Optimal treatment for anxiety?

[When is graduation again?]

As I've been studying recently, I've found conflicting information on the optimal treatment of anxiety related disorders in the literature. Few articles compare medications to therapy, particularly in recent years, but the two articles that most directly addressed this question had opposing data. Both articles use Hedge's g to measure effect sizes.

1 meta-analysis ("Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials" by Carl E, et all) has therapy being superior to medications. While another "Efficacy of treatments for anxiety disorders: a meta-analysis" by Borwin Bandelow, et all) has medications being superior to therapy, by a wider margin than the previous study. Both articles came out in the last 4 years with the former being published this year. The latter has been cited much more and is in a slightly higher impact journal.

What are your thoughts about these articles? Is the truth likely the common teaching that both treatments are equivocal?

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[NickNaylor]

The very rough framework that I have in my mind - and how I often explain this to patients - is that for mild to moderate symptoms, both forms of treatment are essentially equivalent. The medication route may be cheaper and faster, but obviously you will need to take a medication on a regular basis. Medications also don't get to the underlying psychological issues that may be driving the anxiety. Therapy, on the other hand, will take longer and is more of an investment - both financially and in terms of time - but may be more "durable" in that the actual psychological issues are addressed. Skills training that might be provided with a CBT approach can also help manage anxiety without the use of medications. Either is a reasonable option, and I present both to patients. Some have very strong feelings about taking medications, thus they may prefer therapy. Others may not be interested in therapy or are more interested in a quicker fix, thus they may prefer medications. Ultimately, whatever treatment the patient will engage in - and maybe that's both - is what will be most effective.

For patients with severe anxiety, I will usually present both as recommendations. I describe medications as a "band-aid" that get the patient in good enough shape such that they can get into therapy while therapy is the actual "curative" intervention. This is obviously extremely oversimplified but I think gets at the general gist in a way that patients understand. Sometimes patents will still prefer one type of treatment over the other rather than engaging in both; if that's the case, then we go with whatever type of treatment they want to pursue.

I've had success with both therapy and medications, so my experience would suggest that there isn't a huge difference one way or another.

 

[EarlyCareerAcademicPsych]

I'll add from my experience and read on the clinical research literature, it is very important what you mean by "anxiety". GAD is not the same as OCD which is not the same as PTSD, especially with regard to the psychotherapy-based treatments. This is a widely-held view and it drove the decision-making to restructure the DSM such that OCD & PTSD (and related disorders) have their own chapters -- they are no longer included in the anxiety disorders chapter.

I strongly recommend evidence-based psychotherapy for PTSD. I prescribe medications to people who are unwilling to do psychotherapy and try to build a working alliance with them. I have rarely seen medication-based PTSD treatment help much (though this has happened a small percentage of the time).

I may be off here and you are just asking about GAD. In that case, NickNaylor speaks my mind on the subject. i agree with that dude.

 

[phyonaphan]

I would say that if a patient is not psychologically minded or in a position to have therapy an SSRI/SNRI +- mirtazapine if indicated usually at the higher end of the dosage range is most effective for ‘anxiety’ - a dosage more than usual for depressive disorders. TCAs are useful if side effects can be tolerated and suicide risk is not high, clomipramine is considered the gold standard for OCD traditionally. Pregabalin for GAD could also be considered but increasingly is recognised as a medication of abuse.

Psychoeducation on avoidance and impact of safety behaviours in perpetuating anxiety would be important if a patient is not considering CBT etc as options

 

[When is graduation again?]

I'll add from my experience and read on the clinical research literature, it is very important what you mean by "anxiety". GAD is not the same as OCD which is not the same as PTSD, especially with regard to the psychotherapy-based treatments. This is a widely-held view and it drove the decision-making to restructure the DSM such that OCD & PTSD (and related disorders) have their own chapters -- they are no longer included in the anxiety disorders chapter.

I strongly recommend evidence-based psychotherapy for PTSD. I prescribe medications to people who are unwilling to do psychotherapy and try to build a working alliance with them. I have rarely seen medication-based PTSD treatment help much (though this has happened a small percentage of the time).

I may be off here and you are just asking about GAD. In that case, NickNaylor speaks my mind on the subject. i agree with that dude.

Initially when I started searching for this information, I was looking specifically at GAD, but many of the articles I found included other anxiety related disorders in their study. The 2nd article I mentioned had a breakdown of GAD, social anxiety, and panic, though no mention of PTSD.

Definitely agree with you on the PTSD statement though. I've heard that from various attendings as well. Though I did find a study comparing CBT response rates to multiple anxiety related disorders (no medication arm) that showed only small-moderate effect sizes of CBT for PTSD compared to other anxiety related disorders.... largely because of the huge rate of patient drop out I think.
"Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials."

