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First line treatment for panic disorder, GAD, social anxiety disorder, PTSD and OCD?
SSRIs and SNRIs
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2nd line treatments for anxiety disorders
- TCAs
- Novel action anti-depressants (Buproprion and Mirtazepine)
- RIMA/MAOIs
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Based on Can Anxiety Disorder Treatment Guidelines 2006 - which are indicated for PD (panic disorder)?
- SSRI:
- Citalopram (Celexa) - usual dose 20-40mg qD
- Escitalopram (Cipralex) - 5-40 mg qD
- Fluoxetine (Prozac) - 5-60 mg qD
- Fluvoxamine (Luvox) 50-250mg qD
- Paroxetine (Paxil) 10-50mg qD
- Sertraline (Zoloft) 50-200mg qD
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SNRI:
Venlafaxine XR (Effexor) - 37.5mg - 225mg qD
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*cautions - initial agitation, worsening of panic attacks, increased suicidal ideation in young (< 25 yrs), weight gain, sexual dysfxn
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2nd line for PD?
- TCAs - very effective but worse side effects
- cardiac toxicity, overdose effects, seizure risk at higher doses
- Imipramine, Clomipramine
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Which are 1st line indicated drugs for GAD?
- SSRI:
- Escitalopram (Cipralex) 5-40mg/d
- Paroxetine (Paxil) 10-50mg/d
- Sertraline (Zoloft) 50-200mg/d
- SNRI:
- Duloxetine (Cymbalta) 60-120 mg/d
- Venlafaxine XR (Effexor) 37.5 - 225 mg/d
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Indicated drugs for OCD?
- 1st line:
- SSRI's (no SRNI's)
- Escitalopram (Cipralex) 5-40 mg/d
- Fluoxetine (Prozac) 5-60 mg/d
- Fluvoxamine (Luvox) 50-250 mg/d
- Paroxetine (Paxil) 10-50 mg/d
- Sertraline (Zoloft) 50-200 mg/d
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2nd line: TCAs - Clomipramine 25-150 mg/d
3rd line: RIMA/MAOI - Tranylcypromine (Parnate) 20-60mg/d
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Indicated drugs for PTSD?
- Fluoxetine (Prozac) 5-60mg/d
- Paroxetine (Paxil) 10-50mg/d
- Sertraline (Zoloft) 50-200mg/d
- Venlafaxine XR (Effexor) 37.5-225 mg/d
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Indicated drugs for SAD?
- Luvox 50-250 mg/d
- Paxil 10-50mg/d
- Zoloft 50-200mg/d
- 2nd line: Moclobemide (Manerix) 300-900mg/d (a RIMA/MAOI)
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General principles of pharmacologic management
- -specific phobias rarely need meeds
- -SSRI and SNRI are effective for PD, SAD, OCD, PTSD and GAD
- -Paxil and Zoloft are effective for all 5 disorders, others vary
- - All antidepressants should start very low dose - b/c extremely intolerant of agitation and akathisia.
- -Use lowest dose possible at first, but usually need same or higher dose than for depression
- -start low and go slow vs. challenge pts with dose they can't tolerate
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How to try with antidepressant?
- If 1st SSRI/SNRI doesn't help at all after 8 weeks - discontinue slowly and substitute another.
- If 2nd doesn't help - consult psychiatry
- OCD - switch to clomipramine with usual precautions
- Length of treatment for anxiety disorders is at least 12 months, then slow taper
- - relapse during withdrawal is less if given CBT
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Use of anxiolytics in anxiety disorders
- Effective for most
- Not for OCD
- Caution in PTSD b/c high rates of comorbid substance abuse
- Maximum 6-8 weeks in a new case is the suggested limit
- Buspirone helps in GAD to augment antidepressant
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How to augment SSRI/SNRI in OCD?
- Add haloperidol or rispiridone in low dosage
- 0.5mg qD or BID (especially if tics)
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Augmentation strategies in other anxiety disorders?
- -Atypical antipsychotics can be added to antidepressant
- Not for monotherapy
- - Treat 2nd comorbid disorder (if stimulant for ADHD, anticonvulsant for BAD)
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Pyschotherapy
- CBT is best, 1st line therapy for anxiety
- Patient choice is important factor in effect
- Pt who choose to do it do better
- Overall CBT is as effective as medication
- no evidence of combination being better than either one alone
- Ideally 2x/wk for 60-90 min for 12-20 sessions
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What is reasonable to expect of a primary care clinician for anxiety?
- Follow up on complaints of anxiety
- Clarigy major anxiety Sx
- Discuss probably Dx
- Offer psychoeducation about self-help, psychotherapy, medication use
- Refer for community-based self-help
- Offer medication treatment:
- SSRI or SNRI +/- BZD
- second SSRI or SNRI
- specific augmentation
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When to refer to specialist?
- Following attempt to treat patient or earlier if patient is significantly impaired
- Chidren/Teens too fearful to attend school or socialize
- Adults cannot go to work or maintain fxn
- multiple comorbid mental disorders (depression, substance abuse, suicidality)
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OSCE STATION ON ANXIETY - part 1 history
- Hx:
- ID
- CC
- HPI
- exact anxiety Sx - onset, triggers, etc
- impaired fxn
- stressors
- coping/supports
- substances, caffeine
- abuse
- Screen for other anxiety disorders
- Screen for suicidally, depression, mania, psychosis
- Past psych - meds, dx, psychiatrist visits, hospitalizations, suicide attempts
- PMHx - head injury, thyroid problems, anemia, etc.
- Meds
- FHx
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OSCE STATION part 2 physical and labs
- OE: vitals, CVS, neurologic (tremor), thyroid, abdo for masses
- Order labs - CBC, lytes, Cr, LFTs, FBG, F lipids, TSH
- U/A, urine drug screen, 24h CrCl (Hx of renal dz)
- ECG (> 40 yrs)
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OSCE STATION part 3 - mgmt
- psychoeducation of probable Dx
- Self help strategies
- Avoid caffeine and alcohol
- Exercise!
- Box breathing, progressive relax'n exercises
- CBT referral PRN
- SSRI/SNRI +/- BZD
- F/U in 2 weeks
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Self help and self-management resources to tell Pt:
- www.cmha.ca Can Mental Health Association
- www.anxietycanada.ca
- www.anxietytreatment.ca
- Antidepressant Skills Workbook
- www.comh.ca/selfcare/
- Box breathing
- Progressive relaxation
- Exercise
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