, antipsychotics, sedating antihistamines
NICE Guidelines: for treating Social Anxiety Disorders
Psychological and Pharmacological
Psychological:
1. CBT
- inc. exposure therapy (exposre to things that mae you anxious)
- inc. understanding symptoms, turning negatives into positives
2. CBT based self-help
Pharmacological:
1. SSRI
2. SNRI
3. MAOI
NOTE: do NOT USE BDZs, antipsychotics, tricyclic antidepressants, anticonvulsants
Insomnia background
- Women, elderly and people with co-morbidities at ↑ risk
- Insomnia is a risk factro fro depression, anxiety, obesity and hypertension
CAUSE:
- Drugs / meds.
- Life events, trauma
- Illness
- Enviornment
Explain the sleep cycle (Ultradian Rhythm)
We fluctuate between the following phases during our sleep
1. Awake
2. REM (rapid eye movement)
- vivid dreams occur in this phase
- may wake up and fall asleep again (not knowing youve woken up)
3. The 4 Non-REM stages
Non-REM 3 and 4:
- Known as slow wave sleep = deepest part of sleep
- Occurs within first 4 hours of sleep
ISSUE OCCURS WHEN:
- changes in distribution of time spent in each phase
- as get older spend more time in Non-REM 1 and 2 (this is close to REM / being awake)
Big issue for ELDERLY:
- more night awakenings due to lights, noise, bladder, comorbidities
- more early awakenings as melatonin peaks earlier in the evening and diminishes sooner in the morning
- melatonin makes you remain asleep during night
What are the 3 types of insomnia
- Transient = usually sleep well
- e.g. jet lag, shift at work - Short term = lasts a few weeks
- e.g. bereavement, illness - Chronic = unable to maintain satisfactory sleep on 3+ nights a week over the last 3 months AND impacting daily functions
What are the signs and symptoms of insomnia
- Difficulty falling asleep
- Frequently waking during night
- Early morning awakening
- Daytime sleepiness
- Loss of well being due to lack of sleep
- Restless legs / arms
Treating Insomnia Basics
- Need to make sure patient is getting enough sleep (varies between people)
- sleep requirement ↓ with age - If patient is on SSRIs ensure they are taken in morning as they are stimulating = can cause sleep troubles
- Check patients meds as certain drugs can cause disturbed sleep e.g.
- L-dopa
- morphine
- sertraline
What are the Non-pharmacological Treatments patients can do at home
a.k.a. improving sleep hygiene
- Stop daytime naps
- ↓ consumption of alcohol, caffeine, smoking, food, drinks etc. in the evening / before bed
- alcohol makes you spend more time in Non-REM 1 and 2 - Remove all stimulants from room e.g. tv, devices
- Turn off distractions i.e. light, noises
- Increase exercise (makes you tired)
- Have a sleep diary to monitor sleep
How does Sleepio App / CBTi work
Non-pharmacological | CBTi - Cognitive behavioral therapy for insomnia
Sleepio App:
- 6 week self-help programme
- Has tailored approach + follows CBTi principles
- Unsure if app is safe to use in pregnancy / patients with co-morbidities
CBTi
- patient works on routine with therapist
NICE Guidelines: for treating insomnia
Pharmacological
- BDZs or Z-drugs (hypnotics)
- when prescribed they are used for SHORTEST TIME PERIOD
- usually 2 weeks, up to 4 weeks MAX.
- 1 or 2 doses at the lowest effective dose
Have short acting and long acting BDZs / Z-drugs:
- Short acting
= drug acts quick <1hr BUT doesnt last long
= ↑ risk of tolerance / dependance as more likely to adminster freq.
= ↑ rebound insomnia risk
- Long acting
= drug takes time to have its effect (5-6hr) BUT effect lasts longer = sedation next day
= ↓ rebound insomnia risk
NOTE:
- NO diff. in efficacy of the 2 drugs
- NO big diff. in their SE
= prescribe what cost lowest
- Daridorexant
- given if unresponsive to CBTi
- alternative to BDZs / Z-drugs
- CAUTIOUS in mental illness as it can worsen depression / anxiety
- antagonist at orexin receptors to promote sleep
BDZs Further INFO
- NEED to consider half life when selecting drug
- ↓ dose slowly AND monitor for rebound insomnia / withdrawal when coming off
- if withdrawal symptoms emerge pause titration + slightly ↑ dose again - SHORT term ONLY as they alter the sleep cycle (reduce Non-REM 3 and 4 sleep)
- however common to see people on it long-term - BDZs plasma levels are affected by CYP3A3/4 enzyme inducers / inhibitors
What are the risks of Benzodiazepines (BDZs) and Z-drugs
- NEED to consider half life when selecting drug
- ↑ risk of tolerance / dependance / withdrawal if use:
- short half life drug
- high dose
- prolonged use
- tolerance can develop in 3-14 days - high potency
- Affect sleep cycle
- Rebound insomnia
- Avoid in elderly due to risks of falls, sedation
- counsel patients on risk of sedation, diziness etc. esp. if drive - Need to withdraw gradually / slowly titrate dose down
Other pharmacological treatment of Insomnia
- Melatonin
- mimics natural melatonin + promotes sleep initiation + prevents interrupted sleep
- not addictive, well tolerated
- 2mg daily
- CAUTION in younger people as they have a lot of melatonin already
- short term use ONLY - Sedating antihistamines
- can produce a high = problem
- can develop tolerance
- NOT recommended OTC - Clomethiazole
- NOT reccomended due to overdose + respiratory depression risk - OTC preparations
- be careful as with herbal product you don’t know the exact quantity of active ingredient present
- some may not be safe in pregnancy etc.
