Seroquel for Anxiety?

[deleted1041327]

Hello. I need help with figuring out this choice of medications.

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[psyguru]

I was told by a psychiatrist who completed a psychopharmacology fellowship that Seroquel at 25-50 mg is basically an expensive form of Benadryl. I would avoid Seroquel for this purpose and consider Atarax. In the prison, I used Stelazine. I have seen some even use pregabalin.

 

[thepoopologist]

In my limited experience SSRIs are first line for anxiety disorders including social anxiety. If the physician was considering time as a factor and wanted to have the employee return to work sooner then he should consider a benozpdiazpine for the short-course while the SSRI kicks in. At best Seroquel is an adjunct treatment to an SSRI for general anxiety disorder (off label-use) with a starting dose of 25 - 50 mg daily. Though I understand Seroquel may be used for other conditions aside from schizophrenia and bipolar disorder, 100 mg seems a bit too excessive (also considering side effect profile of atypicals). I will also point out the patient also has no indication of a mood disorder or substance use disorder. There were some mild ADHD symptoms noted but these are not significant and may be driven from anxiety. What are your thoughts? Is this a standard of care?

I honestly don't think a mild social anxiety requires meds at all, therapy should be enough.

A low dose PRN use for situational anxiety would be the most conservative way to go. Seroquel below 200 mg is more Benadryl than antipsychotic however as mentioned is a more expensive way to go. The hydroxyzines, gabapentins, or other sorts would work as PRNs.

If the anxiety's more generalized than what you suggest with the SSRI plus short course benzo if needed would be the most conventional way to go, however in many cases the short course benzo tends to be a longer course than you usually imagine and then there's another problem on your hands.

 

[hamstergang]

Patient is a ~35 yo M with no PMH, including no psychiatric history being seen in an IOP setting. He was referred by his employer for mild anxiety symptoms.

Mild anxiety lands him in an IOP, referred by his job? What am I missing?

 

[SmallBird]

Despite the myth that nothing works or nothing has been studied (Exagerrating, but you get the idea) - quetiapine has been studied for anxiety in several randomized controlled trials, and is effective. It has a lot of side effects but I honestly prefer it to a benzodiazepine if I feel I need an additional medication to provide some immediate relief. Being on quetiapine for 3 - 6 weeks while we work in therapy is unlikely to cause much harm. I only consider this if there is significant functional impairment, given, as others have said, the comparatively larger effects sizes and response rates for CBT.

 

[erg923]

Hello. I need help with figuring out this choice of medications.

Patient is a ~35 yo M with no PMH, including no psychiatric history being seen in an IOP setting. He was referred by his employer for mild anxiety symptoms which appear performance type social anxiety. He has since starting receiving psychotherapy. The patient was also initially offered Seroquel (only) but was eventually started on Lexapro 5 mg. 4 days after starting treatment the attending psychiatrist commented if he wanted to return to work sooner he should reconsider taking Seroquel starting at 100 mg daily (and stop the Lexapro).

In my limited experience SSRIs are first line for anxiety disorders including social anxiety. If the physician was considering time as a factor and wanted to have the employee return to work sooner then he should consider a benozpdiazpine for the short-course while the SSRI kicks in. At best Seroquel is an adjunct treatment to an SSRI for general anxiety disorder (off label-use) with a starting dose of 25 - 50 mg daily. Though I understand Seroquel may be used for other conditions aside from schizophrenia and bipolar disorder, 100 mg seems a bit too excessive (also considering side effect profile of atypicals). I will also point out the patient also has no indication of a mood disorder or substance use disorder. There were some mild ADHD symptoms noted but these are not significant and may be driven from anxiety. What are your thoughts? Is this a standard of care?

(My concerned regarding this is heightened as I have heard comments from other physicians that the prescribing physician (+70 yo) should retire, therefore I question if he has kept up on current best-practice guidelines.)

Why in the world would IOP be the appropriate level of care for somebody with mild, performance-oriented anxiety?

 

[vistaril]

Why in the world would IOP be the appropriate level of care for somebody with mild, performance-oriented anxiety?

he probably somehow got approved for it by insurance.....what else matters?

