Disclosures I have done compensated consultation work for Otsuka Pharmaceuticals.

Transcription

1 Beyond Benzodiazepines: Treating Anxiety in Primary Care Sharon Praissman Fisher, MS, ANP-BC, PMHNP-BC Balance Point Wellness Johns Hopkins University School of Nursing NPAM NW District Director and PMHNP Group Facilitator Objectives 1. Identify 2 non-benzodiazepine medication options to manage GAD. 2. Identify appropriate time frame for Benzodiazepine use. 3. Identify a non-pharmacological way to manage anxiety. Disclosures I have done compensated consultation work for Otsuka Pharmaceuticals. DSM-5 Diagnostic Criteria GAD American Psychiatric Association (2013): Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat (p.189) American Psychiatric Association (2013): Excessive anxiety and worry occurring more days then not for at least 6 months The Individual finds it difficult to control the worry. The anxiety and worry associated with 3 (or more) of the following 6 symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Restlessness Fatigue Difficulty concentrating Irritability Muscle tension Sleep Disturbance The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. (p.222) R/O Somatic Causes Thyroid Asthma COPD CHF Anemia Hypoglycemia Substance use/withdraw including caffeine and prescribed medications Epidemiology Lifetime risk of experiencing GAD is 9% Females 2X Males Prevalence: 2.9% adults, 0.9% Adolescents 30=Median age of onset

2 50-90% co morbid mental health issues Approximately 58% go untreated (Kimmel, Zachik, Speed 2014) Score of 10 or above indicates potential illness FDA Approved Pharmacological Treatment for Anxiety SSRIs SNRIs Buspirone Benzodiazepines Paxil, Lexapro Effexor, Cymbalta BuSpar Xanax, Librium, Ativan, Valium, Serax,Tranxene SSRIs Lexapro (escitalopram) MOA: increases serotonin, blocks reuptake, desensitizes serotonin receptors (especially 1A) Half life: hours Typically not sedating, nor weight gain 10-20mg once daily dosing No significant CYP450 Paxil (Paroxetine) MOA: increases serotonin, blocks reuptake, mild anticholinergic, potential norepinephrine reuptake blocking properties Half life: 24 hours Weight gain and sedation are not uncommon 20-50mg once daily dosing Inhibits CYP450 2D6 Not recommended during pregnancy (positive evidence of risk to human fetuses)

3 SSRIs Celexa (citalopram) mg/day SEDATING/SIADH Luvox (fluvoxamine) mg/day SEDATING Zoloft (sertraline) mg/day All SSRIs share side effects of sexual dysfunction, GI, sweating, bruising. Can activate undiagnosed bipolar. SNRI Effexor (Venlafaxine) MOA: increases serotonin, norepinephrine, dopamine; blocks reuptake Half life: 9-13 hours SE: sedation, headaches, insomnia, nausea, dec appetite, sweating, inc. BP mg/day (start with 37.5mg) Avoid in patients with uncontrolled angle-closure glaucoma Cymbalta (duloxetine) MOA: increases serotonin, blocks reuptake, mild anticholinergic, potential norepinephrine reuptake blocking properties Half Life: 12 hours SE: Sexual dysfunction, GI, inc in BP, sweating, urinary retention, insomnia, sedation, dizziness, 60mg once daily dosing CYP450 Inhibitor Buspirone BuSpar MOA: serotonin 1A partial agonist, serotonin stabilizer Half Life 2-3 hours SE: Nausea, restlessness, SEDATION, headache, nervousness, dizziness 20-60mg divided dose 2-3 times/day Benzodiazepines Ativan (lorazepam) MOA: Enhances inhibitory effects of GABA Half life: hours SE: sedation, fatigue, depression, dizziness, ataxia, slurred speech, weakness, forgetfulness, confusion. 1-6mg/day in divided doses (0.5mg available) Valium (diazepam) MOA: Enhances inhibitory effect of GABA Half Life: hours SE: sedation, fatigue, depression, dizziness, ataxia, slurred speech, weakness, forgetfulness, confusion. 2-10mg, 2-4 times/day

