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Treating Generalized Anxiety Disorder with buspirone

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A common question to the Psychiatry Consultation Line is around treatment of Generalized Anxiety Disorder (GAD) in patients with a history of substance use disorders and for whom a Selective Serotonin Reuptake Inhibitor has not been effective. First-line treatments for Generalized Anxiety Disorder include Cognitive Behavioral Therapy (CBT), Serotonin Reuptake Inhibitors (SRI), or a combination of both. In cases where adjunctive CBT and multiple trials of SRIs have failed, buspirone can be given some consideration.

In 1980s-era, double-blind studies of GAD, buspirone’s efficacy was shown to be similar to benzodiazepines. An important difference between benzodiazepines and buspirone is that it takes buspirone longer to start working. Buspirone requires a multi-week or multi-month trial to assess efficacy. Compared to benzodiazepines, buspirone is less likely to cause sedation and, importantly, is not associated with the development of tolerance or dependence. Common side effects of buspirone include dizziness, nausea, and headache.

The FDA max dosing is 60mg/day and while some patients require a high dose, average therapeutic doses are in the range of 20 to 45 mg/day. Buspirone has a short half-life and some patients benefit from TID dosing.

Please refer to your own reference material for full prescribing information regarding medication dosing, risks, benefits, side effects, monitoring requirements, and drug interactions. We most often use Micromedex, UpToDate, or Epocrates. Additionally, there are free databases available to Washington State providers at https://heal-wa.org/professions/.

Author
Ryan Kimmel, MD
Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Chief of Psychiatry, University of Washington Medical Center
Medical Director, Psychiatric Consultation Line

Learn more
How do I address emerging anxiety during substance use recovery?  (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) discuss characteristics between a substance induced anxiety disorder and a primary anxiety disorder, and 2) to talk through different treatment options for anxiety symptoms.

CBT for Anxiety (CBT-A): What can I do with my patient instead of giving them a PRN benzodiazepine?  (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Patrick Raue, PhD
The objectives of this presentation are to 1) understand the CBT model of anxiety symptoms, 2) describe how to give the “treatment pitch” to patients, and discuss the difference between treatment with exposure vs. anxiety management strategies, 3) understand how to develop and work on an exposure hierarchy with patients and 4) describe anxiety management strategies that use physical and cognitive approaches.

Anxiety: fast facts and skills for the primary care physician  (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Ryan Kimmel, MD
A brief overview of diagnosing and treating anxiety in primary care.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

Diagnosing and treating bipolar disorder

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Clinicians call the Psychiatry Consultation Line with a range of questions about individuals with suspected or diagnosed bipolar disorder, which affects an estimated 4.4% of U.S. adults at some time in their lives. Bipolar disorders, sometimes referred to as manic-depressive disorders, are mood disorders that include manic or hypomanic symptoms and depressive symptoms. Accurate diagnosis of bipolar disorder can be difficult, and once a diagnosis is made, clinicians can face numerous decisions regarding acute episode treatment, maintenance treatment, monitoring response, monitoring for adverse effects, and treatment adjustments. These “points to consider” may help as you encounter similar clinical scenarios.

Assessment and Diagnosis

Common PCL Question: How can I assess for bipolar disorder in my primary care practice?

  • A structured assessment can help collect information that any clinician would need to inform diagnosis of bipolar disorder.
  • The Composite International Diagnostic Interview (CIDI) instrument can contribute to a structured assessment by assessing for lifetime experience of manic symptoms. It is important to remember that positive screening results do not equal a clinical diagnosis. In one study in primary care, about 45% of people screening positive on the CIDI, and 15% of people screening negative, were diagnosed with bipolar disorder by a psychiatrist. However, this instrument can help to collect information that might lead clinicians to ask more questions about bipolar disorder in those with a positive screen. PCL psychiatrists can assist with questions about administering structured tools such as the CIDI.
  • Some clinicians also find it useful to have structured tools to assess age of onset of mood symptoms, past mood symptoms and episodes, peripartum mood symptoms, response to medications including to antidepressant medications, family psychiatric history, drug and alcohol use, and other clinical problems, since historical points other than manic symptoms might raise clinical suspicion for bipolar disorders.

Common PCL Question – What questions can I ask patients about past manic symptoms?

  • One strategy to consider in clinical questioning is to ask about discrete periods of concurrently elevated or irritable mood AND increased energy. Then, once identifying a period when that occurred, inquiring about associated hypomanic or manic symptoms.

Common PCL Question – Is there a bipolar disorder spectrum, and does this apply to my patient?

