Download Anxiety - Catterick & Colburn Medical Group

Anxiety
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Key messages
Prevalence of mental health disorders
Types of anxiety disorders
Recognition and diagnosis
– Generalised Anxiety Disorder (GAD)
– Panic disorder (PD)
– Post-Traumatic Stress Disorder (PTSD)
– Obsessive Compulsive Disorder (OCD)
– Social Phobia
Anxiety disorders – key messages
NICE CG 22, December 2004 (amended April 2007)
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Disorders are:
– Common
– Chronic
– The cause of considerable distress and disability
– Often unrecognised and untreated
Left untreated they are costly to the individual and society
There are a range of interventions available
– Medication
– Psychological therapies
– Self-help
Individuals do get better and remain better
Involving patients in partnership, with shared decision making, improves outcomes
Access to information, including support groups, is a valuable part of any package
of care
Prevalence of mental health disorders
Neurotic disorders (Ages 16-74)
16.4%
Mixed anxiety and depression
8.8%
Generalised anxiety disorder
4.4%
Depressive episodes
2.6%
Phobias
1.8%
Obsessive compulsive disorder
1.1%
Panic disorder
0.7%
Personality disorders
0.4%
Probable psychotic disorders
0.5%
Alcohol misuse and dependence
Hazardous drinking pattern in last year
26%
Dependence
7.7%
Drug use and dependence
Use of illegal drugs in the last year
11% (10% cannabis)
Types of anxiety disorders
NICE CG 22 December 2004 (amended April 2007); NICE CG 26
March 2005; NICE CG 31 November 2005
Generalised anxiety disorder (GAD)
Panic disorder (PD)
Obsessive compulsive disorder (OCD)
Post-traumatic stress disorder (PTSD)
Also (not covered by current NICE guidance)
Mixed anxiety and depression
Social phobia (social anxiety disorder)
Specific phobias (spiders, flying)
NB all often co-exist with other disorders
(eg depression, personality disorders, substance misuse)
NICE CG 22
NICE CG 22
NICE CG 31
NICE CG 26
Recognition and diagnosis
NICE TA 97, February 2006
• Anxiety disorders are common but often go unrecognised
– Only an small minority with anxiety disorders actually
undergo treatment
• Often co-exist with other disorders
• DSM-IV and ICD-10 definitions
– Specific descriptions of features that must be present (or
absent for diagnosis)
• Issue of medicalising normal human experience and
responses?
Baldwin DS, et al. J Psychopharm 2005;19:567–96
Treatment
NICE TA 97 February 2006; NICE CG 22 December 2004
(amended April 2007); NICE CG 31, November 2005
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Psychological therapies
Pharmacological therapies
Both
Stepped care approaches recommended in recent clinical
guidelines eg
– Recognition and diagnosis
– Offer treatment in primary care
– Review and offer alternative treatment
– Review and offer referral
– Care in specialist mental health services
Psychological therapies
NICE TA 97 February 2006; NICE CG 22 December 2004
(amended April 2007); NICE CG 31, November 2005
• Generally cognitive behavioural therapy (CGT)
– Aims to reduce dysfunctional emotions and behaviours by altering
individual appraisals and thinking patterns and factors controlling
behaviours
– Self-exposure to situations of increasing difficulty and diary keeping to
record thoughts, beliefs etc before, during and after exposure
• Should be delivered by trained and supervised people, adhering to
protocols
• Optimal length of treatment varies
– GAD optimal range 16-20h in weekly sessions of 1-2h completed
within 4m
– PD optimal range 7-14h in weekly sessions of 1-2h completed within
4m
Pharmacological therapies
• SSRIs – licensed indications vary
• Benzodiazepines – very limited roles
• Other agents – venlafaxine, imipramine, pregabalin
• NICE CG 22 states that before prescribing consider:
– Age
– Previous treatment response
– Risks of deliberate self-harm of overdose
– Possible interactions
– Patient’s preference
– Costs
Safety and adverse effects of SSRIs
NICE CG 22 December 2004 (amended April 2007);
CSM October 2007
• Side-effects include transient increases in anxiety at start of treatment
– Side-effects may be minimised by starting at low dose and slowly
titrating up
• Withdrawal / discontinuation reactions
– All are associated with reactions on stopping or reducing treatment
– Paroxetine and venlafaxine are associated with greater reactions
– A proportion of reactions are individually severe and disabling