 

[vistaril]

I was told by a psychiatrist who completed a psychopharmacology fellowship that Seroquel at 25-50 mg is basically an expensive form of Benadryl.

Wait....he only did 1 'psychopharmacology fellowship' to drop dimes like that? That must have been a damn good program.....

 

[clausewitz2]

Hello. I need help with figuring out this choice of medications.

Patient is a ~35 yo M with no PMH, including no psychiatric history being seen in an IOP setting. He was referred by his employer for mild anxiety symptoms which appear performance type social anxiety. He has since starting receiving psychotherapy. The patient was also initially offered Seroquel (only) but was eventually started on Lexapro 5 mg. 4 days after starting treatment the attending psychiatrist commented if he wanted to return to work sooner he should reconsider taking Seroquel starting at 100 mg daily (and stop the Lexapro).

In my limited experience SSRIs are first line for anxiety disorders including social anxiety. If the physician was considering time as a factor and wanted to have the employee return to work sooner then he should consider a benozpdiazpine for the short-course while the SSRI kicks in. At best Seroquel is an adjunct treatment to an SSRI for general anxiety disorder (off label-use) with a starting dose of 25 - 50 mg daily. Though I understand Seroquel may be used for other conditions aside from schizophrenia and bipolar disorder, 100 mg seems a bit too excessive (also considering side effect profile of atypicals). I will also point out the patient also has no indication of a mood disorder or substance use disorder. There were some mild ADHD symptoms noted but these are not significant and may be driven from anxiety. What are your thoughts? Is this a standard of care?

(My concerned regarding this is heightened as I have heard comments from other physicians that the prescribing physician (+70 yo) should retire, therefore I question if he has kept up on current best-practice guidelines.)

so what is your role in this case, out of curiosity? Some aspects of the post make me think you might be the 35 yom in question, in which case you'd be seeking medical advice. Also, you should be taking up your concerns directly with the psychiatrist who is prescribing these things, especially if you have social anxiety - think of it as an exposure and/or interpersonal effectiveness training.

Fair enough if my hunch is wrong, but I'd appreciate the clarification.

 

[calvnandhobbs68]

so what is your role in this case, out of curiosity? Some aspects of the post make me think you might be the 35 yom in question, in which case you'd be seeking medical advice. Also, you should be taking up your concerns directly with the psychiatrist who is prescribing these things, especially if you have social anxiety - think of it as an exposure and/or interpersonal effectiveness training.

Fair enough if my hunch is wrong, but I'd appreciate the clarification.

Yeah or makes me think this is advice for a family member/friend or something. OP is currently someone who failed to match into psychiatry last year and SOAPed to an IM position for this current year, so I highly doubt he's currently working in a professional role in said IOP as a PGY-1 IM resident.

No matter how OP clarifies, this thread may need to be locked for seeking medical advice.

 

[hamstergang]

he probably somehow got approved for it by insurance.....what else matters?

Providing appropriate care to patients matters to most of us.

 

[vistaril]

Providing appropriate care to patients matters to most of us.

sure, but this is all on a spectrum.....

 

[clozareal]

mild social anxiety disorder, performance only would make me consider a beta blocker which works immediately and if the performance is intermittent and predictable enough to not warrant a daily med. this is particularly a good strategy if their performance anxiety is somatically experienced (sweating, tremors, flushing, etc).

for mild anxiety, i've seen ssris work much faster than in those with more severe symptoms. in one case who was too anxious in meetings to actually speak coherently, sertraline worked within the first week for that patient that started on 25mg and he stayed on that dose for months, never needing to increase the dose.

you can consider gabapentin/pregabalin or hydroxyzine which can also work pretty quickly.

i would not use seroquel as a first, second, third, forth or even fifth line agent for this because of the metabolic side effects.

 

[Old&InTheWay]

for mild anxiety, i've seen ssris work much faster than in those with more severe symptoms. in one case who was too anxious in meetings to actually speak coherently, sertraline worked within the first week for that patient that started on 25mg and he stayed on that dose for months, never needing to increase the dose.

Anecdotes like this are so hard to interpret. Did the medication help because of its putative MOA, or was it placebo. Obviously situational anxiety is psychologically mediated, and I can imagine the idea of a helpful medication could be enough to help significantly. Then the patient continues to speak in meetings and gradually overcomes the phobia by exposure.

