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CPD 15: ANXIETY DISORDERS in situations where the person could be criticized (3). For example, the patient may be very anxious eating in a restaurant, speaking at a meeting or attending a dinner party. The patient tends to avoid such situations. If they do encounter the situation any of the usual symptoms of anxiety can occur, but blushing and trembling are common. Some patients use alcohol to relieve symptoms and alcohol misuse is more common in social phobia compared to the other phobias. Co-morbid depression is common. 2c. Agoraphobia

Types of anxiety disorders 1. Generalised anxiety disorder (GAD) Generalised anxiety disorder is characterized by persistent anxiety symptoms that are not triggered by any particular event or situation(3). It is sometimes described as “free floating” anxiety. The patient experiences the physical and psychological symptoms of anxiety which can be disabling due to their chronic, unremitting time course. GAD affects up to 5% of the population and accounts for around 30% of psychiatric consultations in general practice. 2. Phobic anxiety disorders Patients with phobic anxiety disorders experience the same symptoms as someone with generalized anxiety, but they only show symptoms in response to particular circumstances (3). This could be a certain situation (eg a crowded place), an object (eg spiders) or a natural phenomenon (eg thunderstorms). Clinically phobic anxiety disorders are split into three subtypes; Specific phobia, social phobia and agoraphobia. 2a. Specific phobias If a patient has a specific phobia, they are inappropriately anxious if they encounter one or more object or situation (3). Anticipatory anxiety is common, as is avoidance of the particular situation. For example, a patient who has a phobia of dental treatment may avoid going to the dentist and develop caries. Sometimes patients seek treatment shortly before a particular event – a patient who has a phobia of flying may request treatment before a holiday. In this situation a short course of benzodiazepines may be appropriate. Long term treatment of phobias includes desensitization therapy (gradual exposure to the feared article or situation).

Patients with agoraphobia experience anxiety symptoms when they are away from home, in a crowded place or somewhere that they cannon leave easily (3). Panic attacks are common and anxiety relating to fear of fainting or loss of control can also occur. The syndrome usually begins with a period of anxiety while in a public place. Anticipatory anxiety can then occur the next time a visit to a similar place is planned. Avoidance is common, causing the patient to remain at home, relying on family or friends for help with activities. 3. Panic Disorder This illness is characterized by sudden attacks of the physical symptoms of anxiety accompanied by the fear of a serious consequence such as a heart attack (3). It sometimes accompanies agoraphobia. 4. Obsessive compulsive disorder (OCD) Patients may have obsessional thoughts, where words, ideas or beliefs intrude forcibly into the mind (3). These thoughts may lead to compulsive rituals. For example, an obsessional thought that hands are contaminated can lead to the compulsion to wash the hands many times each day. Depression often accompanies OCD. 5. Post traumatic stress disorder (PTSD) Symptoms of post traumatic stress disorder involve an intense, prolonged and sometimes delayed response to something that an individual perceives as traumatic (3). This could be a natural or man-made disaster such as an earthquake or war, or could be a personal trauma such as a rape or assault. The patient experiences emotional numbness and detachment, followed by flashbacks and vivid dreams. There is considerable co-morbidity with depression, suicide and substance misuse. 6. Mixed anxiety and depressive disorder (MAD)

2b. Social phobia

Patients with a diagnosis of mixed anxiety and depressive disorder do not suffer from either syndrome severely enough to have a diagnosis of either depression or anxiety (3). However the mild symptoms of anxiety and depression together are disabling enough for the patient to be diagnosed with this minor affective disorder. Treatment is generally with antidepressants.

