Anxiaty disorders in primary care setting

Anxiety Disorders in Primary Care Settings

Ashley S. Love, DNP, PMHNP-BCa,*, Rene Love, PhD, DNP, PMHNP-BC, FNAPb

KEYWORDS

� Anxiety disorders � Primary care � Pharmacologic treatment

KEY POINTS

� Anxiety disorders are the most common mental health disorders seen in primary care settings.

� Identification and treatment of anxiety disorders in primary care settings is difficult and often underdiagnosed due to lack of typical presentations and time constraints.

� Effective treatment of anxiety disorders can be improved with utilization of psychometric tools and pharmacologic treatment guidelines.

BACKGROUND AND SIGNIFICANCE

Anxiety disorders are the most common mental health disorders in the United States and one of the most common mental health problems seen in general medical settings.1 Lifetime prevalence of anxiety is estimated to be as high as 29% in the United States.2 However, identification and treatment of anxiety disorders are often difficult in general medical settings. The lack of common presentations with anxiety disorders and time constraints in the clinic setting pose challenges for medical pro- viders within the primary care setting. Results from one study show these rates of misdiagnosis to be as high as 71% for generalized anxiety disorder (GAD).3 When anx- iety is left untreated, societal costs are substantive. In the United States, societal costs of anxiety disorders are estimated to be more than $48 billion per year.4 Adults with untreated social anxiety disorders miss on average 24.7 days of work per year due to the diagnosis.5 Given the significance of health care costs, decreased quality of

The authors whose names are listed certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or nonfinan- cial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this article. a Serenity Psychiatric Care, Benson Health Clinic, 66 Club Road, Suite 140, Eugene, OR 97401, USA; b University of Arizona, College of Nursing, 1305 N Martin Avenue, PO Box 210203, Tucson, AZ 85721-0203, USA * Corresponding author. E-mail address: [email protected]

Nurs Clin N Am 54 (2019) 473–493 https://doi.org/10.1016/j.cnur.2019.07.002 nursing.theclinics.com 0029-6465/19/ª 2019 Elsevier Inc. All rights reserved.

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life, and loss of workforce productivity for patients with anxiety disorders, it is imper- ative that medical settings understand how to properly identify, diagnose, and treat these disorders.

PATHOGENESIS OF ANXIETY DISORDERS

Multiple factors have been targeted for the development of GAD; however, most re- searchers agree that the cause is epigenetic in nature.6 Genetic studies of the devel- opment of anxiety disorders have found heritability estimates between 20% and 65%, with the earlier the onset of symptoms, the higher the likelihood of a genetic compo- nent.7 Research in both animal and human studies have found the cortico-amygdala circuitry system to have an important role in anxiety disorders, specifically, the hippo- campus, prefrontal cortex, and dorsal anterior cingulate cortex.8,9 Gene analysis and neuroimaging studies have found positive associations between the serotonin trans- porter gene (5-HTT) and the catechol-O-methyltransferase.8,10

The other 35% to 80% of factors are caused by environmental factors, including stressful life events, traumatic experiences, disrupted attachments, and parental emotional problems.6 Parenting styles and modeling can play significant roles in the development of anxiety disorders, especially, those parents who exhibit anxious, overly critical, insensitive, or overprotective parenting behaviors.11 Other ways in which children learn anxious or fearful responses from their environment include direct negative experiences (neglect, abuse), false alarms (perceiving a situation negatively with no evidence to support this believe), and/or vicariously witnessing or being told something is dangerous.8

ASSESSMENT

Patients with anxiety disorders are 2 times more likely than the general population to present initially with somatic complaints.12 These complaints range from one specific distressing symptom, such as diarrhea or insomnia, to numerous seemingly unrelated symptoms. Common presenting somatic complaints include palpitations, diapho- resis, nausea, abdominal distress, dizziness, and restlessness.13 Symptoms that have been medically worked up with no identified cause should warrant further assessment to rule out anxiety disorders. Table 1 provides an overview of common symptoms and characteristics of anxiety disorders.