 

[NickNaylor]

I'll add from my experience and read on the clinical research literature, it is very important what you mean by "anxiety". GAD is not the same as OCD which is not the same as PTSD, especially with regard to the psychotherapy-based treatments. This is a widely-held view and it drove the decision-making to restructure the DSM such that OCD & PTSD (and related disorders) have their own chapters -- they are no longer included in the anxiety disorders chapter.

I strongly recommend evidence-based psychotherapy for PTSD. I prescribe medications to people who are unwilling to do psychotherapy and try to build a working alliance with them. I have rarely seen medication-based PTSD treatment help much (though this has happened a small percentage of the time).

I may be off here and you are just asking about GAD. In that case, NickNaylor speaks my mind on the subject. i agree with that dude.

This is a great point - my post was focused primarily on GAD, PD, and unspecified anxiety disorder with characteristics of GAD/PD. PTSD and OCD are different beasts altogether. Agoraphobia can also be challenging, and I've had relatively little luck with medications on that front.

With respect to PTSD, I've found that medications can help with some of the hypervigilance symptomatology (anxiety, increased startle, sleep disturbance, irritability) but doesn't do much for other more "psychological" symptoms (e.g., guilt).

 

[birchswing]

What about long-term? Obviously benzodiazepines are known to stop working and even cause anxiety long-term. Not sure about SSRIs. I tried researching long-term SSRI usage and found some reports of what they called "tardive dysphoria" as it related to depression, but I did not find research related to efficacy of SSRIs in anxiety long term.

 

[Shufflin]

Optimal treatment for anxiety? I'm feeling anxious just thinking about it.

 

[WisNeuro]

Definitely agree with you on the PTSD statement though. I've heard that from various attendings as well. Though I did find a study comparing CBT response rates to multiple anxiety related disorders (no medication arm) that showed only small-moderate effect sizes of CBT for PTSD compared to other anxiety related disorders.... largely because of the huge rate of patient drop out I think.
"Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials."

I'd look at the studies that make up the meta analyses. Based on the authors of many of those studies, I'd wager that most of the PTSD papers included in the meta-analysis were done with VA/military samples. Not a great population from which to measure efficacy of treatment. Just ask anyone who has worked and done clinical research there. GIGO. I still think some treatments have a decent drop out effect for things like PE treatments, but the VA is a different animal due to secondary gain issues influencing participants incentivized to not get better.

 

[EarlyCareerAcademicPsych]

I'd look at the studies that make up the meta analyses. Based on the authors of many of those studies, I'd wager that most of the PTSD papers included in the meta-analysis were done with VA/military samples. Not a great population from which to measure efficacy of treatment. Just ask anyone who has worked and done clinical research there. GIGO. I still think some treatments have a decent drop out effect for things like PE treatments, but the VA is a different animal due to secondary gain issues influencing participants incentivized to not get better.

PTSD is a complex mess. It's the nature of traumatic experience and our response to it.

Childhood attachment trauma, betrayal trauma in incest, combat trauma - not all the same, though some similarities and often some treatments work for some but don't work for others.

I'd look at the RCTs for PTSD as indicating what is possible for treatment, not what is actually going to happen. And it is possible for people to get a lot better. I have done a lot of Prolonged Exposure psychotherapy for combat trauma and just did my first PE for rape trauma case last year. It was grueling and difficult, but intensely rewarding. The person no longer has re-experiencing symptoms, after living for 30 years of his life with them.

Saying all this to supplement the science-based approach (which I fully support) with my own clinical experience.

 

[WisNeuro]

PTSD is a complex mess. It's the nature of traumatic experience and our response to it.

Childhood attachment trauma, betrayal trauma in incest, combat trauma - not all the same, though some similarities and often some treatments work for some but don't work for others.

I'd look at the RCTs for PTSD as indicating what is possible for treatment, not what is actually going to happen. And it is possible for people to get a lot better. I have done a lot of Prolonged Exposure psychotherapy for combat trauma and just did my first PE for rape trauma case last year. It was grueling and difficult, but intensely rewarding. The person no longer has re-experiencing symptoms, after living for 30 years of his life with them.

Saying all this to supplement the science-based approach (which I fully support) with my own clinical experience.

Indeed, I was trained in PE by the Foa people, and have published in this area. As for the RCTs, they are not all created equal, whether or not we match the trauma type, which even then has a lot of variability. Always take research in a system buoyed by secondary gain with a huge grain of salt. If you really want to do a deep dive, look at PTSD rates and treatment outcomes in different countries veterans or war refugees.

 

[Marasmus1]

My experience and observation is optimal treatment of anxiety depends on the patients personality traits and psycho-social factors. Unfortunately in clinical practice there is no such a thing like medication + therapy > therapy > medication as some research shows. I have seen cases where there was minimal response to therapy if any at all but significant response was achieved with SSRi. There were other cases when medications made things worse but extensive psychotherapy helped. It is not easy to predict response of evidence based treatment modalities we have in anxiety disorders.