Patients with social phobia experience anxiety

Most people with anxiety disorders will

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probably experience more than one form. For example, someone with panic attacks may develop agoraphobia. If left untreated this could then further develop into generalized anxiety disorder. Anxiety disorders commonly have a comorbid diagnosis of depression. In patients who present with anxiety alone, effective treatment may prevent the later development of depression. Clinical guidelines relating to anxiety disorders There are several clinical guidelines for primary and secondary care treatment of patients with anxiety disorders. Three key guidelines for Irish pharmacists are; • “Guidelines for the management of depression and anxiety disorders in primary care” Published in 2006 by the Irish College of General Practitioners.(2) • “Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology” published in 2005 (UK guidelines).(4) • National Institute for Health and Clinical Excellence (NICE) Management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. 2007 (UK guidelines). (5) Treatment of anxiety disorders Pharmacological Treatments for Anxiety Disorders For the majority of anxiety disorders benzodiazepines are used for emergency, short term, management. An antidepressant such as an SSRI is used for long term management. Benzodiazepines Benzodiazepines are commonly prescribed in Ireland and across Europe. In a 2008 Europeanwide study it was noted that over 9% of adults had taken a benzodiazepine over the course of 12 months. (6) Benzodiazepines provide rapid relief from anxiety states and are useful for immediate relief of symptoms. However, all current guidelines state that they should be reserved only for anxiety states that are severe and disabling due to their potential for physical dependence (4,5). They should only be used for up to four weeks while long term strategies for management are put into place. Benzodiazepines can be classified as short acting, such as lorazepam, or long acting like diazepam. They can all cause sedation and affect driving performance. Disinhibition is a possible side effect as benzodiazepines increase GABA transmission. This can lead to aggression or a paradoxical increase in anxiety in some patients. (7) Physical dependence on benzodiazepines is common following long term use. At least one third of patients will experience withdrawal symptoms after taking benzodiazepines for more than 4-6 weeks (7). Symptoms of sudden withdrawal include tension, panic attacks, palpitations and sweating – symptoms which

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CPD 15: ANXIETY DISORDERS are similar to the anxiety that was initially being treated. Slow discontinuation can help to manage withdrawal symptoms. Some patients respond to being switched to a long acting benzodiazepine such as diazepam before starting the discontinuation process.

discontinuation symptoms so slow withdrawal is recommended.

NICE recommends that benzodiazepines should not be used in panic disorder as they have been shown to be less effective than SSRIs. (5)

Mirtazepine is a centrally acting antidepressant which has sedative properties which may be helpful for patients with co-existing insomnia. It is not currently licensed for anxiety disorders in Ireland, but is recommended as an alternative to SSRIs in the Maudsley Prescribing Guidelines (7).

Selective Serotonin Reuptake Inhibitors

Pregabalin

Selective Serotonin Reuptake Inhibitors (SSRIs) are listed as first line treatments in the majority of anxiety disorders (7). Individual SSRIs have licenses for different anxiety states but this is probably more to do with the marketing strategies of the manufacturer than the effectiveness of the particular medication in that disorder. A summary of the current anxiety disorder licenses of SSRIs is shown in Figure 2.

Pregabalin (a gamma-aminobutyric acid analogue) is licensed for the treatment of generalized anxiety disorder. It has a rapid onset of action (approximately one week) (10) which is an advantage when compared to the SSRIs. Side effects include dizziness and somnolence in the early stages of treatment. Weight gain has been reported from trial data. It seems to be associated with fewer withdrawal symptoms than lorazepam, when compared in trial patients.

Figure 2 Anxiety licenses for commonly prescribed SSRIs in Republic of Ireland Antidepressant Generalised Anxiety Disorder

Panic Disorder

Fluoxetine

YES

Citalopram Escitalopram

Obsessive Compulsive Disorder

Social Phobia

Post Traumatic Stress Disorder

YES

Sertraline Paroxetine

Beta blockers

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES YES

YES

Doses of SSRIs When starting treatment for anxiety disorders with an SSRI the dose should be approximately half that used to treat depression (9). This is because anxiety is a possible side effect of SSRIs in the early stages and may exacerbate the original symptoms (called activation syndrome). Adding a benzodiazepine for the first two weeks can help to counteract this initial anxiety. Titrate the SSRI dose upwards into the normal antidepressant dose range. The patient may take up to six weeks to show a response and treatment may be needed for at least one year. Patients with anxiety disorders tend to be particularly sensitive to discontinuation symptoms with SSRIs. Doses should be titrated slowly downwards before stopping over several weeks or months. Side effects of SSRIs Side effects tend to occur in the first weeks of treatment then subside. Common side effects include restlessness, dizziness, Gastrointestinal (GI) upset and increase in sweating. A paradoxical increase in anxiety is sometimes seen in the first two weeks. In rare cases

suicidal ideation can occur in the early stages of treatment with SSRIs. Long term side effects include sexual dysfunction and weight changes (increase or decrease have been reported). Discontinuation symptoms Discontinuation symptoms are seen by approximately one third of patients who stop taking antidepressants. Symptoms begin within five days of stopping SSRIs abruptly (7) and include flu like symptoms, “shock-like” sensations, dizziness, insomnia, vivid dreams and irritability. The symptoms can be explained by a “receptor rebound” effect. Paroxetine is most commonly associated with discontinuation symptoms, probably due to its short half life. Other antidepressants used to treat anxiety states Venlafaxine and duloxetine both act on serotonin and noradrenaline (as do tricyclic antidepressants such as amitriptyline.). Both are licensed for generalized anxiety disorder and venlafaxine has additional licenses for panic disorder and social anxiety disorder. Venlafaxine should be avoided in patients at risk of cardiac arrhythmia. It has also been associated with

