Working together to address anxiety disorders
At a recent seminar, Cape Cod Hospital psychiatrist Cassandra Hobgood, MD was talking to medical colleagues about anxiety disorders. She began by asking them to close their eyes and imagine that they had to make a phone call that they dreaded making because they believed the news would be bad. She described the type of situation where your stomach feels tight, your heart is pounding and you feel sweaty and shaky. The longer you put off the phone call, the worse you feel.
“Imagine spending your whole life like that,” Dr. Hobgood said. “Take all those feelings you had and turn them up. That’s what a person with anxiety disorder feels. And the worse part for most of these folks is that asking for help is dreaded.”
Many people never do reach out for help. About 18 percent of the population has an anxiety disorder but only 40 percent of that 18 percent actually get treatment, Dr. Hobgood told the group at a recent educational seminar in Hyannis for primary care providers on how to manage anxiety disorders in their patients. The rest suffer in silence.
Most anxiety disorders start in childhood. They all involve excessive fear and attempts to avoid that fear. Psychiatrists use criteria in the “Diagnostic and Statistical Manual of Mental Disorders” (DSM), for diagnosis and classification of anxiety disorders.
The most common anxiety disorders include:
- Phobias - Irrational fears of specific things. Common ones include spiders, small places, blood and agoraphobia. Agoraphobia, is an irrational fear of leaving home, crowded places or situations where escape appears to be difficult. Social phobia - A phobia subset where patients have a fear of social situations. They suffer from performance anxiety and a fear of humiliation. They believe other people are judging them and finding them lacking. This can lead them to avoid telephone calls, talking to strangers or trying new experiences.
- Panic disorder - Characterized by episodes of intense anxiety and physical symptoms. People with panic disorder can show up at the Emergency Department believing they are dying from a stroke or heart attack. Sometimes people who have panic disorders become so frightened of having another attack in public that they develop agoraphobia.
- Generalized anxiety disorder -Is excessive worry about day to day life events. People with generalized anxiety disorder find they can’t control or stop the worry. Insomnia, fatigue and feeling tense are some additional features of generalized anxiety disorder.
- Obsessive Compulsive Disorder – Obsessions are intrusive thoughts, urges or images that repeatedly come in to the person’s mind. Obsessions are associated with marked anxiety and distress. Compulsions are repetitive behaviors or mental acts, often accomplished to counteract anxiety and the obsessional thoughts.
- Post Traumatic Stress Disorder - Occurs when a person is exposed to traumatic event where the person feels their life or sense of personhood has been threatened. The event doesn’t even have to have happened to them. It could be something they witnessed. It causes flashbacks, intense fear and a feeling of helplessness. Patients freeze and disassociate when something in their environment triggers the recollection of the traumatic event. People can develop PTSD soon after a traumatic event or years later.
For years, benzodiazepines have been widely prescribed for treatment of anxiety disorders. Benzodiazepines is a class of medications which include lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax). Unfortunately, benzodiazepines are addictive and mixing them with alcohol or opioids can be serious or even fatal. If taken in an overdose, the consequences can be grave, particularly when combined with other medications such as opioids.
Benzodiazepines are some of the most commonly prescribed medications for the elderly. Since older people metabolize medications more slowly, taking benzodiazepines can lead to car accidents or falls. Dr. Hobgood said the strong link between benzodiazepines and dementia, have been demonstrated by several studies. One study found that a lifetime use of 90 doses, which is equal to twice a week for one year, was shown to confer a 50 percent higher risk of dementia and double the risk for death.
With these facts in mind, the Psychiatry Department of Cape Cod Healthcare is working towards a policy of limiting benzodiazepines in their patient population. The seminar discussed the best practices of treating anxiety disorders, and how to taper patients off benzodiazepines safely.
“The goal is not to use benzodiazepines for long-term treatment for anxiety disorder,” said Benalfew Legesse, MD, medical director of Cape Cod Healthcare Behavioral Health Services. “We are not saying never use benzodiazepines. These medications do have a role in some conditions. There are other safer medications and psychotherapy options that are proven and approved for the treatment of anxiety disorders. If benzodiazepines are used for anxiety, it will be on a time limited basis, and frequently assessing to lowering dose and discontinue treatment as soon as other treatment options are instituted.”
The recent seminar also included a panel of three psychiatric experts and the Helping Hands clinical pharmacist, who answered audience questions and offered their own advice. The role of psychotherapy in treatment of anxiety disorders was widely discussed. Cognitive behavioral therapy is a highly effective way to help patients change unhealthy thoughts that lead to anxiety into helpful thoughts. Other suggestions included teaching patients to practice mindfulness and encouraging them to get enough physical exercise. A healthy diet and good sleep hygiene can also help.
Even though tapering benzodiazepines is the goal, it can be very tricky to accomplish. The length of exposure is one of the most important considerations for how slowly to taper. The longer the patient has been on the medication, the slower the taper should be.
“Like most places, many older people on the Cape are taking benzodiazepines,” Dr. Legesse said. “Many have been on this medication for years to decades. If stopped abruptly after long term use, then serious medical complications like seizures can occur. Severe benzodiazepine withdrawal in an older adult can be more serious, as older adults have more co-occurring medical problems.”
The quarterly educational seminars are just part of the collaboration between Cape Cod Healthcare Behavioral Health Services in partnership with the CCHC Accountable Care Organization (CCHC ACO) and primary care providers. CCHC ACO’s behavioral case managers work closely with the psychiatry and primary care physicians to ensure the patient’s treatment plan is followed and the communication between both providers are transparent. This has really made a difference in the collaboration and support between primary care providers and psychiatry, according to case manager, Sarah Simonelli, RN.
“The case managers work as a go-between with the patient, the psychiatry team and the primary care practices to ensure the patient is successful in managing their symptoms of anxiety and avoiding unnecessary trips to the Emergency Department,” she said. “We focus on regular patient check-ins, review of medications efficacy and ensuring our patients get plugged into psychotherapy, support groups, and day programs to help them successfully manage their symptoms.”