Hi, I'm Tom Salter.

I'm a psychiatrist at Mayo Clinic

in Rochester and I work in

a primary care practice in an

integrated model.

And I'm here today to talk about

generalized anxiety disorder for

primary care.

I

think an important part is

understanding and establishing

the diagnosis of generalized anxiety

disorder. But then we'll get into a

treatment approaches, looking at the

psychotherapy and non-pharmacologic

approaches and the pharmacotherapy,

and we'll touch on some

unique populations as well.

I am an adult psychiatrist.

So the majority the talk will be

for the adult population.

But I will briefly touch on

some aspects in children and

adolescents.

So we'll start with a question that

will pertain to treatment.

Benzodiazepine use in the elderly

is associated with an increased risk

of a hip fracture by what amount?

And we'll come back to that question

at the end.

And another question: What

percentage of patients with

generalized anxiety disorder

self-medicate with alcohol

or drugs for symptom relief?

Again, we'll

see what percentage we come up with.

So let's think about a case to begin

with. And this is sort of built

through my clinical experience

and really goes back to

when I was a resident,

I was in an internal medicine and

psychiatry combined residency.

So I was the primary care physician

for part of my residency.

And I recall how difficult it was

to find time

to address the depression and

anxiety, say, when you have

a relatively short follow up visit

and you're expected to handle the

diabetes in the heart failure and

the hypertension and how difficult

it can be to address the

anxiety in the depression, which of

course are very important as well.

This case will say the

fidgety freelancer, and we'll use

this to sort of demonstrate some of

the concepts I'm going to talk about

today. So a 34 year old woman,

self-employed as a graphic design

artist, presents with multiple

concerns.

Well, she would like to change her

birth control.

She would like her thyroid check due

to difficulty losing weight.

Her melatonin is not working for

sleep problems and she would like

her fatigue addressed.

She missed work last week, and so

she needs a medical excuse for that.

And her insomnia is still not

the best. And her mother takes

Xanax, so she would like

maybe a prescription for that during

the visit.

You know, she's drinking a large

caffeinated beverage and she's

shaking her leg quite a bit.

And so let's think about this

presentation as we're working

through the understanding of the

diagnosis.

So the first question

and I've challenged my colleagues in

behavioral health to think of this

is how often does a given patient in

primary care have generalized

anxiety disorder as their only

psychiatric diagnosis?

Probably not very often

comorbidity is the rule.

And I think that's one of the

takeaway points that I'd like to

convey today.

Generalized anxiety disorder really

does not not exist a lot by

itself.

And as so often exists

with depression, substance abuse,

other anxiety disorders.

And I think that's where a lot

of the challenge is.

And we know that when you have a

generalized anxiety disorder and a

comorbid condition like major

depression, they're both hard to

treat. The other important aspect

is defining anxiety.

So anxiety is a normal

adaptive response.

We all have it.

We all do it.

But when does it cross the line

and become pathological?

When does it become excessive?

And when does that mean criteria for

a disorder?

One way to think about it

is worry is normal, but

excessive worry or dysregulation

of worry where the person

can't control it or affects

their function or causes avoidance

of important

things in their life.

Those are all examples where it be

crossing the line to a disorder.

The focus of the worry

is really no different than all of

us. We all worry about school

work, finances, but

in GAD patients, the worry is

excessive. And they just can't

control it.

Anxiety just can be hard to ask

about.

I ask patients about anxiety

and maybe I shouldn't lead with that

term.

But they sometimes

freeze and they don't know how to

respond.

They're not sure how to define

anxiety.

Anxiety may not present with the

patient saying anxiety or that

I'm worried and that so often

presents with the other aspect of

the diagnosis, the somatic or the

physical: headaches,

muscle aches, tiredness,

inability to sleep.

These are extremely common

presentations.

And a lot of times the patients may

present with that and not with

actual worry.

And that can make the challenge of

diagnosis

more tricky.

And it can also delay the diagnosis

and delay the time until the patient

gets those evidence based

treatments.

There's also a system level talent,

just like I talked about, I had

a 30 minute visit.

We were already over.

I didn't have the time or necessary

the tools in the clinic to help the

patient with their anxiety.

It is a common diagnosis.

And again, here's that comorbidity

again, not comorbidity just

with mental illness, but comorbidity

with physical medical conditions.

So we know that the more medical

problems you have, the more likely

you're going to have generalized

anxiety disorder.

And we know that chronic

disease risk factors like smoking,

alcohol use and a sedentary

lifestyle is also higher

rates in patients with anxiety

disorders.

So here's one way I think about it

in terms of thinking about the

diagnosis and explaining it to

patients.

Break it down into two parts that

the anxiety, that is.

The psychological part are the worry

and the somatic symptoms.

This may help you in explaining

the diagnosis, but also with

treatment approaches.