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Beta blockers such as propranolol are used to treat the physical symptoms of anxiety. They control symptoms such as palpitations, tremor sweating and shortness of breath. They do not cause physical dependence so can be used for long term treatment. They are sometimes used in combination with other anxiolytics that treat the psychological aspects of anxiety. Other pharmacological treatments Hydroxyzine is an antihistamine which is related to the phenothiazine antipsychotics. There are few studies to show efficacy but it does seem to be of some benefit in the treatment of anxiety. (9) Antipsychotics are sometimes used as adjunctive treatments for anxiety (usually added to an antidepressant or benzodiazepine). There is little evidence for efficacy, but a significant risk of side effects. Their use should be reserved for treatment resistant cases. (9) Non-pharmacological treatments The 2007 NICE guidelines (5) recommend psychological therapies such as cognitive behaviour therapy (CBT) as first line treatment for anxiety disorders. However the guidelines do acknowledge that pharmacological therapies are also effective and that the preference of the patient should be taken into account. In some areas of Ireland CBT may not be readily available so pharmacological treatments may be more suitable. Self help using bibliotherapy based on CBT principles is also recommended by NICE. Lifestyle considerations for patients with anxiety The NICE guidelines for anxiety (5) recommend that the benefits of exercise as part of good general health should be discussed with all patients as appropriate High caffeine intake can worsen the symptoms of anxiety and trigger panic attacks. Patients with anxiety should be advised to reduce intake of drinks and food containing caffeine and to be aware that some over the counter analgesics contain caffeine.

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CPD 15: ANXIETY DISORDERS Figure 3 – Non-pharmacological treatments for anxiety disorders. (7) Generalised anxiety disorder

Panic disorder

Reassurance, CBT, Anxiety Anxiety management, management, Relaxation training Exposure therapy, Cognitive behaviour therapy (CBT)

Post traumatic stress disorder Debriefing if desired, Counselling, Anxiety management, CBT, especially for avoidance behaviour or intrusive images

Nicotine stimulates physiological arousal, increasing the heart rate. Smokers tend to be more anxious and sleep less soundly than their non smoking counterparts. Alcohol is often used as a relaxant by patients with anxiety. However it can lead to dependence and the onset of physical illness such as liver disease if it is chronically misused. Recreational drugs of misuse such as cocaine and amphetamines can aggravate anxiety and induce panic attacks. They should obviously be avoided. Advice for the treatment of special patient groups British Association for Psychopharmacology has the following advice for patients who are in these special groups; (4) 1. Children and adolescents Use psychological treatments first line. If medication is needed, use an SSRI as first choice – avoid benzodiazepines and tricylics due to risk of side effects. Start with low doses and monitor carefully for side effects. 2. Elderly patients Follow same treatment strategy as for adult patients but use lower doses of medication and monitor carefully for side effects. Be aware of physical co-morbidities and increased sensitivity to side effects of medication. 3. Cardiac disease and epilepsy Avoid tricyclic antidepressants and venlafaxine in patients with cardiac disease. Avoid antidepressants that lower seizure threshold in patients with epilepsy. Be mindful of possible drug interactions between anxiety treatments and antiepileptics. 4. Pregnancy and Breastfeeding. Consider potential risks and benefits of treatments, avoiding drug treatment if possible. Fluoxetine or tricyclics are considered first line as there is most evidence surrounding the use of these drugs in pregnancy. Consider SSRIs (apart from fluoxetine and citalopram) or tricyclics for breastfeeding mothers as secretion into milk is low. Further information for patients and families Choice and Medication website – an internet site written by UK pharmacists for patients in

