A brief insight into few pharmacotherapy-related pointers for the management of anxiety and affective disorders, based on the Malaysian CPGs.

1. Anxiety & Affective Disorders [CPGs]

2. Standard Abbreviations
• BZs or BZDs = Benzodiazepines
• SSRIs = Selective Serotonin Reuptake Inhibitors
• SNRIs = Serotonin-norepinephrine reuptake inhibitor
• SRI: Serotonergic reuptake inhibitor
• GAD = Generalised Anxiety Disorder
• PD = Panic Disorder
• SP = Specific Phobias
• CBT = Cognitive-behavioral therapy
• SAD = Social Anxiety Disorder
• OCD = Obsessive Compulsive Disorder
• TCA = Tricyclic Antidepressant

3.  One of the most commonly reported mental illness worldwide are
Anxiety Disorders (ADs).
 Though ADs are the most prevalent of psychiatric conditions, yet
often remain under-diagnosed and under-treated.

5. Panic disorder
 1st-line: either SSRIs or venlafaxine;
 2nd-line: Imipramine and clomipramine;
 BZs may be added to antidepressants in the short term to produce
a more rapid therapeutic response. Due to BZs’ addictive
potential, BZs should be tapered and withdrawn by 4 weeks.
 Depending on availability of treatment and patients’ preference,
CBT or combination Tx (i.e. CBT + SSRIs or venlafaxine) may be
used for the treatment of panic disorder.

6. GAD
 1st-line: either SSRIs or venlafaxine;
 2nd line: Imipramine may be considered (has poor tolerability and
the danger of fatal overdosage).
 2nd line: Mirtazapine may be considered (due to its anxiolytic
effects);
 BZs should not be used for the long-term treatment of GAD.
 Pregabalin may be prescribed due to it’s anxiolytic effects which
may be more rapid acting. (Be cautious when prescribing to
patients who are at risk of abusing substances).

7. GAD (contd’.)
 Adjunctive treatment: Hydroxyzine + other anxiolytic agents ;
 Propranolol is not recommended for long-term treatment.
 Drug treatment must be continued for atleast 32 weeks (high relapse
rates after discontinuing medications).
 CBT may be used as 1st-line treatment psychotherapy for GAD.
 A specialist’s opinion should be sought for patients with complex GAD
and/or with marked functional impairment, or at high risk of self-
harm.

8. Specific Phobias
 1st-line: CBT
 BZs (on short-term basis) – for temporary anxiety relief in
specific phobia, pending resolution of symptoms with other
forms of treatment;

9. SAD
 1st-line: either pharmacotherapy or psychotherapy may be used,
depending on patient preferences, values and economic
considerations;
 1st-line pharmacotherapy: either SSRIs or venlafaxine;
 Use Moclobemide if treatment with SSRIs or venlafaxine is
ineffective.
 BZs (on short-term basis) – for temporary anxiety relief (pending
resolution of phobic symptoms with other forms of treatment);

10. SAD (contd’.)
 Beta-blockers (e.g. atenolol, propranolol) - not recommended -
have been found ineffective;
 Beta-blockers may be used for the treatment of performance
anxiety (e.g. playing an instrument, giving a speech).
 Relapse prevention: Continue pharmacotherapy with SSRIs,
venlafaxine, or moclobemide for atleast 12 months;

11. OCD
 1st-line: either pharmacotherapy or psychotherapy (depending on
patient preferences, values and economic considerations);
 1st-line: 10-12 week trial with an SSRI at adequate doses;
 Use Clomipramine (if trial with SSRI treatment has failed).
 Adequate treatment trial period: atleast 12 weeks;
 If the patient does not respond to treatment in adequate dosages,
seek specialist’s opinion, change the medication(s);
 Consider Venlafaxine for patients who have not responded to
SSRIs and clomipramine. (Monitor BP as venlafaxine at high doses
can raise BP).

12. OCD (contd’.)
 1st-line: CBT may be used if patients prefer psychological treatment
over pharmacotherapy.
 CBT augmentation of serotonergic antidepressants (e.g. SSRIs,
clomipramine) may be considered for those who are treatment-
resistant or partially responsive to medications.
 OCD patients who respond to antidepressants in the acute phase
should be continued on their medication for atleast 12 months.

