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Prof. Muhammad Riaz Bhatti MBBS(K.E.),  DPM., RCP&RCS(Dublin), MCCEE (Canada)  FRSH(Lond),  MRCPsych,(Lond)  FRCPsych.,(Lo...
Evolving Role of Benzodiazepines in the Treatment of Anxiety
<ul><ul><li>An unpleasant emotional state consisting of psycho-physiological response to anticipation of unknown, unreal o...
<ul><li>Anxiety presents with cardiac symptoms </li></ul><ul><li>Anxious patients with no evidence of organic heart diseas...
<ul><li>Cardiovascular symptoms of Anxiety </li></ul><ul><li>Anxiety may present with cardiac symptoms </li></ul><ul><ul><...
Anxiety & Hypertension <ul><li>Many studies show that anxiety has an influence on blood pressure. </li></ul><ul><li>The de...
<ul><li>“ Anxiety, as either cause or effect, accompanies many medical illness and the  use of anti-anxiety drugs as conco...
Evolving Role of Benzodiazepines in Anxiety Disorders <ul><li>Historical trends and the use of multiple classes of compoun...
Anxiety Disorders DSM=Diagnostic and Statistical Manual; GAD=generalized anxiety disorder;  OCD=obsessive-compulsive disor...
Currently Available Interventions  for Anxiety Disorders <ul><li>Antidepressants </li></ul><ul><ul><li>Selective serotonin...
Evolution in the Treatment of Anxiety Disorders Benzodiazepines (Buspirone) TCAs SSRIs & SNRIs CBT Combos CBT=cognitive-be...
Drug Use in Generalized Anxiety Disorder (Percent of Total Rxs) NDTI MAT August 2001.
Drug Use in Panic Disorder  (Percent of Total Rxs) BZD=benzodiazepine; Rxs=prescriptions. NDTI MAT August 2001.   Total BZ...
Pharmacotherapy received by Panic Disorder patients in the HARP study (1989-2001) SE Bruce et al, poster presented at the ...
Current Diagnostic Trends <ul><li>Recognize symptom dimensions (e.g., anxiety, panic) rather than DSM-IV syndromes (e.g., ...
Current Treatment Options <ul><li>Benzodiazepines are typically viewed are combined with antidepressants, or are used in p...
Sites of Action - Benzodiazepines <ul><li>Agents that boost output from either GABA or serotonin neurons each  have at lea...
SSRIs for Anxiety Disorders: Disadvantages <ul><li>Onset of action delayed usually for days to weeks </li></ul><ul><li>May...
Benzodiazepines for Anxiety Disorders: Advantages <ul><li>Rapid onset </li></ul><ul><li>Can be useful as needed for breakt...
Benzodiazepines for Anxiety Disorders: Disadvantages <ul><li>Potential early sedation and incoordination </li></ul><ul><li...
Is Long-term Benzodiazepine Treatment Justified?  <ul><li>Family, spouse can corroborate </li></ul><ul><ul><li>Continued b...
Combining Antidepressants with Benzodiazepines <ul><li>Provides rapid anxiolysis during antidepressant lag </li></ul><ul><...
<ul><li>Clinical Anxiety: Case Study </li></ul>
Patient History <ul><li>23-year old woman </li></ul><ul><li>Successful professional, married with 2 children </li></ul><ul...
Patient History (cont.) <ul><li>Second panic attack:  presented to hospital with chest pains, dizziness, shortness of brea...
Management Questions <ul><li>In ER/ED: </li></ul><ul><ul><li>Prescribe SSRI? </li></ul></ul><ul><ul><li>Prescribe antidepr...
Conclusions <ul><li>Although “officially” benzodiazepines are currently considered second line for anxiety disorders, they...