And the somatic symptoms would be

physical tension, fatigue, sleep

disturbance, muscle

aches or tension, and sometimes

autonomic hyperactivity, sweating,

tremors, GI disturbance.

The rates and the prevalence of

GAD can vary.

It is somewhat

hard study at times.

Sometimes generalized anxiety

disorder is looped

in with other anxiety diagnoses

and that can make studying it

challenging.

But a lot of

surveys of primary care populations

show the prevalence in primary

care can be 8%.

Next question is when is generalized

anxiety disorder present?

And like a lot of other mental

health diagnoses, it's a young

it's a young age.

It's young adulthood, but it does

have a wide range.

Childhood onset, though it

is quite possible and common.

And so you have to look for school

age children with, you know, somatic

symptoms, school refusal

and those types of things.

There's also this interesting

thought. There might be a second

peak of GAD in

older adulthood was some thought

that that's related

to increasing medical problems.

The risk factors for GAD may not

be particularly helpful clinically.

There's a lot of overlap with mood

disorders.

But as you'd expect, adverse

childhood events being

isolated, widowed, divorce,

separated, having a family history,

having other psychiatric diagnoses,

and usually a female to male

ratio of two to one.

The cause is interesting.

It's not something fully understood.

Like many things multifactorial,

there's going to be genetic

elements.

There's a strong association in

terms of heritability with major

depressive disorder and the

personality trait, neuroticism,

from a biologic or neuropsychiatric

standpoint, there have been some

functional MRI studies,

and although this area is a little

complicated, I like to really

simplify it: I like to think about

the emotional part of the brain, the

limbic area and amygdala,

and then the maybe the frontal

prefrontal part.

And it can be thought of as perhaps

an over activation of the limbic

area. And the connection with the

frontal lobe, which is supposed to

modulate that and dampen down

the anxiety, is

aberrant in the connections aren't

that well formed.

So you can see how you have an

overactive part and the part that

supposed to regulate not quite in

sync. There is a psychological

construct that's very common in

patients with the GAD called

intolerance of uncertainty.

So they have a real difficult time

with tolerating uncertain

situations, and that's

extremely common finding.

Another way I may explain it is

there a threat detection system may

just be too good.

So in some ways, this

may serve the patients well, but

if they interpret even

ambiguous things as threatening,

you can see how that can lead to

over worry and

even avoidance, especially when

combined with low-self efficacy.

The idea that they can

do something about it or

change the outcome.

And of course, environmental

stressors, much like depression, can

contribute to screening for GAD

is not really well defined.

Even with depression, although more

and more we're more screening for it

in a formal way.

It depends on the clinic.

It depends on your health system and

depends on the resources.

For example, you're not

going to screen for something if you

don't have the resources in place to

do something about it.

A single screen question that has

been proposed is do you worry

excessively about minor matters?

And so that can be a good question

to pick up on this diagnosis.

And then a common clinical screening

tool is a GAD7.

And this is a seven item

patient--the

patient fills out on their own.

It's very quick and it's very easy.

It's validated screening

tool for GAD in the primary care

setting and it asks about the

symptoms in the past two week, so

we use this in our practice.

I do find it very useful.

So we have anxious patients that

their anxiety may be due to

something else or they may be

self-medicating.

And so

I think we need to understand all

the opportunities that patients may

take something and how that affects

their brain and their presentation

of their anxiety.

So I asked

not just about prescribed

medications that's on

their medication list, but

alcohol and tobacco use.

I ask about caffeine use

and it may seem simple,

but a lot of times patients are

using excessive caffeine and

sometimes that doesn't explain the

anxiety disorder entirely

by reducing the caffeine gradually

can really help the anxiety and

sometimes the insomnia.

Of course, illegal drugs

are part of the routine screening

questions.

I've also broaded at times to

include other ways patients may get

medications.

I've had cases where patients get

medications through the mail from

different country, let's say, but

it's a controlled substance and they

were trying to self medicate an

undiagnosed symptom of anxiety.

Or are they using a

family member's medications?

The medical evaluation that's

in your wheelhouse.

This is bread and butter, primary

care, working up fatigue,

working up other somatic

symptoms.

There is no standard evaluation.

It depends on the presentation

of the patient.

A lot of times

if there's anxiety, you wouldn't

want to rule hypothyroidism,

since that could present as anxiety,

of course, as a treatable medical

condition.

And depending on the circumstances,

you may check a CBC or perhaps

other screening tests that you would

check with an anxiety or depression

presentation.

More rarely: you might think about

catecholamines levels

in, especially if there's more

panic features or something

resembling that triad of

episodic bouts of hypertension,

headaches and then sweating

palpitations.

If there's something atypical

about the presentation, you'd also

probably broaden your medical

workup.

So if the age of onset didn't

quite fit.