– No clear evidence that SSRIs and related antidepressants have
significant dependence liability
– Doses should be reduced gradually over several weeks
Benzodiazepines in anxiety disorders (1)
• CSM, Curr Problems Pharmacovigilance January 1988, No21
– Benzodiazepines indicated for short-term relief (2-4 weeks only) of
anxiety that is severe, disabling or subjecting the patient to
unacceptable distress
– Use to treat short-term anxiety is inappropriate and unsuitable
• NICE CG 22 December 2004 (amended April 2007)
– If immediate management of GAD required consider benzodiazepines
– DO NOT USE FOR MORE THAN 2-4 WEEKS
– Benzodiazepines should NOT be prescribed for the treatment of PD
Benzodiazepines in anxiety disorders (2)
• NICE CG 26 on PTSD, March 2005
– Consider SHORT TERM hypnotic where sleep is a major
problem
• NICE CG 31 on OCD, November 2005
– .....anxiolytics (excluding SSRIs) are NOT considered
effective for the treatment of core symptoms of OCD
– The dependence producing effects of benzodiazepines
argue against their use as long-term treatments
– Should not normally be used without co-morbidity (except
cautiously for short periods to counter early activation of
SSRIs
Generalised anxiety disorder (GAD)
Generalised Anxiety Disorder (GAD)
NICE CG 22, December 2004 (amended April 2007)
• Excessive anxiety and worry (apprehensive expectation) occurring more
days than not for a period of at least 6 months, about a number or events
or anxieties. Plus 3 or more of:
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Restlessness
Being easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Disturbed sleep
Prevalence 4.4%
F>M
Single / divorced people
Aged 35-54 years
NICE: GAD management in primary care (1)
NICE CG 22 December 2004 (amended April 2007)
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If immediate management is necessary consider any or all of the following
– Support and information
– Problem solving
– Benzodiazepines (DO NOT USE FOR MORE THAN 2-4 WEEKS)
– Sedating antihistamines
– Self-help
In the longer-term care of individuals, any of the following should be offered,
taking into account the patient preference
– Psychological therapy
– Pharmacological therapy (antidepressant medication)
– Self-help
The treatment option of choice should be available promptly
Monitor treatment outcomes using short, self-complete questionnaires where
possible
Offer referral to specialist mental health services if tried at least 2 interventions
and still significant symptoms
NICE: GAD management in primary care (2)
NICE CG 22 December 2004 (amended April 2007)
• Psychological therapy
– CBT should be used
– Delivered by trained people with close adherence to
empirically grounded treatment protocols
– Optimal 16-20 hours in weekly sessions of 1-2 hours
completed within 4 months
– If briefer CBT (8-10 hours) integrate with self-help
materials, and supplemented with focused information
and tasks
– Monitor outcomes using short-self-complete
questionnaires wherever possible
– If no improvement try another intervention
NICE: GAD management in primary care (3)
NICE CG 22 December 2004 (amended April 2007)
• Pharmacological therapy
– Offer an SSRI unless otherwise indicated
– Inform patients about potential side effects,
discontinuation/withdrawal symptoms, delay in onset of effect, time
course of treatment
– Side effects minimised by low starting dose and slow titration
– Long treatment and doses at high end of dose range may be needed
– Review efficacy and side effects within 2 weeks of starting treatment
and at 4, 6 and 12 weeks
– If improvement after 12 weeks, continue treatment with review at 812 week intervals (try another SSRI or another type of intervention if
no improvement after 12 weeks)
– Use for 6 months after optimal dose reached before tapering dose
– Reduce dose gradually over extended period when stopping
NICE: GAD management in primary care (4)
NICE CG 22 December 2004 (amended April 2007)
Efexor XL SPC
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Venlafaxine
– Before prescribing consider increased likelihood of discontinuation due to side effects
and higher costs vs. equally effective SSRIs
– More dangerous in overdose vs. Paroxetine
– Ensure hypertension controlled
– Do not use if:
• Uncontrolled hypertension
• High risk of serious cardiac arrhythmias
• Recent MI
– Monitor BP at initiation and during treatment
– Check for signs and symptoms of cardiac dysfunction esp. In CV disease
– Maximum dose 75mg daily for extended release prep.