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Prof Riaz Ahmed

  1. 1. Prof. Muhammad Riaz Bhatti MBBS(K.E.), DPM., RCP&RCS(Dublin), MCCEE (Canada) FRSH(Lond), MRCPsych,(Lond) FRCPsych.,(Lond) <ul><li>Chairman Academic Department of Psychiatry & Behavioural Sciences, King Edward Medical University / Mayo Hospital, Lahore. </li></ul><ul><li>President Psychiatric Welfare Association </li></ul><ul><li>Past President Pakistan Psychiatric Society </li></ul>
  2. 2. Evolving Role of Benzodiazepines in the Treatment of Anxiety
  3. 3. <ul><ul><li>An unpleasant emotional state consisting of psycho-physiological response to anticipation of unknown, unreal or imaginary danger. It can be either physiological as an over prepared state or pathological as a disproportional reaction to any stressful stimuli, which may interfere with daily life activities. </li></ul></ul><ul><li>Diagnostic and Statistical Manual(DSM-IV ) </li></ul>ANXIETY
  4. 4. <ul><li>Anxiety presents with cardiac symptoms </li></ul><ul><li>Anxious patients with no evidence of organic heart disease commonly report unexplained CV symptoms that are frequently chronic and associated with great subjective distress. </li></ul><ul><li>They often lead to impaired functioning, lost days from work & considerable economic cost. </li></ul>Anxiety
  5. 5. <ul><li>Cardiovascular symptoms of Anxiety </li></ul><ul><li>Anxiety may present with cardiac symptoms </li></ul><ul><ul><li>Increased cardiac awareness </li></ul></ul><ul><ul><li>Palpitations </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Sweating </li></ul></ul><ul><ul><li>Tremors </li></ul></ul>
  6. 6. Anxiety & Hypertension <ul><li>Many studies show that anxiety has an influence on blood pressure. </li></ul><ul><li>The degree of anxiety was positively associated with diastolic pressure </li></ul><ul><ul><ul><li>the influence of happiness anger and anxiety on the blood pressure of borderline hypertension. </li></ul></ul></ul><ul><li>Among middle aged men …. Anxiety levels are predictive of later incidence of hypertension </li></ul><ul><ul><ul><li>psychological predictors of hypertension in the Framingham study. Is there tension is hypertension </li></ul></ul></ul>
  7. 7. <ul><li>“ Anxiety, as either cause or effect, accompanies many medical illness and the use of anti-anxiety drugs as concomitant therapy can reduce morbidity and improve prognosis.” </li></ul><ul><ul><ul><ul><ul><li>Psychother Psychosom 1988, 49(2):63-80 </li></ul></ul></ul></ul></ul>
  8. 8. Evolving Role of Benzodiazepines in Anxiety Disorders <ul><li>Historical trends and the use of multiple classes of compounds as anxiolytics </li></ul><ul><li>Current trends and patterns of drug prescriptions for anxiety disorders </li></ul><ul><li>Rationale and indications for usage of benzodiazepines in anxiety </li></ul><ul><li>Conclusions </li></ul>
  9. 9. Anxiety Disorders DSM=Diagnostic and Statistical Manual; GAD=generalized anxiety disorder; OCD=obsessive-compulsive disorder; PTSD=posttraumatic stress disorder. Social anxiety disorder Panic disorder OCD GAD PTSD DMS-IV Spectrum of Anxiety Disorders
  10. 10. Currently Available Interventions for Anxiety Disorders <ul><li>Antidepressants </li></ul><ul><ul><li>Selective serotonin reuptake inhibitors (SSRIs) </li></ul></ul><ul><ul><li>Serotonin-norepinephrine reuptake inhibitors (SNRIs) </li></ul></ul><ul><ul><li>Other new agents </li></ul></ul><ul><ul><li>Tricyclic antidepressants (TCAs) </li></ul></ul><ul><ul><li>Monoamine oxidase inhibitors (MAOIs) </li></ul></ul><ul><li>High-potency benzodiazepines </li></ul><ul><ul><li>Alprazolam </li></ul></ul><ul><ul><li>Clonazepam </li></ul></ul><ul><li>Other compounds </li></ul><ul><ul><li>Azapirones </li></ul></ul><ul><ul><li>Anticonvulsants </li></ul></ul><ul><ul><li>B-blockers </li></ul></ul><ul><li>Cognitive-behavior therapy </li></ul><ul><li>Combination treatments </li></ul>
  11. 11. Evolution in the Treatment of Anxiety Disorders Benzodiazepines (Buspirone) TCAs SSRIs & SNRIs CBT Combos CBT=cognitive-behavioral therapy; SSRIs=selective serotonin reuptake inhibitors; SNRIs=serotonin and norepinephrine reuptake inhibitors; TCAs=tricyclic antidepressants.
  12. 12. Drug Use in Generalized Anxiety Disorder (Percent of Total Rxs) NDTI MAT August 2001.
