Disclosures. Objectives. Symptoms of fear. The Fifteen Minute Hour: Psychotherapy & Medications for Anxiety Management in Primary Care 4/5/18

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1 Disclosures The Fifteen Minute Hour: Psychotherapy & Medications for Anxiety Management in Primary Care I have nothing to disclose Emma Samelson-Jones, MD Assistant Clinical Professor UCSF Department of Psychiatry Objectives Identify and evaluate anxiety symptoms in a primary care setting Use 3 psychotherapy techniques for treating anxiety in a primary care setting Initiate medication management for insomnia and anxiety Weigh the risks & benefits of benzodiazepine use in the treatment of anxiety and insomnia Symptoms of fear (perceived imminent threat) 1. Palpitations, pounding heart, or accelerated heart rate 2. Sweating 3. Trembling or shaking 4. Sensations of shortness of breath or smothering 5. Feeling of choking 6. Chest pain or discomfort 7. Nausea or abdominal distress 8. Feeling dizzy, unsteady, lightheaded, or faint 9. Chills or heat sensations 10. Paresthesias (numbness or tingling sensations) 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself) 12. Fear of losing control or going crazy 13. Fear of dying 1

2 Symptoms of anxiety (anticipation of perceived future threats) 1. Restlessness, feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). 7. Worries Anxiety disorder Disorder when fear and anxiety symptoms are: -marked (both excessive and out of proportion to the actual threat posed) -persistent over time -associated with impairments in functioning Dimensional construct Behavioral Symptoms of Anxiety Disorders Avoidance of perceived threats - internal (ex. unpleasant or unusual bodily sensations) - external (social situations, closed spaces, dogs, new situations, etc.) Mental Health Disorders that may include significant anxiety symptoms Generalized Anxiety Disorder - 6 months Panic Disorder- recurrent, unexpected panic attacks for at least a month + worry about future panic attacks and avoidance Agoraphobia Social Anxiety Disorder fear, anxiety, avoidance of social situations Specific Phobia Separation Anxiety Disorder Adjustment Disorder with anxious mood Body dysmorphic disorder Illness anxiety Disorder PTSD OCD Major depression with anxious features Psychotic disorder with paranoid delusions 2

3 Evaluation of Mental Health Concerns What are you experiencing? Why are you coming in now? How has this impacted your life? What have you tried to help? Sleep / safety (suicide/ipv) Evaluation of anxiety What have you found that makes it better/worse? (Alcohol? MJ? Pills? Caffeine?) What are you avoiding as a result of the anxiety? Have you ever had a panic attack (where all of a sudden you felt frightened and noticed things in your body like your heart going fast, or finding it hard to breathe)? Have you ever had recurrent nightmares or intrusive memories of a traumatic experience? (PTSD) Case 1 25 yo medical student, has always been Type A and a bit of a perfectionist, worries about school but has no functional problems, used to run to burn off energy. She is in her 3 rd year, 4 weeks into an 8 week surgery rotation, and has been struggling to fall asleep for the last 3 weeks. She is sure her attending surgeon hates her, she is stressed all the time, worried about her performance on the rotation, unable to relax. Her neck has been hurting for the last week. She has tried smoking marijuana for the last week, but hasn t found it useful. Never felt like this before. No alcohol or drugs. No panic attacks, no nightmares, no mood symptoms. No SI. Nobody has threatened or hurt her. Does she have generalized anxiety disorder? 1. Yes 2. No 3

4 Motivational interviewing regarding treatment What do you think is going on? What do you think will help? Interest in meds, coping skills, therapy? Psychotherapy #1 Relaxation Techniques Diaphragmatic breathing Pharmacologic Treatment of Insomnia Melatonin / Ramelteon OTC diphenhydramine, doxylamine Z-drugs (zaleplon, zolpidem, eszopiclone), benzos Trazodone (25-200mg) Mirtazapine (7.5mg bedtime) Doxepin 3-10mg Prazosin (PTSD) (1-12mg, start at 1mg, increase q3-7 days by 1mg stop when dizzy or effective) Stimulus control CBT for insomnia Sleep restriction Sleep interfering arousal / activation (online sleepio, SHUTi, CBTforinsomnia.com) 4

