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Treatment Options for Anxiety Disorders
PATIENT CARE
Treatment Options for Anxiety Disorders Pharmacists can guide patients to proper diagnosis and treatment of anxiety disorders, the most common form of mental illness.
Anxiety disorders are the most common of all mental illnesses, affecting approximately one out of every eight Americans. More than "just a case of nerves," anxiety disorders are a group of related illnesses characterized by excessive anxiety and disturbances in underlying biological pathways. By achieving a better understanding of anxiety disorders and current therapies, pharmacists can help patients seek and obtain appropriate medical care.
associated with an increased incidence of upper respiratory infections, elevated prostate-speciftc antigen levels (in men), greater sensitivity to pain, higher serum cholesterol levels, and increased incidence of cardiovascular disease. Because people with anxiety disorders use medical services at a high rate, pharmacists are likely to encounter these individuals frequently. Women are twice as likely to have anxiety disorders as men.
Anxiety Versus Fear
Common Anxiety Disorders
Jeannette Wick, RPh, began this session by noting that anxiety di orders are characterized by excessive fear, worry, avoidance, and, ometimes, ritualistic behaviors. Anxiety differs from fear in e veral important respects. Fear is a necessary, short-lived re pon e to an identifiable external stressor (e.g. , a ftre alarm) re ulting in appropriate mental and behavioral reactions (e.g., running toward afety). Anxiety, however, is a response that lacks per pective, results in elaborate and unneeded behaviors, can be of long duration, and lacks an obvious external stressor. A triad of factors contributes to anxiety: (1) activation of the ympathetic nervous system, (2) poor health behaviors (e.g., sleep deprivation, substance abuse), and (3) individual psychosocial characteristics (e.g., poor social skills). These factors are further molded by cultural factors, socioeconomic status, and education. Some anxiety di orders have a genetic component; others appear to re ult from maladaptive learned responses. The ign and ymptoms of anxiety are varied (see Table 1). In addition to affective (emotional) symptoms (e.g. , fear, dread), anxiety can cau e manife tations that are somatic (e.g., hyperventilation dry mouth), behavioral (e.g. , frequent hand washing, other compul ion ), or cognitive (e.g., obsessions). People who suffer from anxiety are more likely to have comorbid illne es, uch as depression or a physical ailment. Anxiety is
Pharmacists can help patients understand that anxiety disorders are true medical conditions for which effective treatments are available. The major anxiety disorders are: • Generalized anxiety disorder (GAD)-usually begins early in life and lasts longer than 6 months. People with GAD continue to feel excessively anxious even in situations in which their past performances have been good. For example, a straight-A student with GAD may fear test taking despite a record of academic achievement. • Social anxiety disorder-is associated with shyness and social inhibition. This disorder, which includes fear of public speaking, rarely occurs when the individual is alone. • Panic disorder-is characterized by periodic attacks causing
Table 1. Signs and Symptoms of Anxiety Feelings of fear or dread Trembling, restlessness, muscle tension Rapid heart rate Lightheadedness or dizziness Perspi ration Cold hands or feet Shortness of breath or hyperventilation
Based on presentations b Jeannette Wick, RPh, chiefpharmacist, director fo r quality improvement; and Walter Fava, RPh, deputy chief pharmaci t, both of St. Elizabeth 's Hospital, Washington, D.C.
S48
upplement to the Journal of the American Phannaceutical Association
Dry mouth Other (e.g., urinary frequency, ringing in ears)
September/October 2001
Vol. 41, No.5, Suppl. 1
Treatment Options for Anxiety Disorders
intense physical and emotional ymptoms, lasting 10 to 15 minute , and re olving within a half hour. Patients worry about future attacks, which may occur at any time. • Posttraumatic stress disorder (PTSD )-has long been associated with Vietnam War veterans, however, PTSD can occur after any trauma (e.g., a car accident, rape). Patients with PTSD often develop alcohol or substance abuse problems. • Obsessive-compulsive disorder (OeD )-consists of obsessions, which are repetitive thoughts that lead to compulsive behaviors (e.g., excessive hand washing, hair pulling, shoplifting, gambling). • Phobias-consist of excessive or irrational fears. Agoraphobia, for example, is a fear of going outside the home.
Treatment Approaches Management of anxiety disorders consists of nonpharmacological and, often, pharmacological treatments.