 

[whopper]

Seroquel/Quetiapine has multiple functions cause it binds to several receptors.
All atypicals at low dosages can augment depression treatment and lower anxiety due to the 5HT-1A receptor binding. It's also an antihistamine up to about 200 mg/day. Is also binds onto Alpha-2 receptors mimicking the effect of Clonidine that can also lower anxiety especially in patients with ADHD. It's first metabolite-Norquetiapine is an SNRI so it also has SNRI effects.

The D2 blockage also can have some anxiolytic effect simply because it could knock someone out and sedate them.

There's multiple ways to look at this. The bottom line is that all medications have several effects and we oversimplify them by putting them into a black and white category. Had the manufacturer wanted to market it as an SNRI they very well could've.

Another bottom line is does the med work and is it worth the side effects? IMHO Quetiapine is a down-the road option for anxiety mostly because of the weight gain and other side effects such as feeling like a zombie. I'd rather try an SSRI, SNRI (that doesn't cause weight gain or lower risk), Buspirone, and other atypicals before I'd resort to Quetiapine unless the patient is in need of weight gain and suffers insomnia. Heck I'd rather even explore if the patient has ADHD as the root cause of their anxiety before I'd try Quetiapine cause I've found several where the ADHD was the root-cause and this was overlooked cause the patient asks for help for anxiety, yet oddly an ADHD med such as Wellbutrin, Atomoxetine or a stimulant does far better to reduce their anxiety than the typical orthodox meds for anxiety such as an SSRI.

 

[clozareal]

Anecdotes like this are so hard to interpret. Did the medication help because of its putative MOA, or was it placebo. Obviously situational anxiety is psychologically mediated, and I can imagine the idea of a helpful medication could be enough to help significantly. Then the patient continues to speak in meetings and gradually overcomes the phobia by exposure.

Right. Could have been placebo effect. I've tried taking him off at the 3 month mark but the performance anxiety came back in the same amount that it did previously and now we had to go up to 50mg.

 

[SmallBird]

Seroquel/Quetiapine has multiple functions cause it binds to several receptors.
All atypicals at low dosages can augment depression treatment and lower anxiety due to the 5HT-1A receptor binding. It's also an antihistamine up to about 200 mg/day. Is also binds onto Alpha-2 receptors mimicking the effect of Clonidine that can also lower anxiety especially in patients with ADHD. It's first metabolite-Norquetiapine is an SNRI so it also has SNRI effects.

The D2 blockage also can have some anxiolytic effect simply because it could knock someone out and sedate them.

There's multiple ways to look at this. The bottom line is that all medications have several effects and we oversimplify them by putting them into a black and white category. Had the manufacturer wanted to market it as an SNRI they very well could've.

Another bottom line is does the med work and is it worth the side effects? IMHO Quetiapine is a down-the road option for anxiety mostly because of the weight gain and other side effects such as feeling like a zombie. I'd rather try an SSRI, SNRI (that doesn't cause weight gain or lower risk), Buspirone, and other atypicals before I'd resort to Quetiapine unless the patient is in need of weight gain and suffers insomnia. Heck I'd rather even explore if the patient has ADHD as the root cause of their anxiety before I'd try Quetiapine cause I've found several where the ADHD was the root-cause and this was overlooked cause the patient asks for help for anxiety, yet oddly an ADHD med such as Wellbutrin, Atomoxetine or a stimulant does far better to reduce their anxiety than the typical orthodox meds for anxiety such as an SSRI.

Which other atypical would you try first? I think part of why quetiapine works well for me is that, being sedating, if you have a very anxious patient and you dose it at night, you can give them some pretty quick relief while working on implementing a less problematic long term treatment (SSRI + exposures, for example). I use aripirpazole when there is a prominent dimension of obsessive thoughts given its evidence in OCD but I don't consider it helpful in providing quick relief for other forms of anxiety. Zyprexa is even worse than quetiapine with metabolic effects. The risperidone data is far less developed for anxiety as far as I am aware. But other than that I agree with what you are saying.