5 Times up! Case 1 You give her trazodone mg to help with sleep, tell her to practice diaphragmatic breathing for 10 minutes daily. She comes back 4 weeks later sleeping well with trazodone 50mg and thinks it helped her get through her surgery rotation. Agrees to therapy referral to learn techniques for managing anxiety in the future, and you change the trazodone to PRN. What is the first line pharmacologic treatment for GAD (also panic disorder, social anxiety disorder, OCD, and PTSD)? 1) Long-acting benzodiazepine like clonazepam 2) SSRI (fluoxetine, sertraline, citalopram, escitalopram, paroxetine, fluvoxamine) 3) SNRI (venlafaxine, desvenlafaxine, duloxetine) 4) Bupropion 5) All of the above FDA Indications Social Gen. MDD Panic OCD PTSD PMDD Other Anx. Anx. Fluoxetine Bulimia Sertraline Citalopram Escitalopram Paroxetine Fluvoxamine Vilazodone Vortioxetine Venlafaxine Desvenlafaxine Duloxetine Neuropathic pain/ FM/ Musculoskel pain Nefazodone Mirtazapine Levomilnacipran Bupropion Nicotine, Seasonal Affect, ADHD Which med first? No evidence exists that any SSRI or SNRI is better than the others for anxiety disorders (Craske 2016). Medication history Efficacy, side effects?adequate dose / adequate duration. -Patient expectations / placebo response Use: what worked before not what didn t work before SSRI (escitalopram or sertraline) (slide borrowed from Dr. Owen Wolkowitz, 2017) 5

6 1 st Line treatment for Anxiety SSRI (sertraline, escitalopram, paroxetine fluoxetine, citalopram) AND/OR Psychotherapy (remit rates ~50%; Craske 2016) Psycho-ed for SSRIs 1) Takes 2-4 weeks at given dose to begin work 2) Early side effects (nausea, diarrhea, decreased appetite, increase sweating, vivid dreams, sedation or trouble sleeping, headaches, dizziness, increased anxiety or agitation/restlessness, SI) vs. longer term side effects (weight gain, sexual side effects) 3) Expected duration of treatment *if you experience any side effect that makes you want to stop the medication, contact MD *establish hope and maximize placebo Dosing SSRIs/SNRIs for anxiety - Start low, particularly for if there are panic attacks. More likely to have side effects in anxiety than depression. - Titrate high - often need higher doses of SSRIs for anxiety than depression. - Double starting dose after one week if tolerating. If tolerating but no improvement after ~3 weeks on dose, increase again. Keep pushing dose qvisit until some improvement or limited by side effects. If noticing improvement, leave at that dose for 4 weeks. - Full efficacy at any dose ~2-3 months *Goal is return to baseline functioning and/or remission of symptoms. Dosing SSRIs/SNRIs for anxiety Drug Starting GAD Target Dose Escitalopram 5mg 20-30mg Sertraline 25mg mg Fluoxetine 10mg 40mg-60mg Citalopram 10mg 40mg Paroxetine 10mg 40-60mg Paroxetine CR 12.5mg mg Venlafaxine XR 37.5mg mg Duloxetine 15mg 60-90mg 6

7 3 Rules of Psychopharmacology If it works, keep doing it. If it doesn t work, do something different. Be systematic (ie. Know what symptom(s) you are trying to treat and track them over time) Target Symptoms & Measurement GAD7 generalized anxiety scale OASIS (overall anxiety severity and impairment scale) how often symptoms, how severe, avoidance, impact on work and relationships PTSD PCL-C Case 2 70 yo man, long history of social anxiety but that s just who I am. Since he retired 10 years ago, he has had progressive worsening of worries about something bad happening to various family members, and also fears of being in places that he can t escape from (trains, airplanes). I m driving my wife and children crazy. +childhood history of witnessed interpersonal violence but no PTSD symptoms. +2 panic attacks that landed him in the ER ~8 years ago, none since then. +early morning awakening, fatigue, difficulty relaxing x years. +long-standing avoidance of social situations. Interested in treatment with meds. Psychotherapy #2 Patient education re: anxiety Natural human response to stress - problematic when we can t tune it down or turn it off enough to function. Anxiety is uncomfortable but not dangerous. Natural course of panic attack peaks in 10 min. Vicious cycle of anxiety and avoidance Treatment of anxiety involves using medications and/or learning new coping skills in order to reverse cycle of avoidance 7

