An Update on Anxiety Disorders in Primary Care, Part 1: Diagnosis, Presentation, & Evidence-Based Psychological Intervention C. Alec Pollard, Ph.D. Professor.

An Update on Anxiety Disorders

in Primary Care, Part 1: Diagnosis, Presentation, & Evidence-Based

Psychological Intervention

C. Alec Pollard, Ph.D.Professor of Family & Community Medicine

Saint Louis University Director, Anxiety Disorders Center

Saint Louis Behavioral Medicine Institute

Most Prevalent Psychiatric Disorders in Medical Settings

•Anxiety Disorders•Depression•Alcohol/Drug Abuse•Somatoform Disorders

•Goldman, Wise, & Brody (1998)

Risks of Failure to Identify Anxiety Disorders in Primary

Care:

•Continued psychological deterioration•Psychiatric comorbidity•Family conflict/dysfunction•Vulnerability to medical illness, mortality•Costs to society

Primary Symptoms of the Major Anxiety Disorders

SYMPTOM1. Panic attacks

2. Fear/Avoidance a. of panic/symptom attacks b. of social situations/ performance c. of other, specific situations

4. Obsessions, compulsions

5. Worry

6. Flashbacks, nightmares, etc.

DISORDER1.Panic Disorder

2. Phobia a. Agoraphobia b. Social Phobia c. Specific Phobia

4. Obsessive-Compulsive Disorder

5. Generalized Anxiety Disorder

6. Posttraumatic Stress Disorder

A Note on

Mixed Anxiety & Depression

Subclinical levels of both disordersCombination = clinical syndromeMore common in primary care

Physical Complaints/Conditions Associated with Specific Anxiety

DisordersCOMPLAINT/CONDITION1. Attacks of nerves, anxiety, etc. 2. concern: fainting, loss of bladder/bowel control, vomiting3. blushing, trembling, sweating4. difficulty urinating, bladder infection5. chapped, red skin6. actual fainting7. hypertension8. sleep difficulties9. sexual problems10. fatigue

CONSIDER1. Panic Disorder w/ Agor.2. Agoraphobia w/o panic

3. Social Phobia4. Social Phobia

5. OCD 6. Blood/Injec/Injur. Phobia7. anxiety8. anxiety, especially GAD9. anxiety10. anxiety

Management of Anxiety Disorders in Primary Care

1. Education about the disorder & treatment options

2. Education about local (e.g., support groups, programs?) and national resources:

- Anxiety Disorders Association of America (www.adaa.org)

- International Obsessive-Compulsive Disorder Foundation

(www.ocfoundation.org) - National Center for PTSD (

www.ncptsd.va.gov)3. Crisis intervention when needed4. Provide treatment in-house or refer to

specialty care

Evidence-Based Psychosocial Intervention for Anxiety

Disorders•Cognitive Behavior Therapy - Education about treatment model - Cognitive therapy to address misappraisals of threat - Coping skills - Systematic exposure to feared situations - Family/environmental intervention (as needed) - Relapse prevention

•Future Directions - Drugs/behavioral procedures to enhance learning in CBT - Psychological interventions to address treatment ambivalence

Advantages & Disadvantages of CBT (vs medication)

Disadvantages: - takes more effort/time - less accessibleAdvantages: - Fewer side effects - Superior long-term outcome

An Update on Anxiety Disorders

in Primary Care, Part 2: Pharmacological Treatment

Eric Nolan, M.D.Adult Psychiatrist

Chief FellowDivision of Child Psychiatry

Washington University in St. Louis

A Common Presentation…36yo female presents to her PCP’s office with

the chief complaint of poor concentration and difficulty sleeping for the past several years

Stay at home mother of a 4 year old boy and a 6 month old girl

Husband works 60+ hours/week as a laborer when he is able, but work is hard to come by

A Common Presentation…On further questioning, you find out that she

feels overwhelmed frequently, and “worries about everything”

She feels unable to manage the household because she feels “scatterbrained” and is always worried about “what’s going to happen next”

A Common Presentation…When you probe further about her sleep, she

says that once she falls asleep, she is “perfect”

However, it can take up to 2-3 hours for her to do so

She also feels fatigued “most of the day”

In the Office…You have identified what you believe to be

anxiety

You note a moderate amount of impairment—enough to present to a PCP with these symptoms as the primary complaint

You feel that this warrants treatment, but which type—psychotherapy, medication, or both?