If if there was a patient in their

70s and they were just suddenly

anxious, you'd be thinking about

medical causes, or if

there's cognitive changes or

personality changes that don't quite

fit.

Several other psychiatric diagnoses

can certainly present with anxiety.

And I think this is another area

where it's very challenging.

Sometimes it feels like we have too

many diagnoses and a lot of the

symptoms overlap.

But here's a

table I made that might help you

distinguish between some psychiatric

conditions that can present when

things anxiety

and they're often coexisting.

And here is just

a schematic to remind you

that not all anxiety

is generalized anxiety.

I think sometimes we

can get into the habit of doing that

and not looking a little further

to see what is the exact

diagnosis. Is it more panic?

Is it more PTSD?

Is it a medical cause?

So this is just a reminder to think

about the medical causes, to think

about the substances, including some

of the prescribed medications that

could cause anxiety, helping your

patient understand the diagnosis of

anxiety using the right terminology.

So many times

patients come in with a stigma

or a family member telling them,

just don't worry so much.

Well, try talking about someone with

anxiety that doesn't work

or they're ashamed of their anxiety

or they don't know what to call it.

So I think the things we've talked

about and using some of the

terminology to help the patient

understand a normal adaptive

response versus something that's

more pathologic or not

helping them in life can

be helpful.

I also think helping the patient

with validation can be helpful.

Anxiety can be a terrible experience

and they may not know what to call

it or what it is.

And I've noticed that explaining

to the patient that you recognize

it's an awful experience

and it's a serious condition, but

treatable can go a long way.

There is this curve from

psychologists from the early 1900s

Yerkes-Dodson law.

This is an inverted U basically.

And I think about it when I'm

explaining the diagnosis or thinking

about treatment options.

So the idea is that if you look at

arousal and if you substitute the

word anxiety and use them

interchangeably and then you think

about performance, there's this

inverted U relationship.

So often performance

is some anxiety,

some arousal.

But if it's too low, your

performance goes down.

If it's too high, your performance

goes down.

So it's about finding that optimal

spot in arousal.

And sometimes that means

turning the anxiety down with

certain medications.

So everything we've just talked

about in the past few slides are

really getting at the DSM-5

diagnosis of generalized

anxiety disorder.

So the anxiety is excessive.

It's difficult to control.

There are somatic elements being

restless, keyed up, fatigue, easily

concentration, difficulty,

irritability, muscle tension, sleep

disturbance.

One distinguishing thing is in

children: only one of those

items is required.

And of course, it's not by something

else, a psychiatric diagnosis,

a medication or substance,

and it causes distress or impairment

in their life.

Why should we think about

this? And what should we be

worried about?

Well, GAD affects

adversely school, work,

life and health.

And we talked

about comorbidity.

And so you may ask, well, isn't it

just a comorbid conditions that

contribute to that?

Well, there are some studies that

controlled for that.

And even just looking at

anxiety by itself, we know

that's a major problem with

disability, with impairment

in quality of life.

And these patients have higher

health care costs, higher

prescription rates,

and perhaps the greatest burden

is between ages of 15 and 34.

So obviously a very important time

in one's life.

Effects on health have also

been studied.

Quality of life is impaired.

Suicide risk has been looked at

again, difficult distinguish because

anxieties comorbid with depression.

But sometimes the

studies say six times as common

suicide than the general population.

When you look at that GAD diagnosis,

there's also some studies looking

at GAD in middle aged

women and

looking at the risk for

cardiovascular outcomes.

And there

is some thought that GAD, even by

itself, maybe should be considered a

cardiovascular disease risk factor

for a middle aged woman, even when

they controlled for the standard

risk factors and for metabolic

syndrome.

So does GAD

get better? Does it go away?

Why is it so free-floating?

I think it does add to the challenge

as well.

I think of it as a chronic illness,

but it does wax and wane.

So it could be there for a period

of weeks or months because it

was exacerbated and it may go

away for a while.

But it's generally a chronic

condition, meaning the rates of

complete and sustained remission

for the patients with GAD is rather

low.

There is some thought that as

patients get older, GAD

diagnosis, those meeting

criteria for the diagnosis may go

down.

But the other interesting thing is

there's thought that being

the criteria for a somatic anxiety

disorder may go up, as you

would expect, predictors of poor

prognosis, medical problems,

personality disorder, co-occurrence,

current conditions and long duration

before treatment.

So far, we've talked about

understanding and establishing the

diagnosis.

Hopefully you have a little better

understanding of that and how to

talk to your patient about it.

Remember that comorbidity is the

rule and it's important

to look for medical substance

and other causes.

And we're going to validate

the experience and explain why

anxiety has adverse

impacts for the patient.

And if needed, you're going to use a

screening tool to measure the

response to the treatment.

Now we talk about treatment.

I break it up into core

psychotherapy and other

non-drug approaches.

And for pharmacotherapy approaches.

