Session 3: Help Me, Doc - I ve Got High Anxiety! Learning Objectives 1. Recognize the distinguishing features of common anxiety disorders seen in primary care. 2. Use screening measures for diagnosis of anxiety disorders. 3. Consider the advantages and disadvantages of different treatments in order to determine appropriate therapy. 4. Use scales to monitor effectiveness of therapy and patient outcomes.
Session 3 Help Me, Doc: I ve Got High Anxiety! Faculty Mark Zimmerman, MD Associate Professor of Psychiatry and Human Behavior Brown Medical School Director of Outpatient Psychiatry Rhode Island Hospital, The Miriam Hospital Providence, Rhode Island Dr Mark Zimmerman is associate professor of psychiatry and human behavior at Brown Medical School. He is the director of outpatient psychiatry at Rhode Island Hospital and The Miriam Hospital, and the director of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project. The goal of the MIDAS project has been to integrate research methodology into routine clinical practice in order to examine a number of issues related to diagnostic comorbidity and treatment outcome. The MIDAS project is the largest clinical epidemiological study using standardized measures that has been conducted in clinical practice. Dr Zimmerman s research interests during the past twenty five years have been in the area of assessment, diagnosis, and treatment of mood disorders. He is the author of more than three hundred articles published in peer reviewed journals and is on the editorial board of ten journals. Faculty Financial Disclosure Statement The presenting faculty reports the following: Dr Zimmerman receives intellectual property rights for his management position with Psych Product Press.
Faculty Disclosures Session 3: 11:00 AM - 12:00 PM Dr Zimmerman has no financial relationships to disclose. Help Me Doc - I ve Got High Anxiety! Mark Zimmerman, MD Learning Objectives Demographic Question Recognize the distinguishing features of common anxiety disorders seen in primary care Use screening measures for diagnosis of anxiety disorders Consider the advantages and disadvantages of different treatments in order to determine appropriate therapy Use scales to monitor effectiveness of therapy and patient outcomes How many patients with anxiety disorder do you treat each week 1. None 2. 1-5 3. 6-15 4. 16-25 5. Over 25 Outcomes Question #1 Outcomes Question #2 Compared to the prevalence of major depressive disorder, anxiety disorders are: Chronic worrying about a number of different events activities is the core feature of which of the following diagnoses: 1. More common 2. Occur at about the same frequency 3. Less common 4. Can t be measured due to overlap of symptoms 1. Panic disorder 2. Social phobia 3. Adjustment disorder with anxiety 4. Generalized anxiety disorder 5. Applies to all of the above 1
Outcomes Question #3 The first line of pharmacotherapy for anxiety disorder is: 1. Short acting benzodiazepine 2. Long acting benzodiazepine 3. Low dose TCA 4. SSRI or SNRI Patient Case 1 David David is a 43-year-old man David He is married and has 2 teenage children He has been a police officer for 18 years He was evaluated in the emergency room three times in the past 6 months for complaints of chest pain. Cardiac work-up was negative PMH is noncontributory Seven months ago, his father-in-law passed away. He considered his father-in-law his mentor During the past 3 weeks he has missed 5 days of work because he awakened with feelings of restlessness, chest pressure, and a nervous stomach accompanied by nausea He denies feeling depressed Your provisional diagnosis is: 1. Bereavement 2. Major depressive disorder 3. Adjustment disorder with anxiety 4. Generalized anxiety disorder 5. Panic disorder Frequency of Anxiety Disorders in the General Population Anxiety Disorders are Underdiagnosed in Primary Care Disorder Current Lifetime Panic disorder 2.7% 4.7% Generalized anxiety disorder (GAD) 3.1% 5.7% Social anxiety disorder (SAD) 6.8% 12.1% Specific phobia 8.7% 12.5% Posttraumatic stress disorder (PTSD) 3.5% 6.8% Obsessive compulsive disorder (OCD) 1.0% 1.6% Any anxiety disorder 18.1% 28.8% Major depressive disorder 6.7% 16.6% Disorder Prevalence Nondetection by PCP Panic disorder 12.6% 41.5% GAD 31.2% 55.0% Social anxiety disorder 16.5% 81.3% Bipolar disorder 11.4% 49.0% Major depressive disorder 27.2% 55.5% Kessler, et al. Arch Gen Psychiatry 2005;62:593-602. Kessler, et al. Arch Gen Psychiatry 2005;62:617-627. Vermani, et al. Prim Care Companiion CNS Disord. 2011;13(2) 2