4 What s the Beef with Benzos? High potential for abuse Not a long term solution Decreases psychomotor performance, anterograde memory, cognitive ability in long and short term use Long term use associated with poor mental and somatic health outcomes and increase health services utilization Rebound anxiety Commonly indicated in poly-pharmacy overdose Long term use creates sleep issues Potential risk factor for dementia/brain damage (controversial) (Cloos, 2010; Lader, 2005) Benzodiazepines Sordid History Withdraw seen after 4 weeks of use Non-Rx use-7.1% HARP-1/2 of all people with GAD on them, 1/3 >12 years! 4% of Canadians are on them at any given time Most frequent offering on internet supply sites and 89% did not require a Rx. (Lader, 2005) Antihistamines Vistaril (Hydroxyzine) MOA: Blocks H1 receptors Works within 15 minutes SE: SEDATION, dry mouth, tremor mg up to 4 times a day prn Anticonvulsants MOA: Bind to alpha 2delta subunit of voltage-sensitive calcium channels, no direct effects on Gaba Lyrica (pregabalin) Notable SE: weight gain, sedation, dizziness, short half life, twice daily dosing, half dose of gabapentin Neurontin (gabapentin) Notable SE: weigh gain, sedation, dizziness, ataxia, nystagmus 2-3 times a day dosing. start low, go slow Cognitive Behavior Therapy Connects behavior with thoughts and feelings Identifies Core Beliefs Can be short term or long term Multiple studies show efficacy On-line options

5 Alternative Options Magnesium, folate, and calcium deficiency found in sample of people with depression, anxiety, and both. Good evidence: Chamomile Passionflower Kava Promising: Magnesium L-lysine L-arginine (Forsyth, Williams, Deane, 2012; Shahen & Vieira, 2010) Other Options Massage Acupuncture Emotional Freedom Technique-Tapping Mindfulness Essential Oils? Case Example Tiffany is a 28 yo woman with long standing GAD and high ER/Patient First use for somatic complaints that go unfounded. She has a 4 yo daughter and works part time for her parent s landscaping firm. Her BF is supportive but works 60+ hours/week. FH: Father-undx but would never let family fly because planes were dangerous ; brother-ivda Refused all medication initially. Engaged in therapy We discussed a lot of lifestyle changes: daily exercise, finding mom-friends, reducing caffeine/sugar. She eventually agreed to try Lexapro started at 5mg for 2 weeks to mitigate side effects and help reduce her anxiety around medications. Also given Vistaril for immediate relief. 3 months later: no ER visits, enjoying life, less isolated, recommends Lexapro to her friends. Resources Internet based courses for depression and anxiety Meditation Instruction John Kabat-Zinn Ron Siegel: Apps Deep Energy 2.0 Calm EFT: Massage:

6 $25 for 50 minute massage Acupuncture: Many community based ones for under $30/session References Alvarez, E., Olivares, J., Carrasco, J., Lopez-Gomez, V., Rejas, J. (2015). Clinical and economic outcomes of adjunctive therapy with pregabalin or usual care in generalized anxiety disorder patients with partial response to selective serotonin reuptake inhibitors. Annals of General Psychiatry, 14, American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, Amsterdam J., Li Y., Soeller, I., Rockwell, K., Mao, JJ., Shults, J. (2011). A randomized, doubleblind, placebo-controlled trial of oral matricaria recutita (chamomile) extract therapy for generalized anxiety disorder. Journal Clinical Psychopharmacology 29, Borwin, B., Sher, L, Bunevicius, R., Hollander, E., Kasper, S., Zohar, J., Moller, H-J. (2012). Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and post traumatic stress disorder in primary care. International Journal of Psychiatry in Clinical practice, 16, Close, J. (2010). Benzodiazepines and addiction: myths and realities. (2010). Psychiatric Times, 27, Forsyth, AK., Williams, P., Deane, F. (2012). Nutritional status of primary care patients with depression and anxiety. Australian Journal of Primary Health, 18, Kimmel, M., Zachik, C., Speed, T. (2014). Generalized Anxiety Disorder. Johns Hopkins Psychiatry Guide. Retrieved from: d_anxiety_disorder# Lader, M. (2011). Benzodiazepines revisited-will we ever learn? Addiction, 106, Lakhan, S. & Vieria K. (2010). Nutritional and herbal supplements for anxiety and anxiety-related disorders: systematic review. Nutrition Journal, 9, Mewton, L, Wong, N., Comm, B., Andrews, G. (2012). The effectiveness of internet cognitive behavioral therapy for generalized anxiety disorder in clinical practice. Depression and Anxiety 29, Spitzer, RL., Kroenke, K., Williams, JB., Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine 166, Stahl, S. M. (2014). The prescriber s guide: Stahl s Essential Psychopharmacology (5th ed.). New York: Cambridge University Press. Questions? Comments sharonpfisher@gmail.com