So much in the same way you would

approach, you know,

an initial case of hypertension, or

dyslipidemia, you're going to focus

on education and lifestyle

modifications.

And the same can be said for

generalized anxiety disorder.

You're going to talk about

education.

You're going to talk about exercise,

good sleep habits, minimizing

alcohol and caffeine.

And having the patient do their own

learning on the condition.

But the most evidence

based approach for psychotherapy

for GAD is Cognitive Behavioral

Therapy (CBT).

There are other types of therapy

that can be tried and have some

evidence base as well.

And many times patients go through

different types of therapies and

they might need some time to figure

out which one works for them.

The definition I like best of CBT

is from colleague Dr. Sawchuk,

and he phrased it as

CBT is a practical

skill building approach that

emphasizes self efficacy

and self-management of symptoms

while working toward defined and

measurable treatment goals.

These are just some examples

of some of the strategies they would

use in treating anxiety,

so you actually want to expose the

patient to: what makes them anxious?

Which patients don't like?

But in the long term, it is helpful.

And then the concept of response

prevention, reframing

their thoughts that have gone awry.

So these are some of the examples

that the therapist might use.

A standard therapy session

is 12 to 16 sessions,

one hour, and

probably about once per week.

Now, patients don't always follow

that exactly.

And that's OK.

But that's sort of the standard CBT

approach. There have been

modifications, for example,

using CBT

integrated into the primary care

practice, using shorter

than that, less than 12 sessions

say that have been shown to be

effective for anxiety and depression

as well.

Group therapy

is another option.

Now, a lot of time anxious patients

don't like group, so this can

present a challenge.

But sometimes the group therapy

experience can be beneficial because

patients can learn from each other

and they have the peer support

component. Delivering therapy

in novel ways because patients

are often so busy, so using computer

models are using some kind of

outreach telephone method to rural

areas have also been studied.

I want you to imagine this

conversation again.

Busy primary care physician trying

to understand if their patient who

has anxiety is getting the

right kind of therapy.

So the conversation might go

something like this, the PCP might

say: so you're seeing a therapist

for your anxiety and the patient

says "yes".

And the doctor says, good.

How do you like the therapy and how

often do you go in?

The patient says: oh, it's great;

I really like my therapist and I

feel so much better after I leave; I

go every one to two weeks.

Well, how do we know if that's

evidence based treatment or not?

Well, there are some questions you

can ask.

Now, a lot of times the patients

will be in a non evidence based

therapy for anxiety.

Now, there is nothing wrong with

that.

But we do want them to have

a chance at the evidence based

treatments so they can improve the

symptoms of their disorder.

The questions that a primary

care doctor could ask are what

skills are you working on in

treatment?

What are your treatment goals?

How are you and the therapist

monitoring your progress toward

goals?

And does your therapist give you

homework between sessions

and is your treatment time limited?

This can help shed

some light on that.

Here's another common thing I hear

in doing consultant primary

care. Let's say a 28 year old

patient comes in extremely

frustrated.

Has been prescribed, let's say four

antidepressant trials, for

generalized anxiety disorder.

The patient saying, I'm not

depressed. I'm anxious.

Four trials of medications

and the patients says nothing helps.

In fact, these medications make me

feel worse.

They cause me to have more anxiety,

more insomnia, and I feel

emotionally blunted.

Well, I think

one way to approach it is, again,

back to education.

Antidepressant is in some ways a

misnomer: SSRIs

and SNRIs are first-line treatments

for generalized anxiety disorder.

But because the patient understands

their antidepressants, they may be

confused and believe their anxiety

is not being treated.

So I think educating

on that point is very important.

There's several other things we have

to tell the patient with

antidepressants.

They don't work right away.

Your anxiety will not be relieved in

the first few days.

It may take several weeks.

In fact, it may take more than one

antidepressant trial.

These are the things that I think

the patient needs to hear.

When I think about dactyl

medications for GAD

in a lot of ways, in some

ways this is similar to depression.

But I think about three general

categories because there

are so many medications.

The first category is

first line and most evidence,

SSRIs and SNRIs.

I think primary

care providers

are usually comfortable

with some of these because this

will use for depression as well.

The next category are

the benzodiazepines.

Now, this is a challenging category.

Patients frequently want to be put

on benzodiazepines.

They're extremely effective for

anxiety and they work right away.

The problem is there's major

drawbacks. So it's

finessing the use

and finding where you are

on the spectrum of do you never use

it, or do you use it too much?

In the third category, I

would think in your tool box

is what I think of as the non-benzo

and non-first-line category.

Now, this is kind of a hodgepodge of

different medications with different

classes and have lists of those on

the slide.

The thing to point out is they're

all essentially off label for

generalized anxiety.

