Anxiety, OCD and PTSD

Generalized Anxiety Disorder (GAD):

• 6 months or more of excessive worry or anxiety.
• OCD – intrusive thoughts that can not be controlled
• PTSD: trauma related to avoidance of stimuli.
• Benzos are the first line therapy in anxiety.  Can cause tolerance or dependence.  Abrupt discontinuation can lead to withdrawal.   Treat for 3-4 weeks until trial for an antidepressant is complete.
• SSRIs are also effective, as is venlafaxine, duloxetine, and TCAs.  Buspirone is controversial.  Venlafaxine is the agent of choice because it also helps with vasomotor symptoms.
• Misc agents: Beta-blockers can block peripheral symptoms.  MAOIs can treat panic with atypical depression.  Hydroxyzine’s sedating effects can reduce the physical symptoms of anxiety
  Augmentation with quetiapine, olanzapine or risperidone can be tried.

Benzodiazepines:

Benzodiazepine	Onset of Action	Peak Onset (hrs)	Half-life parent (hrs)	Half-life metabolite (hrs)	Comparative Oral Dose
Long Acting
Chlordiazepoxide	Int. (po)	2-4(po)	5-30	3-100	10 mg
Diazepam	Rapid (po, IV)	1(po)	20-50	3-100	5 mg
Flurazepam	Rapid	0.5-2	inactive	47-100	30 mg
Intermediate  Acting
Alprazolam	Int.	0.7-1.6	6-20	–	0.5mg
Clonazepam	Int.	1-4	18-39	–	0.25mg
Lorazepam	Int. (po), Rapid (sl, IV)	1-1.5 (po)	10-20	–	1mg
Oxazepam	Slow	2-3	3-21	–	15mg
Temazepam	Slow	0.75-1.5	10-20	–	30mg
Short Acting
Midazolam	Most  Rapid IV	0.5-1 (IV )	1-4	–	–
Triazolam	Int.	0.75-2	1.6-5.5	–	0.5mg

IV BZDs:

Drug	Diazepam	Lorazepam	Midazolam
Onset (m)	2-5	5-20	2-5
Duration (h)	2-4	4-6	1-2
Prolonged in renal	yes	no	yes
Prolonged in hepatic	yes	no	yes
T 1/2 (h)	24-120	10-20	1-10
Active metabolites	yes	no	yes
CYP 3A4 Interaction	yes	no	yes
Hypotension	yes	no	no
Thrombocytopenia	yes	maybe	no
Propolyne glycol toxicity	no	yes	no

ALOT are better for elder and renal pts (alprazolam, lorazepam, oxazepam, temazepam)

Panic disorders:

• Antidepressants, BZDs.
• Don’t use buspirone, Beta blockers, antihistamines, antipsychotics, bupropion or trazodone.
• Cognitive behavioral therapy (CBT) can be effective.  Start on low doses of antipsychotics.

Obsessive Compulsive Disorder (OCD):

• SSRIs, cognitive behavioral therapy secondary to drugs, augmentation with haloperidol or a second-generation antipsychotic (olanzapine, quetiapine or risperidone) may help.

Post-traumatic Stress Disorder (PTSD):

• Psychotherapy, SSRIs can be used as an adjunct
• Can treat with prazosin for nightmares, anticonvulsants (valproic acid, carbamazepine, lamotrigine, topiramate) for anger, aggression, and depression or atypical antipsychotics (olanzapine, quetiapine, risperidone) for psychotic symptoms.  BZDs for sleep

Seasonal Affective Disorder (SAD):

• CBT most cost-effective. Can also use SSRIs, clonazepam, gabapentin and pregabalin

Phobias:

• No meds help, desensitization is the only therapy.