Clinical Significance of Anxiety Disorders Highly prevalent Impairing Disabling Higher health care costs Suicide risk Greater utilization of medical services Obstacles to Recognition of Anxiety Disorders in Primary Care Patients hesitancy to discuss due to stigma Patients present with physical symptoms PCP lack of education in mental health issues PCP focus on physical symptoms Time pressure Roy Byrne et al., J Clinical Psychiatry 1999; 60: 492 499. Sherbourne et al., Arch Gen Psychiatry 1996; 53: 889 895. Simon et al., Am J Psychiatry 1995; 152: 353 357. Fernandez A. et al.. Gen Hosp Psychiatry 2011;34:227 233. Study of Primary Care Patients Stated Reasons for not Receiving Treatment for Anxiety Disorders Reasons for not receiving medication (n=119) Primary care provider did not recommend (38%) Did not believe in taking medication for emotional problems (36%) Did not believe he/she had a problem (19%) Reasons for not receiving psychotherapy (n=153) Did not believe in therapy for emotional problems (28%) Did not believe he/she had a problem (24%) Too busy (19%) Primary care provider did not recommend (17%) Weisberg R, et al. Am J Psychiatry. 2007;164:276-282. Quality of Primary Health Care for Anxiety Disorders the CALM Study Adequate pharmacotherapy: appropriate anxiety medication at adequate dose for at least 2 months Adequate psychotherapy: counseling with at least 3 of 6 CBT elements at least some of the time Practice dealing with things that make you afraid Teach methods of relaxation Helps look at your thoughts more realistically Help you see mistakes in your thinking Help you understand how your thoughts and feelings are related Asks you to do homework or practice between sessions Stein et al. J Clin Psychiatry; 2011, 72(7), 970-976 Quality of Primary Health Care for Anxiety Disorders PHARMACOTHERAPY Medication Treatment Any Anxiety Disorder (N=1004) Panic Disorder (n=475) Social Anxiety (n=405) PTSD (n=181) GAD (n=756) Anti-anxiety med 57.4% 60.2% 59.3% 57.5% 56.5% Anti-anxiety med 46.3% 47.4% 44.5% 48.0% 46.3% at adequate dose Anti-anxiety med at adequate dose for 2+ months 29.1% 28.1% 30.2% 34.4% 29.3% Quality of Primary Health Care for Anxiety Disorders PSYCHOTHERAPY Any Anxiety Panic Social Disorder Disorder Anxiety PTSD GAD Counseling (N=1004) (n=475) (n=405) (n=181) (n=756) Any counseling 92.9% 94.1% 93.9% 92.2% 93.5% Any counseling w/ 1+ CBT element 46.3% 50.1% 46.2% 50.8% 47.9% Any counseling w/ 3+ CBT elements 21.2% 22.1% 21.5% 23.8% 22.8% Stein, et al. J Clin Psychiatry. 2011;72(7):970-976. Stein, et al. J Clin Psychiatry. 2011;72(7):970-976. 3
Delivering Evidence-Based Treatment in Primary Care CALM Study Components of evidence-based treatment in the CALM study Patient preference Adequate pharmacotherapy dosage and duration Empirically supported psychotherapy Monitoring outcome with standardized scales Efficacy compared to treatment as usual Response rate at 6 months (57.5% vs 36.8%) Response rate at 18 months (64.6% vs. 51.5%) CALM = Coordinated Anxiety Learning and Management Roy-Byrne, et al. JAMA, 2010;303(19):1921-1928. Craske, et al. Behav Ther Res. 2009;47(11):931-937. Patients Satisfaction with Primary Health Care for Anxiety Disorders - CALM Study Satisfaction with care over the past 6 months Overall health care: 66.6% Mental health care: 44.8% Factors associated with satisfaction with mental health care Lower satisfaction associated with Higher education Greater anxiety severity Higher satisfaction associated with Higher quality of psychotherapy (ie, more elements of CBT) Satisfaction not associated with Quality of pharmacotherapy Demographic variables Comorbid depression or medical illness Stein, et al. J Clin Psychiatry. 2011;72(7):970-976. Presentation of Anxiety Disorders in Primary Care I m stressed out I feel anxious I feel nervous Insomnia Fatigue Headache Muscular pain GI distress Work-up of the Patient Who Is Anxious Cause Course (duration) Clinical Symptoms Consequences (Impairment/Distress) ---->Differential Diagnosis Normal reaction Adjustment disorder Anxiety disorder Major depressive disorder Screening Questions for Core Features of Anxiety Disorders Panic disorder Have you ever had an anxiety or panic attack in which you suddenly felt intense anxiety or fear for no reason at all (What are they like) Generalized anxiety disorder Are you a worrier (For how long have you been that way) Social anxiety disorder Do you worry a lot about doing or saying something to embarrass yourself I front of others (What effect has this