  • Some individuals experience hypomanic symptoms that do not reach the level of severity of a hypomanic or manic episode.
  • Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classification includes categories of cyclothymia (subsyndromal hypomanic and depressive symptoms most days over two years), and Other specified bipolar and related disorder due to short-duration hypomanic episodes (i.e. 2-3 day duration), and insufficient number of hypomanic symptoms to reach episode-level (i.e. 3 symptoms). 
  • Additionally, major depressive episodes in major depression can occur with mixed features (concurrent hypomanic symptoms) though the difference in this case is that the individual with major depression with mixed features has never previously experienced a hypomanic or manic episode.
  • Mood fluctuations or ‘swings’ can occur in the absence of bipolar disorder diagnosis. Consider alternate explanations.
  • Visit Psych Education for more information on bipolar spectrum.

Treatment

Common PCL Question – Where do I start with choosing a medication treatment for a patient diagnosed with bipolar disorder?

  • Consider the current mood state. The most commonly experienced mood state in individuals with bipolar disorder is depression with one or more concurrent hypomanic symptoms.
  • There are relatively few FDA-approved or evidence-based medication treatments for bipolar depression and guideline-suggested first-line treatments include quetiapine, lurasidone, lamotrigine and lithium.
  • A greater number of medication treatment options exist for treatment of manic episodes, and guideline-suggested first-line treatments include lithium, quetiapine, risperidone, olanzapine, divalproex (avoid use of divalproex in women of reproductive potential) and aripiprazole.

Common PCL Question – My patient is diagnosed with bipolar disorder. Can I prescribe treatment with an antidepressant?

  • Uncertainty remains about effectiveness of antidepressant medications in treatment of individuals with bipolar disorder. Expert guidelines suggest avoiding antidepressant treatment when two or more concurrent hypomanic symptoms are present, when past antidepressant treatment was associated with onset or worsening of hypomanic symptoms or anxiety symptoms, during an episode with mixed features or in individuals who experience predominantly mixed features episodes, or as monotherapy.
  • If someone is already taking an antidepressant medication, and is not experiencing remission of depression or is experiencing anxiety symptoms or hypomanic symptoms, a reasonable next step is to taper and discontinue treatment with the antidepressant medication.

Common PCL Question – What can I add to this treatment plan that is not a medication?

  • Consider other treatment options including bright light therapy for bipolar depression (administered in midday rather than upon awakening). This treatment was not associated with treatment-emergent hypomanic symptoms in a clinical trial.
  • Psychotherapy options include treatments specific to bipolar depression, and maintenance treatment psychotherapies including strategies to normalize life patterns to reduce risk of mood episode recurrence and improve quality of life.

Monitoring

Common PCL Question – I started this treatment, what can I do next?

  • When caring for individuals diagnosed with bipolar disorder it is important to monitor the effect of any treatment decision. The patient may also have specific treatment goals to monitor.
  • Mood episode recurrence is common, and subsyndromal mood symptoms can occur chronically, which are associated with recurrence.
  • Monitoring symptom severity and frequency as part of measurement-based care could be accomplished with validated patient-reported measures such as the Patient Health Questionnaire-9 for depressive symptoms, and the newer Patient Mania Questionnaire-9 for manic symptoms.

Common PCL Question – What laboratory studies or other monitoring should I do?

  • Some medication treatments such as lithium, quetiapine and other antipsychotic medications require monitoring treatment for a therapeutic medication serum concentration (lithium and divalproex), and for adverse effects such as serum metabolic studies, weight/ body mass index, tremor, or other motor phenomena such as akathisia or involuntary movements. These measurements are usually done at baseline, and every 3-6 months depending on the clinical circumstance. Some individuals treated with antipsychotic medications should have baseline and interval EKG monitoring to measure QTc interval.

Conclusion
Assessment, diagnosis, treatment selection and monitoring can be complicated when caring for individuals with suspected bipolar disorder.  Psychiatrists on the Psychiatry Consultation Line can help clinicians reason through next steps in assessment, treatment decisions, and monitoring. Even in complicated clinical scenarios, discussing a patient’s care with a colleague can lead to a path forward.

For additional reading on bipolar disorder, visit Psych Education by Dr. Jim Phelps.

Author
Joseph Cerimele, MD
Assistant Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Director, Psychiatry and Behavioral Sciences Grand Rounds

References
Pacchiarotti I, et al. The International Society for Bipolar Disorders (ISBD) Task Force Report on Antidepressant Use in Bipolar Disorders. Am J Psychiatry. 2013;170:1249-1262.

Goodwin GM, et al.  Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2016;30:495-553.

Yatham LN, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. 2018;20:97-170.

Cerimele JM, et al. Bipolar disorder and PTSD screening and telepsychiatry diagnoses in primary care. Gen Hosp Psychiatry. 2020;65:28-32.

Cerimele JM, et al. The Patient Mania Questionnaire (PMQ-9): a Brief Scale for Assessing and Monitoring Manic Symptoms. J Gen Intern Med. 2021; Jun 18. doi: 10.1007/s11606-021-06947-7. Online ahead of print.

