The Curbsiders podcast

#429 Anxiety 2.0: with Dr. Jessi Gold

March 4, 2024 | By

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Transcript available via YouTube

Elevate your primary care management of anxiety. Become confident in counseling patients about a new anxiety diagnosis, 2nd and 3rd line medications, augmentation for anxiety treatment, and options for non-pharmacological anxiety treatment. We are joined by psychiatrist and mental health expert Dr. Jessi Gold, @drjessigold (University of Tennessee System; drjessigold.com).

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Show Segments

  • Intro
  • Case from Kashlak
  • Diagnosing anxiety
  • Explaining anxiety to patients
  • Non-pharmacological management of anxiety
  • Pharmacological management of anxiety
  • 2nd and 3rd line treatments
  • Cannabis and anxiety
  • Outro

Anxiety Pearls

  1. Self-directed activities for treating anxiety should be seen as hobbies that also help with anxiety.
  2. Online therapy can be counseled as a bridge to formal psychotherapy.
  3. SSRIs can increase anxiety, consider starting them at half the starting dose for 1-1.5 weeks.
  4. For patients averse to starting an SSRI, Dr. Gold considers starting buspirone which has a lower side effect profile.
  5. Dr. Gold considers bupropion for anxious patients very concerned with weight gain and sexual dysfunction.
  6. Dr. Gold has noticed patients often get switched to a different medication before trying out the maximum dose of a medication.
  7. Dr. Gold likes to prescribe propranolol 10-20 mg BID PRN for as needed treatment of anxiety.
  8. Clonazepam is the best choice when considering benzodiazepines for anxiety management.
  9. Medications can not remove thoughts from our mind. They may allow us to feel less on edge, help us sleep, or to feel better to tolerate certain thoughts, but these thoughts will still be there. Psychotherapy can help change negative thoughts and patterns.

Anxiety 2.0 Show Notes

Diagnosing and Counseling Patients With Anxiety

Anxiety Is Also a Symptom

Although anxiety can be a diagnosis, it is important to remember that anxiety can also be a symptom of other medical illnesses or just of normal life. The diagnosis of anxiety should be a diagnosis of exclusion. A workup should be made to rule out other medical and psychiatric conditions. For example, depression is commonly comorbid with anxiety. Tools like the GAD-7 questionnaire can help distinguish when anxiety symptoms start entering into the realm of a disorder.

Generalized Anxiety Disorder-7 (GAD-7) Questionnaire

The GAD-7 is an easy tool to not only screen for an anxiety disorder but also for objectively measuring symptom severity over time. It can be helpful in determining effectiveness of treatments or quantifying partial responses to treatments.

Counseling a Patient With a New Anxiety Diagnosis

Diagnosing or discussing anxiety with a patient can be difficult. Dr. Gold likes to start with a conversation on how anxiety developed as an evolutionary advantage allowing us to be aware of threats such as where a predator may be habiting (Bateson 2011). We become anxious and alert when we enter a place where we last saw a dangerous predator; this keeps us alive. In the present day, there are less life-threatening situations on a daily basis, but we can still perceive threats around us that give us anxiety. When our threshold for perceiving threats becomes off, such as perceiving many threats incongruous to the situation, then this type of anxiety becomes a problem. At this point, we need to recalibrate this perception of threats to decrease anxiety to a more manageable and functional level.


Non-Pharmacological Management of Anxiety

Self-Directed Activities/Coping Skills

Dr. Gold likes to conceptualize self-directed activities/coping skills for anxiety as hobbies. Although there is evidence on the effectiveness of meditation, mindfulness, journaling, exercise etc., none of these can be beneficial if patients do not do them. Patient-centered discussions should take place, touching on what self care means to patients and what they would be willing to keep up with. You can discuss what has worked for other patients or for yourselves; Dr. Gold shares she has stress balls in her office not only for her patients but also for herself.

Examples of activities and coping skills for anxiety include yoga, physical exercise, Tai chi, mindfulness/spiritual meditation, or other relaxation techniques such as progressive muscle relaxation and cold facial immersion.

Psychotherapy and Cognitive Behavioral Therapy (CBT)

Psychotherapy, and specifically CBT, has been well studied for its effectiveness in treating anxiety disorders (Mitte 2005). Dr. Gold recommends all of her patients who are on anti-anxiety medication to consider psychotherapy/CBT. There are however many barriers to accessing psychotherapy such as cost, time restraints, and availability of therapists. Getting on a waiting list to see a therapist early can be helpful.

The choice to start medication, psychotherapy, or both, should be made with the patient. Some patients may be hesitant to start medication and prefer psychotherapy, while other patients may have time constraints to attending psychotherapy. Some patients with comorbid depression can be too symptomatic to fully engage in CBT.

Although CBT has been the most well studied form of psychotherapy for treating anxiety, Dr. Gold does not discount other forms of psychotherapy. A patient’s fit with his/her/their therapist should be taken into account as well. Patients should be informed of the amount of homework required for CBT. Patients who may be averse to the amount of work required for CBT may consider another option such as psychodynamic therapy.

Dr. Gold notes that medications cannot remove thoughts from our mind. Medications may allow us to feel less on edge, help us sleep, or to feel better to tolerate certain thoughts, but these thoughts will still be there. Therapy can help change negative thoughts and patterns.

Online Therapy and Mobile Apps

There are online therapy providers that can provide therapy quicker and at a lower cost. These services increase access to therapy, but could have decreased quality. Dr. Gold counsels patients to see these services as a bridge to formal therapy. For those who do use these services, she reminds them that you can switch therapists if things are not working with the current one, and to be mindful of the fine print of each company.

