Consultant. Vol. 49 No. 4

Pages: 1 2

Anxiety Disorders:
Guidelines for Effective Primary Care,
Part 2, Treatment

(Anxiety Disorders: Part 1, Diagnosis)

By HANI RAOUL KHOUZAM, MD, MPH
VA Central California Health Care Center, Fresno
University of California, San Francisco | April 1, 2009

Dr Khouzam is medical director, chemical dependency treatment program, Veterans Affairs Central California Health Care System, Fresno. He is also clinical professor of psychiatry, University of California, San Francisco, Medical School Fresno Medical Education Program. The author reports no conflicts of interest concerning the subject matter of this article.

PHARMACOLOGICAL TREATMENT

Most pharmacological therapies for uncomplicated anxiety disorders can be initiated and monitored in the primary care setting.⁷ A broad range of pharmacological agents are available; these include:

• Selective serotonin reuptake inhibitors (SSRIs).
• Serotonin norepinephrine(Drug information on norepinephrine) reuptake inhibitors (SNRIs).
• Tricyclic antidepressants (TCAs).
• Monoamine oxidase inhibitors (MAOIs).
• Buspirone(Drug information on buspirone).
• Benzodiazepines.

Table 1a

Table 1b

Table 1c

Table 1d

Table 2

The selection of a specific agent usually depends on the clinical presentation, the patient’s personal and family history of response to a specific agent, patient preference, the provider’s experience, cost, and informed consent.^1,2,11,12 Common pharmacological agents that are used to treat anxiety disorders are listed in Table 1 a, b, c, d.

Because of their safety and efficacy, the SSRIs are generally considered first-line treatment for anxiety disorders.^3,7 It is important to be aware of the antidepressant product labeling mandated by the FDA, which includes warnings about the increased risk of suicidal thinking and behavior in young adults.

Sexual side effects are associated with decreased adherence to SSRI maintenance therapy.¹³ Strategies to minimize these undesired effects may include using an antidepressant that is not associated with sexual side effects, switching to a different antidepressant if symptoms emerge, adding adjunctive medications to counteract side effects, and adjusting the dose and dosing schedule. A medication holiday in anticipation of sexual activity is not advisable because some reports suggest an increase in relapses occurs even with short medication holidays.^3,13

The SNRIs, TCAs, and benzodiazepines may be considered when patients have not responded to SSRIs or when their adverse effects exceed their benefits.¹⁴ MAOIs are rarely used to treat anxiety in the primary care setting because of the need for strict monitoring of intake of tyramine- containing food as well as potentially serious interactions with other medications, alcohol(Drug information on alcohol), and illicit drugs.

Benzodiazepines are especially useful in the management of acute situational anxiety disorder and adjustment disorder, in which the duration of pharmacotherapy is anticipated to be 6 weeks or less, and for the immediate relief of panic attacks.¹⁵ The risk of addiction with benzodiazepines should be carefully considered before they are used to treat anxiety disorders. These agents should be avoided in patients with a history of alcohol or other drug abuse.^1,3,15

When anxiety symptoms persist, non–FDA-approved medications may be used off-label, either as adjunctive or as primary agents (Table 2). The rationale for using these medications needs to be carefully detailed and documented.¹⁵

Acknowledgments: The author thanks the VA Medical Center director, Mr Alan Perry, FACHE, for his administrative support; Drs Robert Hierholzer, Nestor Manzano, Scott Ahles, and Craig C. Campbell for their clinical guidance; Dr Avak A. Howsepian for his constructive criticism; Matthew Battista, PhD, Thomas Williams, MSW, and Leonard Williams, PA, for their encouragement; and Ms Emma Nichols for her computer assistance.

Additional Resources for Patients With Anxiety Disorders

Anxiety Disorders Association of America
8730 Georgia Avenue, Suite 600
Silver Spring, MD 20910
Telephone: 240-485-1001
Fax: 240-485-1035
http://www.adaa.org

Mental Help NetCenter Site, LLC
570 Metro Place
Dublin, OH 43017
http://mentalhelp.net/poc/center_index.php?id=1

National Institute of Mental Health
Toll-free information line: 866-615-6464
http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

National Mental Health Association
2001 Beauregard Street,
12th Floor
Alexandria, VA 22311
Telephone: 800-969-6642
Fax: 703-684-5968
TDD: 800-433-5959
http://www.mentalhealthamerica.net/go/information/get-info/anxiety-disorders

Part 1 of this article:
Anxiety Disorders: Guidelines for Effective Primary Care, Part 1, Diagnosis

Pages: 1 2

REFERENCES:
1. Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2007.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
3. Gabbard GO. Treatments of Psychiatric Disorders. 3rd ed. Vols 1 & 2. Washington, DC: American Psychiatric Publishing; 2001.
4. Kendrick T. Depression in adults: GPs are not so bad at diagnosis. BMJ. 2008;336:522.
5. Khouzam HR. Depression: guidelines for effective primary care, part 1, diagnosis. Consultant. 2007;47:757-764.
6. Khouzam HR. Depression: guidelines for effective primary care, part 2, treatment. Consultant. 2007;47:841-848.
7. Kroenke K, Spitzer RL, Williams JB, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317-325.
8. Cottraux J, Note I, Yao SN, et al. Randomized controlled comparison of cognitive behavior therapy with Rogerian supportive therapy in chronic posttraumatic stress disorder: a 2-year follow-up. Psychother Psychosom. 2008;77:101-110.
9. Bodden DH, Dirksen CD, Bögels SM, et al. Costs and cost-effectiveness of family CBT versus individual CBT in clinically anxious children. Clin Child Psychol Psychiatry. 2008;13:543-564.
10. Baetz M, Griffin R, Bowen R, Marcoux G. Spirituality and psychiatry in Canada: psychiatric practice compared with patient expectations. Can J Psychiatry. 2004;49:265-271.
11. Lépine JP. The epidemiology of anxiety disorders: prevalence and societal costs. J Clin Psychiatry. 2002;63(suppl 14):4-8.
12. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Panic Disorder. Washington, DC: American Psychiatric Association; 1998.
13. Akpafflong MJ, Wilson-Lawson M, Kunik ME. Antidepressant-associated side effects in older adult depressed patients. Geriatrics. 2008;63:18-23.
14. Bourin M, Lambert O. Pharmacotherapy of anxious disorders. Hum Psychopharmacol. 2002;17:383-400.
15. Otto MW, Pollack MH, Gould RA, et al. A comparison of the efficacy of clonazepam and cognitivebehavioral group therapy for the treatment of social phobia. J Anxiety Disord. 2000;14:345-358.

FOR MORE INFORMATION:
• Khouzam HR, Tan D, Gill TS. Handbook of Emergency Psychiatry. Philadelphia: Mosby; 2007.

TOPIC INDEX

Developmental/Genetic

Nutritional/Metabolic

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Anxiety Disorders: Guidelines for Effective Primary Care, Part 2, Treatment (Anxiety Disorders: Part 1, Diagnosis)

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Anxiety Disorders:
Guidelines for Effective Primary Care,
Part 2, Treatment

(Anxiety Disorders: Part 1, Diagnosis)