 

[NickNaylor]

We use low doses of quetiapine (12.5-50 mg) and olanzapine (2.5-5 mg) for peri-procedural anxiety on our ECT service since BZDs aren't an option. Hydroxyzine is a reasonable choice but many people find it to not be particularly helpful.

I don't think of quetiapine as first-line for anxiety, but depending on the clinical situation it's not unreasonable (e.g., already taking a therapeutic dose qHS for bipolar disorder, why not add a low-dose PRN if needed).

 

[Stagg737]

Agree with most of what's said above. Imo we're missing one of the most important aspects of the question that Whopper touched on which is "How would you describe your anxiety?" I'm using a different treatment plan for the person who has constant worry and perseveration about every single thing in life versus the person who gets autonomic activation a couple times per week/month. Imo, the etiology and presenting symptoms of the anxiety matters.

Quetiapine could be considered, but definitely not something I'd use for most people for anxiety. If needing a PRN then hydroxyzine, propranolol, gabapentin, or low-dose Trazodone are options I'd consider before antipsychotics. I may even consider a low-dose benzo if this was something needed very infrequently (1-2x per month or less). If something scheduled is needed, SSRI, SNRI, buspar, Mirtazapine, or even TCAs are things I'd consider first.

Also agree with NickN that if someone is already on a larger dose then smaller PRN dosing may be better than adding a new med. OP said no past psych hx though, so would be irrelevant for that patient.

 

[LimpSpatula]

Cant have anxiety if sleeping.

 

[robellis]

The bottom line to answer OP question, yes it is odd that you would stop lexapro and start seroquel 100 mg for anxiety as mono therapy..unfortunately there is such a huge variation in how psychiatry is practiced that pretty much anything goes out there in the Wild West that we call community clinical practice

 

[vistaril]

all these psychopharm explanations are good insomnia treatments perhaps, but the reality is that the data indicates there is nothing about Seroquel that means it should be given for anxiety.

I learned a long time ago to cut through all the BS and just go to Cochrane review. And almost every time in our field when a question like this is posed the answer from Cochrane review is "yep, no real evidence to suggest this is an effective treatment"

 

[clausewitz2]

all these psychopharm explanations are good insomnia treatments perhaps, but the reality is that the data indicates there is nothing about Seroquel that means it should be given for anxiety.

I learned a long time ago to cut through all the BS and just go to Cochrane review. And almost every time in our field when a question like this is posed the answer from Cochrane review is "yep, no real evidence to suggest this is an effective treatment"

Cochrane reviews are certainly useful and are a good place to start, but if you think that you can draw definitive conclusions like "no real evidence for this treatment" from them you are engaging in some very poor quality reasoning.

 

[whopper]

Which atypical first for anxiety?

I'd pick the ones with the strongest 5HT1A binding and have found that clinically they tend to have better efficacy with treating anxiety more so than other atypicals. The problem here is that the ones that bind this receptor the strongest (reflected in the K values) are also the more expensive ones. E.g. Rexulti. Another problems is that I've seen no empirical head to head data in a CATIE like trial. I have, however, seen several patients with treatment resistant anxiety disorders (or anxiety-related disorders such as OCD) do much better on the newer atypicals vs the older ones.

For whatever reason the newer atypicals have more 5HT1A action more so than the older ones.

Picking meds is based on the algorithm of efficacy + risks / price. Not based on their class. I tend to pick ziprasidone first only because of the lack of metabolic effects but don't expect much out of it. Aripiprazole also cause it's generic, but pretty much expect the patient to get akathisia on it unless it's at less than 5 mg/day, even then I still see a lot of akathisia with it.

Invega-not a good choice because even at the smallest dosage of 3 mg/day it's more than what's needed for the 5HT1A binding and you'll get D2 blockage at that dosage.

Generally I avoid Quetiapine, Risperidone, or Olanzapine unless the patient wants and/or needs to gain weight, but nothing here is absolute. I've seen good benefits with Olanzapine as an augmentation med but the problem is the metabolic side effects.

And again unfortunately I've seen better effects with the more expensive and more recent atypicals such as Vraylar, Latuda, and Rexulti, likely cause they bind on to 5HT1A better than the older meds in the same category and they have less metabolic side effects.