had on your life) Postraumatic stress disorder Have you ever experienced a traumatic event such as physical or sexual abuse or assault, an accident, combat, or any other extremely upsetting event (Does it still effect you) GAD-7: A Screening Scale for Anxiety Disorders in Primary Care Over the last 2 weeks, how often have you been bothered by the following problems (not at all, several days, more than half the days, nearly every day) Feeling nervous, anxious, or on edge* Not being able to stop or control worrying* Worrying too much about different things Having trouble relaxing Being so restless that it is hard to sit still Becoming easily annoyed or irritable Feeling afraid as if something awful might happen *GAD-2 Kroenke, et al. Annals of Internal Medicine. 2007;146:317-325. 4
Panic Disorder: Demographic and Clinical Features Prevalence: Current: 1.5% Past year: 2.5% Lifetime: 3-5-4.5% Gender: 2x more common in women than men Peak age of onset: late teens, early 20s Genetic component: MZ concordance > DZ concordance Three components 1. Anticipatory anxiety 2. Panic attack 3. Agoraphobic avoidance Eaton, et al. Am J Psychiatry. 1994;151:413-420. Kessler, et al. Arch Gen Psychiatry 2005;62:593-602. David You diagnose panic disorder and begin treatment with: 1. An SSRI/SNRI at the same dose you would typically use for depression 2. An SSRI/SNRI at half the dose you would typically use for depression 3. A TCA at half the dose you would typically use for depression 4. A benzodiazepine 5. An SSRI/SNRI plus a benzodiazepine 6. Bupropion because it is less likely to cause sexual dysfunction and is not addictive Drugs Approved for Anxiety: Use in Specific Anxiety Disorders Drug OCD Panic Disorder GAD PTSD Social Anxiety Excitalopram X Fluoxetine X X Fluvoxamine X Paroxetine X X X X X Sertraline X X X X Duloxetine X Venlafaxine-XR X X X Buspirone X Other Effective Drugs for Anxiety Disorders DRUGS OCD Panic Disorder GAD PTSD Social Anxiety TCAs -- + +/- +/- -- Clomipramine FDA + MAOIs + Benzodiazepines clonazepam FDA alprazolam FDA FDA NOTE: Some agents are not FDA approved for treating any anxiety disorder Common Side Effects of Antianxiety Drugs David: Next Steps Side Effect Anticholinergic Sexual Activation (esp. insomnia) Weight gain CNS depression GI, reduced appetite Drugs/Drug Classes TCAs SSRIs, SNRIs SSRIs, SNRIs, buspirone SSRIs, TCAs Benzodiazepines SSRIs, SNRIs You prescribe drug therapy and tell him you want him to come back for follow-up in: 1. 1 week 2. 2 weeks 3. 4 weeks 4. 6 weeks 5. At his next annual check-up 5
Time Course of Drug Efficacy Onset of Action Time Course of Drug Efficacy Continuation Phase SSRIs separation from placebo effect usually begins at 2-4 weeks TCAs separation from placebo usually begins in the 4 th week Benzodiazepines separation from placebo generally begins in the first 1-2 weeks Risk of relapse when discontinuing medication during the first year of treatment is high Risk of dose escalation by patient of benzodiazepines is low Benzodiazepine abuse potential is greatest in patients with a history of substance use disorders Roy-Byrne & Cowley., Guide to Treatments that Work (Nathan & Gorman, eds) 2007; 395-430. Ravindran & Stein. J Clinical Psychiatry. 2010;71:839-854. David: Take Home Points Anxiety disorders are frequently overlooked First line treatment is SSRIs and SNRIs Measure outcome to monitor course of treatment Patient Case 2 Susan Patients should be seen no later than 2 weeks after initiating treatment Susan: 55-year-old Woman with Increased Anxiety She has always been an anxious person but has not asked for treatment. During the past 4 years she has experienced several losses - Both of her parents passed away - The business where she had worked for 15 years closed down, and she has not been employed for 3 years. - She broke up with her boyfriend of 3 years (living together 2 years) because he indicated that he was not interested in marriage - After breaking up she had to sell her house and move back to her childhood home with her younger brother - Her brother recently mentioned that he would like to move to Florida and she should begin to look for low income housing Susan During the past 6 months she lost 20 pounds (120 to 100 lbs) She reports frequent nausea, reduced appetite, pressure under her rib cage, and back spasms She has a history of celiac disease, diagnosed 10 years ago, and she has followed her diet faithfully She has chronic insomnia that has worsened since her brother told her his plans She reports daily fatigue and does not connect with friends Her physical exam is noncontributory 6
