Prescribing Nurse: Integrated therapy for anxiety

Medication can have an important role in the management of anxiety but there are a number of steps to be considered before prescribing

Most of us have felt anxious at some point in our lives, as it is a normal response to stressful situations. However anxiety can start to become overwhelming when the reaction is out of proportion to the initial stressful event or when it persists after the stressful situation itself has resolved. This can lead to individuals curtailing their activities in an attempt to avoid precipitating the anxious feelings and this can become a self-perpetuating process. It is these individuals who may seek medical help for their anxiety, but even then prescribing is a very small part of the management plan.

Consider Jane, a 35 year-old woman. She recently came home to find that her home had been burgled. The glass in the back door was broken and this is now boarded up. The council tell Jane that it will be two weeks before the glass can be repaired. Jane is now anxious about leaving the house to go to work.

Coming home to find your home broken into is an understandable source of anxiety and the boarded up window will be a continuing reminder of what has happened. However Jane needs to address her fears before the situation escalates such that she develops agoraphobia. This involves Jane thinking about the worst possible case scenario, that her home will be broken into whenever she leaves the house, and testing this out. In the first instance this might involve leaving the house for shorter periods of time than a full working day. So your role may be one of reassuring Jane and perhaps enabling her to work shorter hours for a defined period, by means of a fit note, as a way of her getting her confidence back.

Jane comes back to see you three weeks later. The window has now been fixed and she is managing to go to work for a full day, having initially had reduced hours. However she still feels incredibly anxious when leaving the house, and so has been tending to avoid going out except when essential.

SELF-MEDICATION

Jane has done really well in maintaining her work. However her anxiety is still having a detrimental effect on her life, as she is curtailing her social activities. It is worth exploring with Jane what strategies she has tried herself to ease the situation at this point in time, as this can be the sort of situation that might lead a patient to unhelpful behaviours such as using alcohol or drugs as a form of self-medication.¹ It is also worth remembering that acute withdrawal from drugs or alcohol can masquerade as anxiety.

Jane tells you that she has not been drinking, however she has tried some herbal preparations in the form of St. Johns wort, as one of her friends suggested it to her. She has not found it to be particularly helpful.

Enabling patients to tell you about the strategies that they have tried themselves is a key skill in effective consultations. This is particularly the case in conditions such as mental health issues where the fear of stigma may have led to a considerable delay in seeking medical help. The use of complementary therapies in these circumstances is widespread2,3 and can sometimes have important consequences for your prescribing, such as when herbal preparations are used.

HERBAL REMEDIES

There are multiple preparations that are on the market which are advertised as being helpful in easing anxiety. However, there is only one herbal preparation that has been shown to be of benefit, known as kava (piper methysticum). Due to its potential to cause hepatotoxicity, however, it is currently banned in the UK.⁴ Passionflower (passiflora incarnate L) shows some promise, as does German chamomile (matricuria recutitia) and lemon balm (Melissa officinalis). 5,6 There is no real evidence for the effectiveness of valerian (valerian officialis L), although this is commonly advocated.⁷ St Johns wort (hypericum perforatum L) has been consistently shown to be of benefit in moderate depression8 and some individuals also use it as an anxiolytic, however, it is a potent interacter with the cytochrome P450 enzyme system, which leads to several drug interactions that are of clinical significance. With regard to women, like Jane, of childbearing age, one of these important interactions is with the combined oral contraceptive pill, reducing its contraceptive efficacy.

Jane is clearly still struggling with her anxiety, which has now persisted long after the removal of the precipitating factor of the burglary. Yet despite continued evidence that leaving the house will not result in an inevitable repeat of this, Jane continues to catastrophise about what might happen. Challenging these thought processes is going to be key in helping Jane to move on. It is also worth checking however that Jane is not developing a depressive illness, as this can sometimes be a consequence of prolonged anxiety. This can be done quite simply by asking Jane directly about her mood, and biological symptoms of depression or by using one of the commonly available questionnaires such as the PHQ-9 or HAD score.^9,10 The GAD-7 can also be of benefit in determining the severity of Jane

SELF-HELP

In terms of helping Jane to challenge her thought processes there are a number of self-help techniques that are available to her.^3,12 There are two excellent self-help guides available freely on the Internet. Alternatively you could signpost her to the Books on Prescription scheme which is available in most areas, and would enable her to borrow a recommended title from her local library free of charge. If Jane needs further help or support in working through some of these techniques then it is worth finding out what is offered by the Improving Access to Psychological Therapies (IAPT) service in your local area. Both Gloucestershire (www.talk2gether.nhs.uk) and Oxfordshire (www.talkingspaceoxfordshire.org) have well thought out websites and access to guided self-help. Other resources are shown in Table 1.