That doesn't mean that sometimes

those controlled studies to show

they could be effective, but the

only one in that category that's FDA

approved for generalised anxiety is

buspirone. So if we look at a table

of antidepressants

and there's not a complete list

that's on the slide.

But if we think about

which ones are FDA approved to treat

GAD, a handful of them are

so out of the SSRIs.

Sertraline is escitaloprám

and paroxetine.

And for the SNRIs extended

release venlafaxine and doloxetine.

Now, that's not to say that you

can't use other SSRIs.

In fact, that's commonly done in

clinical practice.

And so we need to keep that in mind.

And if we look at the table of the

SSRI

category, I've put the

standard dose range

and a comment on drug interactions,

drug interactions sometimes and come

into play if the patients on a lot

of medications or if

it's a patient that

is older and may not tolerate

a drug interaction very well.

I think the takeaway

from this, though, is usually

if there is anxiety, even

generalized anxiety and most

definitely if there's panic attacks

or panic disorder, you generally

want to start with half of the usual

starting dose of the SSRI

or SNRI, and

I usually do that for about a week

and make sure the patient tolerate

before increased to the standard

starting dose.

For example, if I was starting,

certainly I might start twenty five

milligrams per day for a week and if

they're tolerating it, then I would

do 50 milligrams per day.

In the table, there's also some

notes on specific considerations

with different antidepressants.

The point is to not learn all of

those today, but over time,

familiarise yourself that

some medications are better for some

and others, there may be some

concerns.

SSRIs and SNRIs

for GAD again are the first

line.

They may work better for reducing

that cognitive worry, more

so than the somatic symptoms.

And I think that's where we face a

lot of challenges.

Patients want relief of that

physical tension, the upset

stomach, the

concentration part.

Sometimes the insomnia and

SSRIs may not do that

or may take a long time to get

there.

Here's another important point:

there's really no evidence

that any one SSRI or SNRI

is better than the others out of the

ones approved or commonly used.

So as much like depression, you're

going to go by patient experience,

by what you know about the

medication and comorbid conditions.

If they're not having a good

response and it's been eight weeks

or so, it is reasonable to consider

augmentation.

If there's some response

or no response.

A different strategy.

So we talked about the lower

starting doses as important.

Therapeutic dosing is usually about

the same for general anxiety and

major depression.

But like depression, partial

response is the norm.

And it's common to have to go

through two or three or more

medication trials until you get

some response.

So what anti-depressants maybe

should be avoided in GAD?

Well, that's a tricky question

because it's so often comorbid with

other conditions.

But if you're really treating just

GAD,

bupropion really is not indicated

for any anxiety disorder and may

make the anxiety worse.

So in that situation,

you may want to avoid bupropion.

There's a handful of "newer

antidepressants" that have come to

the market, say, over the past 10

years or so.

None of these have really proven to

be more effective for depression

or anxiety than the other

antidepressants.

So sometimes we don't use these

because there are greater costs to

the patient.

Many of the "newer antidepressants"

also were approved for major

depression and not generalized

anxiety.

So that's a problem as well.

There may be one exception:

vilazodone, for example, based

on the mechanism where some people

liken it to an SSRI

and buspirone,

some may try that if they are down

at the treatment algorithm to use

that type of medication.

Tricyclics overall would have a

limited role in treating GAD by

itself.

Of course, they have a known role in

treating depression.

Imipramine is not FDA approved,

but has undergone some controlled

studies for GAD.

However, it's very common for

patients to be on things like

amitriptyline or nortriptyline

because those things can be used for

migraine prophylaxis, pain,

insomnia, and sometimes we run

into the challenge of being on too

much serotonergic medications.

So we had to think about

polypharmacy and serotonin

syndrome and things like that.

The TCAs a tricyclic antidepressants

to cause more side effects,

dry mouth constipation

and a month supply or less

could be lethal in overdose.

So these are things we have to keep

in mind. Side effects are common.

We'll see that on the next slide.

Patients may have a strong

belief against antidepressants

and they want to use more

natural ways.

And I think that involves a little

bit of a discussion and education.

Well, I have a slide here on

antidepressant adverse effects.

And again, because there are so

many, I sort of broke it down into

three categories.

One is early; the other

is common, persistent; and the last

is serious.

Now, on the whole,

antidepressants are generally safe,

but it is worth looking at the slide

so early, I think, of activation.

The GI system

is sort of activated.

So patients get nausea, loose

stools, sometimes diarrhea.

That's often transient.

And the patient,

those symptoms or resolve after a

week or so, sometimes two weeks.

The other early side effect is sort

of an activation syndrome.

And by that I mean jitteriness,

anxiety, insomnia,

akathisia, which means a feeling of

inner restlessness.

And you have to just keep moving.

A hypomanic or manic state could

also be possible.

And although that's pretty

significant, it seems to occur

early. So I put it in that category,

the common persistent side effects.

