ESTES PARK, COLO. – The first-line medications for anxiety disorders are the same ones used for depression – the SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) – but the dosing strategies are quite different, Elizabeth L. Lowdermilk, MD, said at a conference on internal medicine sponsored by the University of Colorado.

MDedge News

“We know that folks with anxiety disorders tend to need the higher doses. They just need to get there a little more slowly,” according to Dr. Lowdermilk, a psychiatrist at the university and medical director of outpatient psychiatry at Denver Health.

“The trick is not what drug you use, it’s what dose you started at. For example, when I start sertraline for depression I start it at 50 mg per day. When I start it for anxiety I start it at 25. I just give it a week or 2 at 25 and then I double it to 50. And then I keep going, titrating over 2-3 months to a high or maximum dose,” she explained.

The rapidity of response to the SSRIs and SNRIs is quite different, too. When patients are started on one of these agents as treatment for depression, they can expect that it will take at least 4-6 weeks and maybe as long as 12 weeks before they experience the full therapeutic effect. Not so when the same drugs are used to treat anxiety disorders.

“The anxiolytic effect seems to be more robust sooner. Really, people start noticing something within the first couple days to a week. And they will keep getting better, which people love,” Dr. Lowdermilk said.

One of the early positive effects of SSRI/SNRI therapy that patients can be advised to be on the lookout for is “the Teflon mind,” she said.

“It’s not that the worried thoughts won’t arise, but they’re going to slide out faster and patients are going to be able to shift their focus back to where they want it to be and move forward,” the psychiatrist explained.

Other positive treatment effects include reductions in irritability, anger, perseverative thoughts, restlessness, and physical tension, along with improved sleep.

How to monitor patient response

The most practical anxiety rating scale for busy primary care physicians with tight office visit scheduling is the seven-item Generalized Anxiety Disorder Assessment, or GAD 7. It can be used repeatedly to follow a patient’s treatment response.

“While technically it is picking up the symptoms of GAD, because there are so many overlapping symptoms in all of the anxiety disorders this is going to give you a sense of whether someone is getting better. It won’t pick up their nightmares if they have PTSD, and it won’t necessarily pick up their checking behaviors if they have obsessive-compulsive disorder – you can ask them quickly about that,” she said.

Augmenting an SSRI/SNRI

Be advised: While some patients with an anxiety disorder will experience complete resolution of symptoms on the maximum approved dose of an SSRI/SNRI, such as 200 mg/day of sertraline (Zoloft), lots of patients will have only a partial response. The next move is not to add a second antidepressant, it’s to augment the high-dose antidepressant the patient is already on with something else. Dr. Lowdermilk highlighted the best and worst strategies:

Hydroxyzine: This drug, approved by the Food and Drug Administration for treatment of panic attacks at 25-50 mg up to four times per day, has sedating side effects that help with sleep issues.

“We use a lot of this,” Dr. Lowdermilk said.

Hydroxyzine (Vistaril) can be dosed on a fixed schedule or as needed. She strongly favors scheduled dosing. “It’s better to use drugs to reduce anxiety tone, then teach skills to cope with anxiety. As needed treatment subtly teaches patients to take a pill if they have breakthrough symptoms.”

Buspirone: It takes high doses of this medication to get a robust anxiolytic response. Dr. Lowdermilk recommends starting at 5 mg three times daily and increasing the total daily dose by 15 mg every 2 weeks up to a maximum of 60 mg.

“Buspirone isn’t the strongest medication out there, but it can help. I personally don’t stop until I’m at least at 30 mg per day,” she said.

The drug is especially handy as monotherapy in patients with mild to moderate anxiety who can’t tolerate serotonergic medications well. Also, at higher doses buspirone (Buspar) may reduce the sexual side effects of a concomitant serotonergic agent.

Gabapentin: Dr. Lowdermilk often turns to this drug off label as an SSRI/SNRI augmentation strategy, starting at 100-300 mg three times daily and increasing over the same time frame as for neuropathic pain up to a maximum total daily dose of 3,600 mg. Like hydroxyzine, it helps with sleep.
Atypical antipsychotics: Reserve these for patients with an inadequate response to maximum-dose SSRI/SNRI. There is some evidence of efficacy for low-dose risperidone (Risperdal) at 1-2 mg/day, quetiapine(Seroquel) at 50-100 mg, and aripiprazole (Abilify) at 2-5 mg. Because of the risks of metabolic side effects and tardive dyskinesia, it’s best to evaluate the drug’s effectiveness after 2-4 weeks and consider stopping if there is no clinical improvement.
Benzodiazepines: Yes, they are approved for treatment of anxiety disorders. Nevertheless, Dr. Lowdermilk advises against their as routine practice.

“I want to acknowledge that they really do work for anxiety and there are times you might want to consider them. But we are almost never initiating benzodiazepines anymore. We are learning that they cause more problems than not. What I’ve found over the years is short bursts of use are not short. Patients tend to come back and want more,” according to the psychiatrist.

She is not convinced about the claimed link to dementia, but she does believe long-term use of benzodiazepines is associated with memory and balance problems as well as slowed reaction time. If they are going to be used to treat anxiety disorders, it’s best to turn to a longer-acting agent such as clonazepam (Klonopin) or extended-release alprazolam (Xanax XR), which keep the anxiety tone down without producing the euphoria of short-acting benzodiazepines.

Behavioral therapies: “I really do think that the combination of medication and behavioral therapy is the best approach,” Dr. Lowdermilk said.

Consider referring patients with a problematic anxiety disorder to a behavioral therapist skilled in cognitive behavioral therapy, exposure therapy, response prevention therapy, or eye movement desensitization and reprocessing.

She reported having no financial conflicts regarding her presentation.

bjancin@mdedge.com

Consider dosing as well as drug choice for anxiety disorders