I'd pick Buspirone before I'd even pick an atypical for anxiety (of course assuming they're already partially responding to an antidepressant). It's cheap, works well, and hardly has side effects. It doesn't work well alone but does work great as augmentation for a partially-responding patient already on an antidepressant. Buspirone isn't given much out these days and it's really only cause there's no drug-rep pushing it. It usually works very well under the above conditions when you get it to the maximum dosage.

With all atypicals aside that there's metabolic risks with many of them, there's the TD risk, yes small but it's a serious problem if it happens, and other risks such as akathisia.

 

[vistaril]

Cochrane reviews are certainly useful and are a good place to start

no, they are(unfortunately for most such questions in psych) a good place to finish as well.

A lot of times I'll go to cochrane on such questions in our field(not neccessarily this one) and get the answer- that there is no evidence to support x,y,z as a treatment above placebo. In our field this includes lots of things that are done everyday by many providers.

But too many in our field aren't dissuaded unfortunately by Cochrane. They'll try to rationalize why it 'should' work with a bunch of psychopham babble mixed in with their own anecdotal experiences. "well its a partial antagonist at the alpha centurion Blue moon receptor, but only with affinity for Beta sigmoid Guardians of the galaxy agonist activity.....so it should work!".......Cochrane cuts through all that BS and states "but it doesn't"....

 

[sloh]

But too many in our field aren't dissuaded unfortunately by Cochrane. They'll try to rationalize why it 'should' work with a bunch of psychopham babble mixed in with their own anecdotal experiences. "well its a partial antagonist at the alpha centurion Blue moon receptor, but only with affinity for Beta sigmoid Guardians of the galaxy agonist activity.....so it should work!".......Cochrane cuts through all that BS and states "but it doesn't"....

The siren song of bioplausibility

Vinay Prasad, MD, on 'Medical Reversal'

'Not every reversal puts money in doctors' pockets'

www.medpagetoday.com

“It is worth restating this point: don’t fall for bioplausibility; you need to hear data. If you ask your doctor, why are you giving me nivolumab? The wrong answer is because the drug unleashes the immune system. The right answer is because the drug was superior to the chemotherapy, the previously used treatment, in a randomized trial.” —Vinay Prasad, MD

 

[futureapppsy2]

I'm still stuck on why mild performance-related social anxiety would warrant an IOP and LOA from work, honestly. That's like shooting a squirrel with an elephant gun.

 

[clausewitz2]

no, they are(unfortunately for most such questions in psych) a good place to finish as well.

A lot of times I'll go to cochrane on such questions in our field(not neccessarily this one) and get the answer- that there is no evidence to support x,y,z as a treatment above placebo. In our field this includes lots of things that are done everyday by many providers.

But too many in our field aren't dissuaded unfortunately by Cochrane. They'll try to rationalize why it 'should' work with a bunch of psychopham babble mixed in with their own anecdotal experiences. "well its a partial antagonist at the alpha centurion Blue moon receptor, but only with affinity for Beta sigmoid Guardians of the galaxy agonist activity.....so it should work!".......Cochrane cuts through all that BS and states "but it doesn't"....

Above all, substituting accepting whatever conclusion Cochrane authors come to as the authoritative Law From On High is not sounder reasoning than [insert your favorite here]'s hand-waved psychopharm ramblings as gospel. You're just blindly accepting a different authority's opinion without reflection or critical examination.

Pragmatically, I think you will be hard-pressed to find many Cochrane reviews in our field that say anything like 'it doesn't work.' there are a ton of reviews that conclude there is insufficient evidence to recommend or no-high quality controlled evidence to support the efficacy of various interventions. No argument there. But 'doesn't work' and 'no RCT exists to show' are not even vaguely isomorphic.

This is a really basic point and there there is no reason to get into the more interesting weeds of the limitations of what inferences RCTs or meta-analyses license if we can't agree on that much.

 

[clausewitz2]

I'm still stuck on why mild performance-related social anxiety would warrant an IOP and LOA from work, honestly. That's like shooting a squirrel with an elephant gun.

I am reasonably confident this is...a certain representation of the real situation that motivated the post.