Clinical tips: anxiety

Ben Basger takes a look at anxiety and its treatment

Do you often feel anxious? Do you worry about everything all the time? Has this been going on for months? More than six? Maybe years?

Are you unable to relax and sit still because you feel ‘on edge’? Are you also irritable? Have you got tense muscles? Does the whole thing fatigue you but after you sleep (if you do), you are not refreshed? Is all this interfering with your job? Your social activities? Is your emotional support person suffering?

It could be that you have generalised anxiety disorder (GAD). On the other hand, it could be that your thyroid gland is overactive, you drink too much coffee (caffeine) or you use too much cocaine.

Two thoughts occur when considering treatment. Psychological interventions are first line therapy for GAD. But how often do you see patients taking benzodiazepines or selective serotonin reuptake inhibitors (assuming you know they have GAD) who have not been offered such interventions?

Cognitive behavioural therapy (CBT) is the most empirically supported psychological treatment for youth and adult anxiety disorders.

CBT is a short-term (e.g. 10–20 weeks) treatment that is designed to reduce anxiety-driven biases that interpret ambiguous stimuli as threatening, replace avoidant and safety seeking behaviours with approach and coping behaviours, and reduce excessive autonomic arousal through strategies such as relaxation or breathing retraining.

The question that will elicit the information as to whether psychotherapy has been offered is this one: ‘what else did the doctor tell you to do besides use this (benzodiazepine, SSRI) medicine?

You may then have to elaborate on the usefulness and accessibility (via the GP) of this form of therapy.

The second thought regards the use of benzodiazepines. Controversy continues to surround their use, which some experts think are overused and associated with potentially dangerous outcomes such as increased risk of falls, over-sedation and cognitive impairment (dementia).

Nonetheless, the efficacy of benzodiazepines for anxiety disorders is unequivocal and robust. Most expert guidelines continue to recommend use of benzodiazepines for patients without current (or, ideally, past) alcohol or other substance-use disorders who have failed SSRI and psychotherapy.

How strongly do you feel when you see someone on long-term diazepam? Should we tell patients that Australian guidelines recommend use for no longer than six weeks − for the purpose of controlling severe and disabling anxiety causing unacceptable distress?

A useful analogy may be describing the use of benzodiazepines as a medicine for breakthrough symptoms only.

Dr Ben Basger PhD MSc BPharm DipHPharm FPS AACPA is a clinical pharmacist and educator at Wolper Jewish Hospital and The University of Sydney, NSW.

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