NPS MEDICINEWISE ANXIETY: RETHINKING THE OPTIONS 1

ANXIETY: RETHINKING THE OPTIONS

Figure 1: Impact of anxiety on the Australian population

Symptoms of anxiety7,8

PHYSICAL PSYCHOLOGICAL BEHAVIOURAL

• Difficulty sleeping • Panic attacks (at least 4 of the following: palpitations, dizziness, shortness of breath, sweating, nausea, hot or cold flushes, abdominal discomfort and paraesthesiae) • Fatigue • Muscle tension

• Excessive worry • Nervousness/restlessness • Panic • Irritability • Derealisation (feeling of unreality) or depersonalisation (being detached from oneself) • Poor concentration

• Phobic avoidance

TABLE 1

... of these, 61% receive an evidence-based treatment.2

Only 27% of people with anxiety disordersa seek help...

Limited health literacy4

‘I find it difficult describing symptoms to my GP’

Experience of stigma and discrimination5

‘I’m worried what my friends and family will think'

Perceptions of treatment6

‘I don’t want to see my GP because they may prescribe medicines which don’t work’

Limited awareness of support and resources6

‘I don’t know who I can talk to about my anxiety’

The average timeb from symptom onset…

…to seeking help, is 8.2 years3

Years

Figure 2: Patient barriers to the assessment and management of anxiety

• mental condition (eg, depression, bipolar disorder)

• substance or medicine-induced (eg, caffeine, levothyroxine, alcohol abuse, drug withdrawal)

Consider whether anxiety is a result of, or comorbid with, another cause:8–10

• physical condition (eg, hyperthyroidism, cardiopulmonary disorders)

See Table 2 for specific symptoms of each anxiety subtype.

• Mild anxiety: < 1 day/month

• Moderate anxiety: 1–7 days/month

• Severe anxiety: > 7 days/month

Anxiety disorders are characterised by distressing symptoms which are frequent, persistent (lasting 6 months or more) and impact day-to-day life.9,11 Severity may be determined by assessing the number of days on which a patient is unable to perform daily tasks.9

a Excludes patients with both anxiety and mood disorders; b Average for patients with anxiety and mood disorders presenting to a specialist anxiety clinic

Anxiety disorders are the most common mental health conditions in Australia. Around 14% of people aged 16–85 are affected by anxiety disorders.1

Recognise anxiety symptoms

Consider differential diagnoses

Assess the severity and persistence of anxiety symptoms

NPS MEDICINEWISE ANXIETY: RETHINKING THE OPTIONS 2

Use a shared decision-making approach, selecting and tailoring treatment in collaboration with each patient

Figure 3: Treatment options for anxiety

CBT= cognitive behavioural therapy; SSRI= selective serotonin reuptake inhibitor

CBT and/or SSRI monotherapy are recommended treatments for anxiety disorders. For other psychological treatments, see Medicinewise News. For available medicines, see Insert page 2.

Anxiety subtypes and their diagnostic features10,11

SUBTYPE MAJOR DISTINGUISHING SYMPTOMS (FEATURES)

Panic disorder Recurrent panic attacks, in the absence of situational triggersPersistent concern or worry about having more panic attacks and/or maladaptive change in behaviour related to the attacks

Agoraphobia Marked fear of situations where escape is difficult or help is not available if a panic attack occurs: often crowded situations but also being home alone

Social anxiety disorder (SAD)

Marked fear, anxiety or avoidance of social interactions in which there is possible exposure to scrutiny by othersFear of negative judgement from others or being the focus of attentionFear of being embarrassed, humiliated, rejected or offending others

Generalised anxiety disorder (GAD)

Excessive, difficult-to-control anxiety and worry in multiple domains Accompanied by symptoms such as restlessness/feeling on edge or muscle tension

Obsessive compulsive disorder (OCD)c

Obsessions: recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that cause marked anxiety and distressCompulsions: repetitive behaviours (eg, hand washing) or mental acts (eg, counting) that the individual feels driven to perform

Post-traumatic stress disorder (PTSD)c

Exposure to actual or threatened death, serious injury or sexual violationIntrusion symptoms (eg, distressing memories or dreams, flashbacks, intense distress) and avoidance of stimuli associated with the eventNegative alterations in cognition and mood (eg, negative beliefs and emotions, detachment) as well as marked alterations in arousal and reactivity

Specific phobias Marked, unreasonable fear or anxiety about a specific object, or situation (eg, heights, animals, needles) which is actively avoided

c OCD and PTSD are no longer classified under anxiety disorders in DSM-5

TABLE 2

Recognise anxiety subtypes to help guide effective treatment

Consider these factors when selecting treatment:9

• Severity• Evidence of efficacy• Patient preference• Treatment barriers (eg health literacy)• Accessibility• Affordability • Tolerability • Safety• Anxiety subtype

Provide validation and psychoeducation

CBT SSRI

Address potential contributing factors

Exposure to feared stimuli

3 NPS MEDICINEWISE ANXIETY: RETHINKING THE OPTIONS

Consider evidence-based psychological treatment first when treating people with mild to moderate anxiety8

Figure 4: CBT challenges and changes unhelpful feelings, beliefs and behaviours9,12,13

Figure 5: Structure and components of CBT for anxiety disorders9,13

CBT

99Robust evidence

99Few side effects

99 Low risk of relapse

99Multiple delivery formats

FeelingsElicits feelings and

body sensations

BeliefsChanges irrational and

dysfunctional beliefs

BehavioursTeaches exposure

exercises

• Set realistic expectations of CBT with patients – see Figure 5.