Sometimes are a reason patients go

off an antidepressant

and that could be sexual

dysfunction, weight gain

or excessive sweating.

There are antidotes or

sort of tricks to try if those come

up. The serious side effects,

I made my own little mnemonic

SSRI.

So for S serotonin syndrome,

so you're going to look for

tremor, excessive sweating,

G.I. symptoms, mental status

changes.

This would be if a patient is

on multiple medications

that increased serotonin.

So I think it's important for

primary care physicians and

providers to think about this

diagnosis because so many times our

patients are on multiple medications

from different providers

and we may not put it all together

right away.

The "S" in SSRI

is for slippery platelets,

and that's to remind me that there's

some studies looking at bleeding

risk in SSRIs.

This is usually not clinically

significant enough to change our

mind, for example, to not treat

a major depression or an anxiety.

But there is some

signal in some of the studies that

there is a very small risk

of certain types of bleeds,

especially of the patients on

anticoagulants like clopidogrel

or coumadin.

And the other serious side effects

include suicidal ideation.

No, that's not suicide completions,

but suicidal ideation.

And there is a a box warning

for young patients.

So

children, adolescents up until age

24, that there's increased

suicidal ideation.

And we need to talk about that with

the patient and their family.

And then the other "S" for serious

is seizures.

And the main one we think about

there is bupropion, so if

they've had seizures.

Or they have a reason to have

seizures like they're bingeing on

alcohol or they have an eating

disorder.

We think twice about that.

The "R" for serious is reduced

sodium.

So most antidepressants can

cause hyponatremia.

It may be more common in older

patients and patients taking

diazid or other types of diabetics.

And then the "I" and SSRI

is increased QT interval.

So if we're worried about that, we

try to avoid high dose citalopram.

Tricyclic

antidepressants could also prolong

the QT. In general can

have adverse cardiac effects.

So we usually avoid tricyclics if

there's cardiac problems.

Benzodiazepines, now,

that's our next major

category in our tool box.

Highly effective.

Patients frequently want this

medication, but we have

to understand the risks and explain

it.

The only risk is not addiction or

tolerance.

We have to think about

the effects on cognition.

There are some studies showing long

term use may be associated with

dementia in women.

Now, that's not a causal

relationship, but we have to think

about the long term effects.

There is an increased risk of

falls. We think in older patients.

There is an increased risk of

sedation if there's other sedating

medications and you have to

tell the patient, it can be very

difficult to get off these

medications once the patient

gets used to it, has a relief of

their anxiety, get sleeping better,

they continue taking it and they

could develop tolerance.

And we know that benzodiazepine

withdrawal, like alcohol withdrawal,

can be medically serious.

I think the practice of

prescribing benzodiazepines

have changed, too.

So sometimes we get patients who

have been on them for years and

years because they were started

perhaps at a time 15, 20

or more years ago when that was just

the practice. A person was anxious,

you gave them alprazolam

or a different benzo.

By now, especially with the

opioid epidemic and knowing some

longer term risks.

I think for most of us, our practice

has changed.

So here's another

take-home point with the benzos,

it's probably not right to say never

prescribed them, but we also we

can't overprescribe them.

So thinking about your practice,

your patient population and

where you are on the spectrum of

prescribing using benzodiazepines,

I think is very important.

Alprazolam and diazepam

are two benzodiazepines that are

quickly absorbed and more rapidly

acting.

So those would have more

potential for addiction.

The cases in which you would want to

think twice or maybe not use

a benzodiazepine would be an alcohol

or a substance use disorder.

PTSD, there's some

thought that

we shouldn't use those in PTSD.

It may impair

them preprocessing their trauma

and benefiting from therapy.

Of course, polypharmacy,

the geriatric population,

if there's memory, are cognitive

decline at baseline, pregnancy

and breastfeeding, or if there's

disinhibition risk.

Sometimes they make the behavior

worse in certain

populations, like developmental

delays, common ones that

we would use in practice, lorazepam

and clonazepam.

The idea is we want to start

really slow and we don't want to

take away all the anxiety.

We want to take the anxiety down

enough that it helps the patient.

Again, if you think back to that

inverted you curve, we want to move

them a little toward where the

anxiety is a little less.

So maybe their performance in their

daily lives can improve.

And the last point on the

benzodiazepines is we want

to try to keep it to short term use.

We don't think long term use is

good.

And sometimes

if the patient comes in with

significant anxiety, since we know

the SSRIs or SNRI will take

weeks to become effective

if we're that lucky on the first

trial, then sometimes

using a benzodiazepine for that

first week or two can really

helpful.

But we want

to be careful to not let that

progressed. The long term use in

most cases.

Finally, we have, I made a table

and this is that third kind of

hodgepodge category.

This is a category.

I think we do find ourselves in a

lot because patients have tried

the standard therapies first.

And again, the

only FDA approved treatment, is

really abuse buspirone.