GENERALIZED ANXIETY DISORDER

GAD is defined as excessive, uncontrolled worry and tension about daily events and activities occurring more days than not for at least 6 months. GAD occurs when the worries are persistent and cause notable impairments in day-to-day life. Typical symp- toms include irritability, fatigue, restlessness, sleep disturbances, and muscle tension.14 It is considered a chronic illness with symptom severity waxing and waning; however, remittance of symptoms is possible with proper identification and treatment.15

Children and Adolescents

Anxiety disorders are the most common childhood onset of psychiatric disorders8

affecting between 2.9% and 4.6% of children and adolescents.14 In childhood, distri- bution tends to be equal for both women and men; however, in adolescents the female-to-male ratio is as high as 6:1.8 Initial onset of symptoms occurs in school age years with typical onset around 7 years old.8

Table 1 Comparison of anxiety disorders

Anxiety Disorder Key Characteristics

Generalized Anxiety Disorder

Persistent and extremeworry, stress, and anxiety about day-to-day life events

Social Anxiety Disorder Excessive fear and worry around everyday interactions and social situations specifically with how one is perceived and judged by others

Posttraumatic Stress Disorder

Persistent fear or emotional distress as a result of injury or severe psychological shock to a traumatic event with ongoing intrusive symptoms related to the event

Obsessive Compulsive Disorder

Persistent, uncontrollable thoughts (obsessions) that cause fear, anxiety, and emotional distress. Obsessions are commonly accompanied by behaviors (compulsions) that are done to mitigate the anxiety and fear caused by the obsessions

Panic Disorder Characterized by reoccurring panic attacks or sudden feelings of terror and discomfort that arise within minutes

Data from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

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Presentation of symptoms in both children and adolescents typically focus around fears about the family (health-related and safety concerns) and/or school perfor- mance. The symptoms are difficult to stop and/or control. These preoccupations tend to manifest in an “all or nothing” cognitive bias and perfectionism. If the child does not perform perfectly, they develop thoughts and feelings of negative self- worth (ie, they are no good). Rather than focusing on their successes, they tend to perseverate on their mistakes. Many of these children and adolescents have com- plaints of decreased sleep as a result; however, other clinical manifestations include somatic symptoms such as headaches, decreased appetite, and stomach aches, excessive need for reassurance, explosiveness and oppositional behavior, and/or avoidance.8

Adults

GAD is the most common anxiety disorder in primary care settings. It is estimated that 15% to 20% of patients meet criteria for anxiety disorders in primary care settings.16

Lifetime prevalence of GAD has been shown to be up to 33.7% of the general popu- lation.17 Women are twice as likely as men to have GAD.17

Although persistent worrying is considered the basis for GAD, most patients present with other symptoms related to autonomic hyperactivity, hyperarousal, and muscle tension. Many of these patients have complaints of fatigue, poor sleep, difficulty relax- ing, and somatic symptoms including headache and pain in back, shoulders, and neck areas. Younger adults tend to present with greater severity of symptoms than older adults and with more autonomic anxiety.14,18 Older adult worries tend to revolve around physical independence and physical health.18

Predictors of GAD include the following:

� Chronic physical illnesses, � Comorbid psychiatric diagnosis (depression, phobias, past history of GAD), � Recent adverse life events, � Poverty, � Female gender,

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� Parental loss, � History of mental problems in parents, and � Low affective support during childhood.15

SOCIAL ANXIETY DISORDER

Social anxiety disorder is characterized by excessive fear and worry over being scru- tinized, embarrassed, and/or humiliated in social settings.14 There are no significant differences in degree of impairment between lower-, middle-, and higher-income groups.5 Untreated, social anxiety disorder often leads to the development of major depression, substance abuse, and/or other mental health problems.19

Children and Adolescents

Social anxiety disorder commonly presents in childhood or adolescence.19 The average age of onset in the United States is 13 years.5

Typically, children and adolescents present with social anxiety in events or settings that involve peers or adults who are less familial. Children may exhibit symptoms such as crying, freezing, clinging, avoiding speaking, or tantrums. During the assessment interview, children and adolescents will generally be shy or withdrawn with minimal eye contact or responses to questions until they have had time to develop a rapport with the clinician. They will often describe fears of being laughed at, embarrassed, and/or of saying or doing the wrong thing. Their worries tend to revolve around what others think of them rather than what they think of themselves.20

Adults

Social anxiety disorder affects between 3% and 7% of adults in the United States per year; however, lifetime prevalence rates are as high as 12%.19 Lifetime risks of social anxiety disorder are associated with the following risk factors:

� Age of onset, � Female gender, � Unemployment, � Unmarried (never married or widowed/separated/divorced), � Lower educational status, and � Low household income.5

