Frontiers In Psychiatry Discussion Paper

Thank you Lewis for your input on the discussion.

I must highlight that anxiety disorders are among the leading psychiatric disorder that results in other comorbidities. The common types of anxiety disorders may include panic disorder, social anxiety disorder, and generalized anxiety disorder, which is the most common disorder. I agree that treatment of GAD might take either a pharmacological approach or a psychological approach. However, the pharmacological approach has been established as the first line of GAD treatment. Different medications can be used to treat GAD, including antidepressants like SSRIs and SNRIs (Jakubovski et al., 2018). When administering antidepressants, it is important to note that symptoms may worsen before they get better. The medications have been proven to be the most effective than placebo in GAD treatment, with escitalopram and duloxetine being the most impactful Depending on the severity of the condition, treatment may last between 3-12 months or even longer. The medication has been preferred as they are associated with manageable side effects. Frontiers In Psychiatry Discussion Paper

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Tricyclic antidepressants were previously recommended for the treatment of GAD, as they would act as reuptake inhibitors. However, its efficacy over SSRIs was ruled out because of the adverse side effects. The effects would range from increased weight gain, urinary retention, and mortality risk if overdosed.  I also agree that buspirone can be used ad adjunctive treatment with SSRIs for GAD. However, its effects are smaller when compared to other drugs like benzodiazepine (Garakani et al., 2020). Apart from medications, Cognitive behavioral therapy is a common psychological approach that can be used to treat GAD (Stefan et al., 2019). The approach allows a patient to identify and change thought patterns that could trigger anxiety. Other treatments for GAD are still being investigated to modify the currently approved approaches. Frontiers In Psychiatry Discussion Paper

References

Garakani, A., Murrough, J., Freire, R., Thom, R., Larkin, K., Buono, F., & Iosifescu, D. (2020). Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options. Frontiers In Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.595584

Jakubovski, E., Johnson, J., Nasir, M., Müller-Vahl, K., & Bloch, M. (2018). Systematic review and meta-analysis: Dose-response curve of SSRIs and SNRIs in anxiety disorders. Depression And Anxiety, 36(3), 198-212. https://doi.org/10.1002/da.22854

Stefan, S., Cristea, I., Szentagotai Tatar, A., & David, D. (2019). Cognitive‐behavioral therapy (CBT) for generalized anxiety disorder: Contrasting various CBT approaches in a randomized clinical trial. Journal Of Clinical Psychology, 75(7), 1188-1202. https://doi.org/10.1002/jclp.22779

Erin Lewis
Week Eight Discussion-Main Post-Erin Lewis
COLLAPSE
Week Eight Discussion-General Anxiety Disorder and Anxiolytic Treatments

Generalized anxiety disorder (GAD) is a mental health disorder that produces fear and worry with constant feelings of being overwhelmed. It is characterized by excessive, persistent, and unrealistic

worry about everyday things. It is the most common mental health disorder among adults and is present in almost twenty percent of the population (Munir & Takov, 2022).

Treatment options for GAD include pharmacological therapy, psychological therapy, or a combination of both. Evidence shows that a greater amount of success comes from pharmacological therapy in

comparison to psychological therapy. Despite this, up to 25% of patients treated for GAD do not have a response to the treatment (Slee et al., 2021). Medications used to treat GAD include benzodiazepines, Frontiers In Psychiatry Discussion Paper

antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs), the atypical antipsychotic quetiapine, and buspirone (Munir & Takov,

2022).

The first type of medication used to effectively treat anxiety were benzodiazepines. However, due to its safety profile, they are no longer a first-line medication. First-line medications for GAD are SSRIs

and SNRIs. They have shown to be generally well tolerated and to be effective in up to 50% of patients (Munir & Takov, 2022). Quetiapine has been shown to be effective at reducing anxiety symptoms but

had a lower rate of tolerance among patients due to side effects (Slee et al., 2021). Buspirone, a non-benzodiazepine antianxiety medication, has also been used to treat GAD but is recommended as adjunct or

second line therapy (Munir & Takov, 2022).

Pharmacodynamic and pharmacokinetics of medications can impact the patient’s ability to tolerate treatment depending on the treatment response and its impacts on the patient’s quality of life. This

plays a large role in what medications are selected by providers for their patients. Sertraline, a SSRI, is an example of a well-tolerated medication with minimal impact on quality of life. Sertraline is not

affected by the time of day that it is taken. It can, however, be affected by meals with up to a 25% increase in peak concentrations if taken with food. Despite this, no difference has been found in the area under Frontiers In Psychiatry Discussion Paper

the curve (AUC) when fasting and non-fasting groups were compared. There is some thought that the elderly may have increased concentrations when compared to younger patients, however, this may be due

to body weight and not age. Because of this, elderly patients should be started at a lower dose. A history of liver failure is to be considered as it significantly increases half-life and AUC. Sertraline is

hepatically cleared and should be dose adjusted based on degree of liver failure or avoided in severe liver failure. Patients with gastric bypass also need decreased dosing as absorption was found to be

increased post procedure. Patients with renal impairment do not need to have their dose adjusted (Huddart et al., 2021). The immediate side effects of SSRIs are mostly reported to be gastrointestinal upset.