• Stress that patients need to commit and take an active role.

• Give CBT an adequate trial; allow 4–6 weeks to see an improvement in symptoms.

CBT is the recommended psychological treatment in most cases and has been the most rigorously evaluated.9,12

Stage 1 • Provides patients with psychoeducation about anxiety and treatment • Monitors symptoms • Addresses factors that facilitate or hinder therapy, eg, patient barriers to implementing treatment

Stage 2 • Promotes relaxation and breathing techniques (arousal management) • Encourages patient to face fears through repeated exposure (graded exposure) • Reduces behaviours that maintain anxiety cycles (safety response inhibition) • Encourages patient to let go of safety signals and learn adaptive self-efficacy (surrender of safety signals)

• Includes cognitive restructuring, behavioural experiments and related strategies (cognitive strategies)

Stage 3 • Prevents relapse • Informs patient of possible future recurrences • Encourages patient to view recurrences as lapses rather than failure and to apply their coping strategies to anxiety

Online CBT (eCBT) has similar efficacy and effectiveness compared to face-to-face CBT. It may be more suitable for those who have difficulty accessing a therapist.9

Examples of evidence-based eCBT programs and their features9,14

ONLINE CBT PROGRAM COST FEATURESThisWayUp.org.au $59 • Self-referral, or registered health professionals can directly refer and monitor patients’ progress

• Specific programs include GAD, SAD, panic disorder, social phobia, OCD, PTSD, and mixed anxiety and depressiond

• Specific perinatal, teenage depression and anxiety programs and free wellbeing courses

MentalHealthOnline.org.au Free • Self-referral • Optional access to Mental Health Online therapists • Specific programs include GAD, SAD, panic disorder, OCD, PTSD and depression

MindSpot.org.au Free • Registered health professionals can directly refer and monitor patients’ progress • Guidance through programs by MindSpot therapists via telephone or email • Programs target symptoms of anxiety and depression in different age groupsd

• Specific programs for OCD and PTSD • Specific program for Aboriginal and Torres Strait Islander adults

MoodGYM.com.au Free • Self-referral • Program targets symptoms of anxiety and depression • Available in English and German

d Benefit shown in clinical settings for programs covering comorbid anxiety and depressive disorders

Information correct at time of print; for further eCBT programs see www.blackdoginstitute.org.au/emhprac

TABLE 3

Educate patients on what to expect from CBT

Independent. Not-for-profit. Evidence-based.This program is funded by the Australian Government Department of Health.

© 2019 NPS MedicineWise Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read our full disclaimer. January 2019 NPS2093

nps.org.au Level 7/418A Elizabeth Street Surry Hills NSW 2010 PO Box 1147 Strawberry Hills NSW 2012 02 8217 8700 02 9211 7578 info@nps.org.au

References available online at: nps.org.au/anxiety-card-refs

EX

PE

RT

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EV

IEW

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S Associate Professor Lisa Lampe Discipline Lead Psychiatry, School of Medicine and Public Health, University of NewcastleStaff Specialist Psychiatrist, Hunter New England Local Health District

Associate Professor Louise StoneSpecialist Lead (Rural and Remote Practice) – Mental Health Portfolio, HETI Higher Education Clinical Associate Professor Academic Unit of General Practice, Australian National University Medical School

Figure 6: Pharmacological management of anxiety disorders9,15,16

Awaitresponse

6–12

mon

ths

Continue treatment ifresponse is satisfactory

Startlow

From

1–2

wee

ks

Start treatment withSSRI monotherapy

Titrate slowly to the minimum dosein the recommended therapeutic range(start with approximately half the starting dose given for depression)

Goslow

4–6

wee

ks Reviewresponseto initial

treatment

If response is unsatisfactory:• Adjust dose• Try an alternative treatment

Maintaintreatment

1–4

mon

ths

Discuss stepping down then stoppingtreatment with the patient.

Downward-titrate medicine slowlywhile monitoring discontinuation symptoms

Include exposure therapy as part of overall management even when using a medicine10

Avoid using benzodiazepines as first-line medicines9!

When starting pharmacological treatment, discuss expected side effects and their management with patients.9

When reviewing a treatment plan:• Assess the number of prescribed medicines and their

indications. Do not combine antidepressants.15 • Assess and manage medicine-related side effects.

Examples of common SSRI side effects include:9,15,16

• Agitation, anxiety• Gastrointestinal effects (nausea, vomiting, diarrhoea)• Headache• Insomnia, drowsiness• Sexual dysfunction

Pharmacological treatment is recommended when CBT is not sufficiently effective or available, or when preferred by the patient.8,9

SSRIs are highly effective, better tolerated and safer than other antidepressants.9

Use SSRI monotherapy where pharmacological treatment is indicated9,15