But several other medications can be

considered, especially if there's a

comorbidity that would make sense.

So pregabalin, for example, that's

actually approved to use for a GAD

in Europe, but not here in

the United States.

Several randomized

controlled trials have shown some

benefit in, but,

of course, it carries its own

concerns.

And you would have to renally dose

it.

Gabapentin doesn't really

have a lot of evidence for GAD.

But in clinical practice,

we see it used commonly because

there's so many comorbidities that

the patient may benefit from, like

certain pain syndromes, alcohol

use disorder, migraines, headaches,

hydroxylzine is another example of

one that has some

evidence that may help anxiety.

This is a sedating antihistamine.

It may have an edge

because you can use it as a p.r.n.

dosing.

And so it may help the patient

if you want to avoid

benzodiazepines, for example, but

want to use something short acting

or as a p.r.n.

or as needed basis.

The antidepressants that are not

really SSRI or SNRIs may

help to. Trazodone could help

us sleep.

And sometimes what those anxious

racing thoughts at night, the

imipramine from the TCA category we

talked about and they mirtazapine,

it can be incredibly useful,

especially for the older population,

though we have to look for weight

gain as a side

effect.

It typically helps with sleep,

helps low appetite,

and it may help anxiety.

The one

thing about mirtazapine is lower

doses usually help more the

insomnia and usually need a little

bit more than moderate or higher

doses to help to depression or

anxiety.

Atypical antipsychotics are another

category.

We want to be really careful

with those because they have such a

side effect burden.

They would carry the risk of extra

pyramidal symptoms and tardive

dyskinesia, although less likely

than their first generation

counterparts, but also metabolic

syndrome.

We already talked about GAD is

associated with less favorable

health outcomes.

So we had to be careful with using a

medication that could cause them to

have worsening A1c, glucose

or lipid panel.

Propranolol, I put in there

really no evidence it's effective

for GAD.

But again, sometimes you're just

down that treatment algorithm.

You have no other choice.

It may have a role in a performance

type anxiety in terms of the social

anxiety realm.

So if they're particularly anxious

about performing a task,

it may be worth a try.

If they don't have

contraindications.

So we talked about the buspirone and

I'll just mention it here, because

it is the one that's

approved for anxiety.

I would say, psychiatrist generally

don't use it as monotherapy.

We're usually adding it onto an

SSRI.

Side effects are usually mild

nausea, headaches, dizziness.

The one

difference is and the question I get

sometimes, how long does it take

buspirone to work? What kind of

intermediate between a

benzodiazepine and SSRI?

But I would say closer to the SSRI,

two to three weeks might be the

range, but definitely not

immediate.

And that's an important patient

education point.

And we talked about monitoring

when someone's on a typical

antipsychotic and being really

careful about their use.

Treatment, again, there's no clear

treatment algorithms and sort of you

wait this number of weeks, that

number weeks. It kind of depends on

the patient and the comorbidity.

But you want to be checking in

especially early to make sure

they're tolerating the medication,

not stopping it right away and

ideally having some way to monitor

their treatment response.

If there's the resource of a

collaborative care approach, we know

that that can help depression.

And when we use that

approach in our practice, meaning

a primary care physician, a care

manager and a psychiatrist

helping the patient get through a

chronic behavioral health problem,

oftentimes anxiety improves in those

situations as well.

So, again, just to review for kind

of the education, to tell your

patient SSRIs and SNRIs

are not opioids.

They're not addictive or habit

forming.

You may want to check in with

patient to avoid, "a deal breaker

side effects". So some patients say

no way to weight gain or

no way to sexual side effects.

Now, that's hard to avoid

in those.

But you want to understand that

upfront and our work

with your pharmacist to see what you

can do about it.

Again, efficacy of these bills over

time.

So often I see the patient stopping

after a few days because they said

it's not helping their anxiety.

That requires more education,

reminding them side effects

predominate early but could subside

and the efficacy comes later.

And reminding the patients, don't

stop the medication on your own

and reminding the patient and

yourself that venlafaxine

probably has the most significant

discontinuation

symptoms paroxetine

and duloxetine may also have them.

But if you have a patient where

you're really worried about

compliance and not taking the

medication every day, you may want

to try to avoid venlafaxine if

you can.

And then a general side effect

discussion, of course, for any more

significant side effects.

And remind them antidepressant

is a misnomer there for anxiety as

well. So how do you start?

You have the anxious patient.

You start with medication,

psychotherapy or both.

It's hard to know.

There's been some meta-analysis to

try to figure this out.

And there's no overall clear answer.

Basically, you want to do

the approach with the least side

effects. But some evidence, so

after the education component,

you're going to usually offer CBT.

Now, if the patient has a lot of

comorbidities, you may

more likely offer a medication.

If it's a more severe presentation,

you're more likely to offer a

medication earlier in the course.

Patients frequently don't get

better. It's a chronic illness.

What do you do when that happens?

Well, again, just cycle back

to the beginning.

In my having am I getting the

diagnosis right?

Could I be missing ADHD,

a manic episode, OCD,

these are the things you may need

help with from a psychiatrist

or behavioral consultant.

Reassess for

similarly comorbid conditions.

Personality disorders

in which, you know, anxiety

more likely will be chronic and may

not get better with medications.

PTSD, I think, is a common

one. And patients may not

feel comfortable talking about

trauma or symptoms

unless they feel comfortable with

the provider.

And I think evaluating

the role of the psychotherapy

is important

and making sure the patients are

getting evidence based

psychotherapy.

And, of course, refer to psychiatry

or psychology as indicated

and is available.

And then keep working through the

tool box. So you're three categories

of medications using

those.

And sometimes it's just

form a connection with the patient

until you find something that works.

Anxiety in children.

Again, it's it's really beyond my

practice scope.

There's a couple of differences

in the diagnosis that we are talked

about, but not too much.

You know, school refusal and somatic

symptoms would make

you think about an anxiety disorder.

You know

SSRIs when a medication is

indicated, is still going to be the

first line for childhood anxiety

disorders.

When the decision is that you can

use a medication,

however, SSRIs alone, or

medications alone are really not

a good evidence based

treatment plan.

And CBT should always be part

of the treatment plan.

And of course, the box warning that

we talked about earlier.

As so many times, too, I see

anxiety that persists.

But the patient may have persistent

life stressors or there's something

in the realm of social determinants

of health that need to be addressed.

And

I think we have to address that

along with the anxiety.

And that's where social work or

community health worker

may come into play.

I think all patients may not be

comfortable with the primary care

setting, may not be comfortable with

SSRIs.

And a lot of times patients from

different backgrounds or cultural

groups may not see

the illness or the treatment the

same way.

And so we may need

to ask about that.

And we need to recognize

the impact of racism, discrimination

or historical distrust

that certain groups may have.

The GAD-7 and the

PHQ-9 for depression do come in

various languages.

So if you can get that set

up with your front desk.

That's one way that you can

adopt the practice.

Two different

non-English speaking patients, but

still monitor the changes.

Another common question is cannabis

use. And the bottom line is we just

don't have enough answers.

Many patients self medicate with

marijuana.

Many states have medical

marijuana in Minnesota.

PTSD is a qualifying condition,

but it's

hard to find the real evidence that

that's effective.

And we're not quite

recommending that, as you know,

an approach for GAD, or even

PTSD.

We need we need more research.

Some of the studies that looked at

marijuana use and anxiety

disorders suggest there could

be a signal in social anxiety

and PTSD.

But I didn't find much for

specifically GAD.

And I have a suggested outline

for everything we've gone

through in terms of establishing the

diagnosis.

Thinking about the treatment options

and utilizing your resources or

consultations.

If you if you get stuck

or the patient is challenging.

There's many areas that we don't

know.

Again, the duration of treatment.

It's kind of like depression.

If you have your first episode, you

may continue the antidepressant for

a year and then try to taper off.

Many patients ask about

pharmacogenomics testing or P450

testing that

really has not been shown to be

effective or help the patient.

But if the patient has lots of

intolerances,

you may order that in the right

clinical setting.

And there hasn't

been a lot of new treatments for

anxiety. And so that's a challenging

area.

And there's some studies looking

at augmentation to make the

psychotherapy work better.

For example, using d-cycloserine

but nothing that we do

in terms of a standard way or

recommendation.

And then a bigger question

is what the impact of our current

life, our current circumstances,

economic hardships, the pandemic,

how will this impact people's

anxiety?

Will there be more

anxiety or more cases

of some syndromal anxiety?

Maybe we're already seeing those.

Maybe we'll see more cases of

self-medication.

These are all challenges ahead.

Back to the questions we started out

with.

The benzodiazepine use in the

elderly is associated with an

increase in hip fracture by

what amount?

Well, we think 50%.

There was a study showing,

I think, a couple of important

findings.

That even early on,

there was a risk for falls

and even at relatively low doses of

benzodiazepines.

There was a risk for falls and hip

fracture.

And so we know the significance of

that.

So we need to be very careful

about thinking about the risks and

the side effects.

And the second question was on the

self medication in terms of patients

with GAD, and that's

about 35%.

Again, you're going to find a range

on that number.

But the takeaway point

is it's a lot.

And if you have a patient using

a substance like alcohol, you may

want to ask about anxiety.

This is a challenging diagnosis,

but hopefully with

the things we went over, it'll

help you think about the diagnosis.

Talk to the patient about the

diagnosis and make give you

an overview of some of the evidence

based treatments and other things we

try because it can be such

a challenging presentation.

So thank you.