Prof Riaz Ahmed
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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 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.
    • 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