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To manage anxiety, start with an SSRI and add CBT.


ORLANDO -- Do selective serotonin reuptake inhibitors work for late-life generalized anxiety disorder?

"The answer is, 'Yes, a little.' The benefits are limited in the randomized controlled trials and in my own clinical experience. Many people will get some benefit, but fairly few will get such a substantial benefit that that's all they need. Maybe on the order of 40% at most," Dr. Eric J. Lenze said at the annual meeting of the American Association for Geriatric Psychiatry.

He should know. He was the principal investigator in two of the three randomized, placebo-controlled trials that have established the efficacy of SSRIs for later-life generalized anxiety disorder (GAD), including by far the largest study, involving escitalopram (JAMA 2009;301:295-303).

For patients who don't achieve remission of anxiety symptoms with SSRI monotherapy, a good option and one of proven benefit--is dual therapy along with cognitive-behavioral therapy (CBT). In a randomized, placebo-controlled clinical trial involving 73 older adults with GAD, Dr. Lenze and his colleagues showed that during a lead-in phase with 12 weeks of open-label escitalopram, patients showed a modest reduction in worry symptoms on the Penn State Worry Questionnaire, but if they then had CBT added, they showed a substantial further reduction in worry, compared with those who did not receive CBT. Continued escitalopram prevented relapse, but for many patients CBT allowed sustained drug-free remission (Am. J. Psychiatry 2013;170:782-9).

The concept is that starting out with an SSRI helps reduce the patient's distress and somatization, then adding the CBT addresses the underlying pathologic worry.

"The combination seems to be effective, and it's an attractive one. CBT has what the psychologists call 'durable' benefits: You get a course of CBT, it's stopped, and those benefits are maintained," explained Dr. Lenze, professor of psychiatry at Washington University in St. Louis.

The beauty of CBT in terms of late-life anxiety is that relaxation training seems to be the single most effective component of CBT for this condition, as shown by researchers at the University of California, San Diego (Am. J. Geriatr. Psychiatry 2009;17:105-15).

"This is important because relaxation training--deep breathing, muscle relaxation, and pleasant imagery is also the easiest component of CBT, which means that if I had the time in my clinic, even I could probably pull this off with patients. If you have a bevy of therapists you can refer to, your patients will get benefit from it," the psychopharmacologist continued.

Pharmacologic options beyond the three SSRIs supported by placebo-controlled, randomized trial evidence sertraline, citalopram, and escitalopram --include the various other SSRIs. Also, two selective norepinephrine reuptake inhibitors (SNRIs)--venlafaxine and duloxetine--are supported by retrospective analyses of earlier Food and Drug Administration approval studies that showed the drugs appeared equally efficacious in young adults and the elderly with GAD.

A large multisite study of pregabalin for late-life GAD showed it was effective starting at 50 mg b.i.d. and titrating up as tolerated to 100 mg t.i.d. And a multicenter study showed quetiapine XR was effective at much lower doses than those used for schizophrenia. But neither pregabalin nor quetiapine XR are approved for GAD.

The use of benzodiazepines is problematic. They induce falls and cognitive impairment at a lower dose than is effective for anxiety. And short-acting benzodiazepines are not safer than long-acting ones. Yet benzodiazepines, to Dr. Lenze's dismay, are heavily prescribed for late-life anxiety, especially by primary care physicians.

"I sometimes do use benzos, but I would say about 10 times less than many of my colleagues. By the time a patient with anxiety gets to a psychiatrist, they're probably already on a benzo. For most of my patients, one of the key questions in my mind is, 'When am I going to start tapering that benzo someone else put them on?' " said Dr. Lenze.

He reported having received grants from Roche and Lundbeck.

Caption: DR. LENZE

Caption: Relaxation training, which included muscle relaxation and pleasant imagery, appears to be the most effective component of CBT for treating anxiety.

Eight-rule checklist seeks to promote compassionate care

Dr. Lenze's work with older patients who have anxiety has led him to develop the following checklist that should help you respond to these patients with compassion:

* Include an objective measurement of severity in assessment. Patients with GAD will often come in for a follow-up visit unaware that they're now spending much less of their day wracked by worry and that they now feel they have some ability to stop it. It helps to show them the earlier numbers.

* Think twice about prescribing a benzodiazepine.

* Provide psychoeducation about anxiety. "A lot of the bite of anxiety is defanged if you just understand what anxiety is. It's not going to kill you. It's a set of alarm systems in your brain that helps you survive by responding to threats at the cost of making you miserable. That's all it is. If you can get that across to a patient and the family, that's a crucial part of getting well and staying well," said Dr. Lenze.

Physicians often don't have a lot of time for patient education in the office, and patients might not remember much of what was said anyway, because they were stressed out about the visit. So recommendations for good self-help books are useful, added Dr. Lenze.

* Start low and go slow in elderly patients. "Starting low is a good exercise in graduated exposure for these patients so they feel more comfortable. But get them up to the same doses of SSRIs (selective serotonin reuptake inhibitors) and SNRIs (selective norepinephrine reuptake inhibitors) you use in younger adults as quickly as you can for their level of comfort. Ten weeks of escitalopram at 2.5 mg is not the way to treat these individuals," he continued.

* Arrange for frequent follow-up within the first month of starting therapy or a dose change in order to monitor response and encourage adherence. "This is really important," he said. "They get anxious about treatment, scared of medication, and frequently stop therapy."

* For first-line therapy, stick to what you're used to prescribing. You'll project more confidence when a patient calls back about side effects.

* Consider augmentation and switch strategies for inadequate responders.

* Provide maintenance therapy. "An area where many in our field make errors is in letting people drop out of long-term treatment. Antidepressants have maintenance benefits. That means they prevent relapse if you keep taking them. One place where we can all do better is in continuing to remind our patients of the benefits of maintenance treatment," Dr. Lenze emphasized.


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Author:Jancin, Bruce
Publication:Clinical Psychiatry News
Date:May 1, 2014
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