Pharmacological Treatment of Anxiety & Depressive Disorders Dr Gary Jackson (MB BCh FRCPsych) Consultant Psychiatrist The Priory Hospital Chelmsford Wellesley Hospital Southend-on-Sea Medical Secretary: Jane Cusick (direct line: 01245 244717) Private Enquiries/Referrals: GP@priorygroup.com 24/7 Telephone: 0800 090 1354 Fax: 0207 605 0911
Scope Introduction General Principles of Treatment Psychological Therapy General Anxiety Disorder Panic Disorder (+/- Agoraphobia) Social Phobia Simple Phobia PTSD OCD Depression
General Treatment Principles Information to patients and carers Bibliotherapy Support groups Internet treatment packages National Associations etc. Monitoring Clinic reviews Standardised questionnaires Patient s own treatment preferences Exercise and Diet Reassurance and Encouragement
General Treatment Principles cont. Anxiety and depressive symptoms on a spectrum from transient / mild to chronic or severe. In mild, recent onset anxiety and depression overall usefulness of drugs not demonstrated. Reassurance and advice powerful. Watch and see. Need for drug treatment determined by chronicity / severity of symptoms, presence of co-morbid psychiatric disorder, level of disability, impact on functioning, other medications being used, patients history of tolerating drugs. Check for significant anxiety in patients presenting with depression and other psychiatric syndromes and vice versa. If moderate severe depression present with anxiety disorder, treat the depression too (specifically) and vice versa.
General Treatment Principles cont. Monitor patients on drugs 2 nd weekly until stable and then 6 12 weekly. Build up dose gradually. Escalate dose as necessary. If no progress change drug or swap to different treatment e.g.cbt. Treat for 6 months for a first episode. Consider long-term drug treatment for chronic / relapsing conditions. Be aware of co-morbid disorders ask for them.
Aetiology Genetic Environmental (life events) Personality
Psychlological Therapies Advice on General Stress Management Balance Pacing Communication Relaxation Training CBT & EMDR (eye movement desensitisation reprocessing) Other appropriate therapies Interpersonal Problem solving Couples counselling & family therapy Psychodynamic Behavioural activation
Mode of Action NA & 5HT reup inhib TCA / venlafaxine (high dose) / duloxetine / vortioxetine SSRI Low dose venlafaxine (<150mg) / citalopram / paroxetine / fluoxetine / sertraline NA reup inhib reboxetine 5-HT2 blockade & SSRI trazodone MAOI phenelzine Pre- synaptic alpha-2-autoreceptor block mirtazapine DA reup blockers buproprion
Treatment Duration First episode 6 months post recovery Second episode 2-3 yrs Third episode 5 yrs + Withdraw over 4 weeks +
Generalised Anxiety Disorder A vague feeling of threat, a generalised sense of menace, an ineffable state of dysphoria and intolerable, heightened, but unfocussed expectation, that is all pervasive and continuing. - Lasts more than 6 months - Not secondary to physical illness - Co-exists often with Substance misuse - Mood Disorder - Psychotic illness James Park
Generalised Anxiety Disorder cont. Prevalence - 4.5% point prevalence Females more than males Age of onset - 3 rd decade Natural history chronic recurring/continuous (for diagnosis symptoms need to be present continuously for 6 months and must not be secondary to some other cause e.g. medical illness or substance misuse)
Drug Treatments for Generalised Anxiety Disorder Acute Efficacy SSRI TCA s Other Escitalopram Paroxetine Sertraline Imipramine Venlafaxine CBT Buspirone Pregabalin Trifluoperazine Long-term Efficacy Escitalopram Paroxetine Venlafaxine CBT Relapse Prevention Paroxetine Escitalopram CBT NB No B Blockers No Benzodiazepines
Panic Disorder (with or without Agoraphobia) Recurrent unexpected severe anxiety with varying degrees of anticipatory anxiety between attacks. Physical symptoms sweating, palpitations, weakness and dizziness. Psychological symptoms e.g. fear of dying, making a fool of self, going mad, having a heart attack. Symptoms peak within 10 minutes and last 30 45 minutes. 2/3 go on to develop agoraphobia a fear of places/situations from which escape might be difficult or where help won t be available. Such places are avoided or endured with dread.
Panic Disorder (+/- Agoraphobia) cont. Prevalence - 12% point prevalence Females more than males - 2:1 Age of onset - 2 nd or 3 rd decade Natural history - episodic over long-term Co-morbidity - Other Anxiety Disorders - Mood Disorders - Alcohol, cocaine, amphetamines
Drug Treatments for Panic Disorder Acute Panic Attack Acute Efficacy Long-term Efficacy SSRI TCA s Benzodiazepines Other Citalopram Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline Citalopram Fluoxetine Paroxetine Sertraline Alprazolam Lorazepam Clomipramine Alprazolam CBT Imipramine Clonazepam Phenelzine Diazepam Moclobemide Lorazepam Mirtazapine Venlafaxine Reboxetine Clomipramine Alprazolam Moclobemide Imipramine CBT Paroxetine Sertraline Relapse Prevention Fluoxetine Paroxetine Sertraline Imipramine CBT NB Avoid anti psychotics - sedative antihistamines - b blockers
Social Phobia Marked, persistent, unreasonable fear of being observed or evaluated negatively by other people in social or performance situations. Associated with physical and anxiety panic symptoms. Feared situations avoided or endured with dread and distress.