  13. 13. Drug Use in Panic Disorder (Percent of Total Rxs) BZD=benzodiazepine; Rxs=prescriptions. NDTI MAT August 2001. Total BZD=42%
  14. 14. Pharmacotherapy received by Panic Disorder patients in the HARP study (1989-2001) SE Bruce et al, poster presented at the 22 nd ADAA meeting, March 2002
  15. 15. Current Diagnostic Trends <ul><li>Recognize symptom dimensions (e.g., anxiety, panic) rather than DSM-IV syndromes (e.g., generalized anxiety disorder, panic disorder) </li></ul><ul><li>Anxious patients may present without psychiatric symptoms, but rather with multiple unexplained physical symptoms </li></ul><ul><li>Patients with comorbid medical illnesses and anxiety may appear as “difficult patients” who are not compliant or do not respond to treatments of their medical illness </li></ul>
  16. 16. Current Treatment Options <ul><li>Benzodiazepines are typically viewed are combined with antidepressants, or are used in patients who are intolerant to antidepressants </li></ul><ul><li>Cognitive-behavioral therapy also is effective </li></ul>
  17. 17. Sites of Action - Benzodiazepines <ul><li>Agents that boost output from either GABA or serotonin neurons each have at least 2 chances – from both outside and inside the amygdala  to diminish the likelihood of anxiety and fear </li></ul>Fear Stahl SM. J Clin Psychiatry 63:9, 2002
  18. 18. SSRIs for Anxiety Disorders: Disadvantages <ul><li>Onset of action delayed usually for days to weeks </li></ul><ul><li>May activate and transiently worsen anxiety at onset of treatment </li></ul><ul><li>Sexual dysfunction is common </li></ul><ul><li>May induce withdrawal reactions when discontinued </li></ul><ul><li>Weight gain </li></ul>
  19. 19. Benzodiazepines for Anxiety Disorders: Advantages <ul><li>Rapid onset </li></ul><ul><li>Can be useful as needed for breakthrough symptoms </li></ul><ul><li>SSRI therapy augmented by benzodiazepines may enhance adherence to treatment and alleviate activating symptoms of SSRIs </li></ul><ul><li>No or mild sexual dysfunction </li></ul><ul><li>Safe with good tolerability </li></ul>Ballenger et al. J Clin Psychiatry. 1998;59(suppl 9):51. Furukawa et al. J Affect Disord. 2001;65:173. Goddard et al. Arch Gen Psychiatry. 2001;58:681. .
  20. 20. Benzodiazepines for Anxiety Disorders: Disadvantages <ul><li>Potential early sedation and incoordination </li></ul><ul><li>Risk for withdrawal reactions with abrupt discontinuation (usually a re-emergence of anxiety symptoms) </li></ul><ul><li>Low but definite abuse potential, especially in polysubstance abusers </li></ul>Ninan. J Clin Psychiatry. 1999;60(suppl 22). Petursson and Lader. Br J Addict. 1981;76:133.
  21. 21. Is Long-term Benzodiazepine Treatment Justified? <ul><li>Family, spouse can corroborate </li></ul><ul><ul><li>Continued benefit </li></ul></ul><ul><ul><li>No nonmedical benzodiazepine use </li></ul></ul><ul><ul><li>No benzodiazepine-related toxicity </li></ul></ul><ul><li>Consultation </li></ul><ul><ul><li>More clinical clarity </li></ul></ul><ul><ul><li>Less medicolegal liability </li></ul></ul><ul><li>Document rationale in patient record </li></ul>DuPont and DuPont. Clinical Textbook of Addictive Disorders. 1998.
  22. 22. Combining Antidepressants with Benzodiazepines <ul><li>Provides rapid anxiolysis during antidepressant lag </li></ul><ul><li>Decreases early anxiety associated with initiation of antidepressant </li></ul><ul><li>Treats residual anxiety with antidepressant treatment </li></ul><ul><li>Prevents and treats potentially depressive effects of benzodiazepines </li></ul>
  23. 23. <ul><li>Clinical Anxiety: Case Study </li></ul>
  24. 24. Patient History <ul><li>23-year old woman </li></ul><ul><li>Successful professional, married with 2 children </li></ul><ul><li>First panic attack: presented to emergency room with complaints of chest pains and fear of having a heart attack </li></ul><ul><li>Cardiac workup negative for ischemia </li></ul>
  25. 25. Patient History (cont.) <ul><li>Second panic attack: presented to hospital with chest pains, dizziness, shortness of breath, and palpitations </li></ul><ul><li>Second cardiac workup negative </li></ul><ul><li>Results revealed no other significant physical findings </li></ul><ul><li>ER/ED MD recommended follow up with primary care physician </li></ul><ul><li>Diagnosed with clinical anxiety and panic attacks </li></ul>
  26. 26. Management Questions <ul><li>In ER/ED: </li></ul><ul><ul><li>Prescribe SSRI? </li></ul></ul><ul><ul><li>Prescribe antidepressant? </li></ul></ul><ul><ul><li>Prescribe benzodiazepine? </li></ul></ul><ul><ul><li>Wait for office visit? </li></ul></ul><ul><li>Office visit follow up: </li></ul><ul><ul><li>How would you decide on therapeutic approach? </li></ul></ul>
  27. 27. Conclusions <ul><li>Although “officially” benzodiazepines are currently considered second line for anxiety disorders, they are still the most frequently prescribed </li></ul><ul><li>Benzos are especially useful at the beginning of treatment with SSRIs, treating residual anxiety in patients on SSRIs, and those who do not respond to or do not tolerate SSRIs </li></ul>
  28. 28. Thanks
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