More About Mood Disorders
Most uncomplicated anxiety disorders can be treated in the primary care setting. Following the initial treatment, patients require ongoing care, which combines psychosocial and psychopharmacological therapies. Treatment of anxiety disorders can lead to improved interpersonal, social, and vocational functioning.
In the second part of this 2-part series, I describe the various treatments, with emphasis on those that are typically used in the primary care setting. In part 1 (CONSULTANT, March 2009, page 169), I addressed the clinical presentation, the relevant diagnostic studies, and the differential diagnosis.
TREATMENT OF ANXIETY DISORDERS AND COMORBID CONDITIONS
Sequence of treatment. The management of an anxiety disorder depends on the specific diagnosis and the presence of comorbid medical and psychiatric conditions.1 If the presenting anxiety symptoms are secondary to a medical condition, treatment of the condition usually leads to remission of anxiety.1,2 Thus, comorbid medical conditions should be treated first, followed by the anxiety disorder. When a comorbid psychiatric condition is present, simultaneous treatment with the anxiety disorder is recommended.1,3,4
Comorbid substance abuse. The management of anxiety disorders in patients with alcohol or substance abuse disorders should be coordinated with a psychiatrist or an addiction specialist.3,5,6 Discuss the long-term risks of dependence, withdrawal, and abuse, as well as the intended course of treatment. In general, it is advisable to treat alcohol and substance abuse disorders before the initiation of pharmacological therapy for anxiety disorders.1-3
INITIAL PRIMARY CARE INTERVENTION
In a primary care setting, the following immediate steps can be instituted7:
• Perform an evaluation to identify a provisional diagnosis of an anxiety disorder.
• Assess the degree and the severity of personal, social, and vocational impairment.
• Educate the patient about the nature and origin of anxiety symptoms.
• Incorporate family and social support resources to encourage anxious patients to use their coping skills and problem-solving abilities.
• Suggest lifestyle changes as appropriate, including stress reduction techniques; avoidance of alcohol, caffeine, nicotine, and illicit drug use; and proper diet and regular exercise.
• Establish and maintain a therapeutic alliance that conveys a sense of understanding and empathy.
Resources for patients, including those that can provide referrals to specialists and self-help groups, are listed in the Box (at the end of this article).
WHEN TO SEEK PSYCHIATRIC CONSULTATION
An urgent psychiatric consultation for the evaluation and treatment of anxiety disorders may be necessary under the following circumstances5,6:
• There is serious risk of suicide.
• The diagnosis is uncertain.
• Psychotic symptoms are present.
• Comorbid illicit drug or alcohol use is present.
• The anxiety symptoms are chronic, severe, and disabling.
• The patient is elderly or is a child or adolescent.
• The patient refuses to adhere to the recommended treatment.
• No improvement is evident after a period of initial treatment and follow-up.
The main difficulty in referring to psychiatric services is discussing the referral with the patient. The stigma attached to mental illness continues despite medical and community education programs. As a consequence, referral needs to be handled tactfully. Discussing emotional factors and illness, explaining and demystifying psychiatric services, and addressing patient fears and beliefs about psychiatrists are key elements in the process.5,6
PSYCHOSOCIAL AND SPIRITUAL INTERVENTIONS
Psychosocial interventions should be routinely recommended as treatment options for anxiety disorders. Inform patients about all the available forms of treatment, including various psychotherapies. Patients may benefit from a wide variety of psychotherapeutic approaches. A large body of evidence supports the effectiveness of cognitive behavioral therapy (CBT) and supportive psychotherapy for anxiety disorders.8
Cognitive behavioral therapy. The basic concepts of CBT are that thoughts cause feelings and behaviors; it relies on a collaborative effort between the psychotherapist and the patient. The patient’s role is to identify goals, to express concerns, and to learn and implement learning. The psychotherapist’s role is to help the patient define the goals and to listen, teach, and encourage.
CBT is based on “rational thought,” which can be described in facts, not assumptions. It is structured, directive, and rooted in the notion that maladaptive behaviors are the result of skill deficits and faulty thinking. It also emphasizes that most emotional and behavioral reactions are learned. Therefore, the goal of therapy is to help patients unlearn their unwanted reactions and to learn a new way of reacting. Homework is a central feature of CBT, in which assignments on how to identify the feelings that provoke thoughts and behaviors are completed following each therapy session. It is a brief and timelimited therapy with an average of 16 sessions.9
Spiritual interventions. An assessment of the patient’s religious and spiritual beliefs may allow the integration of another source of referral and support. Such referral could provide additional effective interventions, such as prayer, meditation, or Bible readings, for those patients with anxiety disorders who derive strength, endurance, and coping from their personal religious faith.10
1. Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2007.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
3. Gabbard GO. Treatments of Psychiatric Disorders. 3rd ed. Vols 1 & 2. Washington, DC: American Psychiatric Publishing; 2001.
4. Kendrick T. Depression in adults: GPs are not so bad at diagnosis. BMJ. 2008;336:522.
5. Khouzam HR. Depression: guidelines for effective primary care, part 1, diagnosis. Consultant. 2007;47:757-764.
6. Khouzam HR. Depression: guidelines for effective primary care, part 2, treatment. Consultant. 2007;47:841-848.
7. Kroenke K, Spitzer RL, Williams JB, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317-325.
8. Cottraux J, Note I, Yao SN, et al. Randomized controlled comparison of cognitive behavior therapy with Rogerian supportive therapy in chronic posttraumatic stress disorder: a 2-year follow-up. Psychother Psychosom. 2008;77:101-110.
9. Bodden DH, Dirksen CD, Bögels SM, et al. Costs and cost-effectiveness of family CBT versus individual CBT in clinically anxious children. Clin Child Psychol Psychiatry. 2008;13:543-564.
10. Baetz M, Griffin R, Bowen R, Marcoux G. Spirituality and psychiatry in Canada: psychiatric practice compared with patient expectations. Can J Psychiatry. 2004;49:265-271.
11. Lépine JP. The epidemiology of anxiety disorders: prevalence and societal costs. J Clin Psychiatry. 2002;63(suppl 14):4-8.
12. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Panic Disorder. Washington, DC: American Psychiatric Association; 1998.
13. Akpafflong MJ, Wilson-Lawson M, Kunik ME. Antidepressant-associated side effects in older adult depressed patients. Geriatrics. 2008;63:18-23.
14. Bourin M, Lambert O. Pharmacotherapy of anxious disorders. Hum Psychopharmacol. 2002;17:383-400.
15. Otto MW, Pollack MH, Gould RA, et al. A comparison of the efficacy of clonazepam and cognitivebehavioral group therapy for the treatment of social phobia. J Anxiety Disord. 2000;14:345-358.
FOR MORE INFORMATION:
• Khouzam HR, Tan D, Gill TS. Handbook of Emergency Psychiatry. Philadelphia: Mosby; 2007.