The Anxiety Medications A Patient-Centered, Evidence-Based Treatment Approach A Presentation for the Students of Ohio University Heritage College of Osteopathic Medicine Kendall L. Stewart, MD, MBA, DLFAPA November 6, 2012 Please read, The Truth About Drug Companies, Marcia Angell (2004) and subscribe to The Medical Letter. (www.medicalletter.com ).
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The Anxiety Medications
A Patient-Centered, Evidence-Based Treatment Approach
A Presentation for the Students of Ohio University Heritage College of Osteopathic Medicine
Kendall L. Stewart, MD, MBA, DLFAPANovember 6, 2012
Please read, The Truth About Drug Companies, Marcia Angell (2004) and subscribe to The Medical Letter.(www.medicalletter.com).
Why should I learn about these medications?
• They are among the most widely prescribed drugs.1
• Some of the older medications are dangerous.• The benzodiazepines are safe and effective, but
they cannot always be used interchangeably. • Only those persons with a history of alcohol and
drug misuse are likely to abuse the benzodiazepines.
1 Anxiety can make you irrational. Larry Fried was trying to make a big, nervous fellow feel more at ease.
What are some examples of antianxiety drugs?• All these drugs are sedating, but that’s not all they
do.• The late 1800s brought alcohol, bromide salts,
chloral hydrate and paraldehyde.1 • Then came popular barbiturates in the 1950s.• Meprobamate was the sedative of the 50s and
60s.• Then came the safe and effective
benzodiazepines, and they have become the gold standard.
1 I’m not a drinker, but I’ve been around a lot of them. Alcohol clearly has some appeal. And it occasionssome unhappiness. I returned to my office to find a drunk, but Jeff Hill saved me.
What are some of the guidelines for benzodiazepine use?• Fully utilize the non-medicinal anti-anxiety
strategies.• Short-term use is preferred if possible.• Inadequate dosage is the most common cause of
treatment failure.• Don’t forget to identify and treat the primary
disorder.• Remember to taper slowly when discontinuing these
drugs.• Don’t confuse dependence and addiction.1• Use short-acting drugs in the elderly—if you must
use them at all.
1 These drugs are widely misunderstood. They are not abused by most people. In fact, they are usuallytaken less often than they are prescribed. Be cautious in patients with a history of substance abuse.
• Gamma-aminobutyric acid is an inhibitory neurotransmitter in the CNS.
• Benzodiazepines potentiate the inhibitory effects of GABA by increasing the flux of chloride ions into neurons.
• This may result in decreased neuronal firing and diminish anxiety.1
1 This sedation produces undesirable consequences when these drugs are used in high dosages. This is true for all sedatives. A patient on lorazepam didn’t remember talking to me. A woman shot herself duringa blackout.
1 I learned this first hand as a junior medical student from my first DO mentor. I gave an elderly womanlorazepam and then endured the jabs of my colleagues as I bagged her in the hall.
How are the benzodiazepines metabolized?• These drugs are metabolized by microsomal
enzyme systems in the liver.• Most undergo
transformation of the diazepine ring or hydroxylation followed by conjugation by glucuronic acid.
• Ring transformation and hydroxylation may be compromised in medically ill patients.
• These capacities also decrease with aging.• Select those benzodiazepines that only require
conjugation in the elderly (i.e., lorazepam, oxazepam, temazepam)1
1 Elderly people who take these drugs are more likely to be involved in accidents and to sustain hip fractures. If you decide to use them, choose a short-acting agent.
What are the characteristics of benzodiazepine dependence?
• It usually only becomes apparent during the drug discontinuation phase.
• Of those who have taken a benzodiazepine regularly for 4-6 months, 50% will have developed dependence.1
• Withdrawal symptoms from the short-acting drugs appear more rapidly, but they are not more severe.
• Discomfort instead of danger is the rule, but there are exceptions.
1 Patients will blame all sorts of undesirable behavior on medication. A businessman wanted me to providea statement that he signed an unfavorable contract while on lorazepam. He fired me when I refused.
What are some of the common benzodiazepine withdrawal symptoms?• Anxiety • Irritability1
• Insomnia• Fatigue• Headache• Muscle twitching or
aching• Tremor, shakiness
• Dizziness• Concentration
difficulties• Nausea, loss of
appetite• Observable
depression• Derealization• Depersonalization
1 Some people are just irritable by nature. A farmer was griping at his wife at breakfast. She couldn’t fix The eggs to please him, and he was critical of her metabolic syndrome.
How should the benzodiazepines be tapered?
• First, discuss the possibilities– No reaction– Discontinuation
syndrome– Reoccurrence of the
underlying disorder– Rebound
• If taken less than two weeks, just stop
• Higher daily dosages and longer duration of treatment demand slower taper
• The duration of the taper will depend on the initial response
• Adherence to an agreed upon schedule is key1
• Tapering sometimes fails
1 Some patients are highly resistant to taking even small, infrequent dosages of these medications. Some prefer to get through their panic attacks on their own. Education and experience are very helpful.
• Safe and effective treatment for Generalized Anxiety Disorder1,2
• Not effective for Panic Disorder• Dependence does not develop• Will not protect from
benzodiazepine withdrawal1 This medication takes a while to work. It works best in benzodiazepine virgins. They are hard to find. 2 It reminds me of ordering a Virgin Mary in Las Vegas.
• They are preferred for long-term use and in persons with a history of substance abuse.
• They often must be started at lower dosages and titrated up more slowly in anxiety patient who are more sensitive to side effects.
• They take longer to work.• Most antidepressants block panic attacks and
possess sedative side effects.• Some of them are specifically helpful in OCD.
1 If the chronic administration of medication for anxiety is required, these are the drugs of choice. Mostpsychiatrists see the toughest cases, and we all have patients on both antidepressants and benzodiazepines.
Where can you find evidence-based information about mental disorders?
• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.
• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.
• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.
• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.
• Download this presentation and related presentations and white papers at www.KendallLStewartMD.com.
• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.
• Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.