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33 Cards in this Set
- Front
- Back
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GAD Rating Scales |
GAD-7: self rated, 5min -5-mild -10-moderate -15-severe anxiety HAM-A(Hamilton Anxiety Scale) -0-17 Mild -18-24 Mild to moderate -25-30 Moderate to severe -Remission >70% or score< 7 -Improved 50% better from baseline -Partial respinse 25-49% -Non-Response< 25% BAI (Beck Anxiety Inventory) -0-7 Minimal -8-15 Mild -16-25 Moderate -26-63 Severe PSWQ-Penn State Worry Questionnaire-Self-rated. GAD subjects score >/60 SAS-Zung self-rating anxiety scale- 20-44 Normal 45-59 Moderate 60-74 Moderate to severe 75-80 Severe
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GAD 1st Line Pharmacotherapy
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Escitalopram 10-20mg Paroxetine 20-50mg Sertraline 50-150mg venlafaxine XR 75-225mg Duloxetine 60-120mg |
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GAD 2nd Line Pharmacotherapy |
BZDP-adjuct tx for 2-4weeks Pregabalin 150-600mg imipramine 75-200mg |
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GAD Other Pharmacotherapy |
Hydroxyzine 37.5-75mg- effective in trials for acute anxiety, but ADR ( daytime sedation) limit use Buspirone 15-60mg-indicated for GAD, but efficacy results were inconsistent |
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Panic Disorder Rating Scales |
PDSS-Panic Disorder Severity Scale Remission Score < 3 -Without Agoraphobia --0-1 Normal --2-5 Borderline --6-9 Slightly ill --10-13 Moderately ill -->/14 Markedly ill -With Agoraphobia --3-7 Borderline --8-10 Slightly ill --11-15 Moderately ill -->/16 Markedly ill PAS-Panic & Agoraphobic Scale -Used for diagnosis multidimensional design SPRAS-Sheehan Pt-Rated Anxiety Scale -evaluates severity of symptoms, somatic symptoms PRIME-MD-Primary care Eval. of Mental Disorder Anxiety Module -Used to screen in primary care settings |
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Panic Disorder 1st Line Pharmacotherapy |
Citalopram 20-40mg Escitalopram 10-20mg Fluoxetine 20-40mg Fluvoxamine100-300mg Paroxetine 20-60mg Sertraline 50-150mg Venlafaxine 75-225mg |
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Panic Disorder 2nd Line Pharmacotherapy |
Imipramine 75-200mg Clomipramine 75-250mg BZDP-adjuct tx for 2-4 weeks Alprazolam 1.5-8mg/day Clonazepam 1-4mg/day Diazepam 5-20mg/day Lorazepam 2-8g/day |
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Panic Disorder Treatment Resistance Pharmacotherapy |
Phenelzine |
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BZDP-Short half-life/higher potency |
Short half-life/higher potency (Withdraw symptoms are common, so tapper dose): Alprazolam T1/2 6-12hr, Lorazepam T1/2 10-18hr, clonazepam T1/2 20-50 Withdrawal begins: "1-2 days after dc, shorter duration, more intense" |
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BZDP-Longer half-life/ low potency |
Longer half-life/ low potency (minimal withdraw symptoms): Diazepam T1/2 20-100hr Chlordiazepoxide T1/2 5-30hr Withdrawal begins: "5-10 days after dc and can last a few weeks" |
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BZDP withdraw symptoms |
Common symptoms: anxiety, insomnia,irritability, nausea, diaphoresis, systolichypertension, tachycardia, tremor Possible consequences: delirium, confusion,psychosis, seizures |
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BZDP withdraw medical managment |
Patients on longterm BZDP therapy (> 2 Months): Treatment guidelines recommend therapy for at least 1year after resolution of symptoms before consideringdiscontinuation |
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BZDP Tapering Schedule |
Typical tapering schedule for benzodiazepines: • 25% per week reduction in dosage until at 50%of dose, then reduce by one eighth every 4-7days – Therapy > 8 weeks: taper over 2-3 weeks – Therapy > 6 months: taper over 4-8 weeks – Therapy > 1 year: taper over 2-4 months • For patients on high potency benzodiazepines formonotherapy of panic disorder, a very gradualdiscontinuation is recommended |
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Clonazepam 2mg taper over 5 weeks |
Clonazepam -week 1: 0.5mg AM and 1mg PM -week 2: 0.5mg BID -week 3: 0.25mg AM and 0.5mg PM -week 4: 0.25mg BID -week 5: 0.125mg HS -week 6: no more |
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Clinical Pearls for tapering BZDP over 2-4 months: |
Alprazolam doses >3 mg/day • Decrease dose by 0.5 mg every 2 weeks until 3 mg • Then decrease by 0.25 mg every 2 weeks until 1 mg • Then decrease by 0.125 mg every 2 weeks Clonazepam • Decrease dose by 0.25 mg every 2 weeks Diazepam • Decrease dose by 2.5 mg every 2 weeks Lorazepam • Decrease dose by 0.5 mg every 2 weeks |
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Social Anxiety Rating Scales |
LSAS-Leibowitz Social Anxiety Scale >/95-Very Severe 80-95- Severe 65-80-Marked 55-65-Moderate Response: score of 50 Remission: score < 30 SPAI-Social Phobia and Anxiety Inventory -Self-rated, Screening tool, distinguishes between agoraphobia and social phobia SPIN-Social Phobia Inventory -Self-rated, Screening tool. Measures SAD, severity and outcome after treatment |
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SAD 1st Line Pharmacotherapy |
Tx for at least 12 months Escitalopram 10-20 mg Fluvoxamine 100-300 mg Paroxetine 20-50 mg Fluoxetine 20-40 mg Sertraline 50-150 mg Venlafaxine XR 75-225 mg |
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SAD 2nd Line Pharmacotherapy |
Imipramine 75-200 mg Clonazepam 1.5-8 mg/day, when patient has no history of dependence; may combinewith antidepressants for first 2-4 weeks |