13. PTSD
 1st-line: either SSRIs or venlafaxine;
 2nd-line: Mirtazapine;
 Consider either amitriptyline or imipramine if 1st-line and 2nd-line
Tx are ineffective or poorly tolerated.
 BZs should not be used for the treatment of PTSD.
 Adjunctive Tx: Risperidone, olanzapine, quetiapine, and
lamotrigine in conjunction with SSRIs.
 Adequate treatment trial period: atleast 12 months;

14. PTSD (contd’.)
 CBT should be used as the 1st-line psychological treatment for
PTSD.
 2nd-line: Eye Movement Desensitisation and Reprocessing therapy;
 If CBT or eye movement desensitisation and reprocessing therapy
for PTSD are contraindicated or have failed, then
CBT + pharmacotherapy may be used.

15. Anxiety disorders in pregnancy
 If a woman is planning a pregnancy / is already pregnant / is
breastfeeding…
 Consider stopping medication and starting CBT, if necessary and if
not already tried.
 Switch to a safer drug, if the decision is to maintain the patient on
medication.
 Choose drugs with the lowest risk potential for the mother and
foetus/infant.
 Start medications at the lowest effective dose, and slowly titrate
upwards.
 Continue medications for the shortest possible duration.
 Use monotherapy instead of combination Tx as far as possible.

16. Anxiety disorders in pregnancy (contd’.)
 Avoid sertraline, paroxetine and citalopram during pregnancy.
 BZs should not be routinely prescribed for pregnant and
breastfeeding women, except for short-term treatment of extreme
anxiety and agitation.
 Assess risk-benefit ratio of prescribing BZs on a case-by-case basis
(use the lowest dose for the shortest time, or avoid prescribing at
all during the first trimester).

17. Anxiety disorders in pregnancy (contd’.)
 Prescribe atypical antipsychotics with caution in patients suffering
from or at risk of gestational diabetes.
 Maintain medication(s) for nursing mothers at the lowest effective
dose to minimize infant exposure.
 When antidepressant treatment is indicated in the postpartum
period, women should generally not be advised to discontinue
breastfeeding.

18. Anxiety disorders in pregnancy (contd’.)
 In ‘treatment-naïve’ breastfeeding women, paroxetine or
sertraline should be preferred over other SSRIs due to the low
infant exposure to these drugs.
 Fluvoxamine, venlafaxine, bupropion and mirtazapine should
not be considered as first-line therapies in breastfeeding
women (as little data exist regd. their safety profiles). However,
these medications can be used in special cases.
 SSRIs, TCAs, or SNRIs should be the specific 1st-line treatment if
Tx has proven to be successful and there are no
contraindications. Always perform individual risk-benefit
assessment before Tx.

19. Anxiety disorders in pregnancy (contd’.)
 Women on long-term treatment with high dose BZs should
continue to breastfeed, as stopping the BZs may precipitate
withdrawal symptoms in the infant. Gradual tapering and
stopping of BZs may be attempted at a later stage when the
infant has grown bigger.
 During maternal treatment with BZs, monitor the infants for
signs of sedation, lethargy, poor feeding and weight loss.

20. WHAT YOU (PHARMACIST) MUST CONSIDER WHILE DECIDING
THE THERAPEUTIC REGIMEN
 Patient’s age
 Treatment response
– When a member of a certain drug class has been proven
effective, it must not be assumed that the other members of
that drug class will be similarly effective.
 Risks for accidental overdose and deliberate self-harm
 Tolerability
 Patient’s previous experience of treatment with individual drugs
(eg adherence, effectiveness, side effects, experience of
withdrawal syndrome);

21. Pharmacist to consider (contd’.)
 Patient’s preference
• Discuss patient’s reason for this intervention and other
concerns;
 Cost of therapy

22. REFERENCES:
 Malaysian Clinical Practice Guidelines Management of
Major Depressive Disorders (2nd Edition); ISBN: 978-967-
2173-83-0
 Khek Choong Ho et al. (2020). Adherence to the Malaysian
clinical practice guideline for depression by general
practitioners in private practice in Penang. Asian Journal of
Psychiatry 48 (2020), Pgs. 1-5.
 Abdul Khaiyom JH, Mukhtar F, Oei TP. Treatments for
anxiety disorders in Malaysia. Malays J Med Sci.
2019;26(3):24–36.
https://doi.org/10.21315/mjms2019.26.3.2

23. THE END