Treatment of Anxiety (without benzos)

Transcription

1 Treatment of Anxiety (without benzos) Alison C. Lynch MD MS Clinical Professor Departments of Psychiatry and Family Medicine University of Iowa Health Care

2 None Disclosures

3 Overview/objectives Review common anxiety disorders Discuss various treatment options for anxiety that can work in primary care Consider steps for negotiating a non-benzo management plan to treat your anxious patient

4 Some questions How often do you see a patient with anxiety? What is your first-line approach to starting treatment for anxiety? What is your go-to agent for a prn to treat anxiety? Does treating anxiety make you anxious?

5 Case 1 A 33 yo woman, married mother of three children, comes to see you because she is having a lot of anxiety. She worries about everything, always feels tense, it interferes with sleep/focus/relationships. She hasn t had treatment for it before. A friend told her that she should come and ask you to prescribe xanax, as it has worked for her. Your patient tried one of her friend s pills and it did help.

6 Case 2 A 38 yo female patient is new to you, used to see one of your colleagues who has moved to a new clinic, comes in requesting a refill of clonazepam 1.5mg tid and alprazolam 2mg qid prn (takes it 4x/day). Has been taking these medications for 7 years.

7 What is anxiety? We all have it It has a positive role in our lives

8 What is an anxiety disorder? Too much of a good thing

9 Types of anxiety disorders Generalized Anxiety Disorder (0.9%/2.9%) Excessive anxiety/worry most of the time for at least 6 mos, causing restlessness, fatigue, trouble concentrating, irritability, muscle tension, sleep disturbance (3 or more) Panic Disorder (2-3%) Recurrent, unexpected panic attacks, and worrying about having another one Agoraphobia (1.7%) is a separate condition in DSM 5 Social Anxiety Disorder (~7%) Marked fear or anxiety about social situation(s) Judgment, scrutiny, humiliation, embarrassment, rejection Specific Phobia (~7-9%) Marked fear/anxiety about a specific object or situation

10 Other (anxiety) disorders Post Traumatic Stress Disorder (3.5%) Exposure to a traumatic event, intrusion symptoms, avoiding triggers, negative alterations of mood or cognition, reactivity or arousal changes Obsessive Compulsive Disorder (1.2%) Obsessions and/or compulsions, time consuming, distressing

11 DSM-IV anxiety OCD PTSD GAD, PD, SP, SAD

12 DSM 5 Trauma and stressrelated disorders: PTSD Anxiety disorders: GAD, PD, SP SSRI s Obsessive-compulsive disorders: OCD

13 Anxiety screening GAD-7 Hamilton Anxiety HAM-A scoring: 1-17 mild, mild-moderate, moderate-severe, >30 severe GAD-7 scoring: 5-9 mild, moderate, 15+ severe

14 Treatment goals Management (rather than cure) Quality of life, functioning Turn down the volume

15 What has been shown to work? Medication Non-pharmacologic treatment Individual counseling, e.g. CBT Exercise Mindfulness training Organization/routine Self-help

16 A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patientoriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults AB Locke, MD, FAAFP; N Kirst, MD; and CG Shultz, PhD, MSW Am Fam Physician May 1;91(9):

17 Meds SSRIs first line Other antidepressants SNRI s, mirtazapine Buspirone TCAs More PRNs

18 SSRI s Fluoxetine, sertraline, escitalopram, citalopram, paroxetine Consider starting at a lower dose for first 7-10 days to reduce increased anxiety initially Fluoxetine 10mg daily, sertraline 25mg daily, escitaolpram 5mg daily Troubleshoot common side effects Emphasize that it takes time and higher dose may be needed Discuss non-pharmacologic strategies to use while waiting I find that patients with anxiety may ultimately need higher doses of SSRI s than patients with depression

19 Beyond SSRI s SNRI s Venlafaxine mg daily Duloxetine mg daily Common side effects of SNRIs are nausea, dizziness, insomnia, sedation, constipation, and sweating. Buspirone 7.5mg bid, up to 30mg bid Mirtazapine mg qhs, weight gain and sedation

20 More options (I use rarely) Tricyclic antidepressants Nortriptyline mg qhs Amitriptyline mg qhs Check blood levels and EKG (QTc) Bupropion--may worsen anxiety but helpful for some people, mg daily (not if sz d/o)

21 Other medications (I don t use) Gabapentin Social anxiety disorder more than GAD mg tid Pregabalin not FDA approved in US, used in Europe for GAD 75mg bid, increase up to 300mg bid

22 PRN s Hydroxyzine 25-50mg q4-6h prn Trazodone 12.5mg tid prn Quetiapine 25-50mg bid prn Beta blockers Help with performance anxiety symptoms by controlling autonomic arousal 10-20mg tid prn, some may take up to 60mg at once Non medication prn s: take a walk, breathe, meditate, switch activities, stretch

23 What about benzo s? BZDs are highly effective in the short-term management of GAD There is no evidence from clinic trials to support longer-term usage (greater than 4-6 weeks) Risks: addiction, withdrawal, impaired cognitive function, rebound anxiety, falls, hip fracture

24 Tapering benzo s Get buy in These medications have real risks The medicines are addictive, it is not a personal failure Go slowly Moving forward slowly is progress, and it is hard for many people to come off of these medications Meet face to face at each dose change It s ok to hold steady sometimes but don t lose sight of the goal to discontinue With prn s you can slowly reduce the number of pills/month over a number of months months

25 Counseling

26 What to tell your patients about CBT CBT is A scientifically supported form of psychotherapy that identifies and challenges negative patterns of thought about the self and the world to alter unwanted behavior patterns Focused on the present Problem-solving oriented Generally time-limited As effective as medication for the treatment of anxiety (and a number of other disorders).

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28 Key CBT concepts Homework, preparation, worksheets Testing thoughts, cognitions Collaboration, structure Set goals and work to accomplish them

29 Mindfulness Based Stress Reduction Mindfulness is being aware of what is happening as it s happening in an open, non-judgmental, accepting, and compassionate way. Mindfulness focuses on developing habits of responding wisely and skillfully to what is actually occurring. Resources at UIHC, books by Jon Kabat-Zinn PhD, online at The Center for Mindfulness at UMass

30 Free Smartphone Apps Breathe2Relax Headspace (mindfulness) (10 free sessions) MindShift (for teens, young adults) Pacifica (thinkpacifica.com) Panic Relief (cognitivetherapyapp.com) Self Help Anxiety Management (sam-app.org.uk) These apps generally provide tools for meditation, breathing, imagery, relaxation, education, symptom monitoring and tracking, coping skill development, planning and goal setting

31 Other electronic resources Moodgym self-help training in CBT moodgym.com.au $39(AUD)/year Anxiety and Depression Association of America

32 Summary Anxiety disorders are common and frequently managed in primary care. Treatment goals should focus on symptom management as well as functional outcomes such as social and occupational engagement. When prescribing medications to treat anxiety, there are many medication options to choose. Limit or avoid use of benzodiazepines when possible.