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SAD Treatment Resistance Pharmacotherapy |
Buspirone adjunct with SSRI ( not effective as monotherapy Phenelzine Performance SAD-Atenolol or propranolol |
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SAD Goals of Therapy -Acute -Continuation -Long-term |
– Acute (first 4-12 weeks): Reduce physiologicsymptoms of anxiety, social anxiety, and phobicavoidance – Continuation (3-6 months): Extend therapeuticbenefits, participation in social activities,improvements in disability, concurrent psychiatricconditions and QOL – Long-term: Remission (i.e., full resolution ofsymptoms across all 3 SAD domains); sustained for 3months; Liebowitz Social Anxiety Scale ≤ 30 points |
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OCD Rating Scales |
Y-BOCS- Yale-Brown Obsessive-Compulsive Scale: "Commonly Used" -32-40: Extremely severe symptoms -24-31: severe symptoms -16-23: Moderate symptoms - 8-15: mild symptoms -0-7: Subclinical symptoms Reduction >/25% reduction in score Remission score </8 OCI-R Obsessive-Compulsive Inventory-Revised(Score ranges from 0-72) -Used for diagnosis and to determine severity of symptoms |
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OCD 1st Line Pharmacotherapy |
Higher SSRI doses produce higher response ratesand greater magnitude of symptom relief : Escitalopram 10-20 mg Fluoxetine 40-60 mg Paroxetine 40-60 mg Fluvoxamine 100-300 mg Sertraline 50-200 mg
Doses can be titrated more rapidly in OCD(inweekly increments to maximum dosage), rather thanwaiting for treatment response for 1-2 months Example (Case 5), the patient would go from 50mg at the end of week 1 to 100 mg at the end ofweek 2, with subsequent increases of 50 mg/dayat weekly intervals up to 200 mg/day |
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OCD 2nd Line Pharmacotherapy |
Typically reserved until after failure with 2 SSRIs -Clomipramine 75-250 mg; equally effective as SSRIs but less well-tolerated |
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OCD Pharmacotherapy Treatment Resistance |
Intravenous clomipramine (not FDA approved or available in USA) was more effective than oralclomipramine SSRI + antipsychotic (haloperidol, quetiapine, olanzapine, risperidone) moreeffective than SSRI alone |
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OCD Duration of Therapy |
After response, patient should remain onpharmacotherapy for at least 1-2 years • Medication should be tapered over anextended period of time – Decrease dose by 25% every 2 months • Life-long prophylaxis recommended after 2-4 severe relapses or 3-4 mild relapses |
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PTSD Rating Scales |
CAPS-Clinician Administered PTSD Scale "Gold-standard" -PTSD Diagnosis is made if: -1"B"symptom -3 "C" symptoms -2 "D" symptoms -along with the other DSM-V criteria met -Remission >70% or score< 7-Improved 50% better from baseline -Partial respinse 25-49% -Non-Response< 25% PTSD Checklist ( multiple vesions) -Used for diagnosis, screening and monitoring -Response: a change in 5 its is the minimal threshold IES-R-Impact of Event Scale Revised -Used to gauge response > 2wk after trauma event or evaluate recovery PSS-I PTSD Symptom Scale Interview Version -Used for diagnosis and severity of symptoms M-PTSD Mississippi Scale for Combat Related -Self-reported, Used for diagnosis and screening |
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PTSD 1st Line Pharmacotherapy |
Tx for 12 to 24 months All decrese 3 main symptoms domains in PTSD (1. hyper arousal, avoidance/numbing, and re-experiancing) Fluoxetine 20-40 mg Paroxetine 20-40 mg Sertraline 50-100 mg Venlafaxine 75-300 mg Prazosin may be more effective in combat-related PTSD |
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PTSD 2nd Line Pharmacotherapy |
TCAs – amitriptyline, imipramine 75-200 mg Mirtazapine 30-60 mg Lamotrigine (study doses ranged from 50-500 mg/day) Nefazodone (effective in small, controlled trial in male combat Veterans) |
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PTSD Pharmacotherapy Treatment Resistance |
Venlafaxine Prazosin Quetiapine + venlafaxine Gabapentin + SSRI |
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Atypical antipsychotic as an adjunctive agent for PTSD |
Veterans Administration/Department of Defense PTSD Clinical PracticeGuideline – Atypical antipsychotics are not recommended as monotherapy – Risperidone is contraindicated for use as an adjunctive agent -potential harm (side effects) exceeds benefits – There is insufficient evidence to recommend any other atypicalantipsychotic as an adjunctive agent for PTSD |
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PTSD Treatment: Augmenting Agents |
Antiadrenergics:Hyperarousal, flashbacks and impulsivity – monitor BP,pulsePrazosin – nightmares and sleep disruption Anticonvulsants: Startle response, nightmares Antipsychotics: Psychosis or flashbacks with hallucinations, dissociation Cyproheptadine: Nightmares Lithium: Irritability, mood swings Benzodiazepines are not recommended in patients with PTSD; earlyadministration does not prevent emergence of PTSD and may be associated with aless favorable outcome |
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Separation Anxiety Rating Scales |
Severity Measure for Separation Anxiety Disorder- Child Age 11-17 Score range from 0-40, high represent severe SAD Adult Separation Anxiety Questionnaire Score > /16: diagnosis for SAD in adults |
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Separation Anxiety Disorder |
More commonly seen in adults then children and adolescents Tx: 1st line tx is CBT w/ or w/o SSRI |