Susan What would be your next step 1. Refer her for a GI work-up 2. Refer her for a psychiatric evaluation 3. Inquire about other symptoms of major depressive disorder 4. Begin her on an antidepressant that indicated for anxiety disorders 5. Begin her on a benzodiazepine 6. All of the above Susan The results of a GI work-up are negative. At the next follow-up visit she completes the PHQ-9, and scores 14 (ie, she screens positive for moderate depression). What would be your next step 1. Refer for a psychiatric evaluation 2. Inquire about other symptoms of major depressive disorder 3. Begin an antidepressant that also is effective for anxiety disorders 4. Begin a benzodiazepine Depression or Anxiety Nonpharmacologic Treatment Modalities Screening scales such as the PHQ-9 are NOT diagnostic measures Necessary to follow-up positive screen with a diagnostic interview Positive predictive value of a screening measure depends, in part, on the prevalence of the disorder Overlapping symptoms: low energy, poor concentration, sleep problems Majority of patients with major depressive disorder also report anxiety symptoms. Half of patients with MDD have a diagnosable anxiety disorder. Education Cognitive restructuring Exposure Homework Zimmerman, et al. American J Psychiatry. 2000;157:1337-1340. Fava, et al. Comprehensive Psychiatry. 2000;41:97-102. Brief Psychotherapies for Anxiety and Depression in Primary Care Meta-analysis of 34 studies 13 studies of CBT 8 studies of counseling 12 studies of problem solving therapy Results All treatments were effective CBT for anxiety disorders more effective than CBT for depression Susan: Take Home Points Most medications used to treat depression are effective in treating anxiety disorders Patient preference should be considered in deciding between medication or psychotherapy Psychotherapy is as effective, if not more effective, in the treatment of anxiety disorders Cape, et al. BMC Medicine. 2010;8:38. 7
Beth is a 38-year-old woman with insomnia Patient Case 3 Beth She presents with complaints of insomnia and fatigue x 6 weeks Affect anxious Husband of 8 years unexpectedly moved out of the house 6 weeks ago and she learned that he was having an affair Beth PMH Noncontributory Interview Reports daily difficulty falling asleep and feeling tired the next day She has dreams about her husband almost nightly She reports having obsessive thoughts about her husband having sex with another woman. She reported feeling nauseated for a week, having a reduced appetite for a month, and having lost 10 pounds (170 to 160 lbs). Mood is depressed and anxious daily, for about half the day. She is worried about the future, concerned about finances, living situation, potential custody fight, etc. Beth, continued She has problems concentrating, and missed 1 week of work after her husband left. Subsequently, she returned to work, and has been keeping up. Continues to care for children and last week enjoyed oldest child s school play Beth Adjustment Disorder What is the most likely diagnosis 1. Major depressive disorder 2. Generalized anxiety disorder 3. Obsessive compulsive disorder 4. Adjustment disorder 5. No disorder The development of emotional or behavioral symptoms in response to an identifiable stressor The symptoms are clinically significant as indicated by marked distress or impairment Criteria are not met for another specific psychiatric disorder No evidence that medication effective Psychotherapy is treatment of choice From Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association 2010. 8
Conclusion Outcomes Question #1 Anxiety disorders can be over diagnosed in primary care Over diagnosing adjustment disorder as an anxiety disorder risks unnecessary prescription of medication The treatment of choice for adjustment disorders is psychotherapy Compared to the prevalence of major depressive disorder, anxiety disorders are: 1. More common 2. Occur at about the same frequency 3. Less common 4. Can t be measured due to overlap of symptoms Outcomes Question #2 Outcomes Question #3 Chronic worrying about a number of different events activities is the core feature of which of the following diagnoses: The first line of pharmacotherapy for anxiety disorder is 1. Short acting benzodiazepine 1. Panic disorder 2. Social phobia 3. Adjustment disorder with anxiety 2. Long acting benzodiazepine 3. Low dose TCA 4. SSRI or SNRI 4. Generalized anxiety disorder 5. Applies to all of the above Questions 9