In social or performance situations, symptoms of social anxiety disorder in adults include physical manifestations of anxiety such as diaphoresis, tremors, heart palpita- tions, and facial flushing, which can sometimes result in a panic attack. The person will often worry for hours or days before the feared event or setting; however, there is commonly a fear that others will notice their irrational anxiety and thus symptoms may go unnoticed. They may even avoid the feared setting or event entirely, or if they participate, it is with immense anxiety or more subtle avoidance behaviors such as poor eye contact and/or not engaging in conversations with others. Common feared events and situations include public speaking, large crowds, eating or drinking in public, or even using a public urinal. After the event is over, the person may persev- erate on their shortcomings, feel depressed, and berate themselves.19

POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder (PTSD) presents with 4 main symptom clusters: intru- sion, avoidance, negative alterations in mood and cognition, and hyperarousal.14 To distinguish PTSD from other anxiety disorders, those with the diagnosis must have

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an event precipitating the symptoms. The reoccurring and uncontrollable thoughts, dreams, and emotional reactions are related to the traumatic event. In some individ- uals, dissociative reactions can be present to the extent that the person feels they are reliving the event and may be unaware of their present surroundings.14

Individual prerisk factors for the development of PTSD include the following:

� Female gender, � Lower education, � Lower socioeconomic status, � Previous trauma, � Age at trauma, � Childhood adversity, � Personal and/or family psychiatric history, � History of child abuse, � Poor social support, and � Initial severity of reaction to the traumatic event.21

Children and Adolescents

Although more than 60% of children and adolescence will experience some sort of traumatic event before adulthood, only about 15.9% will develop PTSD.22,23 Rates are similar between boys and girls; however, boys are more likely to experience phys- ical violence, whereas girls are more likely to be victims of sexual abuse.24 Those who experienced the trauma in childhood have more difficulty with affect regulation with an increased severity of symptoms.23

In children, nightmares are not always directly related to the traumatic event but can cause sleep difficulties, including a fear of awakening during or after the dream. Nega- tive emotions in children also increase, including fear, guilt, anger, and shame. Emotional reactivity increases and can present as symptoms of irritability, anger out- bursts, physical violence, or temper tantrums. In addition, anhedonia, decreased con- centration, and decreased social connectedness to others can result in the child or adolescent feeling detached or estranged.23

Adults

The lifetime prevalence of PTSD ranges from 6.1% to 9.2% with higher rates found in North American countries than other regions worldwide.5 Women are twice as likely to develop symptoms of PTSD after a traumatic event.21

Symptoms of PTSD are most often triggered by responses to trauma-related stimuli leading to flashbacks, anxiety, and fleeing or combative behavior. These individuals typically try to avoid the trauma-related stimuli to reduce this intense arousal; howev- er, this can result in anhedonia, emotional numbing, and even detachment from others.

OBSESSIVE COMPULSIVE DISORDER

Obsessive compulsive disorder (OCD) is characterized by uncontrollable, reoccurring thoughts, sensations, feelings (obsessions), behaviors that drive them to do some- thing repeatedly (compulsions), or both. The individual can attempt to ignore or sup- press the obsessive thoughts or to neutralize them by some other thought or action, such as performing a compulsion. Compulsive behaviors then are aimed at reducing anxiety or preventing some imagined event or situation; however, these acts are excessive and/or not realistically connected to what they are designed to neutralize.14

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Compulsions are not pleasurable for the individual and thus not to be mistaken for an impulsive act that is associated with immediate gratification (ie, gambling, shopping). Obsessions are also not associated with day-to-day worries, which occur in GAD or are regarding perceived defects in physical appearance, which occur in body dysmorphicdisorder.25

Children and Adolescents

OCD typically presents in childhood or adolescence and persists throughout a per- son’s life. Without treatment, symptoms are chronic but fluctuate for most individuals. Average onset of symptoms is between 9 and 11 years for male children and 11 and 13 years for female children. Mens are more commonly affected in childhood than women.26

Children with OCD are more likely to present with obvious compulsions than with obsessions such as the washing of their hands excessively. For some children, detect- ing obsessions can be difficult for practitioners because very young children may not be able to verbally describe their obsessions. Untreated and undiagnosed OCD in chil- dren and adolescents can lead to difficulty with separation-individuation from parents and occupational achievement as adults.27

Rarely, children may develop sudden onset of episodic symptoms with concomitant motor tics, hyperactivity, or choreiform movements. This presentation has been asso- ciated with underlying infectious agents in several case studies of children with OCD.28

Adults

The lifetime prevalence rate of OCD among adults in North America is estimated at 3.7%.29 Although the specific content of compulsions and obsessions varies among individuals, there are identifiable themes, or “symptom dimensions,” which include the following:

