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KEY CONCEPTS

KEY CONCEPTS

  • imageAnxiety disorders are among the most common of mental disorders and are underdiagnosed and undertreated.

  • imageThe long-term goal in treatment of generalized anxiety disorder (GAD) is remission with minimal or no anxiety symptoms and no functional impairment.

  • imageAntidepressants are the agents of choice for the management of GAD.

  • imageAntidepressants have a lag time of 2 to 4 weeks or longer before antianxiety effects occur in GAD.

  • imageWhen monitoring the effectiveness of antidepressants in panic disorder, it is important to allow an adequate amount of time (8–12 weeks) to achieve full therapeutic response.

  • imageThe optimal duration of panic therapy is unknown; 12 to 24 months of pharmacotherapy is recommended before gradual drug discontinuation over 4 to 6 months is attempted.

  • imageSocial anxiety disorder (SAD) is a chronic long-term illness requiring extended therapy. After improvement, at least a 6- to 12-month medication maintenance period is recommended before considering treatment discontinuation.

  • imageThe selective serotonin reuptake inhibitors or venlafaxine are considered first-line pharmacotherapy for social anxiety disorder.

  • imageAn adequate trial of antidepressants in generalized SAD lasts at least 8 weeks, and maximal benefit may not be seen until 12 weeks.

  • imageThe three principal domains in which improvement should be observed in generalized SAD are symptoms, functionality, and well-being.

PATIENT CARE PROCESS

Patient Care Process for Anxiety Disorders

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Collect

  • Patient characteristics (eg, age, sex, pregnancy)

  • Patient medical history (personal and family)

  • Patient psychiatric history (personal and family)

  • Social history (eg, caffeine, nicotine, ethanol, illicit drug use including route of administration)

  • Current medications including over-the-counter (OTC), herbal products, dietary supplements, and prior psychiatric medication use

  • Mental status examination

  • Objective data

    • Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, and weight

    • Labs including thyroid stimulating hormone (TSH)

    • Urinalysis including urine drug testing

    • Generalized Anxiety Disorder 7-Item Scale, Hamilton Anxiety Disorder Rating Scale, Sheehan Disability Scale, and Patient Health Questionnaire-9 (PHQ-9)

Assess

  • Presence of generalized anxiety disorder, panic disorder, or social anxiety disorder

  • Presence of comorbid depression or substance use disorder

  • Ability/willingness to begin nonpharmacologic treatments, including availability in geographic region

  • Ability/willingness to begin pharmacologic treatment

  • Ability/willingness to afford nonpharmacologic and/or pharmacologic treatment(s)

  • Support of family members/caregivers for treatment

Plan*

  • Drug therapy regimen including specific medication(s), dose, route, frequency, and duration (see Figure 87-1, Tables 87-4, 87-5, 87-8, and 87-9)

  • Monitoring parameters including efficacy (eg, rating scales, quality of life)

  • Patient education (eg, disease, life style changes, medication adherence, when to expect medication to begin working, possible adverse effects, expected duration of therapy, when to contact healthcare professional)

  • Self-monitoring for resolution of anxiety symptoms

Implement*

  • Provide patient education regarding all aspects of treatment plan

  • Use motivational interviewing and coaching strategies to maximize adherence

  • Schedule follow-up

Follow-up: Monitor and Evaluate

  • Resolution of anxiety symptoms

  • Presence of adverse effects (eg, sedation, psychomotor impairment, nausea, headaches, weight gain, sexual dysfunction, etc.)

  • Psychiatric rating scale results

  • Patient adherence to treatment plan using multiple sources of ...

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