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anthony-stark

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Anxiety disorders
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  1. Anxiety disorders

  2. Recognition and diagnosisNICE TA 97, February 2006 • Anxiety disorders are common but often go unrecognised (c.f. depression) • Only a small minority of people who experience anxiety disorders actually undergo treatment • Often co-exist with other disorders • DSM-IV and ICD-10 definitions • Specific descriptions of features that must be present (or absent) for diagnosis • Issue of medicalising normal human experience and responses?

  3. In brief… Baldwin DS, et al. J Psychopharm 2005;19:567–96

  4. TreatmentNICE TA 97, February 2006; NICE CG 22, December 2004 (Amended April 2007); NICE CG 31, November 2005 • Psychological therapies • Pharmacological therapies • (or both) • Wide variation in care practices among individual GPs • ‘Stepped care’ approaches recommended in recent clinical guidelines, for example: • Recognition and diagnosis • Offer treatment in primary care • Review and offer alternative treatment • Review and offer referral • Care in specialist mental health services

  5. Psychological therapiesNICE TA 97, February 2006; NICE CG 22, December 2004 (Amended April 2007); NICE CG 31, November 2005 • Generally cognitive behaviour therapy (CBT) • Structured approach that aims to reduce dysfunctional emotions and behaviours by altering individual appraisals and thinking patterns and factors controlling behaviours • Self-exposure to situations of increasing difficulty and diary keeping to record thoughts, beliefs etc. before, during and after exposure • Should be delivered by trained and supervised people, adhering to protocols • Optimal length of treatment varies • e.g. GAD optimal range is 16–20 hours delivered in weekly sessions of 1–2 hours, completed within 4 months • e.g. PD optimal range is 7–14 hours delivered in weekly sessions of 1–2 hours, completed within 4 months

  6. Pharmacological therapies • SSRIs – licensed indications vary • Benzodiazepines – very limited roles • Other agents – e.g. venlafaxine, imipramine, pregabalin • NICE CG 22 states before prescribing consider (D): • Age • Previous treatment response • Risks of deliberate self-harm or accidental overdose • Possible interactions • Patient’s preference • Cost

  7. SSRIs and other antidepressants with anxiety-related licensed indicationsSPCs accessed from emc.medicines.org.uk, February 2008 But see current SPCs for full details!

  8. Safety and adverse effects of SSRIsNICE CG 22, December 2004 (Amended April 2007); CSM, December 2004 • Side-effects include transient increases in anxiety at start of treatment • Side-effects may be minimised by starting at low dose and slowly up titrating • Withdrawal/discontinuation reactions • All SSRIs may be associated with withdrawal/discontinuation reactions on stopping or reducing treatment • Paroxetine and venlafaxine seem to be associated with a greater frequency of withdrawal/discontinuation reactions than other SSRIs • A proportion of SSRI withdrawal/discontinuation reactions are severe and disabling to the individual • No clear evidence that SSRIs and related antidepressants have a significant dependence liability as defined by DSM-IV or ICD-10 • Doses should be reduced gradually over several weeks Worth thinking about terminology and how patients might interpret withdrawal vs. discontinuation?

  9. Trends in Prescribing of Anxiolytics in General Practice in England Trends in Prescribing of Anxiolytics in General Practice in England NHSBSA 2008

  10. Trends in Prescribing of SSRIs in General Practice in England Trends in Prescribing of SSRIs in General Practice in England NHSBSA 2008

  11. Overall summary • Many different types of anxiety disorder and often co-exists with other disorders • Psychological (CBT-based) therapies are often appropriate ahead of pharmacological treatment • SSRIs are generally the agents of choice if pharmacological therapy required (check SPCs) • Risks of discontinuation reactions, suicidality issues and side-effects of SSRIs are very real and must be appropriately considered and addressed • Benzodiazepine anxiolytics have a very limited role in the short-term initial management of some anxiety disorders and no role in longer term management