 

[whopper]

There's already a plethora of data and treatments for anxiety. The usual SSRI or SNRI, if partially effective add Buspirone, or then a B-blocker etc. I've had a few patients that are treatment-anxiety resistant to several medications.

I'm talking now about stuff I've seen not in textbooks that I've found highly effective.
Screen for ADHD. If the person has ADHD treating the ADHD itself may treat the anxiety as anxiety is often times a comorbid and secondary outcome of untreated ADHD. I first noticed this when I gave ADHD patients Wellbutrin and their anxiety greatly decreased despite that Wellbutrin doesn't treat anxiety. Well it's cause the anxiety was secondary to ADHD. I've noticed that getting tired on Wellbutrin or anxiety being decreased pretty much always correlated with the person also having ADHD.

Likewise I've seen some people take a stimulant and actually sleep better on them. This is not a majority of ADHD patients but it's a few of them. It makes sense when they have hyperactive ADHD and they are only calm when their ADHD is treated.

Some atypicals now bind so strongly to 5HT1A that I've seen some very strong anti-anxiety benefits with some of them.

Alpha-Stimulation has greatly decreased anxiety in several patients. The problem here is a machine is about $1000 and insurance doesn't cover it. There is a competitive device (CES Device) that runs for about $200 and I have seen success with that too but I don't know if one machine works better than another cause there's no head-to-head studies. There's a large body of data now supporting Alpha-Stim.

Silexan 80 to 160 mg daily has been found to be very effective in treating anxiety. There's published data backing it up.

Ashwagandha Root in some people, although I've noticed it's a minority helped their anxiety. It's main known effect is lowering cortisol which long-term is helpful so in theory it will help people cope with long-term stress/anxiety but I have seen some people tell me they feel much better after taking it and feeling quick benefit. Maybe that's just placebo.

 

[RhyeLu]

There's already a plethora of data and treatments for anxiety. The usual SSRI or SNRI, if partially effective add Buspirone, or then a B-blocker etc. I've had a few patients that are treatment-anxiety resistant to several medications.

I'm talking now about stuff I've seen not in textbooks that I've found highly effective.
Screen for ADHD. If the person has ADHD treating the ADHD itself may treat the anxiety as anxiety is often times a comorbid and secondary outcome of untreated ADHD. I first noticed this when I gave ADHD patients Wellbutrin and their anxiety greatly decreased despite that Wellbutrin doesn't treat anxiety. Well it's cause the anxiety was secondary to ADHD. I've noticed that getting tired on Wellbutrin or anxiety being decreased pretty much always correlated with the person also having ADHD.

Likewise I've seen some people take a stimulant and actually sleep better on them. This is not a majority of ADHD patients but it's a few of them. It makes sense when they have hyperactive ADHD and they are only calm when their ADHD is treated.

Some atypicals now bind so strongly to 5HT1A that I've seen some very strong anti-anxiety benefits with some of them.

Alpha-Stimulation has greatly decreased anxiety in several patients. The problem here is a machine is about $1000 and insurance doesn't cover it. There is a competitive device (CES Device) that runs for about $200 and I have seen success with that too but I don't know if one machine works better than another cause there's no head-to-head studies. There's a large body of data now supporting Alpha-Stim.

Silexan 80 to 160 mg daily has been found to be very effective in treating anxiety. There's published data backing it up.

Ashwagandha Root in some people, although I've noticed it's a minority helped their anxiety. It's main known effect is lowering cortisol which long-term is helpful so in theory it will help people cope with long-term stress/anxiety but I have seen some people tell me they feel much better after taking it and feeling quick benefit. Maybe that's just placebo.

Can some people keep anxiety at bay with just a Beta-Blocker? Can they be used long term?

What about an Alpha-2 Receptor Agonist like Clonidine? I have known a few people on that instead of beta blockers they have reported better results. Can they be used long term?

*I am just a college student, sorry of the q's are basic.

 

[clausewitz2]

MAOIs can be incredibly useful for the anxious. I tend to use more phenelzine these days partly because it seems to be more helpful for anxiety but also because it is dramatically cheaper than tranylcypromine. If is someone is sensitive to sedation or weight gain it's not great. Literally the only patient I've had so far who had any struggle with the actual diet (rather than the alarmist lists of food you run across with a quick google search) was someone who made their own kimchi and just could not give it up. I might also hesitate with someone who was a heavy drinker, mainly because draft beer is a very bad idea (impossible to know how clean they're keeping the lines).