� Harm: examples include fears of harm to self or others and associated checking compulsions (eg, door locks)

� Symmetry: examples include alignment or symmetry obsessions and counting, ordering, and repeating compulsions

� Cleaning: examples include fear of contamination and cleaning compulsions (eg, excessive hand washing)

� Forbidden or unacceptable thoughts: examples include sexual, religious, and/or aggressive obsessions and related compulsions30

Because of the severity of symptoms, it is common for adults with OCD to exhibit avoiding behaviors and struggle with suicidal ideation.30 Beliefs around obsessions and compulsions can cause individuals to have dysfunctional beliefs including perfec- tionism, overvaluing need to control thoughts and their importance, and a tendency to overestimate threats.

PANIC DISORDER

Individuals with panic disorder suffer from reoccurring panic attacks that are either un- expected or triggered by something in their environment. Panic attacks are short ep- isodes of intense fear that culminate within minutes. Symptoms of panic attacks include the following:

� Feelings of impending doom, � Trembling or shaking,

Anxiety Disorders in Primary Care Settings 479

� Paresthesias, � Diaphoresis, � Heart palpitations, accelerated heart rate, or pounding heartbeat, � Sensations of choking, shortness of breath, chest pain, or not being able to catch one’s breath, and

� Feelings of being out of control.31

People with panic attacks often worry about when the next episode will occur and will actively try to avoid a reoccurrence of a panic attack by avoiding things, places, or behaviors that they associate with panic attacks.31 Concern over upcoming panic at- tacks causes significant disruption in a person’s life and can lead to the development of other psychological disorders such as agoraphobia.31

Children and Adolescents

Rarely do panic attacks begin in childhood or adolescence, but when they do, they can be extremely debilitating for the individual.32 Without recognition and appropriate treatment, panic attacks can interfere with the child or adolescent’s schoolwork, development, and relationships. Since the fear of panic attacks can lead to anxiety even when panic attacks are not present, the child or adolescent’s mood is also affected. Some children and adolescents with panic disorder can develop depression and suicidal thoughts/behaviors and are at higher risk of abusing drugs or alcohol.32

Adults

Statistics on lifetime prevalence rates of panic attacks for adults for all countries combined has been shown to be around 13.2%.5 Panic attacks typically develop af- ter age 20 years with the median age of onset being 32 years with higher prevalence in women.5 They can lead to interruptions in one’s occupational and social life, as it is common for those with panic attacks to miss work and avoid situations where a panic attack might occur. It can also be a financial burden for those experiencing panic attacks, as they tend to have more frequent visits to their doctor and/or emer- gency room, convinced that they are experiencing a life-threatening medical emergency.33

PSYCHOMETRIC SCREENING TOOLS Children and Adolescents

Some studies suggest that parents and children can differ in their reports on symp- toms and severity; therefore, it is pertinent to obtain the child or adolescent’s own perception of symptoms.34 Some children may even feel more comfortable endorsing symptoms of anxiety and related functional impairments in a questionnaire versus in an interview.35 For an overview of free child and adolescent psychometric scales for anxiety see Table 2.

Adults

Because of time constraints in primary care settings, psychometric tools can be helpful in identifying anxiety disorders in adult populations. Psychometric tools assist the provider in diagnosing, treating, and assessing changes in anxiety levels following treatment response; however, it is pertinent to ensure that the patient’s subjective response is also considered when evaluating changes in symptoms severity. Treatment decisions should thus be dictated by patient choice and subjec- tive experience.4 For an overview of free adult psychometric scales for anxiety see Table 3.

Table 2 Free, online child and adolescent psychometric scales for anxiety disorders

Scale Description Number of Items Administration Psychometric Properties Obtainable

Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS)

Screening tool for obsessive compulsive behaviors

Monitors symptom changes over time

10 Parent-reported Sensitive to change http://icahn.mssm.edu/ research/centers/center-of- excellence-for-ocd/rating- scales

Penn State Worry Questionnaire for Children (PSWQ-C)

Screening tool for generalized anxiety disorder

16 Self-reported http://www.childfirst.ucla. edu/Resources.html

Child PTSD Symptom Scale (CPSS)

Screening and diagnostic tool for children and adolescents aged 8–18 y

24 Self-administered or clinician-reported

Sensitive to change ude.nnepu.dem.liam@aof

Mini-Social Phobia Inventory (Mini-SPIN)-1

Screening tool for social phobia studied in adolescents

3 Self-administered Accurate and efficacious [email protected]

Hamilton Rating Scale for Anxiety (HAM-A)-

Screening tool for anxiety symptoms studied in adolescents

Monitors symptom changes over time

14 Clinician-reported Sensitive to change http://psychology-tools.com/ hamilton-anxiety-rating- scale/

Data from Beidas RS, Stewart RB, Walsh L, et. al. Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cogn Behav Pract. 2016; 22(1):5-19 and Connor KM, Kobak KA, Churchill LE, et. al. Mini-SPIN: a brief screening assessment for generalized social anxiety disorder. Depress. Anxiety 2001; 14(2):137-140.

