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Prof Riaz Ahmed
 

Prof Riaz Ahmed

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    Prof Riaz Ahmed Prof Riaz Ahmed Presentation Transcript

    • Prof. Muhammad Riaz Bhatti MBBS(K.E.), DPM., RCP&RCS(Dublin), MCCEE (Canada) FRSH(Lond), MRCPsych,(Lond) FRCPsych.,(Lond)
      • Chairman Academic Department of Psychiatry & Behavioural Sciences, King Edward Medical University / Mayo Hospital, Lahore.
      • President Psychiatric Welfare Association
      • Past President Pakistan Psychiatric Society
    • Evolving Role of Benzodiazepines in the Treatment of Anxiety
        • An unpleasant emotional state consisting of psycho-physiological response to anticipation of unknown, unreal or imaginary danger. It can be either physiological as an over prepared state or pathological as a disproportional reaction to any stressful stimuli, which may interfere with daily life activities.
      • Diagnostic and Statistical Manual(DSM-IV )
      ANXIETY
      • Anxiety presents with cardiac symptoms
      • Anxious patients with no evidence of organic heart disease commonly report unexplained CV symptoms that are frequently chronic and associated with great subjective distress.
      • They often lead to impaired functioning, lost days from work & considerable economic cost.
      Anxiety
      • Cardiovascular symptoms of Anxiety
      • Anxiety may present with cardiac symptoms
        • Increased cardiac awareness
        • Palpitations
        • Chest pain
        • Dyspnea
        • Sweating
        • Tremors
    • Anxiety & Hypertension
      • Many studies show that anxiety has an influence on blood pressure.
      • The degree of anxiety was positively associated with diastolic pressure
          • the influence of happiness anger and anxiety on the blood pressure of borderline hypertension.
      • Among middle aged men …. Anxiety levels are predictive of later incidence of hypertension
          • psychological predictors of hypertension in the Framingham study. Is there tension is hypertension
      • “ Anxiety, as either cause or effect, accompanies many medical illness and the use of anti-anxiety drugs as concomitant therapy can reduce morbidity and improve prognosis.”
              • Psychother Psychosom 1988, 49(2):63-80
    • Evolving Role of Benzodiazepines in Anxiety Disorders
      • Historical trends and the use of multiple classes of compounds as anxiolytics
      • Current trends and patterns of drug prescriptions for anxiety disorders
      • Rationale and indications for usage of benzodiazepines in anxiety
      • Conclusions
    • Anxiety Disorders DSM=Diagnostic and Statistical Manual; GAD=generalized anxiety disorder; OCD=obsessive-compulsive disorder; PTSD=posttraumatic stress disorder. Social anxiety disorder Panic disorder OCD GAD PTSD DMS-IV Spectrum of Anxiety Disorders
    • Currently Available Interventions for Anxiety Disorders
      • Antidepressants
        • Selective serotonin reuptake inhibitors (SSRIs)
        • Serotonin-norepinephrine reuptake inhibitors (SNRIs)
        • Other new agents
        • Tricyclic antidepressants (TCAs)
        • Monoamine oxidase inhibitors (MAOIs)
      • High-potency benzodiazepines
        • Alprazolam
        • Clonazepam
      • Other compounds
        • Azapirones
        • Anticonvulsants
        • B-blockers
      • Cognitive-behavior therapy
      • Combination treatments
    • Evolution in the Treatment of Anxiety Disorders Benzodiazepines (Buspirone) TCAs SSRIs & SNRIs CBT Combos CBT=cognitive-behavioral therapy; SSRIs=selective serotonin reuptake inhibitors; SNRIs=serotonin and norepinephrine reuptake inhibitors; TCAs=tricyclic antidepressants.
    • Drug Use in Generalized Anxiety Disorder (Percent of Total Rxs) NDTI MAT August 2001.
    • Drug Use in Panic Disorder (Percent of Total Rxs) BZD=benzodiazepine; Rxs=prescriptions. NDTI MAT August 2001. Total BZD=42%
    • Pharmacotherapy received by Panic Disorder patients in the HARP study (1989-2001) SE Bruce et al, poster presented at the 22 nd ADAA meeting, March 2002
    • Current Diagnostic Trends