 

[clausewitz2]

There's already a plethora of data and treatments for anxiety. The usual SSRI or SNRI, if partially effective add Buspirone, or then a B-blocker etc. I've had a few patients that are treatment-anxiety resistant to several medications.

I'm talking now about stuff I've seen not in textbooks that I've found highly effective.
Screen for ADHD. If the person has ADHD treating the ADHD itself may treat the anxiety as anxiety is often times a comorbid and secondary outcome of untreated ADHD. I first noticed this when I gave ADHD patients Wellbutrin and their anxiety greatly decreased despite that Wellbutrin doesn't treat anxiety. Well it's cause the anxiety was secondary to ADHD. I've noticed that getting tired on Wellbutrin or anxiety being decreased pretty much always correlated with the person also having ADHD.

Likewise I've seen some people take a stimulant and actually sleep better on them. This is not a majority of ADHD patients but it's a few of them. It makes sense when they have hyperactive ADHD and they are only calm when their ADHD is treated.

If you have the recurring, life-long experience of dropping the ball and f***ing things up because you missed an important detail or weren't quite careful enough, you are going to start worrying about dropping the ball and f***ing things up. Additionally, some people with ADHD use repetitive worrying as a substitute for more robust spontaneous recall; can't forget you were meant to do something if you just literally never stop thinking about how you need to do it.

I have had the same experience re: sleep with a couple of people. It's always hard to figure out how much of this is keeping them awake during the day and thus consolidating their sleep and how much is getting them to the point at they actually allow themselves to lie down and do something as boring as close their eyes in bed.

Some atypicals now bind so strongly to 5HT1A that I've seen some very strong anti-anxiety benefits with some of them.

0.25 to 0.5 mg risperidone is really magic for some people, at least where anxiety has a very explicit cognitive component of not being able to not attend to repetitive worried thoughts.

Silexan 80 to 160 mg daily has been found to be very effective in treating anxiety. There's published data backing it up.

It also gives people a chance to experience perhaps the most adorable side medication side effect, namely lavender burps. If they ever wondered what it would taste like to eat potpurri, this is their chance.

 

[erg923]

Speaking of this, can we please stop with the infantilizing of the veteran population on and around the July 4th holiday by insisting that everyone be quiet?

Believe it or not, many veterans believe it is quite insulting to fight for freedom in World Wars for only a few of us say that we ARE SO FRAGILE as to break at the sound of unexpected loud noise in the neighborhood! This is stereotyping and pathologizing at it's Zenith!

Loud noises are a part of living in the (suburban) world....and never actually hurt anyone.

 

[WisNeuro]

Speaking of this, can we please stop with the infantilizing of the veteran population on and around the July 4th holiday by insisting that everyone be quiet!?

Believe it or not, many veterans believe it is quite insulting to fight for freedom in world wars for only a few of us say that we ARE SO FRAGILE as to break at the sound of unexpected loud noise in the neighborhood! This is stereotyping and pathologizing at it's Zenith!

Loud noises are a part of living in the (suburban) world....and never actually hurt anyone.

To be fair,loud noises hurt people all of the time (e.g., ruptured ear drums, tinnitus).

 

[erg923]

To be fair,loud noises hurt people all of the time (e.g., ruptured ear drums, tinnitus).

For goodness sake son...why trample all over my point?

 

[WisNeuro]

For goodness sake son...why trample all over my point?

This is SDN. This is just what we do here.

 

[birchswing]

Speaking of this, can we please stop with the infantilizing of the veteran population on and around the July 4th holiday by insisting that everyone be quiet?

Believe it or not, many veterans believe it is quite insulting to fight for freedom in World Wars for only a few of us say that we ARE SO FRAGILE as to break at the sound of unexpected loud noise in the neighborhood! This is stereotyping and pathologizing at it's Zenith!

Loud noises are a part of living in the (suburban) world....and never actually hurt anyone.

I wrote a long diatribe about this last year, and I wrote one this year again but realized it was so similar I decided not to post it.

But this is the second time you've posted loud noises never hurt anyone.

I won't debate the other part.

But loud noise is a huge part of hearing loss. So, that does hurt people.

Maybe you live in a neighborhood without yahoos, but most people don't, and they continually set off fireworks throughout June and July, and some of them are extremely close and extremely loud.

The other night I woke up to what sounded like bombs going off and it took me a while to realize it was fireworks.

I can't imagine for the children who live with these people who are even closer to the sounds.

There's a reason musicians wear ear plugs. They want to be able to enjoy music when they get older and not have a constant ringing in their ears.

As to my other arguments, I think I made them last year.

I think the social contract should be: You get one night. That's it. But tonight still we had them going off, and my poor dog goes into panic mode. It seems like mid June to mid July is open season on these fireworks.

 

[JKinSC]

lavender burps

Sounds like I've got the name of my next band. We should have kind of a Cocteau Twins vibe.