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Table 3 Free, online adult psychometric scales for anxiety disorders

Measure Description Number of Items Administration

Psychometric Properties Obtainable

Generalized Anxiety Disorder Screener (GAD-7)

Screening and diagnostic tool for generalized anxiety disorder

Monitors symptom changes over time

7 Self-administered Reliability in primary care settings was 0.91

https://www.integration.samhsa. gov/clinical-practice/screening- tools#anxiety

Penn State Worry Questionnaire (PSWQ)

Screening tool for generalized anxiety disorder

Differentiates PTSD from generalized anxiety disorder

16 Self-administered 71.7% sensitivity and 99.9% specificity

https://www.outcometracker.org/ library/PSWQ.pdf

Hamilton Rating Scale for Anxiety (HAM-A)

Screening tool for anxiety symptoms

Monitors symptom changes over time

14 Clinician-reported Sensitive to change http://psychology-tools.com/ hamilton-anxiety-rating-scale/

Liebowitz Social Anxiety Scale Clinician/ Self-Report (LSAS-CR/SR)

Assesses avoidance and fear of social situations

Screening tool for social anxiety symptoms

Monitors symptom changes overtime

24 Self-administered or clinician- reported

Sensitive to change http://healthnet.umassmed.edu/ mhealth/ LiebowitzSocialAnxietyScale. pdf

http://asp.cumc.columbia.edu/ SAD/

Social Phobia Inventory (SPIN)

Screening tool for social phobia Monitors symptom changes over

time

17 Self-administered Sensitive to change http://www.psychtoolkit.com

Panic Disorder Severity Scale (PDSS)

Diagnostic and screening tool for Panic Disorder

Monitors symptom changes over time

7 Clinician-reported Sensitive to change http://www.outcometracker.org

The PTSD Checklist–Civilian Version (PCL-C)

Diagnostic and screening tool for PTSD

17 Self-administered Sensitive to change http://www.istss.org/assessing- trauma/posttraumatic-stress- disorder-checklist.aspx

Data from Refs.36–38

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PHARMACOTHERAPY

Themajor neurotransmitters studied in relation to the pharmacologic treatment of anx- iety disorders include norepinephrine, serotonin, and gamma-aminobutyric acid. Peo- ple with anxiety disorders have malfunctioning noradrenergic systems with low threshold levels for arousal. When coupled with an unpredictable increase in activity, anxiety symptoms manifest.39

The goal of medication treatment of anxiety is to reduce severity of symptoms, improve overall functioning, and attain remission of symptoms. There are numerous classes of anxiolytic medications that are approved for treatment of anxiety disorders; however, there are few studies directly comparing the efficacy of specific medications. Therefore, when selecting a medication, it is pertinent to consider patient preferences, severity of symptoms, comorbidities including past or current history of substance abuse, history of previous treatment, and cost.13 It is always crucial to weigh the risks of pharmacologic treatment, but this is especially crucial in the child and adolescent populations due to concerns around increased risk of suicide with certain classes of medications.40 Once a medication has been selected, it should be continued for 6 to 12 months after remission of symptoms to reduce likelihood of relapse.40 Tables 4 and 5 include an overview of pharmacologic treatment options for each anxiety dis- order in children and adolescents and adults, respectively, including common side ef- fects, dosage range, and approvals from Food and Drug Administration.