Obsessive compulsive disorder

Social Phobia

Exposure therapy, CBT, Exposure Behavioural therapy, Combined therapy, CBT, drug and Combined drug psychological and psychological treatment most treatment most effective effective Surgery

the UK and Ireland. Discusses the different types of medication available for psychiatric illnesses. Printable leaflets on different medications. Contains useful comparison charts for different treatments. http://www.choiceandmedication.org/nsft/ Reach Out – an Irish website for young people with mental health difficulties. Has a section on anxiety disorders. www.reachout.com Royal College of Psychiatry website – has a range of printable leaftlets on mental health issues, including types of medication and information about counselling and alternative remedies. http://www.rcpsych.ac.uk/ Overcoming Anxiety by Helen Kennerley, a selfhelp guide using Cognitive Behavioural Therapy (CBT) techniques. Other similar books are available and are useful if patients cannot attend CBT therapy in person. Practice points for community pharmacists • Be aware of the overuse of benzodiazepines. Look out for patients on long term benzodiazepine treatment. Consider that some patients may attend more than one GP and pharmacy to obtain supplies of benzodiazepines. • Inform patients of the lag time between starting antidepressants and seeing a benefit. Up to six weeks may be needed to see maximum effect. However side effects can start from day one. • Encourage compliance with long term preventative treatments such as SSRIs. Early discontinuation could lead to a recurrence of anxiety symptoms. Treatment may be needed for one year or more. • Counsel patients with regards to the withdrawal effects or discontinuation symptoms when near the end of a course of treatment. Encourage slow downwards titration of doses rather than sudden stopping of medication. • Give lifestyle advice to reduce the risk of further episodes of anxiety. References 1. McDonagh, M. Don’t let anxiety get you down. Irish Times 2.8.2011. 2. Irish College of General Practitioners. Guidelines for the management of depression and anxiety disorders in primary care. 2006. www.icgp.ie 3. Gelder M, Mayou R. Cowen P. Shorter Oxford Textbook of Psychiatry Fourth Edition. 2001. Oxford University Press.

4. Baldwin D S et al. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J.Psychopharm19(6) (2005) 567–596 5. National Institute for Health and Clinical Excellence (NICE) Management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. Clinical guideance 22. Amended April 2007 www.nice. org.uk 6. Demyttenaere K et al. Clinical factors influencing the prescription of antidepressants and benzodiazepines: results from the European study of the epidemiology of mental disorders (ESEMeD).J Affect Disord. 2008 Sep;110(1-2):84-93. 7. Taylor D, Paton C, Kapur S. Maudsley Prescribing Guidelines 10th Edition. 2009 Informa, London. 8. Summary of Product Characteristics for each product accessed on www.medicines.ie February 2012. 9. Bazire S. Psychotropic Drug Directory. 2007. Healthcom UK Ltd. Aberdeen. 10. Strawn JR, Geracioti TD. The treatment of generalized anxiety disorder with pregabalin, an atypical anxiolytic. Neuropsychiatric Disease and Treatment.2007, 3(2), 237-243.

Pfizer Healthcare Ireland are committed to supporting the continuous professional development of pharmacists in Ireland. We are delighted to be partnering with Irish Pharmacy News in order to succeed with this. Throughout the year, Irish Pharmacy News will deliver 12 separate modules of continuous professional development, across a wide range of therapy areas. These topics are chosen to support the more common interactions with pharmacy patients, and to optimise the patient experience with retail pharmacy. We began the 2011 programme with a section on the Gastrointestinal System. Other topics include Diabetes (Types I and II), the Cardiovascular System, Smoking Cessation, Infections, Parkinson’s Disease, Alzheimer’s Disease, Depression and others. We hope you will find value in all topics. Pfizer’s support of this programme is the latest element in a range of activities designed to benefit retail pharmacy. Other initiatives include the Multilingual Pharmacy Tool, a tailored Medical Communications Programme, Educational Meetings and Grants, our Patient Information Pack, new pharmacy Consultation Room brochures and other patient-assist programmes including the Quit with Help programme and www.mysterypain.ie. If you would like additional information on any of these pharmacy programmes, please contact Pfizer Healthcare Ireland on 01-4676500 and ask for the Established Products Business Unit. EPEU/2012/022

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CONTINUING PROFESSIONAL DEVELOPMENT - ISSUE 3 - 2012  

60 Second Summary: In some people anxiety occurs all the time and is severe enough to affect day to day living. It is estimated that once in...

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