      • Recognize symptom dimensions (e.g., anxiety, panic) rather than DSM-IV syndromes (e.g., generalized anxiety disorder, panic disorder)
      • Anxious patients may present without psychiatric symptoms, but rather with multiple unexplained physical symptoms
      • Patients with comorbid medical illnesses and anxiety may appear as “difficult patients” who are not compliant or do not respond to treatments of their medical illness
    • Current Treatment Options
      • Benzodiazepines are typically viewed are combined with antidepressants, or are used in patients who are intolerant to antidepressants
      • Cognitive-behavioral therapy also is effective
    • Sites of Action - Benzodiazepines
      • Agents that boost output from either GABA or serotonin neurons each have at least 2 chances – from both outside and inside the amygdala  to diminish the likelihood of anxiety and fear
      Fear Stahl SM. J Clin Psychiatry 63:9, 2002
    • SSRIs for Anxiety Disorders: Disadvantages
      • Onset of action delayed usually for days to weeks
      • May activate and transiently worsen anxiety at onset of treatment
      • Sexual dysfunction is common
      • May induce withdrawal reactions when discontinued
      • Weight gain
    • Benzodiazepines for Anxiety Disorders: Advantages
      • Rapid onset
      • Can be useful as needed for breakthrough symptoms
      • SSRI therapy augmented by benzodiazepines may enhance adherence to treatment and alleviate activating symptoms of SSRIs
      • No or mild sexual dysfunction
      • Safe with good tolerability
      Ballenger et al. J Clin Psychiatry. 1998;59(suppl 9):51. Furukawa et al. J Affect Disord. 2001;65:173. Goddard et al. Arch Gen Psychiatry. 2001;58:681. .
    • Benzodiazepines for Anxiety Disorders: Disadvantages
      • Potential early sedation and incoordination
      • Risk for withdrawal reactions with abrupt discontinuation (usually a re-emergence of anxiety symptoms)
      • Low but definite abuse potential, especially in polysubstance abusers
      Ninan. J Clin Psychiatry. 1999;60(suppl 22). Petursson and Lader. Br J Addict. 1981;76:133.
    • Is Long-term Benzodiazepine Treatment Justified?
      • Family, spouse can corroborate
        • Continued benefit
        • No nonmedical benzodiazepine use
        • No benzodiazepine-related toxicity
      • Consultation
        • More clinical clarity
        • Less medicolegal liability
      • Document rationale in patient record
      DuPont and DuPont. Clinical Textbook of Addictive Disorders. 1998.
    • Combining Antidepressants with Benzodiazepines
      • Provides rapid anxiolysis during antidepressant lag
      • Decreases early anxiety associated with initiation of antidepressant
      • Treats residual anxiety with antidepressant treatment
      • Prevents and treats potentially depressive effects of benzodiazepines
      • Clinical Anxiety: Case Study
    • Patient History
      • 23-year old woman
      • Successful professional, married with 2 children
      • First panic attack: presented to emergency room with complaints of chest pains and fear of having a heart attack
      • Cardiac workup negative for ischemia
    • Patient History (cont.)
      • Second panic attack: presented to hospital with chest pains, dizziness, shortness of breath, and palpitations
      • Second cardiac workup negative
      • Results revealed no other significant physical findings
      • ER/ED MD recommended follow up with primary care physician
      • Diagnosed with clinical anxiety and panic attacks
    • Management Questions
      • In ER/ED:
        • Prescribe SSRI?
        • Prescribe antidepressant?
        • Prescribe benzodiazepine?
        • Wait for office visit?
      • Office visit follow up:
        • How would you decide on therapeutic approach?
    • Conclusions
      • Although “officially” benzodiazepines are currently considered second line for anxiety disorders, they are still the most frequently prescribed
      • Benzos are especially useful at the beginning of treatment with SSRIs, treating residual anxiety in patients on SSRIs, and those who do not respond to or do not tolerate SSRIs
    • Thanks