– SPC states discontinue at 8 weeks if no clinical response
NICE: GAD management in primary care (5)
NICE CG 22 December 2004 (amended April 2007)
• Self-help:
– Offer bibliotherapy based on CBT principles
– Consider large group CBT
– Offer information about support groups
– Discuss benefits of exercise
– Computerised CBT may be useful
– Monitor progress as required (every 4-8 weeks likely)
Panic disorder (PD)
Panic disorder (PD)
NICE CG 22, December 2004 (amended April 2007)
• Recurrent unexpected panic attacks, followed by at least one month or
persistent concern about having another panic attack, worry about the
possible implications or consequences of the panic attacks, or significant
behavioural change related to the attacks
– At least 2 unexpected panic attacks are needed for diagnosis of the
disorder
– May be complicated by agorophobia
• Prevalence 0.7%
• Aged 15-25 years
• F:M 2:1
PD management in primary care (1)
NICE CG 22 December 2004 (amended April 2007)
• Psychological therapy
• Pharmacological therapy
• Self-help
• The treatment option of choice should be available promptly
• Offer referral to specialist mental health services is tried at
least 2 interventions and still significant symptoms
PD management in primary care (2)
NICE CG 22 December 2004 (amended April 2007)
• Psychological therapy
– CBT should be used
– Delivered by trained people with close adherence to
empirically grounded treatment protocols
– Optimal 7-14 hours in weekly sessions of 1-2 hours
completed within 4 months
– If briefer CBT (7 hours) integrate with self-help materials,
and supplemented with focused information and tasks
– Sometimes more intensive CBT over a very short period
might be appropriate
– Monitor outcomes using short-self-complete
questionnaires wherever possible
– If no improvement try another intervention
PD management in primary care (3)
NICE CG 22 December 2004 (amended April 2007)
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Pharmacological therapy
– Benzodiazepines, sedating antihistamines and antipsychotics should NOT be prescribed
for the treatment of panic disorder
– Before prescribing drugs consider:
• Age
• Previous treatment response
• Risks
• Tolerability
• Concomitant needs
• Patient preference
• Cost where equal effectiveness
– Unless otherwise contraindicated offer an SSRI licensed for PD. If SSRI unsuitable /
ineffective consider imipramine or clomipramine (both unlicensed)
– Inform patients about potential side effects, discontinuation/withdrawal symptoms,
delay in onset of effect, time course of treatment
PD management in primary care (4)
NICE CG 22 December 2004 (amended April 2007)
– Side effects minimised by low starting dose and slow titration
– Long treatment and doses at high end of dose range may be needed
– Review efficacy and side effects within 2 weeks of starting treatment and at 4, 6 and 12
weeks
– If improvement after 12 weeks, continue treatment with review at 8-12 week intervals
– If no improvement after 12 weeks of SSRI consider imipramine or clomipramine (both
unlicensed)
– Use for 6 months after optimal dose reached before tapering dose
– Reduce dose gradually over extended period when stopping
PD management in primary care (4)
NICE CG 22 December 2004 (amended April 2007)
• Self-help
– Offer bibliotherapy based on CBT principles
– Consider large group CBT
– Offer information about support groups
– Discuss benefits of exercise
– Computerised CBT may be useful
– Monitor progress as required (every 4-8 weeks likely)
Post-Traumatic Stress Disorder (PTSD)
Post-Traumatic Stress Disorder (PTSD)
NICE CG 26, March 2005
• Diagnosis restricted to people who have experienced
exceptionally threatening and distressing events that lead to:
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Re-experiencing the trauma (flashbacks etc)
Avoidance of stimuli associated with the trauma
Inability to recall important aspects of the event
Increased arousal (irritability, sleep disturbance etc)
• Epidemiology unclear
Post-Traumatic Stress Disorder (PTSD)
NICE CG 26 March 2005
• NICE considers interventions and approach separately for adults and
children and at different time points after the event etc
– Early / immediate
– Within 3 months
– Symptoms present for > 3 months
• Trauma-focused psychological therapy (CBT or Eye Movement
Desensitisation and Reprocessing, EMDR) should be routine first-line
treatment