8 Psychotherapy #3 - exposure SSRI prescription 1 thing that you have been avoiding that makes you a somewhat nervous that you could try to approach before our next visit. Observe your anxiety while doing this activity how long does the peak anxiety last how did you feel after having done this activity? How long to continue the med? (if patient responds to it?) -no evidence-based strategies exist -expert guidelines recommend 12 months, then attempt gradual discontinuation over several months. - ~40% relapse rate within a year of medication discontinuation (Craske, 2016) What about benzos? Highly effective for short term relief of anxiety Interfere with fear extinction PRNs - Anxiety -> pill -> vicious cycle of disempowerment. Physiologic dependence & rebound anxiety Adverse effects on cognition, memory, increased falls, accidents,?increased risk dementia Don t start in someone with history of drug / alcohol use disorder, or someone on chronic opioids. XANAX DON T DO IT. DON T DO IT. DON T DO IT. Please, please preach the evils of Xanax. Rebound anxiety, dependence, impaired fear extinction, street market Tracy Foose, MD 8

9 Appropriate use of benzos: short-term Anxiety associated with time-limited situation Panic disorder and severely impaired functioning, starting an SSRI and engaged in treatment, plan for short-term treatment until SSRI kicks in Standing dosage, not PRN. Someone who has had trouble with initial agitation/anxiety on SSRIs standing dosage Someone whose anxiety/agitation is secondary to severe depression or psychosis and engaged in treatment for primary condition short-term treatment only, prefer standing Klonopin 0.5mg bedtime, mg BID Ativan 0.5-1mg BID-TID. What if they come to you benzos? 1) Confirm that they are actually already on benzos and taking them (Pharmacy check, Toxicology) 2) Establish therapeutic relationship, and in partnership, discuss the risks/benefits of benzos. 3) Consider initiating alternative treatment for anxiety 4) Move towards a very slow taper. Tips for tapering benzos. If engaged patient with h/o long-term use 10% tapering per step schedule wait until pt feels well again, then another 1-2 weeks before dropping dose again. End of taper is the hardest. Treat insomnia see previous slide Treat anxiety during the day SSRI +/- adjunctive treatments I need something, Doc! Adjunctive treatments: -Pregabalin 50mg TID ( mg) -Gabapentin* 100mg TID ( mg) -Hydroxyzine* 50mg TID PRN Not FDA approved 9

10 Pharmacologic treatment algorithm for anxiety SSRI #1 full trial SSRI #2 full trial Venlafaxine Expert referral If robust but partial response for GAD, push dose further or consider augmenting with buspirone. Therapy for anxiety Psycho-ed re: cycle of anxiety/avoidance, anxiety is not dangerous, avoidance is problematic. Specific coping strategies (diaphragmatic breathing and other relaxation techniques, CBT for anxiety and exposure based work) Consider referral for therapy for anyone with GAD severe enough to consider meds Why do I dread this anxious patient? Summary 1) Psychotherapy for anxiety in primary care 2) Non-benzo sleep meds (trazodone, mirtazapine, doxepin, prazosin) 3) SSRIs, start low, push dose, extensive education before starting 4) Don t use Xanax. Limited uses for benzos in 1 st line treatment 10

11 References / Further Reading Questions? Combs and Markman. Anxiety Disorders in Primary Care. Med Clin N Am 98 (2014) Craske & Stein. Anxiety. Lancet 2016; 388: Kroenke K et al. Anxiety Disorders in Primary care: Prevalence, Impairment, Comorbidity, and Detection. Ann Intern Med. 2007;146: