Page 1

CPD 45: GENERALISED ANXIETY DISORDER IN TEENAGERS Biography - Amy Louise Oates. I qualified from the Robert Gordon University Aberdeen with a Master in Phamacy in 2011. I then undertook my pre-registration year with Gordons Chemists in Edinburgh. After registration I moved back home, where I am now working for Johnstons Pharmacy in Lanesborough, Co Longford and Ballygar, Co. Galway. I also recently completed a Cardiology in Clinical Pharmacy Practice module with Trinity College Dublin.

Module 1 June 2012

1. REFLECT - Before reading this module, consider the following: Will this clinical area Educational distance be relevant to my practice. 2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area.

Published by IPN and supported with an unrestricted educational grant from Pfizer learning content for healthcare professionals in Ireland Healthcare Ireland. Copies can be downloaded 4. EVALUATE - Did this article meet my from www.irishpharmacytraining.ie

- will this article satisfy those needs - or will more reading be required? learning needs - and how has my practise changed as a result? Have I identified further learning needs?

Disclaimer: All material published in CPD and the Pharmacy is copyright and no part of this can be used within any other publication without the permission of the publishers and author.

Chronic Pain – assessment and management in primary care

3. PLAN - If I have identified a knowledge gap

5. WHAT NEXT - At this time you may like to record your learning for future use or assessment. Follow the 4 previous steps, log and record your findings.

Generalised Anxiety Disorder in Teenagers

60 Second Summary

As a normal Sheehan et al reported in 1996 that the estimated cost of emotion anxiety pain for 95 patients to the Irish Health Services when added enhances Pain is one of the commonest reasons for patients to seek performance and to the amount of Social Welfare payments received and 1 productivity, and medical attention. A recent survey has shown that as many the lost earnings of each patient amounted to 1.9 million it is experienced as 8.3 visits per year to primary care physicians in Ireland 6 bytime everyone at pounds at the of referral. The recent data from PRIME some stage in were due to symptoms of pain.2 A large scale survey carried survey showtheir thatlives. the mean cost per chronic pain patient However out in 15 European countries and Israel in 2006, screening these symptoms is estimated when at €5,665 per year across all grades of pain, that the prevalence of chronic are particularly distressing flight response is also known as the acute WHAT IS ANXIETY? 46,394 respondents reported which was extrapolated €5.34 billion or 2.86% of Irish and disabling,tothey will require pain of moderate to severestress intensity in adultEssentially, Europeansthe was response. response 7 intervention. GDP per year. This demonstrates an urgent need for cost Anxiety is a natural human reaction, involving 3 prepares the body to either fight or flee the both the mind and body.19%. It functions as an Somatic Symptoms Cognitive effective strategies to manage chronic painSymptoms effectively. threat. The response can be triggered due to

Introduction

important basic survival mechanism, acting both real and imaginary threats. - Faster heartbeat - Irritability recent when survey data from another study, carried out The body’s as an alarm system thatMore is activated sympathetic nervous system is activated - Quicker breathing - trouble sleeping a person perceives danger or a threat. a chronic pain and 1,472 primary in 2,019 peopleAswith due to the sudden release of hormones.Understanding chronic pain normal emotion anxiety care enhances performance - Muscle Tension - lack of concentration physicians across 15 European countries, havesystem stimulates The sympathetic nervous and productivity, and it is experienced by Chronic pain is defined as pain that outlasts normal healing triggering that chronic the painadrenal affectsglands 12-54% of adultthe release of - Sweaty Palms everyone at some stagedemonstrated in their lives. However time adrenaline and noradrenaline. This results in (usually three to six months), and is most frequently Europeans, and its prevalence in Ireland is up to 13%.2 The when these symptoms are particularly - Queasy stomach an increase in heart rate, blood pressureassociated and with musculoskeletal disorders such as low distressing and disabling, they will require Impact and Cost of Chronic Pain) study, PRIME (Prevalence, breathing rate. After the threat is gone, itback takespain and - Trembling or legs .1 arthritis. hands However, it can also be associated intervention between 20 to 60 minutes for the body to return on the other hand, determined the prevalence of chronic Anxiety disorders are among theormost common with other disorders such as depression metabolic to in normal. Physical sensations ofpain anxiety include: mental health conditions. They can affect people to be as high as 35.5% Ireland.4 The PRIME study Somatic Symptoms - Faster heartbeat - Quicker breathing - Muscle Tension

disorders or of neurologic conditions such multiple Over all ages; adults, children andas teenagers. was designed to investigateAnxiety the prevalence disorders of arechronic amongpain the most Cognitive Symptoms the past 20 years there has been an increase in sclerosis. common mental health conditions. They can in- Irritability Ireland; compare the psychological and physical health the numbers of children and college students affect people of all ages; adults, children and suffering from anxiety disorders. profiles of those with and without chronic pain; and explore Pain (acute or chronic) can be categorised as nociceptive teenagers. Over the past 20 years there has - trouble sleeping 4 Teenagers with GAD worry excessively about pain-related disability. Responses survey in questions wereof children been an to increase the numbers or neuropathic. Nociceptive painevents, is caused an active things such as future socialby acceptance, - lack of concentration and college students suffering from anxiety obtained from 1,204 people. matters and school performance. illness, injuryfamily and/or inflammatory process associated with

disorders. 1 Approximately 13% of children and Symptoms to look out for in teenagers and actual or potential tissue damage i.e. Nociceptive pain adolescents affected. young people include: Despite the magnitude of the problem, are chronic pain Itis is estimated that results from activity in neural pathways secondary to actual - Queasy stomach 33% of children diagnosed with one anxiety A step-by-step approach should be taken for both under-recognised and undertreated in primary care.2,5 disorder will also meet criteria for at leastortwo potential tissue damage. is cation mediated the management Nociceptive of GAD. Earlypain identifi and - Trembling hands or legs Indeed, up to 38% of patients reported inadequately other anxiety being disorders, with depression and diagnosis is important for effective treatment. A by pain receptors located in skin, musculoskeletal system, 2 attention deficit hyperactivity full history should be obtained including details primary care for their pain symptoms. In disorder also These sensations are feltmanaged as part ofinthe 8 bone, and joints. Neuropathic pain, on abuse, the other hand, of medication use, substance symptoms being conditions. The body’s “fight-flight” response. This refers with to chronic addition, people paincommon reportedcomorbid waiting up to of mood and to disruptive behaviour disorders. course of an anxiety disorder is often chronic: results from direct injury a peripheral or central sensory a physiological reaction that occurs in the 2.2 years between help of and diagnosis, and with 1.9 an anxiety Parents also should be interviewed in order to adults diagnosed presence of something that is mentally or seeking70% nerve; the affected nerves do not produce transduction at assess the families functioning and the response 2 beforeThe theirfightpain wasdisorder adequately managed. report that their symptoms developed physically frightening oryears distressing. 8 toPain the teenager’s symptoms. nociceptors. characteristics and associated conditions 2 before adulthood. - Sweaty Palms

for both types of pain are shown in Table 1.

use by Healthcare Professionals in the Republic of Ireland only Learning, Evaluation,For Accredited, Readers, Network | www.learninpharmacy.ie © Copyright 2012 Pfizer Healthcare Ireland Date of Preparation: Module 1 June 2012 EPBU/2012/XXX

Supported by

Established Products


CPD 45: GENERALISED ANXIETY DISORDER IN TEENAGERS

DIFFERENT TYPES OF ANXIETY DISORDERS 7 - Generalised Anxiety Disorder (GAD) - Obsessive Compulsive Disorder (OCD) Module 1

June 2012

- Phobias

- Social Phobia (Social Anxiety)

Attacks sionals -inPanic Ireland - Post Traumatic Stress Disorder (PTSD) GENERALISED ANXIETY DISORDER (GAD)

anagement in primary GAD is associated with excessive,care persistent

and unrealistic worry that is not focused on a specific object or situation.3 The prevalence rate for school-aged children is 3% and increases in adolescence to 10%. Generalised Anxiety Disorder has been documented as early as age 4, but the mean age of onset is between 10-13 years of age.2 Gender ratio is approximately equal until adolescence, when it tends to be more common in females. If untreated, GAD is a significant risk factor for future anxiety disorders, major depression, suicide, and psychiatric hospitalization. Teenagers with GAD worry excessively about things such as future events, social acceptance,

- Worries about friends, school, activities - Refusal to go to school - Frequent stomach aches, headaches

onic pain is defined as pain that outlasts normal healing e (usually three to six months), and is most frequently ociated with musculoskeletal disorders such as low k pain and arthritis. However, it can also be associated h other disorders such as depression or metabolic orders or neurologic conditions such as multiple rosis.

n (acute or chronic) can be categorised as nociceptive europathic. Nociceptive pain is caused by an active ss, injury and/or inflammatory process associated with ual or potential tissue damage i.e. Nociceptive pain ults from activity in neural pathways secondary to actual otential tissue damage. Nociceptive pain is mediated pain receptors located in skin, musculoskeletal system, e, and joints.8 Neuropathic pain, on the other hand, ults from direct injury to a peripheral or central sensory ve; the affected nerves do not produce transduction at iceptors.8 Pain characteristics and associated conditions both types of pain are shown in Table 1.

2) Difficulty controlling the worry

- Muscle aches

And also three or more of the following symptoms:

- sleep disturbance

-

Restlessness

- Lack of concentration

-

Fatigue

- Fatigue

-

Irritability

- Irritability

-

Muscle tension

The exact cause of GAD is not known, but different factors can contribute to GAD, such as biological, family and environmental factors. Family history plays a part in increasing the likelihood that a person will develop GAD, and it is likely that the tendency is inherited. Anxiety and fear can also be learned from family members who show increased anxiety. A traumatic experience may also trigger anxiety, things that cause distress even such as changing jobs or schools. GAD may also become worse during periods of stress and worry.

-

Sleep disturbance

-

Difficulty concentrating

DIAGNOSIS OF GENERALISED ANXIETY DISORDER A formal diagnosis using the DSM-IV

ehan et family al reported in 1996 that the estimated cost of (Diagnostic and Statistical Manual of Mental matters and school performance. n for 95 patients to the Irishout Health when Symptoms to look for inServices teenagers andadded Disorders, 4th edition) classification system young people include: requires two major symptoms:4 he amount of Social Welfare payments received and lost earnings of each patient amounted to 1.9 million nds at the time of referral.6 The recent data from PRIME vey show that the mean cost per chronic pain patient stimated at €5,665 per year across all grades of pain, ch was extrapolated to €5.34 billion or 2.86% of Irish P per year.7 This demonstrates an urgent need for cost ctive strategies to manage chronic pain effectively.

derstanding chronic pain

1) excessive anxiety and worry about a number of events and situations

For a diagnosis symptoms should be present more days than not at least 6 months and should cause significant distress in school, social activities or other important areas of functioning. MANAGEMENT OF GENERALISED ANXIETY DISORDER According to NICE Guidelines5, a stepby-step approach should be taken for the management of GAD. Early identification and diagnosis is important for effective treatment. A full history should be obtained including details of medication use, substance abuse, symptoms of mood and disruptive behaviour disorders. Parents also should be interviewed in order to assess the families functioning and the response to the teenager’s symptoms. Diagnosis of GAD should be considered for patients who present with anxiety or worry, repeatedly complain of somatic symptoms or who repeatedly worry over a wide range of issues. Treatment should begin with educating the patients and their family about GAD. Reassurance about the symptoms and explaining why they are happening can help the patient feel at ease and less stressed. If education and monitoring of the condition makes no improvement, the next step is to commence psychological interventions. Cognitive Behavior Therapy (CBT) is recommended as first-line treatment of Generalised Anxiety Disorder in teenagers. This is a type of talk therapy where a person learns new ways to think and act in a situation that can cause anxiety. Teenagers can be taught to recognise the signs of anxiety and to develop coping techniques. Behavioral techniques such as relaxation training, imagining and visualisation, and cognitive techniques such as identifying and modifying self-talk and challenging irrational beliefs are methods used in therapy. In some areas CBT may not be readily available, and so pharmacotherapy can also be commenced. It has also proven to be of benefit when used in combination with CBT and other psychological interventions. DRUG ACTION IN THE CENTRAL NERVOUS SYSTEM Psychotropic drugs are defined as drugs that

Supported by

Established Products

Learning, Evaluation, Accredited, Readers, Network | www.learninpharmacy.ie


CPD 45: GENERALISED ANXIETY DISORDER IN TEENAGERS

affect the mood and behaviour. There is no consistent basis for classifying psychotropic drugs, however they include benzodiazepines, SSRIs and anti-depressant drugs. Drug targets in the CNS include ion channels, receptors, enzymes and transporter proteins. Most nueroactive drugs are non-sepcific and can affect several different targets. The molecular and cellular mechanisms underlying Educational distance the drug action in the CNS and in the periphery are very similar. A lot is understood about drug effects in relation to synaptic transmission and neuromodulation, but less is known about long term adaptive processes. Pyschotropic drugs often take a couple of weeks to develop therapeutic effect and so it is likely they reflect adaptive responses.

Module 1 June 2012

learning content for healthcare professionals in Ireland

Chronic Pain – assessment and management in primary care

γ- aminobutric acid (GABA) is the main inhibitory transmitter in the brain. GABA acts on two types of receptor, one – the GABAA receptor being a ligand-gated channel, the other GABAB being a G-protein – coupled receptor. GABAA receptors are the target for many important drugs that act on the CNS, including benzodiazepines and barbiturates. Benzodiazepines which have powerful anxiolytic and sedative effects, bind to an accessory site on the GABAA receptor and its agonist effect is enhanced. Anxiolytic effects . If there is nothat reponse by this stage, SELECTIVE SEROTONIN REUPTAKE Sheehan etbe al seen reported in 1996 the estimated cost of receptors containing are mediated by GABAAIntroduction alternative treatment shoud be considered.6 INHIBITORS pain for 95 patients to the Irish Health Services when added the α2 subunit, while sedation occurs through Pain 15 is one of the commonest reasons for patients to seek Barbiturates share those with the α1 subunit. the amount Welfare DueoftoSocial the risks posedpayments with SSRIreceived use in and Selective Serotonin Reuptake Inhibitors to (SSRIs) 1 A recent survey has shown that as many medical with benzodiazepines the ability attention. to potentiate children and adolescents, the drugs citalopram, are currently first-line medications in thethe lost earnings of each patient amounted to 1.9 million the action of GABA, butas they to per a different 8.3bind visits year to primary care of physicians in Irelandin children and escitalopram, paroxetine and sertraline treatment anxiety disorders 6 pounds at the time of referral. The recent data from PRIME site and their action is less specific. 2 are considered unfavourabe for use in this were due to symptoms of pain. A large scale survey carried teenagers. Fluoxetine (Prozac) is approved for survey show that the mean cost per chronic pain patient 6 population group. The exception is fluoxetine, theand treatment of2006, depression in children, while out inis15 European countries Israel in screening 5- Hydroxytryptamine (5-HT) another is estimatedhowever at €5,665 year across grades it is per associated with all a small riskofispain, self sertraline (Lustral) is approved for treatment important CNS transmitter. The processes of reported 46,394 respondents that the prevalence of chronic and so to patients of of ago of OCD. 6 Currently there are no medications which was harm, extrapolated €5.34under billion18 oryears 2.86% Irish its synthesis, storage , release and degredation pain of moderate to severeapproved intensity in Europeans was should be monitored for suicidal thoughts and foradult treatment of GAD in teenagers. closely resemble noradrenaline. 5-HT1a GDP per year.7 This demonstrates an urgent need for cost 3 behaviour. 19%. in the limbic While the SSRIs have shown promise in various receptors are widely distributed effective strategies to manage chronic pain effectively. investigations, further study to determine their system and are believe to be the main target Many of the side effects of SSRI treatment are safety, efficacy, “Off-label” use of SSRIs is recent survey another study, carried out of certain drugs used toMore treat anxiety and data from dose related. The most common side effects observed in the treatment of teenage GAD. The depression. Buspirone isina2,019 potentpeople agonistwith of chronic pain and 1,472 primary Understanding chronic can include: nausea,pain vomitting, diarrohea, 15 SSRIs are generally well tolerated, they don’t 5-HT1a receptors. It can also bind to dopamine stomach pain, anorexia weight loss, care physicians across 15 European countries, have require routine serum monitoring, and their side pain is defined as pain thatwith receptors but it is the 5-HT related actions that Chronic outlasts normal healing drowsiness and headache. that chronic effect pain affects of adult Several studies profile 12-54% is more favorable. are important in relation demonstrated to anxiety suppression. time (usually three to six months), and is most frequently 2 antidepressants haveinshown these Selective Serotonin Reputake Inhibitors Europeans, and(SSRIs) its prevalence Irelandeffi iscacy up toof13%. The associated BENZODIAZEPINES with musculoskeletal disorders such as low in the treatment of anxiety disorders in youths. act selectively on 5-HT receptors. PRIME (Prevalence, Impact and Cost of Chronic Pain) study, A complication of the use of SSRIs in teenagers back pain and arthritis. However, it can alsoused be associated Benzodiazepines are commonly for adults the other hand, determined prevalence of ischronic DRUG TREATMENT OFon GENERALISED with the anxiety disorders an “activation phase” with anxiety, but they should be considered with other disorders such as depression or metabolic 4 ANXIETY DISORDER pain to be as high as 35.5% in Ireland. The sometime PRIME study that often occurs during the first adolescents due to disorders orsecond-line neurologictreatment conditionsinsuch as multiple 12 This may feel like of treatment. was designed to investigatefew theweeks prevalence of chronic pain their addictive potential and the limited data The risks of complications of GAD in teenagers worsening anxiety. Suicidal ideation andsclerosis. supporting their safety and efficacy in this in Ireland; compare and physical health is too great to delay treatment, even in the the psychological aggression may occur in a small percentage of population. They should be restricted for use profiles of treatment those with and without chronic and explore absence of clear evidence-based teenagers. Thispain; activation can be minimized Painby (acuteas or rescue chronic) can be categorised as nociceptive medication for acute management guidelines. starting with very low doses of SSRIs. During pain-related disability.4 Responses to survey questions were of severe anxiety episodes. Benzodiazepines or neuropathic. Nociceptive pain is caused by an active this phase, children and teenagers may be can be helpful in conjunction with an SSRI, with obtained from 1,204 people. illness, injury and/or inflammatory process associated Complication for teenagers include: physically active, talkative, may feel jittery, during the early stages of treatment while the actual or potential tissue damage i.e. Nociceptive pain and have trouble falling asleep. These adverse SSRI dose is being titrated up and full effi cacy Despite the magnitude of the problem, chronic pain is - Comorbid Depression reactions are typically experienced before results from activity in neural pathways secondary to actual has not yet been achieved. Benzodiazepines 2,5 both under-recognised andthe undertreated primary care. and so many therapeuticineffects develop, often more effective at reducing - School truancy and withdrawal or potentialare tissue damage. Nociceptive pain issomatic mediated Indeed, up to 38% of patients reported being inadequately parents discontinue the medication prematurely. symptoms compared to SSRIs, but they have by pain receptors located in skin, musculoskeletal system, 2 It is important that parents are less effective in reducing psychological - “self-medication” leading to substance managed in primary care for their pain symptoms. Inare aware of this 8 bone, and joints. Neuropathic pain, on thesedation other hand, response to encourage compliance. Patients symptoms. Side effects include and abuse addition, people with chronic pain reported waiting up to should be monitored on SSRI treatment results and fromcognitive impairment. . Whenor being used as direct injury to a peripheral central sensory 2.2 yearsdue between seekingreviewed help andevery diagnosis, and 1.9 1 -2 weeks at the start ofnerve; the affected - Strained family relationships to acute symptom relief, benzodiazepines with nerves do not produce transductiona at 2 It managed. may take 4-6 weeks for benefit to demanding behaviour short half-life, such as lorazepam or alprazolam, years before their pain wastreatment. adequately 8

nociceptors. Pain characteristics and associated conditions for both types of pain are shown in Table 1.

use by Healthcare Professionals in the Republic of Ireland only Learning, Evaluation,For Accredited, Readers, Network | www.learninpharmacy.ie © Copyright 2012 Pfizer Healthcare Ireland Date of Preparation: Module 1 June 2012 EPBU/2012/XXX

Supported by

Established Products


CPD 45: GENERALISED ANXIETY DISORDER IN TEENAGERS are preferred. CSM guidelines advise that benzodiazepines should not be used to treat short-term mild anxiety. They are only indicated for short-term relief (2-4 weeks) of severe anxiety related symptoms.10 BARBITURATES

Module 1 June 2012

Barbiturates are non-selective CNS depressants. They produce effects ranging from sedation and reduction of anxiety to and death from respiratory sionals unconsciousness in Ireland and cardiovascular failure. For this reason they are very dangerous in overdose and in large doses and so they are rarely used as an anxiolytic agent. They act partly by enhancing the action of GABA, but not as specific as with benzodiazpines. Although their use is no longer recommended, pentobarbital and other typical barbiturates are very occasionally used to treat anxiety.15

anagement in primary care

TRI- CYCLIC ANTIDEPRESSANTS (TCA)

Some small studies indicate that TCAs may be useful in the treatment of some teenagers with anxiety disorders, but the evidence is quite limited. 2 They are used less frequently, due mainly to their adverse effects, which limits the dose that can be tolerated Overdosage with TCA is associated with a very high risk of fatality, and their potential of toxicity also their use. Side effects with the use of ehan et limits al reported in 1996 that the estimated cost of TCAs, include arrhythmias, heart block, suicidal n for 95 patients the Irish Health Services when added thoughts,todizziness, confusion, antimuscarinic effects such Welfare as dry mouth, blurred vision,and he amount of Social payments received 14 constipation, TCAs lost earnings of each urinary patient retention. amounted Iftoused 1.9 million should be started at low doses and titrated 6 nds at the time of referral. The recent data from PRIME gradually. They should be slowly reduced vey showbefore that the mean cost per chronic discontinuing. TCAs have apain longpatient half life is favourable, once-alldaily dosing is stimatedwhich at €5,665 per year as across grades of pain, possible. ch was extrapolated to €5.34 billion or 2.86% of Irish

7 P per year. This demonstrates an urgent need for cost BUSPIRONE ctive strategies to manage chronic pain effectively.

Buspirone is widely used in treatment of adult Generalised Anxiety Disorder. 2 It has been proven effective forpain this population and it has derstanding chronic a low potential for dependence and abuse. onic painIt isis defined as painfor that outlasts normal healing poorly studied used in children and teenagers and its use is not recommended. e (usually three to six months), and is most frequently

ociated with musculoskeletal disorders such as low OTHER TREATMENTS k pain and arthritis. However, it can also be associated Pregabalin andas venlafaxine areorlicensed for h other disorders such depression metabolic the treatment of Generalised Anxiety Disoder orders orinneurologic multiple adults,butconditions again theirsuch use inasteenagers rosis. under 18 years of age is not recommened. In 2006, the EC approved this new indication for

has also proved beneficial for the treatment of GAD in adults. Venlafaxine also lacks the sedative and antimuscarinic effects of the TCAs. Further studies need to be done to evaluated their use in children and teenagers.

REFERENCES 1.

Culliton, G. Anxiety disorders: a modern problem. Irish Medical Times, May 21, 2008.

Beta-blockers, such as propranolol (Inderal) can prevent the physical symptoms of anxiety disorders for children and teenagers.12 They can reduce symtoms of palpitation and tremor, however they do not affect muscle tenions.6 When a feared situation can be predicted (such as giving a speech) beta-blockers can be used to keep symptoms under control.

2.

Strasburger. V.C. et al [2006] Adolescent medicine [electronic resource] : a handbook for primary care ,Philadelphia : Lippincott Williams & Wilkins, c2006.

3.

Nutter, D.A. et al. Paediatric Generalised Anxiety Disorder Clinical Presentation,2013

4.

American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (4th edition), American Psychiatric Association, Washington DC 1994

5.

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLANCE (NICE), 2011. Generalized anxiety disorder and panic disorder (with or without agoraphobia) in adults. National institute for health and clinical excellence. Available from: http:// guidance.nice.org.uk/CG113.

6.

BRITISH NATIONAL FORMULARY. No 67. March 2014. BNF online www.bnf.org.uk

7.

PARKER, S et al. [2005] Developmental and behavioural paediatrics : a handbook for primary care, Philadelphia, Lippincott Williams and Wilkins

8.

Lebowitz, Eli R. et al. [2013] Treating childhood and adolescent anxiety : a guide for caregivers, Chichester , John Wiley & Sons.

9.

Child and adolescent psychiatry [electronic resource] : the essentials / [edited by] Keith Cheng, Kathleen M. Myers, Philadelphia : Lippincott Williams & Wilkins, c2005.

CAUTIONS OF TREATMENT Suicidal thoughts and hostility, aggression, oppositional behavior and anger are commonly observed in clinical trials among children and adolescents treated with antidepressants. Carefully monitoring for the appearance of suicidal symptoms is vital. There is limited evidence available concerning the long-term effect on safety in children and adolescents, including effects on growth, emotional and behavioural developments. Growth and pubertal development should be monitored during and after treatment with antidepressants.12 HOW CAN PHARMACISTS HELP? Pharmacists are ideally placed in the community to offer help and advice to teenagers (and their parents) regarding anxiety. Getting the problem treated can help a person feel like themselves again. -

Advice to tell a parent or other adult (school counsellor, teacher) about fears, worries and physical symptoms.

-

See a doctor to make sure there is no other cause of the symptoms

-

Eat well and sleep well

-

There is evidence to suggest that physical activity could help to reduce symptoms of anxiety.5

-

Herbal remedies such as chamomile and ginkgo biloba have shown efficacy in reducing anxiety in patients with GAD.5

-

Patients should be advised to reduce caffeine intake, including OTC medications that contain caffeine.

-

Counsel patients and parents on the lag time to expect when beginning treatment. It can take 4-6 weeks for benefits to be seen.

pregabalin, allowing its use in adults for the n (acute or chronic) can be categorised as nociceptive 14 treatment of GAD. europathic. Nociceptive painPregabalin is caused is byabsorbed an active quickly with peak plasma levers within one hour ss, injuryofand/or inflammatory process associated administration and has a sustained effect.with ual or potential tissue damage i.e. Nociceptive An advantage of pregabalin treatment ispain where take a pathways couple of weeks to have an ults from SSRIs activitycan in neural secondary to actual effect, pregabalin is effective after one week of otential tissue damage. Nociceptive pain is mediated treatment. It also has a more favourable side pain receptors located in skin, musculoskeletal system, effect profi le that treatments such as SSRIs, 8 with the main complaints being and e, and joints. Neuropathic pain, on thedizziness other hand, 3 ults from drowsiness. direct injury to a peripheral or central sensory ve; the affected nerves not produce transduction at Venlafaxine is ado selective serotonin and 8 iceptors.noradrenaline Pain characteristics associated conditions reuptakeand inhibior (SNRI) which both types of pain are shown in Table 1.

Warn patients of the risks of abrupt withdrawal of antidepressant medications. Symptoms of withdrawal can be seen within five days of stopping. Flu-like symptoms, dizziness, irritability and insomnia are some that can be experienced. Be aware of the overuse of benzodiazepines. They shouldn’t be used as treatment of chronic anxiety; their use should be limited to 2-4 weeks for acute episodes.

10. COMPASS Therapeutic Notes on the management of Generalized Anxiety Disorder and Panic Disorder in Adults in Primary Care, October 2011 11. NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLANCE (NICE), 2013. Clinical knowledge Summaries: Generalised Anxiety Disorder. [online]. London: National institute for health and clinical excellence. Available from: http:www.cks.nice.org.uk/generalizedanxiety-disorder 12. Summary of Product Characteristics for each medication accessed on www. medicines.ie June 2014 13. National Institute of Mental Health • Generalized Anxiety Disorder (GAD) accessed from www.nimh.nih.gov/health/ topics/generalized-anxiety-disorder-gad June 2014 14. Baldwin, D.S. et al, Role of pregabalin in the treatment of generalized anxiety disorder, 2007

Supported by

Established Products

Learning, Evaluation, Accredited, Readers, Network | www.learninpharmacy.ie

Cpd 45 anxiety in teenagers  
Cpd 45 anxiety in teenagers  
Advertisement