NONPHARMACOLOGIC STRATEGIES

Psychotherapy modalities and interventions have been widely explored in the treat- ment of anxiety disorders. Among these different therapies, cognitive behavioral ther- apy (CBT) has the strongest evidence and is considered a first-line treatment option as monotherapy and/or concomitantly with medication treatment.13 A combination of CBT with pharmacotherapy has been shown in several studies to be the superior choice in the treatment of children, adolescence, and older adults.41,42 If accessibility or affordability is a concern, several studies have found that internet-based CBT for panic disorder, OCD, and PTSD are superior to placebo, placement on a waiting list, and results to be equivalent to standard CBT.43

Evidence supports that both short- and long-term exercises can have anxiolytic ef- fects.43,44 Adults who regularly exercise report experiencing fewer anxiety symptoms, supporting the assumption that exercise has protective factors against the develop- ment of psychological disorders.45

Another practice associated with anxiolytic effects is meditation.46 Single mindful- ness sessions, even as short as 5 minutes, offer psychological benefits including an increased sense of well-being and reduced anxiety levels.47,48 When combined with aerobic exercise, either before or after, mindfulness may achieve higher additional anxiolytic benefits than exercise or medication alone.49

DISCUSSION

Identification, treatment, and management of anxiety disorders can be challenging. Screening tools can be very helpful in recognizing symptoms of anxiety disorders so that further evaluation and work-up can be performed by the provider during the interview. The primary care provider is often the first to learn of a patient’s anxiety or traumatic experience. More severe or treatment-resistant anxiety disorders are best managed with collaboration and consultation with mental health providers and therapists. In addition, referrals should be considered when there are multiple mental

Table 4 Pharmacological treatment of anxiety disorder in children and adolescents

Medication Dosage Range Common Side Effects

Commonly Prescribed for (Bold for FDA Approval) Comments

SSRI Nausea, insomnia, somnolence, jitteriness, diarrhea, sexual dysfunction

Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18–24 y of age) with major depressive disorder (MDD) and other psychiatric disorders.

Citalopram 10–40 mg OCD

Fluoxetine 7–18 y: 10–60 mg OCD

Fluvoxamine 8–11 y: IR: 25–200 mg 12–18 y: IR: 25–300 mg

OCD Note: When total daily dose of immediate release exceeds 50 mg, the dose should be given in 2 divided doses with larger portion administered at bedtime.

The extended-release formulation has not been evaluated in pediatric patients.

Paroxetine 7–17 y: 10–60 mg 8–17 y: 10–50 mg

OCD SAD

Sertraline 6–12 y: 25–200 mg 12–18 y: 50–200 mg

OCD

SNRI Nausea, insomnia, somnolence, jitteriness, sexual dysfunction, hypertension

Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18–24 y of age) with MDD and other psychiatric disorders

Duloxetine 7–17 y: 30–120 mg GAD

Benzodiazepines Somnolence, dizziness

Safety and efficacy not established in children and adolescents; however, used often but at lower end of dosing scale.

Use with caution due to risk of tolerance, abuse, addiction, overdose, and/or withdrawal symptoms.

Must be discontinued gradually, as abrupt or overly rapid reduction can cause life-threatening withdrawal symptoms (ie, seizures).

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Ta 4 (co nued )

Me ation Dosage Range Common Side Effects

Commonly Prescribed for (Bold for FDA Approval) Comments

A azolam 7–18 y: IR: 0.005 mg/kg/dose or 0.125 mg/dose TID–0.02 mg/kg/dose or 0.06 mg/kg/d

Anxiety

L zepam <12 y: 0.05 mg/kg/dose or 0.02–0.1 mg/kg/dose

12–18 y: 0.25–6 mg/d; maximum dose: 2 mg/dose

Anxiety, acute

Tri ic A depressants

Orthostasis, anticholinergic, weight gain, cardiac arrhythmias

Use with caution in those with active suicidal ideation. May be lethal in overdose.

Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18–24 y of age) with MDD and other psychiatric disorders

C ipramine 25–200 mg/d or 3 mg/kg/d OCD Initially titrate in divided doses. After titration may give as single dose daily at bedtime.

Ot medication

H roxyzine <6 y: 50 mg/d 6–18 y: 50–100 mg/d

Dry mouth, dry eyes, sedation

Anxiety, acute Usually administered in divided doses

Abbr tions: IR, instant release; SNRI, serotonin-norepinephrine reuptake inhibitors; SSRI, selective serotonin reuptake inhibitors. Da rom Albano AM, Alvarez E, Brent D, et al. Psychotherapy for anxiety disorders in children and adolescents. https://www.uptodate.com/contents/

psych erapy-for-anxiety-disorders-in-children-and-adolescents. Updated December 4, 2018 and Stahl SM. Prescriber’s Guide. 6th ed. Cambridge, UK: Cambridge Univ ty Press; 2017.