There are mobile phone applications that can provide services to treat anxiety such as through meditation. As meditation is not everyone’s cup of tea, Dr. Gold reminds us that sometimes even a bedtime story through these apps can also be helpful.


Pharmacological Management of Anxiety

When Should Patients Start Medication

Patient preference is important on whether to start medication for anxiety. For patients who are hesitant to start a medication regimen, Dr. Gold will offer as needed medication first. Medication should be considered when anxiety is interfering with their job, interactions with friends and family, or other important functional parts of their lives like sleep.

First-Line Medications

Selective serotonin reuptake inhibitors (SSRIs) are first-line medications for anxiety (Baldwin 2011). Although serotonin-norepinephrine reuptake inhibitors (SNRIs) are also recommended as first-line, Dr. Gold tends to use SSRIs first due to the negative effects from skipped doses and tapering off of SNRIs. SNRIs can still be considered for patients with concurrent symptoms of neuropathic pain or vasomotor issues.

Dr. Gold usually starts at half of a normal starting dose for 1-1.5 weeks due to the risk of side effects, especially for the possibility of increasing anxiety (Naslund 2017). If increasing a dose increases anxiety, she will consider going back down and increasing the dose by a lower amount.

If a patient has taken the maximum dose of an SSRI for 4-6 weeks and still has not received an adequate response, you can taper off the initial drug and start another SSRI. Dr. Gold notes that she sees many patients who are switched to a different drug before trying the maximum dose of the previous drug.

Although not recommended as a first-line medication for anxiety treatment, Dr. Gold will consider bupropion for patients very concerned with weight gain and sexual dysfunction. She will counsel on risks/benefits of this choice including reports of higher anxiety due to its activating nature, but sees many patients who choose to start bupropion over other medications.

Second-Line Medications

Mirtazapine works relatively fast and has low drug interactions, but sedation and weight gain are prominent side effects (Huh 2011). Sedation and weight gain may be a deterrent for some, but beneficial for others. Lower doses of mirtazapine can cause greater sedation than at a higher dose.

Buspirone can be used as monotherapy or as augmentation in partial responses to first-line treatments (Chessick 2006). Buspirone works faster than SRIs, has low potential for abuse, and is not addictive.

Benzodiazepines can be considered for patients without a potential for drug abuse/addiction, but are not a solution for long-term treatment. They are however very effective in the short-term, with Clonazepam as the best choice due to its relatively longer half-life with lower addiction potential and side effects (Wang 2016).

Hydroxyzine is usually classified as a third-line medication for anxiety, but can be considered for patients with concurrent insomnia as it is highly sedating (Guaiana 2010).

As Needed Medications

Dr. Gold likes to use propranolol 10-20 mg BID PRN for as needed treatment for anxiety in her patients (as long as there are no contraindications). Propranolol is great for treating the physical symptoms of anxiety, and also non-sedating compared to other options.

Benzodiazepines, hydroxyzine, and gabapentin can all be used for as needed treatment, but are sedating.

Although buspirone is not officially recommended as an as needed medication, Dr. Gold will sometimes prescribe it to patients once daily and once as needed—especially for patients hesitant to start medications with greater side effects like SSRIs.

Partial Responses and Augmentation

Patients on a maximum dose of an SSRI, or ones who do not wish to increase the dose but require more relief in symptoms can be augmented with buspirone (Sussman 1998).

Augmenting with a different medication can be considered as well if certain symptoms would like to be addressed, for example gabapentin or hydroxyzine augmentation for trouble with sleeping.

Anxiety and Cannabis

There is no good evidence that cannabis is beneficial for any mental health illness. Dr. Gold recommends the cessation of cannabis for her patients and counsels them on the possibility of rebound anxiety and rebound insomnia (Xue 2021).

For patients set on continuing cannabis consumption, she will try to work with the patient so they only consume the same strain from the same store. She explains to the patient that we are trying to minimize variables as the patient is trying out different medications.


Dr. Gold’s Take Home Points

  • There is less of a stigma seeing a primary care provider for mental health than a psychiatrist. That being said, if you feel something is beyond the scope of what you are comfortable with or have time for, then that is when you should refer to a psychiatrist.
  • Try to understand how a patient feels towards a medication or why they may be hesitant to take it.
  • It is possible for anxiety to be addressed before it becomes a big problem. Primary care physicians are blessed to be in a position where they can address and prevent anxiety before it festers into a disruption in someone’s life.

Links

  1. National Alliance on Mental Illness
  2. www.drjessigold.com

Goal

Listeners will develop an approach to confidently diagnose, treat, and manage generalized anxiety disorder in the primary care setting.

Learning objectives

After listening to this episode listeners will…  

  1. Provide tips for self-directed management of anxiety and mood disorders
  2. Manage generalized anxiety disorder with pharmacological and non-pharmacological treatments in the primary care setting.
  3. Develop an approach for utilizing second and third-line agents for GAD treatment.

Disclosures

Dr. Gold reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Jyang E, Achi S, Gold J, Williams PN, Watto MF. “#429  Anxiety 2.0”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast March 4th, 2024.

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Episode Credits

Writer, Producer, Show Notes, Infographic, Cover Art: Edison Jyang
Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP
Reviewer: Sai Achi MD, MBA
Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP
Technical Production: PodPaste
Guest: Jessi Gold MD

CME Partner

vcuhealth

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

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