Counseling Treatment The most successful behavioral interventions make the patient a partner in the recovery process and emphasize biologic repair and self-help. Patients should be encouraged to set reasonable, measurable, achievable goals. The starting point of treatment is patient education to improve sleep hygiene, exercise, and nutrition. Counseling treatment should match the patient's needs and preferences. Options include cognitive-behavioral approaches (e.g., relaxation techniques, graduated exposure to stressors). Other behavioral interventions include eye movement desensitization reprocessing, visualization, hypnosis, and group therapy.
Pharmacological Therapy Walter Fava, RPh, emphasized that drug therapy for patients with anxiety should be individualized, using the lowest effective dose. Pharmacists should ask patients about their response to therapy and inquire about possible side effects. Several major classes of drugs are available to treat anxiety disorders, including benzodiazepines, older antidepressants (monoamine oxidase inhibitors [MAOIs] and tricyclic antidepressants), selective serotonin reuptake inhibitors (SSRIs), and atypical antidepressants. Numerous benzodiazepines are available, and all work by enhancing the inhibitory neurotransmitter 'Y-aminobutyric acid. Benzodiazepines are generally safe and effective, but their usefulness is limited due to their potential for abuse, dependence, drug interactions, and adverse effects (e.g., sedation, fatigue, memory difficulties). However, their rapid onset of action make them useful for treating acute symptoms or as adjunctive therapy for patients receiving medications with a slower onset of action. To prevent withdrawal symptoms, long-term therapy with benzodiazepines should be tapered gradually over a 4-to-8-week period. Several classes of antidepressants are used to treat anxiety disorders. Older agents, such as MAOIs, are rarely used because of their potential to cause interactions with tyramine-containing foods and certain medications. Likewise, tricyclic antidepressants, Vol. 41, No.5, Suppl. 1
September/October 2001
PATIENT CARE
although effective for some anxiety disorders, are not generally recommended because newer agents with improved safety proflies are preferred for most patients. The American Psychiatric Association recommends SSRIs as first-line therapy for anxiety disorders. These drugs inhibit neuronal reuptake of serotonin in the central nervous system and have weak effects on norepinephrine and dopamine neuronal reuptake. The SSRIs vary in their Food and Drug Administration-approved indications for specific anxiety disorders. For example, paroxetine (Paxil-GlaxoSmithKline) is indicated for GAD, social anxiety disorder, OCD, and panic disorder, while sertraline (ZoloftPfizer) is indicated for OCD, posttraumatic stress disorder, and panic disorder. In choosing an SSRI, clinicians should also consider differences among these drugs in their pharmacokinetics, potential interactions with other drugs, dosing, and adverse-event profiles. Patients should be counseled to consult a physician or pharmacist before deciding to stop therapy. Although SSRIs are generally safe and well tolerated, patients who discontinue these medications abruptly may develop serotonin withdrawal syndrome. Conversely, excessive doses of SSRIs may lead to serotonin syndrome. This difficult-to-diagnose disorder can cause varied symptoms, including high fever, agitation, and tremors. Atypical antidepressants also are effective for some patients. For example, venlafaxine (Effexor-Wyeth-Ayerst), which inhibits reuptake of serotonin and norepinephrine, may be especially appropriate for patients with combined depression and GAD. Buspirone (BuSpar-Bristol-Myers Squibb), a selective 5hydroxytryptarnine 1a partial agonist, also may be useful as a treatment for GAD. Pharmacists should be aware that people with anxiety may selfmedicate with herbal remedies, such as kava kava (Piper methysticum), which has been shown to have anxiolytic and sedative effects. Patients should be cautioned not to exceed a daily dose of 300 mg/day, because high doses can cause toxicity. Both speakers emphasized the importance of providing medication counseling for all patients who require pharmacotherapy. Wick advised pharmacists to use the counseling session to screen for actual or potential medication problems, provide support and encouragement, and help patients make informed decisions that will help them achieve agreed-upon goals.
Summary • Anxiety disorders are the most common of all mental illnesses. • People with anxiety disorders are likely to have comorbid illnesses and use health care services at a high rate. • Behavioral interventions should be tailored to the needs and preferences of the patient, who should be treated as a partner in the recovery process. • SSRIs are considered first-line therapy for anxiety disorders, but benzodiazepines and atypical antidepressants also are useful for some patients. Older antidepressants, such as tricyclics and MAOIs, are no longer widely prescribed. This symposium was made possible by an unrestricted educational grant from GlaxoSmithKline. Supplement to the Journal of the American Phannaceutical Association
S49
Treatment Options for Anxiety Disorders Pharmacists can guide patients to proper diagnosis and treatment of anxiety disorders, the most common form of mental illness.
