PHRX 4040 Psychiatry - Exam 2 Study Guide

what 2 rating scales are used for GAD?

- BAI

- HAM-A

describe the beck anxiety inventory scale

mesures severity and distinguishes anxiety from depression

- self rated

describe the HAM-A scale

assesses severity of anxiety symptoms and documents response to therapy

- clinician rated

what % reduction in HAM-A score aligns with a clinical response of: remission

more than 70% (score less than 7)

what % reduction in HAM-A score aligns with a clinical response of: improved

50-70%

what % reduction in HAM-A score aligns with a clinical response of: partial response

25-49%

what % reduction in HAM-A score aligns with a clinical response of: non response

less than 25%

what are 5 key substances that may contribute to worsening anxiety?

- caffeine

- corticosteroids

- bupropion

- stimulants

- bronchodilators

describe withdrawal induced anxiety

anxiety caused by the withdrawal of substances such as alcohol, barbs, benzos, cannabis and opioids

where is GAD primarily treated?

in the primary care setting

describe the clinical course of GAD

- can occur at any age with mean onset at 35

- symptoms wax and wane and more than 50% of pts will have a major depressive episode

overall, what is first line treatment for GAD?

SSRIs or SNRIs

which 4 SSRIs have the most evidence for efficacy in GAD?

- paroxetine

- escitalopram

- citalopram

- sertraline

overall, what are the 6 second line treatments for GAD?

- alt first line agent

- CBT adjunct

- pregabalin

- vilazodone

- benzos

- buspirone

overall, what are the 7 third line treatments for GAD?

- alt second line agent

- antihistamine = hydroxyzine

- second gen antipsychotic

- valproate

- trazodone

- TCA

- vortioxetine

when treating GAD, after a 1st line therapy has been initiated, what should be done after 4-6 weeks if there is non-response?

move to second line treatment

when treating GAD, after a 1st line therapy has been initiated, what should be done after 4-6 weeks if there is a partial or improved response?

titrate to max tolerated dose and reevaluate after 12 weeks of treatment

describe the onset of antidepressant meds for GAD treatment

requires 4-12 weeks for response and many pts will not achieve remission

what is an important consideration to take when using antidepressants for GAD?

antidepressants may initially worsen anxiety symptoms, consider starting at a lower dose and titrate slowly

describe the use of CBT for GAD

- most effective psychological therapy but it is not as effective for GAD as it is for MDD

- identify negative thought patterns that worsen anxiety symptoms

what line of treatment are benzos considered for GAD?

second line, important to note that they are not first line because they do not treat the underlying symptoms of GAD

how are benzos prescribed for GAD?

only prescribed for short term acute treatment of anxiety to provide rapid relief of symptoms

why are benzos not recommended for long term GAD use?

- long term use associated with dependance and withdrawal symptoms

- can cause rebound anxiety

define rebound anxiety

immediate transient return of anxiety symptoms with increased intensity compared to baseline

when is treatment with a benzo initiated for GAD?

may use when starting an antidepressant for GAD until the antidepressant begins to take effects (2-3 weeks) or for treatment resistant GAD

what benzo considerations regarding SUD and MDD should be considered?

- avoid with history of SUD

- not effective for depression and may worsen PTSD

describe the onset of action for diazepam

rapid

describe the onset of action for alprazolam

rapid intermediate

describe the onset of action for clonazepam

intermediate

describe the onset of action for lorazepam

intermediate

describe the onset of action for oxazepam

intermediate slow

which benzos are most associated with misuse?

diazepam and alprazolam due to rapid onset

what is a serious withdrawal symptom seen with benzos?

seizures

- higher risk with high doses, long duration of therapy and use with drugs that lower seizure threshold

what effects will hepatic enzyme inducers (carbamazepine, phenytoin, phenobarbital) have on benzos that undergo phase I metabolism?

alprazolam and diazepam:

- decrease benzo concentration and effectiveness

what effects will CYP3A4 inhibitors have on benzos?

increase benzo concentration

overall, explain the discontinuation of benzos

- goal is to avoid withdrawal seizures

- reduce dose by 25% per week until 50% of dose is reached

- then reduce by 1/8 every 4-7 days

what is the optimal taper duration for benzo therapy that is 8+ weeks?

2-3 weeks

what is the optimal taper duration for benzo therapy that is more than 6 months?

4-8 weeks

what is the optimal taper duration for benzo therapy that is more than 1 year?

2-4 months

what should be considered when switching meds in anxiety disorders?

want to try an alt first line medication before switching to second line

how is pregabalin used for GAD?

- efficacy in both short and long term treatment

- should continue for 1 yr after response

what is important to remember when using pregabalin for GAD?

concern for misuse or abuse, should not give to a pt who has a history of SUD

describe the onset of pregabalin for GAD

onset = 1 week, more rapid than antidepressants

describe the MOA of pregabalin

- GABA analog

- binds to alpha-2-delta subunit of voltage dependent Ca channels

what is the initial dose of pregabalin?

50 mg TID

how should pregabalin dose be increased?

100 mg TID

what is the effective dose for pregabalin?

300 mg/day

what dose adjustments are required for pregabalin?

hepatic

describe the onset of buspirone effects for GAD

onset = 2 or more weeks, may take 2-6 weeks for full effects

how long should treatment with buspirone continue after response?

