BREAKING THE BENZO CYCLE- ALTERNATIVES TO TREATING ANXIETY DISORDERS

Rebecca Dorsey, RN, MSN, PMHNP-BC, FNP-BC

Portland, Oregon

DISCLOSURES

I have no disclosures or endorsements to report

OBJECTIVES

1

1. Discuss the challenges of treating anxiety

2

2. Identify the pathophysiology of anxiety to include a brief review of brain structure and applicable neurotransmitters

3

3. Summarize new research evidence on the long-term use of benzodiazepines

4

4. Explore the limited role of benzodiazepines and treatment alternatives for common anxiety disorders

WHAT’S THE REAL ISSUE WE FACE AS PROVIDERS?

BENZODIAZEPINE USE HAS REACHED EPIDEMIC LEVELS…

- Between 1996 and 2013, the number of adults filing a prescription for a benzodiazepine increased 67% from 8.1million to 13.5 million (Bachuber, Hennessy, Cunningham, Starrels, 2016)

CONSEQUENCE OF LONG-TERM USE

- Loss of efficacy over time

- Emotional blunting

- Cognitive dulling

- Memory loss and impaired learning

ALZHEIMER’S DISEASE AND DEMENTIA

Benzodiazepine use, for periods of over 3 months, show an overall increase in dementia diagnosis of 51%. (James, 2017)

The strength of association increases 30% when comparing the long-term use of short-acting to long-acting benzodiazepines. (Gage, Maride, Ducruet, Kruth, Vedoux, Tournier, Periente, and Begaud, 2014)

WITHDRAWAL SYMPTOMS

- agitation, anxiety, and dysphoria

- increased awareness of sensory stimuli

- perceptual disturbances and depersonalization

- confusion, delirium, and seizures

- with abrupt discontinuation an appreciable increase in arterial pressure could result in myocardial ischemia

SO WHAT CHOICE DO I REALLY HAVE?

ANXIETY AND THE BRAIN

1. Amygdala2. Cortico-striato-thalamo-

cortical (CSTC) Loops

LET’S TALK NEUROTRANSMITTERS-

Dopamine

Serotonin

GABA

Norepinephrine / Noradrenaline

DOPAMINE

SEROTONIN

NORADRENALINE

GABA

MOST COMMONLY SEEN ANXIETY DISORDERS IN CLINIC:

- GENERALIZED ANXIETY DISORDER

- SOCIAL ANXIETY DISORDER

- PANIC DISORDER

- POST-TRAUMATIC STRESS DISORDER

GENERALIZED ANXIETY DISORDER

Stahl, 2013

SOCIAL ANXIETY DISORDER

Stahl, 2013

PANIC DISORDER

Stahl, 2013

POST-TRAUMATIC STRESS DISORDER

Stahl, 2013

REGARDLESS OF THE FORMAL DIAGNOSIS, ANXIETY CAN BE BROKEN DOWN INTO TWO PRIMARY CATEGORIES OF SYMPTOMS:

FEAR AND WORRY

Stahl, 2013

Stahl, 2013

SSRI SNRI A2L* BZ* BUSP* REM* ATYP* MAOI BB* TRZ* AH*GAD 1st 1st 1st 2nd 1st 2nd Adj 2nd 2nd

PANIC 1st 1st 2nd 2nd Adj 2nd

SAD 1st 1st 1st 2nd 2nd 2nd

PTSD 1st 1st 2nd 2nd 2nd

Key:A2L- Alpha 2 Ligands ATYP- Atypical AntipsychoticBZ- Benzodiazepine BB- Beta BlockerBUSP- Buspirone TRZ- TrazodoneREM- Remeron AH- Antihistamines

SELECTIVE SEROTONIN REUPTAKE INHIBITORS

1. Sertraline/ Zoloft

2. Fluoxetine / Prozac

3. Paroxetine / Paxil

4. Fluvoxamine / Luvox

5. Citalopram / Celexa

6. Escitalopram / Lexapro

SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS

1. Venlafaxine / Effexor

2. Duloxetine / Cymbalta

ALPHA2 LIGANDS

Gabapentin and Pregabalin (bind to voltage sensitive calcium channels which blocks excitatory neurotransmitters that results in fear and worry)

BUSPIRONE / BUSPAR

Binds to serotonin type 1A receptors to help address symptoms of both anxiety and depression

Partial agonist actions post-synaptically may diminish serotonergic activity (anxiety)

Partial agonist actions pre-synaptically at serotonin autoreceptors may enhance serotonergic activity (depression)

MIRTAZAPINE / REMERON

Alpha 2 antagonist

NaSSA (noradrenaline and specific serotonergic agent)

Dual Serotonin and NE agent

Blocks H1 histamine receptors

ATYPICAL ANTIPSYCHOTICS

1. Quetiapine / Seroquel

2. Aripiprazole / Abilify

3. Olanzapine / Zyprexa

4. Risperidone / Risperdal

MONOAMINE OXIDASE INHIBITORS

1. Isocarboxazid / Marplan

2. Phenelzine / Nardil

3. Selegiline / Emsam

4. Tranylcypromine / Parnate

BETA-BLOCKERS

1. Propranolol / Inderal

2. Atenolol / Tenormin

TRAZODONE

Potent serotonin 2A receptor blocker

Blocks serotonin reuptake pump less potently

ANTIHISTAMINES

1. Hydroxyzine / Vistaril

2. Diphenhydramine / Benadryl

PEARLS

Establish guidelines and boundaries with patients from the beginning - Consider a formal benzo agreement

If you start it, be prepared to manage it

Use an established formula for discontinuation http://www.benzo.org.uk/manual (Ashton Manual)

Once you set a taper plan, follow-through

REFERENCES

• Bachhumber, Hennessy, Cunningham, and Starrels (2016). Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996-2013. AJPH. 106(4) 686-688.

• Gage, Moride, Ducruet, Kurth, Verdoux, Tournier, Pariente, and Begaud (2014). Benzodiazepine use and Risk of Alzheimer’s Disease: case-control study. https://www.ncbi.nlm.nih.gov/pubmed/26123874

• James (2017). Hypnotics and Risk of Dementia. Clinical Journal of Sleep Medicine. 3(6) 837-839.• National Health Service (2008). Guidance for Prescribing &Withdrawal of Benzodiazepines &

Hypnotics in General Practice. www.benzo.org.uk/amisc/bzgrampian.pdf• NIMH (2014) Press release: Despite risks, benzodiazepine use highest in older people.

https://www.nimh.nih.gov/news/science-news/2014/despite-risks-benzodiazepine-use-highest-in-older-people.shtml

• Pliska (2003). Neuroscience for the Mental Health Clinician. New York: The Guilford Press.• Stahl (2014). Stahl’s Essential Psychopharmacology: Prescriber’s Guide. San Diego, California:

Cambridge University Press.• Stahl (2013). Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical

Application. New York: Cambridge University Press.