Anxiety disorders are the most common of all mental illnesses, affecting approximately one out of every eight Americans. More than "just a case of nerves," anxiety disorders are a group of related illnesses characterized by excessive anxiety and disturbances in underlying biological pathways. By achieving a better understanding of anxiety disorders and current therapies, pharmacists can help patients seek and obtain appropriate medical care.
associated with an increased incidence of upper respiratory infections, elevated prostate-speciftc antigen levels (in men), greater sensitivity to pain, higher serum cholesterol levels, and increased incidence of cardiovascular disease. Because people with anxiety disorders use medical services at a high rate, pharmacists are likely to encounter these individuals frequently. Women are twice as likely to have anxiety disorders as men.
Anxiety Versus Fear
Common Anxiety Disorders
Jeannette Wick, RPh, began this session by noting that anxiety di orders are characterized by excessive fear, worry, avoidance, and, ometimes, ritualistic behaviors. Anxiety differs from fear in e veral important respects. Fear is a necessary, short-lived re pon e to an identifiable external stressor (e.g. , a ftre alarm) re ulting in appropriate mental and behavioral reactions (e.g., running toward afety). Anxiety, however, is a response that lacks per pective, results in elaborate and unneeded behaviors, can be of long duration, and lacks an obvious external stressor. A triad of factors contributes to anxiety: (1) activation of the ympathetic nervous system, (2) poor health behaviors (e.g., sleep deprivation, substance abuse), and (3) individual psychosocial characteristics (e.g., poor social skills). These factors are further molded by cultural factors, socioeconomic status, and education. Some anxiety di orders have a genetic component; others appear to re ult from maladaptive learned responses. The ign and ymptoms of anxiety are varied (see Table 1). In addition to affective (emotional) symptoms (e.g. , fear, dread), anxiety can cau e manife tations that are somatic (e.g., hyperventilation dry mouth), behavioral (e.g. , frequent hand washing, other compul ion ), or cognitive (e.g., obsessions). People who suffer from anxiety are more likely to have comorbid illne es, uch as depression or a physical ailment. Anxiety is
Pharmacists can help patients understand that anxiety disorders are true medical conditions for which effective treatments are available. The major anxiety disorders are: • Generalized anxiety disorder (GAD)-usually begins early in life and lasts longer than 6 months. People with GAD continue to feel excessively anxious even in situations in which their past performances have been good. For example, a straight-A student with GAD may fear test taking despite a record of academic achievement. • Social anxiety disorder-is associated with shyness and social inhibition. This disorder, which includes fear of public speaking, rarely occurs when the individual is alone. • Panic disorder-is characterized by periodic attacks causing
Table 1. Signs and Symptoms of Anxiety Feelings of fear or dread Trembling, restlessness, muscle tension Rapid heart rate Lightheadedness or dizziness Perspi ration Cold hands or feet Shortness of breath or hyperventilation
Based on presentations b Jeannette Wick, RPh, chiefpharmacist, director fo r quality improvement; and Walter Fava, RPh, deputy chief pharmaci t, both of St. Elizabeth 's Hospital, Washington, D.C.
S48
upplement to the Journal of the American Phannaceutical Association
Dry mouth Other (e.g., urinary frequency, ringing in ears)
September/October 2001
Vol. 41, No.5, Suppl. 1
Treatment Options for Anxiety Disorders
intense physical and emotional ymptoms, lasting 10 to 15 minute , and re olving within a half hour. Patients worry about future attacks, which may occur at any time. • Posttraumatic stress disorder (PTSD )-has long been associated with Vietnam War veterans, however, PTSD can occur after any trauma (e.g., a car accident, rape). Patients with PTSD often develop alcohol or substance abuse problems. • Obsessive-compulsive disorder (OeD )-consists of obsessions, which are repetitive thoughts that lead to compulsive behaviors (e.g., excessive hand washing, hair pulling, shoplifting, gambling). • Phobias-consist of excessive or irrational fears. Agoraphobia, for example, is a fear of going outside the home.
Treatment Approaches Management of anxiety disorders consists of nonpharmacological and, often, pharmacological treatments.