Jane contacts the local IAPT service, which recommends some guided self-help techniques to her. She manages to work through these with their help and finds that her anxiety improves. However she still finds it difficult to go out socially and her life is still influenced by her anxiety.

Jane has now tried all of the initial first steps in addressing her anxiety and this is where there may be a role for considering some medication. She may also benefit from having some more intensive talking type therapies such as formal cognitive behavioural therapy (CBT), and this should be accessible to her though her continuing contact with IAPT. This in line with the stepped care approach to the treatment of anxiety suggested by NICE, which advocates patient choice as the determinant of whether to try medication or higher intensity psychological interventions at this stage.³

RECOMMENDED DRUGS

If Jane does choose medication, the recommended preparations are serotonin reuptake inhibitors (SSRIs). NICE3 currently recommends sertraline, at a dose of 50mgs, as the first line drug, despite it lacking a licence for this indication, as the most cost-effective choice. Jane will need to be counselled about this so that she can make an informed decision. You will also need to explain to her the likelihood of initial side effects such as nausea, that there will be a delay in its onset of action and the likely duration of treatment. It is likely that Jane is going to need treatment for at least twelve weeks. Alternatives to SSRIs include clomipramine or imipramine, but again neither of these has a licence for this indication. It is also worth remembering that starting medication could lead to a deterioration in Jane

It is also worth bearing in mind that Jane is a woman of childbearing age so it is important to establish that she is not pregnant or breastfeeding. SSRIs can be used in these circumstances but only when the benefit outweighs the risk, and this might be a reason to steer Jane towards talking therapies in the first instance.

In Jane's case, the diagnosis of anxiety was a simple one as there was a clear precipitant to her symptoms, even if her eventual response was out of proportion to the initial event. Similarly sometimes patients present in anticipation of an anxiety-provoking event, and for these individuals such a stepped approach to treatment would not be appropriate. Common examples might be fear of flying or an impending exam, such as a driving test. In these cases the situation is predictable and relatively uncommon so rather than trying to address the underlying fear, medication may be appropriate as a short-term measure13. For flying, benzodiazepines, such as diazepam 2-5mgs might be appropriate, although you would need to check that the individual was not planning to drive on arrival at their destination, due to its potential for sedation. For driving tests clearly such sedating drugs would not be appropriate but the use of beta-blockers, such as propranolol, to reduce the somatic symptoms of anxiety can have a dramatic effect on an individual's performance.

Sometimes, however, patients do not recognise their somatic symptoms as being a consequence of anxiety but rather become concerned about potential serious underlying health issues. In these consultations the key is to utilise the minimum number of investigations to ensure patient safety without increasing the potential for health anxiety. Palpitations are a frightening occurrence for patients and it is understandable that they would seek reassurance for these symptoms. Finding out about stressful events and what is going on in their life at the present time can be time well invested in empowering the patient to be able to make the link themselves between their psychological health and physical wellbeing. For a very small minority of patients, further investigations such as thyroid function tests, if hyperthyroidism is suspected, or liver function tests, if alcohol misuse is suspected, are worth undertaking. Simple lifestyle advice about avoiding alcohol and caffeine, as well as promoting exercise and relaxation would also be of benefit.

CONCLUSION

Anxiety is a common, disabling health condition. Some studies have even suggested that up to 20% of individuals consulting their GP have some form of anxiety disorder.14,15 So being open to it as one of the diagnostic possibilities is important. This enables patients to get the treatment that they need and so prevent them entering the vicious cycle of ongoing symptoms and needless invasive physical investigations .¹⁶

REFERENCES

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8. St Johns wort http://www.herbfacts.co.uk/pages/herb-file/st-johns-wort.php (accessed May 2012)

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