Psych Disorders Discussion
Benzodiazepines are a class of medications often prescribed to treat insomnia, anxiety, and seizures among other disorders. These medications are highly effective, as they have a rapid onset, crossing the blood-brain barrier, where they increase activity at neurotransmitter gamma-aminobutyric acid (GABA) (Soyka, 2017). As this transmitter decreases the activity of neurons, the resultant effect is rapid decrease in the fight or flight response feeling of anxiety. While benzodiazepines do have a place, their use should be for short-term relief, less than 2-4 weeks, while waiting for medications that potentiate the reuptake of serotonin to reach therapeutic levels. Benzodiazepines are considered safe medications as they have low toxicity, but are very addicting and have high potential for abuse. As such, these medications should not be prescribed for patients with a history of polysubstance abuse, except in short-term detox settings.
Generalized anxiety disorder (GAD) is a disorder which is characterized by chronic incessant worry, poor concentration, irritability, and decreased level of social functioning (Stein & Sareen, 2015). This disorder is also often associated with somatic complaints such as back pain, stomachaches, and headaches. Women are diagnosed with GAD twice as often as men (Kato et al., 2018). As GAD is chronic, the persistent anxiety must last for 6 months or longer in order to meet the criteria. A diagnosis of GAD must meet DSM-V criteria, and can be assessed utilizing different screening tools such as GAD-7 or the Penn State Worry Questionnaire (Spitzer et al., 2006). The GAD-7 is an 8 question self-answered diagnostic tool that helps a clinician assess the level of anxiety and the overall effect on the patient’s life. Treatment of GAD requires a stepped approach and should also include cognitive behavior therapy as pharmacological interventions are not a “cure” for anxiety, but rather they suppress activity in the amygdala and pre-frontal cortex (Abejuela & Osser, 2016).
KT is a young adult female who is experiencing anxiety related to a generalized adjustment disorder. Utilizing DSM-V criteria, KT has been given a diagnosis of Generalized Anxiety Disorder. The first line therapy for GAD is a selective serotonin reuptake inhibitor (SSRI) (Abejuela & Osser, 2016), although a serotonin and norepinephrine reuptake inhibitor (SNRI) such as duloxetine is also an option, especially if KT had more somatic symptoms such as pain. In KT’s case, given her age, a few options to consider would be fluoxetine or escitalopram (Kato et al., 2018). As both medications are generally well tolerated with few side effects, either would be beneficial. SSRIs reach therapeutic levels in 6-8 weeks, with a patient seeing the first signs of improvement in sleep, appetite, and energy within the first 2 weeks, and significant improvement in anxiety in 2-4 weeks. In the interim, KT could be prescribed an as needed medication that would help decrease the uncomfortable feelings of anxiety such as hydroxyzine, propranolol, gabapentin, or clonidine. If her anxiety was not manageable in the short-term with these medications, then a small dose of a benzodiazepine, such as clonazepam, could be considered for the first 2 weeks (Stein & Sareen, 2015). KT should follow up in 4-6 weeks. If she has not achieved a 50% decrease in her symptoms at that time, it would be time to re-evaluate medications and either consider an increase in dose, a medication change, or an addition of another medication (Kato et al., 2018).
Major Depressive Disorder (MDD) is characterized by pervasive feelings of sadness, loss of interest, hopelessness, and trouble completing activities of daily living (Depression, n.d.). One tool clinicians use when evaluating depression in patients is the Hamilton Rating Scale for Depression (Sharp, 2015). This is a series of either 17 or 21 questions to evaluate symptomatology of depression including sleep, social functioning, quality of life, and feelings of hopelessness. SSRI’s are considered the gold standard for treating MDD, but other medications such as SNRIs or bupropion, a norepinephrine dopamine reuptake inhibitors (NDRI) may be used (Kato et al., 2018). As with medications for GAD, these medications take 6-8 weeks to reach maximum therapeutic levels, with patients generally endorsing decreased levels of depression within the first 2-4 weeks.
WD, a 49-year-old male, with underlying health conditions, recently suffered a myocardial infarction, and is noted to be depressed. As criteria for major depressive disorder (MDD) has already been established, it is in WD’s best interest to start an anti-depressant. Given WD’s medical health, an SSRI such as fluoxetine or sertraline would be a first-line treatment. These medications are generally considered safe in patients with hypertension and glaucoma (Kato et al., 2018).
Most people struggle with insomnia at some point in their lives. For many people, poor sleep hygiene can be a component. Additionally, studies show that 50% of people endorsing insomnia have an underlying untreated mental health condition (Winkelman, 2015). Insomnia has different components such as difficulty falling asleep, difficulty staying asleep, and early morning awakening. Cognitive behavioral therapy with improved sleep hygiene are the first line treatments for insomnia. However, many people also require temporary pharmacological interventions.
JM, a 42-year-old female, with poor sleep hygiene, in conjunction with depression, is endorsing continued insomnia despite her current regimen of temazepam 30 mg at bedtime. JM should be counseled regarding the poor lifestyle choices that she is making, such as high caffeine intake, lack of exercise, and high emotional stress levels. While a pharmacological intervention should be initiated, if JM does not make lifestyle changes and seek CBT, the interventions will not be as effective. As JM is endorsing depression as well as insomnia, an addition of trazodone or low dose quetiapine before bed would be beneficial (Winkelman, 2015). Temazepam should be considered only as a short-term hypnotic for sleep and be discontinued. As JM is struggling with daytime alertness and depression, she would be a good candidate for bupropion (Cipriani et al., 2018).
References
Abejuela, H., & Osser, D. N. (2016). The psychopharmacology algorithm project at the harvard south shore program. Harvard Review of Psychiatry, 24(4), 243–256. https://doi.org/10.1097/hrp.0000000000000098
Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., Leucht, S., Ruhe, H. G., Turner, E. H., Higgins, J. T., Egger, M., Takeshima, N., Hayasaka, Y., Imai, H., Shinohara, K., Tajika, A., Ioannidis, J. A., & Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. The Lancet, 391(10128), 1357–1366. https://doi.org/10.1016/s0140-6736(17)32802-7
Depression. (n.d.). Retrieved September 22, 2020, from https://www.nimh.nih.gov/health/topics/depression/index.shtml
Kato, T., Furukawa, T. A., Mantani, A., Kurata, K., Kubouchi, H., Hirota, S., Sato, H., Sugishita, K., Chino, B., Itoh, K., Ikeda, Y., Shinagawa, Y., Kondo, M., Okamoto, Y., Fujita, H., Suga, M., Yasumoto, S., Tsujino, N., Inoue, T.,…Guyatt, G. H. (2018). Optimising first- and second-line treatment strategies for untreated major depressive disorder — the sun☺d study: A pragmatic, multi-centre, assessor-blinded randomised controlled trial. BMC Medicine, 16(1). https://doi.org/10.1186/s12916-018-1096-5
Sharp, R. (2015). The hamilton rating scale for depression. Occupational Medicine, 65(4), 340–340. https://doi.org/10.1093/occmed/kqv043
Soyka, M. (2017). Treatment of benzodiazepine dependence. New England Journal of Medicine, 376(12), 1147–1157. https://doi.org/10.1056/nejmra1611832
Spitzer, R. L., Kroenke, K., Williams, J. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder. Archives of Internal Medicine, 166(10), 1092. https://doi.org/10.1001/archinte.166.10.1092
Stein, M. B., & Sareen, J. (2015). Generalized anxiety disorder. New England Journal of Medicine, 373(21), 2059–2068. https://doi.org/10.1056/nejmcp1502514
Winkelman, J. W. (2015). Insomnia disorder. New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/nejmcp1412740