Counseling Treatment The most successful behavioral interventions make the patient a partner in the recovery process and emphasize biologic repair and self-help. Patients should be encouraged to set reasonable, measurable, achievable goals. The starting point of treatment is patient education to improve sleep hygiene, exercise, and nutrition. Counseling treatment should match the patient's needs and preferences. Options include cognitive-behavioral approaches (e.g., relaxation techniques, graduated exposure to stressors). Other behavioral interventions include eye movement desensitization reprocessing, visualization, hypnosis, and group therapy.
Pharmacological Therapy Walter Fava, RPh, emphasized that drug therapy for patients with anxiety should be individualized, using the lowest effective dose. Pharmacists should ask patients about their response to therapy and inquire about possible side effects. Several major classes of drugs are available to treat anxiety disorders, including benzodiazepines, older antidepressants (monoamine oxidase inhibitors [MAOIs] and tricyclic antidepressants), selective serotonin reuptake inhibitors (SSRIs), and atypical antidepressants. Numerous benzodiazepines are available, and all work by enhancing the inhibitory neurotransmitter 'Y-aminobutyric acid. Benzodiazepines are generally safe and effective, but their usefulness is limited due to their potential for abuse, dependence, drug interactions, and adverse effects (e.g., sedation, fatigue, memory difficulties). However, their rapid onset of action make them useful for treating acute symptoms or as adjunctive therapy for patients receiving medications with a slower onset of action. To prevent withdrawal symptoms, long-term therapy with benzodiazepines should be tapered gradually over a 4-to-8-week period. Several classes of antidepressants are used to treat anxiety disorders. Older agents, such as MAOIs, are rarely used because of their potential to cause interactions with tyramine-containing foods and certain medications. Likewise, tricyclic antidepressants, Vol. 41, No.5, Suppl. 1
September/October 2001
PATIENT CARE
although effective for some anxiety disorders, are not generally recommended because newer agents with improved safety proflies are preferred for most patients. The American Psychiatric Association recommends SSRIs as first-line therapy for anxiety disorders. These drugs inhibit neuronal reuptake of serotonin in the central nervous system and have weak effects on norepinephrine and dopamine neuronal reuptake. The SSRIs vary in their Food and Drug Administration-approved indications for specific anxiety disorders. For example, paroxetine (Paxil-GlaxoSmithKline) is indicated for GAD, social anxiety disorder, OCD, and panic disorder, while sertraline (ZoloftPfizer) is indicated for OCD, posttraumatic stress disorder, and panic disorder. In choosing an SSRI, clinicians should also consider differences among these drugs in their pharmacokinetics, potential interactions with other drugs, dosing, and adverse-event profiles. Patients should be counseled to consult a physician or pharmacist before deciding to stop therapy. Although SSRIs are generally safe and well tolerated, patients who discontinue these medications abruptly may develop serotonin withdrawal syndrome. Conversely, excessive doses of SSRIs may lead to serotonin syndrome. This difficult-to-diagnose disorder can cause varied symptoms, including high fever, agitation, and tremors. Atypical antidepressants also are effective for some patients. For example, venlafaxine (Effexor-Wyeth-Ayerst), which inhibits reuptake of serotonin and norepinephrine, may be especially appropriate for patients with combined depression and GAD. Buspirone (BuSpar-Bristol-Myers Squibb), a selective 5hydroxytryptarnine 1a partial agonist, also may be useful as a treatment for GAD. Pharmacists should be aware that people with anxiety may selfmedicate with herbal remedies, such as kava kava (Piper methysticum), which has been shown to have anxiolytic and sedative effects. Patients should be cautioned not to exceed a daily dose of 300 mg/day, because high doses can cause toxicity. Both speakers emphasized the importance of providing medication counseling for all patients who require pharmacotherapy. Wick advised pharmacists to use the counseling session to screen for actual or potential medication problems, provide support and encouragement, and help patients make informed decisions that will help them achieve agreed-upon goals.
Summary • Anxiety disorders are the most common of all mental illnesses. • People with anxiety disorders are likely to have comorbid illnesses and use health care services at a high rate. • Behavioral interventions should be tailored to the needs and preferences of the patient, who should be treated as a partner in the recovery process. • SSRIs are considered first-line therapy for anxiety disorders, but benzodiazepines and atypical antidepressants also are useful for some patients. Older antidepressants, such as tricyclics and MAOIs, are no longer widely prescribed. This symposium was made possible by an unrestricted educational grant from GlaxoSmithKline. Supplement to the Journal of the American Phannaceutical Association
S49