• Do not offer drugs as routine first-line treatment
– Trauma-focused psychological therapy preferred)
Post-Traumatic Stress Disorder (PTSD)
NICE CG 26 March 2005
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Consider paroxetine or mirtazeptine (amitriptyline or phenelzine under specialist
mental health care supervision) in adults:
– If prefers not to engage in or cannot start psychological treatment because of
serious threat of further trauma
– If have not benefitted from a course of further trauma
– As an adjunct to psychological treatment where there is significant co-morbid
depression or severe hyperarousal that significantly affects the individuals
ability to benefit from psychological treatment
If respond to drug treatment continue for at least 12 months before gradual
withdrawal
If don’t respond to initial drug treatment, increase dose or change class or use
adjunctive olanzapine
Only paroxetine licensed for PTSD
For sleep disturbance consider short-term hypnotic or a suitable antidepressant
for longer term use
Obsessive-Compulsive Disorder (OCD)
Obsessive-Compulsive Disorder (OCD)
NICE CG 31, November 2005
• Characterised by:
– Unwanted intrusive thought, image or urge that repeatedly enters a
person’s mind (obsessions), which increase anxiety
– Repetitive behaviours or mental acts that a person feels driven to
perform (compulsions), which decrease anxiety
– Estimated to affect 1-3% of population
• Useful questions for recognition
– Do you wash or clean a lot?
– Do you check things a lot?
– Is there any thought that keeps bothering you that you would like to
get rid of but can’t?
– Do your daily activities take a long time to finish?
– Are you concerned about putting things in a special order or are you
upset by mess?
– Do these problems trouble you?
Obsessive-compulsive disorder (OCD) in adults
NICE CG 31 November 2005
• Mild functional impairment / low intensity approach:
– Offer CBT (including exposure and response prevention
– Up to 10 specialist hours per patient, brief individual with structured
self-help materials or by phone, or group format
• Moderate functional impairment / CBT inadequate:
– Offer choice of SSRI alone or more intensive CBT
• Severe functional impairment / CBT inadequate
– Offer combined CBT + SSRI
– If inadequate response at 12 weeks offer different SSRI or
clomipramine
– If no response after a full trial of SSRI, combined SSRI + CBT, or
clomipramine, then refer to multidisciplinary team with expertise
Obsessive-compulsive disorder (OCD) in adults
NICE CG 31 November 2005
• For adults, recommends fluoxetine, paroxetine, fluvoxamine or sertraline
(all licensed) or citalopram (unlicensed)
• Should not normally use without co-morbidity:
– TCAs (except clomipramine)
– SNRIs
– MAOIs
– Anxiolytics (except cautiously for shorter periods to counter early
activation of SSRIs)
• Antipsychotics as monotherapy should not normally be used for OCD
Obsessive-compulsive disorder (OCD) in children
NICE CG 31 November 2005
• Children / young people
– Mild functional impairment:
• Consider guided self-help
– Moderate to severe functional impairment / GSH failed or refused:
• Offer CBT (group or individual)
• If inadequate response at 12 weeks / declined, consider SSRI (after
assessment and diagnosis by a child / adolescent psychiatrist) in
combination with CBT
• Consider SSRI + ingoing CBT in groups aged 12-18 years
• If unsuccessful consider different SSRI or clomipramine + ongoing
CBT
Obsessive-compulsive disorder (OCD) in children
NICE CG 31 November 2005
• Sertraline or fluvoxamine should be used when a
SSRI is prescribed except in patients with
significant co-morbid depression when fluoxetine
should be used
• Do not use:
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TCAs
SNRIs
MAOIs
Antipsychotics alone
Social phobia
Social phobia
Schneier FR. N Engl J Med 2006; 355:1029-36
den Boer JA. BMJ 1997; 315: 796-800
• Characterised by a marked persistent fear of behaving in an embarrassing
or humiliating manner while under the gaze of others
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Exposure to feared situation provokes anxiety
Leads to avoidance of situations that stimulate this fear
May be generalised (fears most social situations) or non-generalised
Unrelated to another medical or mental disorder
Person recognises that the fear is excessive /unreasonable
• Lifetime prevalence estimates vary (<1% to 12%?)