Pharmacological TreatmentSSRI’s

SNRI’s

Mirtazapine, bupropion

Benzodiazepines

Buspirone

TCA’s

Fluoxetine (Prozac)First of this groupMost well-studied in adultsStarting dose of 20mg/day, max 60mg/dayCommon side effects: activation, +/- weight

gain, sexual side effectsFDA indications for OCD, Panic DO

Sertraline (Zoloft)Second SSRI to obtain approvalStarting dose 50mg/day, up to 200mg/dayCommon side effects: sedation, sexual side

effects, LESS ACTIVATING than fluoxetineIndicated for treatment of PTSD, OCD, Panic

DO, social phobia (social anxiety disorder)

Paroxetine (Paxil)Approved around the same time as sertralineStarting dose of 20mg/day, max 60mg/dayMost active serotonin inhibitorleast well-

toleratedCommon side effects: sedation, weight gain,

sexual side effects, anti-cholinergic side effects

Indicated for treatment of OCD, Panic DO, PTSD, social phobia (social anxiety DO), GAD

Citalopram (Celexa)/Escitalopram (Lexapro)Most recent additions to the SSRI’sStarting doses:

Citalopram 20mg/day, max 60mg/dayEscitalopram 10mg/day, max 30mg/day

Very well-tolerated due to less potent activation of 5HT receptor

Side effects are uncommonIndicated for treatment of GAD

Venlafaxine (Effexor XR)First SNRIStarting dose 37.5-75mg/day, max 300mg

dailyCommonly used to treat co-morbid anxiety

and depressionEffective for anxiety at HIGHER doses

(>150mg/day)Common side effects: dizziness, diaphoresis,

headache, monitor for elevations in BPIndicated for treatment of MDD

Duloxetine (Cymbalta)Newest SNRIStarting dose 30mg/day, max 120mg/dayCommonly used to treat anxiety associated

with pain syndromesCommon side effects: diaphoresis,

headaches, insomnia (usually dose-related)Indicated for treatment of GAD, fibromyalgia,

chronic musculoskeletal pain

Mirtazapine (Remeron)/Bupropion (Wellbutrin)Not indicated for treatment of anxiety

disordersSome retrospective data suggests there may

be some utility for bupropion in anxiety disorders, but the data is not sufficient at this time to warrant use as primary pharmcotherapeutic agent

BenzodiazepinesAct at the GABA-A receptor (same as alcohol)Very effective in the treatment of anxietyHOWEVER: must be very judicious in their

useDifferent benzodiazepines carry different sets

of riskLong-acting benzodiazepines:

Clonazepam (Klonopin), diazepam (Valium)Short-acting benzodiazepines:

Lorazepam (Ativan), alprazolam (Xanax)

BenzodiazepinesConsider severity of symptoms in deciding

whether or not to start a benzodiazepineBenzodiazepines should NEVER be used as

monotherapy for treatment of an anxiety disorder

May start at low-dose concurrently with an SSRI, with the goal that as SSRI becomes effective over 4-6 weeks, benzodiazepine may be decreased/discontinued

Buspirone (Buspar)5HT-1A receptor partial agonistMild anxiolyticOften used with SSRI’s for treatment of mild

anxietyEfficacy is debatedStarting dose is 15mg/day, max 60mg/dayNo potential for abuse/dependenceNo common side effectsIndicated in treatment of GAD

Children and Elderly: Other ConsiderationsThese medications are generally considered

safe in children and the elderlyHowever, there is less data to support their

useBLACK BOX WARNING for SSRIs/SNRIs in

children and adolescentsGeneral rule: “start low, go slow”More susceptible to side effects

Conclusions

•Many AD sufferers still do not receive evidence-based treatment.

•Most who do receive evidence-based treatment obtain significant improvement in symptom relief and functioning.

•Both drug and cognitive behavioral therapies are effective, but each has limitations and strengths.

•Combined approach is superior for some patients, especially the more severe.

•CBT improves long-term outcome and can reduce relapse if initiated during drug discontinuation.

Related Readings

1. American Psychiatric Association. (1995). Diagnostic and Statistical Manual of Mental Disorders IV: Primary Care Version. Washington DC: APA Press.

2. Kroenke et al. (2007). Anxiety disorders in primary care: Prevalence, impairment, comorbidity, & detection. Annals of Internal Medicine, 146, 317.

3. Stein. M. B. (2003). Attending to anxiety disorders in primary care. Journal of Clinical Psychiatry, 64 (suppl 15), 35.

4. Sullivan et al. (2007). Design of the coordinated anxiety learning and management (CALM) study: Innovations in collaborative care for anxiety disorders. General Hospital Psychiatry, 29, 379.

5. ZoberiK., & Pollard, C.A. (2010). Treating anxiety without SSRIs. Journal of Family Practice, 59, 313.

Address1129 Macklind Ave

St. Louis, MO 63110

Phone: 314-534-0200, Ext. 424Fax: 314-534-7996

Website: www.slbmi.comEmail: [email protected]