Wk 27 - Anxiety 2 Flashcards
Outline the important points for pharmacotherapy
- SSRI = 1st line
- Benzodiazepines effective in anxiety but ST
- SSRI + venlafaxine: initial worsening or emergence of suicidal ideation
- Benzodiazepines: discontinuation symptoms, rebound anxiety + w/drawal
Outline the detection + diagnosis of GAD treatment
- Symptoms + signs
- Asses level of disability to help determine threshold for treatment
- Ask bout long-standing anxiety symptoms when presenting w/ depression or unexplained physical symptoms
Outline the acute treatment of GAD
- SSRI, venlafaxine, benzodiazepines, imipramine, buspirone, hydroxyzine
- Higher dose of SSRI or venlafaxine = greater response
- CBT
- 12 wks needed to asses efficacy
Outline the long term treatment of GAD
- Continue drug treatment for 6 months for those responding at 12 wks
- SSRI (escitalopram, paroxetine) to prevent relapse
- CBT
- Monitor efficacy + tolerability regularly
Is combining drugs + psychological approaches recommended for treating GAD?
No
What do you do when initial treatment of GAD fails?
- Venlafaxine/imipramine after non-response to acute treatment to SSRI
- Benzodiazepine after non-response to SSRI + SNRI
Outline the detection + diagnosis of panic disorder treatment
- Familiarise diagnostic criteria for panic disorder
- Asses agoraphobia avoidance
- Ask about panic attacks + agoraphobia when presenting w/ depression or medically unexplained physical symptoms
Outline the acute treatment of Panic disorder
- All SSRI, TCAs, benzodiazepine, venlafaxine + reboxetine
- CBT
- Inc dose if insufficient response
- Initial s/e minimised by slowly inc dose
- 12 wks needed to assess efficacy
Outline the long term treatment of panic disorder
- Cognitive therapy w/ exposure - red relapse rates
- Continue drug treatment for 6 months for those responding at 12 wks
- 1st line: SSRI
- 2nd line: imipramine
Monitor efficacy + tolerability
- 3 months for taper period
What do you do when initial treatment of panic disorder fails?
- Combination if no contraindications
- Add paroxetine or buspirone to psychological treatment after partial response
- Add paroxetine whilst continuing CBT
- Add group CBT in non-pharmacological response
- Refer to specialist in refractory patients
Outline the detection + diagnosis of social phobia treatment
- Familiarise diagnostic criteria for social phobia
- Asses disability to distinguish social phobia from shyness
- Ask bout social anxiety symptoms when presenting w/ depression, panic attack in social situations or alcohol misuse
Outline the acute treatment of social phobia
- Most SSRI, venlafaxine, phenelzine, moclobemide, some benzo, anticonvulsants + olanzapine
- CBT
- high dose of SSRI not recommended
- 12 wks to assess efficacy
Outline the long term treatment of social phobia
- Continue drug treatment for 6 months for those responding at 12 wks
- Cognitive therapy w/ exposure as red relapse
- Prevent relapse: SSRI + CBT
- Clonazepam 2nd line
- Monitor efficacy + tolerability
What do you do when initial treatment of social phobia fails?
- Switch to venlafaxine after non-response to acute treatment
- Add buspirone after partial response to SSRI
- Benzo: haven’t responded
- Combine when no contraindications
- Combine + CBT
- Refer to specialist in refractory patient
Outline the detection + diagnosis of simple phobia treatment
- Asses no. fears, impairment + comorbidity to judge severity
- Ask bout anxiety symptoms when present w/ specific fears or phobias
Whats is the treatment for simple phobia?
- 1st line: exposure technique
- Paroxetine/benzo when patient w/ distressing + impairing phobia have not responded to psychological approach
Outline the prevention of post-traumatic symptoms
- After major trauma + no contraindications, consider preventative treatment w/ propranolol
- Trauma focused CBT prevent chronic PTSD in patients w/ post-traumatic symptoms lasting 1 month
Outline the acute treatment of chronic PTSD
- Some SSRI, phenelzine, mirtazapine, venlafaxine, lamotrigine
- Trauma focused CBT + EMDR
- 12 wks to assess efficacy
What is the long term treatment for PTSD?
- Continue drug treatment for 12 months for those responding at 12 wks
- SSRI to prevent relapse
- Monitor efficacy + tolerability
What do you do when initial treatment of PTSD fails?
- Combine when no contraindications
- Combine drugs + psychological treatment
- Augmentation of antidepressants w/ atypical antipsychotic after initial non-response
- Refer to specialist in refractory patients
Outline the detection + diagnosis of OCD treatment
- Familiarise w/ criteria for OCD
- Assess time engaged in OCD behaviour, associated distress + impairment + degree of attempted resistance to confirm diagnostic
- Ask about OCD symptom when presenting w/ depression
Outline the acute treatment for OCD
- Clomipramine + SSRI
- Exposure therapy + CBT
- Inc SSRI dose
- 12 wks needed to assess efficacy
Outline the long term treatment for OCD
- Continue drug treatment for 12 months for those responding at 12 wks
- SSRI prevent relapse
- Monitor efficacy + tolerability
What do you do when initial treatment of OCD fails?
- Inc dose
- Switch btw other treatments
- Combine when no contraindications
- Combine drug treatment + exposure therapy/CBT
- Augmentation w/ antipsychotic or pindolol after initial SSRI non-response
- Refer to specialist in refractory patients
Outline the considerations made when treating children + adolescents
- Reserve pharmacological treatment when no response to psychological treatment
- SSRI 1st line but avoid benzodiazepines + tricyclic
- Monitor adverse effects
Outline the considerations made when treating someone with cardiac disease + epilepsy
- Avoid tricyclic antidepressants in cardiac disease
- QT prolongation w/ venlafaxine, predisposes to cardiac arrhythmias tf avoid
- Avoid antidepressants that lower seizure threshold
Outline the considerations made when treating someone who is pregnant + breastfeeding
- Fluoxetine or tricyclic antidepressants: 1st line in pregnancy
- SSRI + tricyclic antidepressant when breastfeeding
When should patients be referred to secondary care mental health services?
- Primary care practitioner feels insufficiently experienced
- 2/more attempts at treatment have no improvement
- Severe coexisting depressive symptoms or risk of suicide
- Comorbid physical illness + prescribed treatment could interact
- Proposed interventions not available w/in primary care service