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Table 5 Pharmacologic treatment of anxiety disorder in adults

Medication Dosage Range Common Side Effects

Commonly Prescribed for (Bold for FDA Approval) Comments

SSRI Nausea, insomnia, somnolence, jitteriness, diarrhea, sexual dysfunction

First-line treatment of ongoing anxiety disorders Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18–24 y of age) with major depressive disorder (MDD) and other psychiatric disorders

Citalopram 10–40 mg/d 20–40 mg/d 10–40 mg/d 20–40 mg/d 20–40 mg/d

GAD OCD Panic disorder PTSD SAD

Recommended maximum dosage is 40 mg due to concerns of QT prolongation

Contraindications: use of MAO inhibitors intended to treat psychiatric disorders (concurrently or within 14 d of discontinuing either citalopram or the MAO inhibitor [MAOI]); initiation of citalopram in a patient receiving linezolid or intravenous methylene blue; concomitant use with pimozide

Escitalopram 10–20 mg/d 10–40 mg/d 5–20 mg/d 10–40 mg/d

GAD OCD Panic disorder PTSD

Contraindications: use of MAOIs intended to treat psychiatric disorders (concurrently or within 14 d of discontinuing either escitalopram or the MAOI); initiation of escitalopram in a patient receiving linezolid or intravenous methylene blue; concurrent use of pimozide

Fluoxetine 20–80 mg/d 5–60 mg/d 10–80 mg/d 10–60 mg/d

OCD Panic disorder PTSD SAD

Contraindications: use of MAOIs intended to treat psychiatric disorders (concurrently, within 5 wk of discontinuing fluoxetine or within 2 wk of discontinuing the MAOI); initiation of fluoxetine in a patient receiving linezolid or intravenous methylene blue; use with pimozide or thioridazine

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Table 5 (continued )

Medication Dosage Range Common Side Effects

Commonly Prescribed for (Bold for FDA Approval) Comments

Fluvoxamine IR: 50–300 mg/d ER: 100–300 mg/d IR: 25–200 mg/d IR: 75 mg BID/d IR: 50–300 mg/d ER: 100–300 mg/d

OCD Panic disorder PTSD SAD

Note: manufacturer’s labeling recommends that daily doses >100 mg be given in 2 divided doses, with the larger dose administered at bedtime

Contraindications: concurrent use with alosetron, pimozide, thioridazine, or tizanidine; use of MAOIs intended to treat psychiatric disorders (concurrently or within 14 d of discontinuing either fluvoxamine or the MAOI); initiation of fluvoxamine in a patient receiving linezolid or intravenous methylene blue

Paroxetine 20–50 mg/d 20–60 mg/d 10–60 mg/d CR: 12.5–75 mg/d 20–50 mg/d 20–60 mg/d CR: 12.5–37.5 mg/d

GAD OCD Panic disorder PTSD SAD

Contraindications: concurrent use with or within 14 d of MAOIs intended to treat psychiatric disorders; initiation in patients being treated with linezolid or methylene blue IV; concomitant use with pimozide or thioridazine; pregnancy (Brisdelle only)

Sertraline 25–200 mg/d 50–200 mg/d 25–200 mg/d 25–200 mg/d 25–200 mg/d

GAD OCD Panic disorder PTSD SAD

Contraindications: use of MAOIs including linezolid or methylene blue (concurrently or within 14 d of stopping an MAOI or sertraline); concurrent use with disulfiram (oral solution only); concurrent use with pimozide

SNRI Nausea, insomnia, somnolence, jitteriness, sexual dysfunction, hypertension

Second-line treatment for ongoing anxiety disorders Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18–24 y of age) with MDD and other psychiatric disorders

Contraindications: use of MAOIs intended to treat psychiatric disorders (concurrently or within 14 d of discontinuing the MAOI); initiation of MAOI intended to treat psychiatric disorders within 7 d of discontinuing venlafaxine; initiation in patients receiving linezolid or IV methylene blue

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Duloxetine 30–120 mg/d GAD

Venlafaxine ER: 37.5–225 mg/d IR: 75 mg TID–350 mg/d ER: 75–350 mg/d ER: 37.5–225 mg/d ER: 37.5–300 mg/d ER: 37.5–225 mg/d

GAD OCD Panic disorder PTSD SAD

Benzodiazepines Somnolence, dizziness Lowest possible effective dose for shortest possible period of time

Usually administered in divided doses Use with caution due to risk of tolerance, abuse, addiction, overdose, and/or withdrawal symptoms

Must be discontinued gradually, as abrupt or overly rapid reduction can cause life-threatening withdrawal symptoms (ie, seizures)

