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Anxiety • • • • 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) • • • • • • 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 • • • • 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: – – – – – – • • • • 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) • • • • • 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 • 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) • 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: – – – – 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 • • • • • 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: – – – – 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 – – – – – 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