Patients using SSRIs long-term have other side effects leading to intolerance. These include sexual dysfunction, weight gain, and sleep disturbances. Patients should be counseled in regard to a withdrawal

period with abrupt cessation. The symptoms associated with abrupt stoppage start about one week after cessation and last approximately three weeks. These symptoms include dizziness, nausea, lethargy,

headache, anxiety, and agitation (Ferguson, 2001).

Quetiapine is recommended to be used only if first line or second line therapy fails, or as an adjunct therapy along with a SSRI. Providers that decide to add this medication to their patient’s regimen

need to be aware that it does carry a risk of weight gain and diabetes (Katzman, 2014). Quetiapine’s absorption is minimally affected by food and the pharmacokinetics are unchanged by smoking. Though it

has less sleep disturbance than SSRIs, it does cause sedation which is not well tolerated by many. Along with fatigue, extrapyramidal symptoms lead to intolerance and cessation by many who are prescribed

quetiapine. It is not affected by renal dysfunction, but patients with liver failure need dose adjustment or avoidance. Elderly patients will require a decreased dose compared to standard adult dosing (Maneeton

et al., 2016). Frontiers In Psychiatry Discussion Paper

Though benzodiazepines are no longer recommended as first line treatment for anxiety, they can still be used for acute anxiety symptoms. This type of usage has been found to be well tolerated in

patients who are generally compliant with their overall treatment regimen. There does still remain a concern for misuse, dependence, and increased safety concerns with concomitant use of opioids or alcohol

(Slee et al., 2021). Side effects include sedation, fatigue, ataxia, slurred speech, memory impairment, and weakness. They also carry a risk of withdrawal reactions with abrupt cessation with this risk

increasing with patients who have a longer history of use. Elderly patients who take benzodiazepines are at a much greater risk of falls and fractures. Patients with renal disease do not need the dose adjusted,

however, patients with liver failure do need the dose decreased secondary to hepatic clearance (Slee et al., 2021).

Buspirone, a non-benzodiazepine anxiolytic, does not carry with it a concern for dependency as bezodiazepines do, nor does it cause sedation or develop tolerance. It does, however, have a longer onset

of action and is not beneficial for acute attacks as traditional benzodiazepines have been (Munir & Takov, 2022). It is used as a second-line agent after SSRIs have failed or as an adjunct to SSRIs to decrease

sexual dysfunction associated with SSRI usage. Taking this medication with food does increase absorption but will decrease first pass metabolism. Because of this, patients need to take it consistently either

with or without food. The does does need adjustment for pateints with renal failure and it is not recommended for use in patients with liver failure. The most commonly reported side effect is dizziness;

however, patients may also report confusion, blurred vision, tremor and weakness (Wilson & Tripp, 2022).

References

Huddart, P., Hicks, K., Ramsey, L., Strawn, J., Smith, D., Babilonia, M., Altman, R., & Klein, T. (2020). PharmGKB summary: Sertraline pathway, pharmacokinetics. Pharmacogenet Genomics,

30(2), 26-33. https://doi.org/10.1097/FPC.0000000000000392

Ferguson, J. (2001). SSRI antidepressant medications: Adverse effects and tolerability. Primary Care Companion to the Journal of Clinical Psychiatry, 3(1). https://doi.org/10.4088/pcc.v03n0105

Katzman, M., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., Van Ameringen, M., & the Canadian Anxiety Guidelines Initiative Group. (2014). Canadian clinical practice guidelines for the management

of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry, 14. https://doi.org/10.1186/1471-244X-14-S1-S1

Maneeton, N., Maneeton, B., Woottiluk, P., Likhitsathian, S., Sittajit, S., Boonyanaruthee, V., & Srisurapanont, M. (2016). Quetiapine monotherapy in acute treatment of generealized anxiety disorder:

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A systemic review and meta-analysis of randomized controlled trials. Drug Design Development and Therapy, 10. https://doi.org/10.2147/DDDT.S89485

Munir, S. & Takov, V. (2022). Generalized anxiety disorder. StatPearls. Retrieved July 18, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK441870/

Slee, A., Nazareth, I., Bondaronek, P., Liu, Y., Cheng, Z., & Fremantle, N. (2019). Pharmacological treatments for generalized anxiety disorder: A systematic review and network meta-analysis. Lancet,

393(10173). https://doi.org/10.1016/S0140-6736(18)31793-8

Wilson, T. & Tripp, J. (2022). Buspirone. StatPearls. Retrieved July 18, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK531477/ Frontiers In Psychiatry Discussion Paper