Contraindications: acute narrow-angle glaucoma; severe respiratory insufficiency (except during mechanical ventilation)

Alprazolam IR: 0.25–4 mg/d IR: 0.5–6 mg/d ER: 0.5–6 mg/d

GAD Panic disorder

Clonazepam 0.25 BID–4 mg/d Panic disorder

Diazepam 2–40 mg/d Anxiety disorder and symptoms of anxiety (short-term)

Lorazepam 2–10 mg/d Anxiety disorder

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Me ation Dosage Range Common Side Effects

Commonly Prescribed for (Bold for FDA Approval) Comments

Tri ic A idepressants

Orthostasis, anticholinergic, weight gain, cardiac arrhythmias

Use with caution in those with active suicidal ideation. May be lethal in overdose

Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18–24 y of age) with MDD and other psychiatric disorders

Contraindications: acute recovery period after a myocardial infarction; use of MAOIs intended to treat psychiatric disorders (concurrently or within 14 d of discontinuing either imipramine or the MAOI)

C ipramine 25–250 mg/d 10–250 mg/d

OCD Panic disorder

Initially titrate in divided doses. After titration may give as single dose daily at bedtime

I ramine 10–239 mg/d 50–300 mg/d

Panic disorder PTSD

Ot medication

B irone 10–30 mg/d in 2–3 divided doses; maximum 60 mg/d

Dizziness, seating, nausea, insomnia, somnolence

GAD Administered in 2–3 divided doses Contraindications: concomitant use ofMAOI orMAOI use within past 14 d before starting medication

Lo ve

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ve 4 8 8

ble nti

dic

cycl nt

lom

mip

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usp

Hydroxyzine 50–400 mg/d Dry mouth, dry eyes, sedation

Anxiety, acute Usually administered in divided doses Contraindications: prolonged QT interval, early pregnancy

Gabapentin 300 mg BID–1800 mg TID; maximum 3600 mg/d

300 mg BID–1800 mg TID; maximum 3600 mg/d

Somnolence, dizziness Anxiety (adjunct) SAD

Usually administered in divided doses

Pregabalin IR: 150 mg BID–300 mg BID; maximum 600 mg/d

300 mg/d in 3 divided doses–600 mg/d

Somnolence, dizziness GAD SAD

Usually administered in divided doses

Propranolol 10–60 mg per anxiety-inducing event

10–240 mg/d

Bradycardia, hypotension, dizziness, weight gain

Anxiety, acute (SAD, performance anxiety, panic)

PTSD, prophylactic

Encourage patient to try out medication before precipitating event to determine tolerability and efficacy

May theoretically block effects of stress from trauma but evidence is limited and mixed

Contraindications: history of asthma, diabetes, and certain cardiac conditions (conduction problems)

Quetiapine IR: 25–300 mg/d ER: 50–300 mg/d IR: 25–400 mg/d IR: 25–800 mg/d

Somnolence, dizziness, weight gain, and other long-term metabolic side effects

GAD OCD PTSD

Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18–24 y of age) with MDD and other psychiatric disorders

Abbreviations: ER, extended release; IR, instant release; IV, intravenously; SNRI, serotonin-norepinephrine reuptake inhibitors; SSRI, selective serotonin reuptake inhibitors.

Data from Stahl SM. Prescriber’s Guide. 6th ed. Cambridge, UK: Cambridge University Press; 2017 and Bystritsky A, Hermann R, Stein MB. Pharmacotherapy for generalized anxiety disorder. https://www.uptodate.com/contents/pharmacotherapy-for-generalized-anxiety-disorder-in-adults?search5pharmacology%20of% 20anxiety%20disorders&source5search_result&selectedTitle51w150&usage_type5default&display_rank51. Updated August 31, 2018. Accessed December 18, 2018.

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health and/or medical comorbidities, a high number of concomitant medications, or if there is concern for the patient’s personal safety or safety of others. If safety concerns are imminent, emergent care should be obtained through the crisis center helpline or other available community resources. A validating, empathetic, and resourceful encounter is pertinent in helping to increase the likelihood of early intervention and treatment. Potential for improved treatment outcomes may be maximized by using evidence-based recommendations and guidelines in the pharmacologic approach. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibi- tors are the preferred first-line treatments. Benzodiazepines should be used with caution and in short-term settings as adjuncts to initial pharmacologic treatment. All agents should be used after consideration of their risks and benefits to the patient in order to maximize patient compliance and treatment response.

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