1 year

is buspirone used with benzos?

less likely for buspirone to be effective if the pt has had benzos within 1 month

describe the MOA of buspirone

5-HT1a partial agonist = serotonergic med

describe the PK of buspirone

- extensive first pass metabolism and major CYP3A4 substrate

- half life is 2.5 hrs so it is dosed 2-3x per day

what is the initial dose of buspirone?

7.5 mg BID

what is the maintenance dose of buspirone?

15-60 mg/day divided in 2-3 doses

is buspirone recommended for hepatic or renal impairment?

not recommended in severe renal or hepatic impairment

when is hydroxyzine used for GAD?

- third line

- prn relief of anxiety and tension with rapid onset

- effective for up to 12 weeks

what are the brand names for hydroxyzine?

- atarax

- vistaril

describe the MOA of hydroxyzine

H1 and 5-HT1 receptor antagonist

describe the PK of hydroxyzine

- rapidly absorbed

- hepatically metabolized to cetirizine

what key ADRs are associated with hydorxyzine use?

- anticholinergic

- antihistamine = sedation

what dosing considerations should be taken with hydroxyzine?

- can be scheduled or prn

- lower doses in elderly

describe the duration of therapy for GAD

continue med for 12+ months after treatment response and gradually reduce prior to discontinuation

what is the starting dose of citalopram?

20 mg/day

what is the starting dose of escitalopram?

10 mg/day

what is the starting dose of fluoxetine?

20 mg/day

what is the starting dose of paroxetine?

IR = 20 mg/day

CR = 25 mg/day

what is the starting dose of sertraline?

25 mg/day

what is the starting dose of duloxetine?

20-30 mg BID

what is the starting dose of venlafaxine?

37.5-75/day

what dose adjustments are needed for citalopram?

geriatric and hepatic

what dose adjustments are needed for escitalopram?

geriatric and hepatic

what dose adjustments are needed for fluoxetine?

geriatric and hepatic

what dose adjustments are needed for paroxetine?

geriatric, renal and hepatic

what dose adjustments are needed for sertraline?

renal and hepatic

what dose adjustments are needed for duloxetine?

geriatric renal and hepatic

what dose adjustments are needed for venlafaxine?

renal and hepatic

explain the DSM-5 criteria for panic disorder

recurrent panic attacks with 1 or more attack followed by at least a month of:

- constant concern of having another attack

- anxious about implications of attack

- maladaptive behavior changes to avoid another attack

explain the DSM-5 criteria for agoraphobia

fear or anxiety in 2 or more of the following situations:

- public transportion

- open spaces

- enclosed spaces

- crowds or standing in line

- outside of home alone

describe first line treatment for PD

psychotherapy (CBT) and/or SSRIs or venlafaxine XR

what are the 4 second line treatment options for PD

- alt first line agent

- benzos for residual anxiety or rapid symptom control

- TCAs

- exercise

describe the use of TCAs for PD

- similar to SSRIs but less well tolerated so they are second line

- may be used if SSRI/SNRI is intolerable or ineffective

- can use imipramine or clomipramine

describe the use of benzos for PD

- avoid with history of SUD or comorbid MDD

- most commonly used = alprazolam and diazepam

describe the onset of antidepressants for treatment of PD

- onset = 3-4 weeks (shorter than with MDD)

- may be more than 6 moths for full remission

describe the acute phase of PD treatment

acute phase = 1-4 months

- change treatment if no response after 12 weeks at max tolerated dose

describe the maintenance phase of PD treatment

continue effective agent for 12 months after treatment response

describe the discontinuation phase of PD treatment

- depends on pt specific factors

- if discontinuing, taper slowly over 4-6 months to avoid relapse

what are 4 risk factors for SAD?

- psych comorbidity

- genetics

- family factors

- early childhood anxiety disorders

describe the clinical course of SAD

- onset = early, 14-16 years

- most pts have concurrent anxiety, depression or SUD

- chronic and lifelong without treatment

describe the pathophysiology of performance only SAD

caused by NE system dysfunction

describe the pathophysiology of general SAD

- decreased D2 receptor binding

- low DA metabolite levels

- hypersensitive 5-HT2 receptors

overall, what are the 3 first line treatments for SAD?

- CBT

- SSRIs

- Venlafaxine

which SSRIs are used for SAD?

- paroxetine

- sertraline

- escitalopram

- fluvoxamine

describe the use of venlafaxine for SAD

- as effective as paroxetine

- effects seen by week 3

overall, what 4 treatments are considered second line for SAD?

- alt first line agent

- pregabalin

- mirtazapine

- gabapentin

overall, describe the treatment of performance related SAD

use beta blockers to help decrease HR and BP to decrease tremor, palpitations and blushing

which 2 beta blockers are often used for performance related SAD?

- propanolol

- atenolol

how is propranolol dosed for SAD?

10-80 mg 1-2 hrs before performance

how is atenolol dosed for SAD?

25-50 mg 1-2 hrs before performance

describe the onset of SAD therapy

- onset = 6-8 weeks

- consider increasing dose if there is no response after 4 weeks

- continue at max dose for 10-12 weeks before considering an alt