anxiety and benzodiazepines

MODULE 3: ANXIETY DISORDERS AND OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

Introduction

With a lifetime prevalence of 29%, anxiety disorders are the most common mental health disorder for adults in the United States. (Gabbard 2014, pg. 339) Adolescents are significantly affected by anxiety disorders as well with a lifetime prevalence of 25%. (Any Anxiety Disorder Among Children) Many psychotherapies and pharmacological treatments have been found to be beneficial in the management of anxiety and obsessive-compulsive related disorders. In this module we will be focusing on the disorders with the most evidence for the use of pharmacological treatment.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are considered first-line therapy for anxiety and obsessive-compulsive related disorders. Other second- and first-generation antidepressants have demonstrated efficacy for various disorders in these categories as well. Just as with other mental health disorders, the choice of medication should be based on patient specific factors like history of response, comorbid illnesses and sensitivity to potential adverse effects, concurrent medications, cost, and personal preference.

Patients suffering from anxiety tend to be more sensitive to the psychomotor activation, like increased anxiety and agitation, that is seen within the first couple weeks of starting an antidepressant or with dose increases. This, along with the several weeks it takes to see effect from antidepressants, make adherence difficult for most patients. Benzodiazepines are often used in the beginning of treatment as they can help relieve the psychomotor activation and provide quick relief of anxiety. This class of medications can also be helpful when used on an as needed basis for acute episodes and before experiencing anticipated stressors. Due to the risk of tolerance and abuse, however, the continued use of benzodiazepines should be evaluated frequently and efforts should be made to stabilize patients on more safer long-term treatment alternatives, like antidepressants.

Psychiatric comorbidities are very common in this patient population. More than 90% of people with an anxiety disorder have a lifetime history of one or more other mental health disorder, with depression being the most common. (Chisholm-Burns 2013, pg. 718) Many of the medications and psychotherapies used for the treatment of anxiety and obsessive-compulsive related disorders have demonstrated efficacy for depression and other common comorbidities. Evaluating for potential comorbidities and tailoring treatment to specific patient presentations can help reduce pill and appointment burden, as well as improving overall adherence.

Objectives

By the end of this module the student should be able to:

Choose an appropriate first line treatment for an anxiety or obsessive-compulsive disorder based on patient specific factors.

Choose an appropriate modification to therapy in the event of nonadherence, partial response, nonresponse, or intolerability.

Appropriately initiate, discontinue, and re-evaluate the need for benzodiazepines in specific patient cases.

Read It

Stahl's Essential Psychopharmacotherapy

Chapter 9 Anxiety Disorders and Anxiolytics

Gabbard's Treatments of Psychiatric Disorders

Part IV - Anxiety Disorders and Obsessive-Compulsive and Related Disorders

Introduction; pg 339 - 342

Chapter 16: Panic Disorder; pg 343 - 357

Chapter 18: Social Anxiety Disorder (Social Phobia); pg 367 - 380

Chapter 19: Generalized Anxiety Disorder; pg 381 - 392

Chapter 21: Obsessive-Compulsive Disorder; pg 405 - 418

DynaMed summaries

This will provide a more detailed summary of pharmacological treatment guidelines and important information about medications (adverse effects, interactions, monitoring, etc.)

Panic Disorder

Social Anxiety Disorder

Generalized Anxiety Disorder

Obsessive-Compulsive Disorder (OCD)

Highly Recommended

Pharmacotherapy Principles and Practice

Chapter 40: Generalized Anxiety Disorder, Panic Disorder, and Social Anxiety Disorder

This chapter is a nice introductory reading to the pharmacology and the treatment of anxiety disorders