Approach to Outpatient Anxiety/Depression¶
Kunal Patel
Background¶
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Anxiety disorders: generalized anxiety disorder (GAD), panic disorder (PD), agoraphobia, social anxiety disorder (SAD), specific phobia
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Some of the most prevalent psychiatric disorders
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Age of onset varies: SAD (~teens), PD (~20s), GAD (broad range, incl. >50)
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Depression: can refer to a mood state, syndrome, or mental disorder
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1-year prevalence of 10%; lifetime prevalence of 21%
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USPTF recommends screening for depression in the general adult population
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Average age of onset 30 years
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More common in females (2:1), younger adults, lower income patients, and those who are divorced, separated, or widowed
Evaluation¶
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Anxiety disorders
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See table for features to elicit in history
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Labs (not all may be necessary): CBC, BMP, TSH, UA, EKG, UDS
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Major depressive disorder (MDD)
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See table for features to elicit in history
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Labs (not all may be necessary): CBC, BMP, TSH, RPR, hCG, UDS, B12, Folate, EKG
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Determine severity: mild, moderate, severe
- Degree of functional impairment and disability
Disorder (Symptom scales) |
DSM-5 Criteria | Symptoms/features |
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Generalized Anxiety Disorder (GAD-7, Hamilton Anxiety Scale) |
Excessive anxiety/worry with ≥3 of 6 sx occurring most days for >6 months Difficult to control worry Causes clinically significant distress Not attributable to something else |
Restlessness Fatigued Difficulty concentrating Irritability Muscle tension Sleep disturbance |
Panic Disorder | Recurrent panic attacks with 1 or more attacks followed by >1 month of fear of another panic attack (≥4 sx) or maladaptive behavior | Palpitations Sweating Trembling SOB Feeling of choking Chest pain Nausea Dizziness, lightheaded Chills/heat sensation Paresthesias Derealization/depersonalization Fear of losing control Fear of dying |
Social Anxiety Disorder | Fear of social or performance situations to the point where there is impairment in function | Avoidance behavior Anxiety out of proportion Anxiety interfering with living Fear of scrutiny, embarrassment Fear not better explained by other medical condition |
Major Depressive Disorder (PHQ-9, HAM-D, MDI, Montgomery-Asberg Depression Rating Scale) |
≥5 sx during same 2 week period; depressed mood and/or loss of interest/pleasure must be present; exclude sx clearly due to other medical condition + Sx cause significant distress, not attributable to other medical condition or substance, not better explained by other psychotic disorders, no history of manic or hypomanic episode |
Depressed mood Loss of interest/pleasure Weight gain/loss Insomnia/hypersomnia Psychomotor agitation/retardation Fatigue Feeling worthless/guilt Decreased concentration Thoughts of suicide/death |
Management¶
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Anxiety
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Psychotherapy and/or pharmacotherapy
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Depression
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Mild: psychotherapy and symptom monitoring
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Moderate: psychotherapy and pharmacotherapy
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Severe: psych consult, psychotherapy, pharmacotherapy
Psychotherapy¶
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Cognitive behavioral therapy: identifying and modifying negative thoughts
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Behavioral activation: scheduling positive activities and increasing positive interactions
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Interpersonal psychotherapy: addressing interpersonal issues in structured manner
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Find with psychotherapists through VUMC behavioral health referral or psychologytoday.com
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VA specific: First refer to PCMHI (teams for same day assessment, otherwise consult) and then if needed to BHIP
Pharmacotherapy¶
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Good starting agents are SSRIs/SNRIs
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Choose based on patient’s specific symptoms, age, adverse effects, co-morbidities, and any potential drug-drug interactions
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Typically, start at low doses and titrate up every 2 weeks as needed until maximum dose reached
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Full effects not seen until 8-12 weeks, should wait this time before switching
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If no response, switch to another SSRI/SNRI
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If partial response, augment
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Anxiety disorders: buspirone or gabapentin/pregabalin
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MDD: Addition of second agent from different class (e.g. bupropion)
Drug | Daily dose | Adverse effects | Other considerations |
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SSRIs | GI, sexual dysfunction, weight gain | ||
Citalopram | Initial: 20 mg Target: 20-40 mg |
QTc++ (Most QT prolonging) Sedation |
Preferred in older adults due to safety profile Black-box for doses >40 for QT prolongation |
Escitalopram | Initial: 10 mg Target: 10-20 mg |
QTc+ | Preferred in older adults due to safety profile the only true serotonin selective so least off target effects, less drug-drug interactions |
Fluoxetine | Initial: 20 mg Target: 20-80mg |
The only weight neutral SSRI Activating QTc+ |
Long half-life (low withdrawal risk), 1 wk wash-out when switching |
Fluvoxamine | Initial: 50 mg Target: 50-200 mg |
QTc+ | Low SD, good for GAD + MDD but many drug-drug interactions, higher doses require BID schedule |
Paroxetine (IR) | Initial: 20 mg Target: 20-50 mg |
Anticholinergic sedating Worst SD Least QTc |
Short half-life (high risk of withdrawal). Not recommended in older adults due to anticholinergic effects. |
Sertraline | Initial: 50 mg Target: 50-200 mg |
QTc+, high SD Activating |
Preferred in older adults due to safety profile |
SNRIs | GI, sexual dysfunction, activating | ||
Duloxetine | Initial: 30-60 mg Target: 60-120 mg |
Some weight gain | Good for attention and low energy, good for pain |
Venlafaxine | Initial: 37.5-75 mg Target: 150-375 mg |
QTc+ Worst SD Some weight gain Diastolic HTN |
Risk of withdrawal, good for attention and low energy |
Desvenlafaxine | Initial: 25-50 mg Target: 50-100 mg |
Diastolic HTN | Risk of withdrawal, good for attention and low energy |
TCAs | Anticholinergic+++, drowsiness+++, SD+++, weight gain+++ | ||
Amitriptyline | Initial: 25 mg Target: 150-300 mg |
QTc+ | Greater risk profile than others; not first-line. |
Clomipramine | Initial: 25 mg Target: 75-250 mg |
QTc++ | Greater risk profile than others; not first-line. |
Others | |||
Buspirone | Initial: 10-15 mg Target: 15-60 mg |
Dizziness, HA, nervousness, drowsiness, activating | Anxiety disorders, add-on for MDD (off-label) |
Mirtazapine | Initial: 7.5-15 mg Target: 15-45 mg |
Drowsiness+++, anticholinergic, weight gain, dizziness, QTc | Good add-on with SSRI/SNRI for MDD; good for sleep, nightly dosing |
Trazodone | Initial: 100 mg Target: 200-400 mg |
Drowsiness+++, dizziness, blurred vision, constipation, priapism, QTc++ | Good for sleep- typically used at lower doses for insomnia |
Bupropion | Initial: 150 mg Target: 150 mg BID |
Dry mouth, nausea, activating, dizziness, sweating, QTc, lowers seizure threshold | Good add-on with SSRI/SNRI for MDD |
Pregabalin | Initial: 150 mg/day Target: 150-600 mg divided BID or TID |
Dizziness, drowsiness, resp depression, falls, edema, SJS/rash, DRESS | Anxiety disorders as adjunct (off-label), consider if another indication (neuropathic pain) |
Gabapentin | Initial: 100-300 mg/day Target: 2.4g/day divided BID or TID |
Dizziness, drowsiness, resp depression, falls, edema, SJS/rash, DRESS | Anxiety disorders as adjunct (off-label), consider if another indication (neuropathic pain) |