Social Phobia cont. Prevalence - 2% point prevalence Female more than male - 2:1 Age of onset - 2 nd decade Natural history - chronic or natural decline over long term Co-morbidity - Other Anxiety Disorders - Substance Misuse - alcohol - cannabis - anxiolytics
Drug Treatments for Social Phobia Acute Efficacy Long-term Efficacy SSRI TCA s Benzodiazepines Other Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline Escitalopram Fluvoxamine Paroxetine Sertraline Moclobemide Bromazepam Clonazepam Moclobemide Venlafaxine Gabapentin CBT Phenelzine Pregabalin Olanzapine CBT Phenelzine Venlafaxine Relapse Prevention Escitalopram Paroxetine Sertraline Clonazepam CBT
Simple Phobia Excessive or unreasonable fear of animals, objects or situations (e.g. dentist, flying) which are avoided or endured with significant distress and dread.
Simple Phobias cont. Prevalence - 7% point prevalence Female more than male - 2:1 Age of onset - 2 nd or 3 rd decade Natural history - chronic Co-morbidity - Other Anxiety Disorders
Drug Treatments for Simple Phobia Most cases respond to CBT If drug treatment is necessary - SSRI
Post Traumatic Stress Disorder A history of exposure to an extraordinary trauma with a response of intense fear, helplessness or horror. Later development of re-experiencing symptoms (e.g. flashbacks), avoidance and hyperarousal.
Post Traumatic Stress Disorder cont. Prevalence - 1-2% point prevalence Female more than male - 1:1 Age of onset - any Natural history - half natural recovery - half chronic/relapsing Co-morbidity - Other Anxiety Disorders - Mood Disorders - Substance misuse
Drug Treatments for PTSD Prevention Acute Efficacy SSRI TCA s Benzodiazepines Other Fluoxetine Paroxetine Sertraline Amitriptyline Alprazolam Imipramine Hydrocortisone Propranolol Traumafocused CBT Traumafocused CBT EMDR Brofaromine Phenelzine Lamotrigine Mirtazapine Venlafaxine Long-term efficacy Relapse Prevention Sertraline Fluoxetine Sertraline CBT?
Obsessive Compulsive Disorder Recurrent obsessional thoughts, images or impulses. And/or physical or mental rituals which are distressing, time consuming and interfere with social and occupational functioning.
Obsessive Compulsive Disorder cont. Prevalence - 1 2% point prevalence Female more than male - 2:1 Age of onset - 2 nd or 3 rd decade Natural history - 2/3 episodes lat < 1 year. - majority chronic relapsing course Co-morbidity - Other Anxiety Disorders - Perfectionistic/obsessional personality - Tic disorders
Drug Treatments for OCD Acute Efficacy Long-term Efficacy Relapse Prevention SSRI TCA s Benzodiazepines Other Citalopram Fluoxetine Fluvoxamine Paroxetine Sertraline Fuoxetine Sertraline Fluoxetine Paroxetine Sertraline Clomipramine Clonazepam CBT Imipramine Clomipramine Clonazepam CBT CBT
Depression Symptoms Low mood Anxiety Negative cognitions Poor concentration Suicidal ideation Appetite loss Anhedonia Reduced libido Signs Weight loss Sleep disturbance Agitation Psychomotor retardation Tearfulness Irritability Social withdrawal
No Response:? Diagnosis ( Physical / Psychiatric )? Alcohol / Drugs? Perpetuating Factors? Compliance? Secondary Gain
Treatment Escalation SSRI Increase dose Switch to different SSRI Change class Venlafaxine Mirtazapine Duloxetine TCA MAOI Mega dose Combination Venlafaxine / Mirtazapine Augment Lithium Carbamazepine Olanzapine Risperidone Flupenthixol Tryptophan Combinations of anti depressants T4 Phenelzine/MAOI s ECT Deep brain stimulation Vagal nerve stimulation
Supplementation Lithium Carbonate 4 week trial Atypical Anti psychotic Olanzapine Quetiapine Risperidone Anti epileptics Lamotrigine
Other Physical Treatments ECT Deep Brain Stimulation
Special Cases Cardiac patients Epilepsy Pregnancy - SSRI s - Avoid TCA s - Avoid Venlafaxine - Most anti depressants can lower seizure threshold - Beware: drug interactions between anti depressants and anti epileptics. - TCA s - Fluoxetine Breast Feeding - Paroxetine - Sertraline
Anti depressant Drug Discontinuation Syndrome Uncommon but real Paroxetine & Venlafaxine +/- 10 x more likely to cause DS Tapering may reduce risk Usually onset once drug stopped Syndrome - G.I.T. e.g nausea Lasts 1 2 weeks - Dizziness If severe, re-increase dose - Gait problems - Odd shooting sensation in limbs - Sleep disturbance
Conclusion - Questions and Answers Thank You Dr Gary Jackson (MB BCh FRCPsych) Consultant Psychiatrist The Priory Hospital Chelmsford Wellesley Hospital Southend-on-Sea Medical Secretary: Jane Cusick (direct line: 01245 244717) Private Enquiries/Referrals: GP@priorygroup.com 24/7 Telephone: 0800 090 1354 Fax: 0207 605 0911