Case study
• Caroline is a 37y old mother of two who presents complaining
of feeling overanxious, tired and irritable on most days for the
last 7 months. Recently her mind has been racing at bedtime,
she has difficulty getting to sleep, sometimes taking her over
an hour. She has aching muscles in her neck and shoulders.
She works 3 days a week as a legal assistant in a solicitor’s
office and has been under pressure at work. She has been
finding it difficult to cope and has been experiencing
relationship difficulties with her husband
What further information would you seek?
• Time course of symptomatology in relation to social factors,
work/life balance, level of parental support
• Ask about mood symptoms to rule out depression
• History of smoking, alcohol and caffeine intake
• Ask about recreational drug taking
• Check heart rate and BP
• Any recent body weight changes?
• Is there a cyclical pattern to symptoms?
• What coping strategies has she tried?
• Have any complementary therapies been tried or considered?
What diagnosis would you consider here?
• Generalised anxiety disorder (GAD)
What advice / treatment would you offer at
this stage?
• Self-help
– Bibliotherapy
– Relaxation tapes
• Information about local support groups
• Discuss social support
– Family support
– Childcare
– Benefits
– Parenting groups
• Discuss benefits of exercise
• Consider CBT if locally accessible in acceptable timeframe
• Offer lifestyle advice
– Reducing alcohol / caffeine intake
– Sleep hygiene measures
• She returns 6 weeks later. She has tried self-help, lifestyle and
social measures as suggested. She is no better. She has had
two short periods of stress-related absence from work. She
asks for some medication to help her
What would you suggest now?
• Check all options previously discussed have been attempted
• Consider trialling an antidepressant licensed for GAD eg
escitalopram, paroxetine, trazadone (sedative properties) or
venlafaxine
• Start dosage low and increase slowly to reduce the risk of
transient worsening of anxiety symptoms during early phases
of therapy
• Following discussion you offer paroxetine 20mg daily
What counselling points would you offer
regarding her medication?
• Common side effects
– Nausea / vomiting
– Dyspepsia
– Rash
– Insomnia
– Extra-pyramidal reactions (more common with paroxetine)
• Symptoms may worsen initially. Contact GP is this occurs
• Don’t stop medication suddenly
– Can cause discontinuation reactions eg anxiety,
paraesthesias, ‘electric shock’ like sensations) – requires
gradual withdrawal
How often should she be reviewed?
• Check efficacy and side effects of treatment at 2, 4, 6 and 12
weeks
• Side effects minimised by starting low dose and increasing
slowly
• Higher doses may be required if needed
Should you increase above 20mg paroxetine if
her symptoms don’t respond?
• CSM advise is recommended dose is 20mg for
– Generalised anxiety disorder
– Depression
– Social phobia
– Post-traumatic stress disorder
• 40mg daily is recommended for
– Obsessive compulsive disorder
– Panic disorder
• After taking paroxetine for 12 weeks she returns. She feels a
lot better and asks whether she should stop the treatment
Is it appropriate for her to stop?
• If showing improvement, continue for at least 6 months after
the optimal dose is reached, after which taper the dose
• If after 12 weeks there is no improvement, another SSRI or
another form of therapy should be offered
• Long term treatment may be necessary for some
• Several months later she returns complaining of acute back
pain after lifting. She has tried paracetamol and ibuprofen
• You give 100mg TDS tramadol
• After a few days she complains of sweating, confusion and
increased anxiety
What has caused these symptoms and what
would you advise?
• Tramadol has some serotonin reuptake inhibitory activity
which may augment that of SSRIs
• It is also metabolised via the cytochrome p450 2D6 pathway
• Paroxetine is a potent inhibitor of this enzyme leading to
increased plasma levels
• Stop taking tramadol immediately
End