Approach to Outpatient Anxiety/Depression¶

Kunal Patel

Background¶

Anxiety disorders: generalized anxiety disorder (GAD), panic disorder (PD), agoraphobia, social anxiety disorder (SAD), specific phobia
Some of the most prevalent psychiatric disorders
Age of onset varies: SAD (~teens), PD (~20s), GAD (broad range, incl. >50)
Depression: can refer to a mood state, syndrome, or mental disorder
1-year prevalence of 10%; lifetime prevalence of 21%
USPTF recommends screening for depression in the general adult population
Average age of onset 30 years
More common in females (2:1), younger adults, lower income patients, and those who are divorced, separated, or widowed

Evaluation¶

Anxiety disorders
See table for features to elicit in history
Labs (not all may be necessary): CBC, BMP, TSH, UA, EKG, UDS
Major depressive disorder (MDD)
See table for features to elicit in history
Labs (not all may be necessary): CBC, BMP, TSH, RPR, hCG, UDS, B12, Folate, EKG
Determine severity: mild, moderate, severe
- Degree of functional impairment and disability

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¶

Anxiety
Psychotherapy and/or pharmacotherapy
Depression
Mild: psychotherapy and symptom monitoring
Moderate: psychotherapy and pharmacotherapy
Severe: psych consult, psychotherapy, pharmacotherapy

Psychotherapy¶

Cognitive behavioral therapy: identifying and modifying negative thoughts
Behavioral activation: scheduling positive activities and increasing positive interactions
Interpersonal psychotherapy: addressing interpersonal issues in structured manner
Find with psychotherapists through VUMC behavioral health referral or psychologytoday.com
VA specific: First refer to PCMHI (teams for same day assessment, otherwise consult) and then if needed to BHIP

Pharmacotherapy¶

Good starting agents are SSRIs/SNRIs
Choose based on patient’s specific symptoms, age, adverse effects, co-morbidities, and any potential drug-drug interactions
Typically, start at low doses and titrate up every 2 weeks as needed until maximum dose reached
Full effects not seen until 8-12 weeks, should wait this time before switching
If no response, switch to another SSRI/SNRI
If partial response, augment
Anxiety disorders: buspirone or gabapentin/pregabalin
MDD: Addition of second agent from different class (e.g. bupropion)

Drug	Daily dose	Adverse effects	Other considerations
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)

Last update: 2022-06-24 16:00:54