How to help patients experiencing dementia with behavioral disturbance

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Forgetfulness, memory impairment and difficulty with self-care are a major challenge for people living with dementia. But the neuropsychiatric symptoms of dementia can cause the most distress for patients and their caregivers.

Common neuropsychiatric symptoms include behavioral issues such as aggression, agitation and wandering. Mood, psychotic and sleep-related disturbances are also very common. Usually, patients have a combination of symptoms making it very challenging to know how to intervene.

A family who wants to care for a beloved parent at home can become demoralized and burned out when their loved-one is combative, awake all night or prone to wandering. Experienced caregivers in elderly care settings can struggle with keeping patients safe when they are distressed, pacing and paranoid of staff.

In the past, providers routinely prescribed antipsychotic medications to manage even mild symptoms. Today’s providers try to use these medications sparingly, informed by the current FDA warnings about the risks of use of these medications in the elderly. Without medications, providers might feel they have little to offer patients and families in these situations. But in many cases, significant improvements in symptoms and quality of life can be made for these patients without a prescription.

So, how do you best approach your patient with concerning neuropsychotric symptoms?

First, assess the situation: Is there a risk of harm to self or others? If so, ensure safety first by considering increasing the level of care through the addition of caregivers, one-on-one supervision, or hospitalization. In cases with the risk of severe harm, short-term pharmacologic treatment will likely be indicated along with hospitalization.

More commonly, the risk level is lower. In these cases, thinking through a few key areas can have a major positive impact:

1. Identify and treat the underlying cause. Most often, these symptoms do not occur in a vacuum. Pain, distress and underlying illness can be a driver, and one that when properly identified can be alleviated. Below is a list of commonly found underlying causes:

  • Delirium: assess for untreated medical illnesses, new medications, metabolic issues.
  • Medication side effects: have a high suspicion for this with the prescribing of benzodiazepines, anticholinergics and opioids.
  • Pain: a patient with major neurocognitive disorder may not be able to tell you they are in pain, so look at other clues such as body language and facial expression. Scheduled instead of as-needed non-narcotic pain medications can be helpful.
  • Depression and anxiety: assess for this with the help of the caregiver. Consider a trial of an SSRI.
  • Sleep disorders: sleep-wake disturbance is common in dementia. Emphasize good sleep hygiene, exposure to morning light, consistent schedule.
  • Sensory deficits: Poor vision and hearing can worsen confusion and lead to agitation as well as worsened fall risk.

2. At times, simple interventions can go a long way:

  • Implement daily, scheduled activities. Instruct families and caregivers to find activities that are soothing to the patient. Some patients will spend hours sorting through pictures, rearranging a silverware drawer or sweeping. Empower families and caregivers to get creative and try a variety of different strategies.
  • Environmental interventions such as reducing clutter, improving lighting and adding soothing features such as music or pets can help.

As a provider, helping a family discover that their mom loves to arrange silverware, can do so for hours and is able to remain calm and content throughout the day can be satisfying and bring a sense of relief in not having to add a new medication to an elderly person’s already long list. As a prescriber working with geriatric patients, less is always more when it comes to medications.

Author
Amanda Focht, MD
Clinical Assistant Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Medical Director, University of Washington Medical Center, Outpatient Psychiatry Clinic

References
Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA 2012; 308:2020.

Lyketsos CG, Steinberg M, Tschanz JT, et al. Mental and behavioral disturbances in dementia: findings from the Cache County Study on Memory in Aging. Am J Psychiatry 2000; 157:708.

Gitlin LN, Winter L, Dennis MP, et al. Targeting and managing behavioral symptoms in individuals with dementia: a randomized trial of a nonpharmacological intervention. J Am Geriatr Soc 2010; 58:1465.

How to ask about substance use

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If you struggle with asking patients about their alcohol and/or drugs use, you are not alone. Asking sensitive questions in a way that makes it more likely a patient will respond honestly can be challenging, and defensiveness or resistance to answering are not uncommon. Complicating this is the need to build a connection with your patient, and fear that a negative response to being asked will alter your rapport. For some, the challenge lies in asking the question; for others, it is what to do if you suspect a patient has a substance use issue.

Why, then, should providers ask about substance use? The pandemic has fueled escalating rates of both mental health and substance overuse, with one in 10 people reporting they started or increased their substance use during the. Suicide rates are up, as are overdose rates in our state. Before the pandemic, The National Institute on Drug Abuse estimated that there were over 20 million adults in the US with a substance use disorder. Of those, 38% of them also had mental illness.  Substance use disorder has a significant impact to personal health, and early intervention is key to preserving patient health and lowering health care costs. And, primary care is the de facto setting where many patients access mental health and substance use care.

There are over a dozen evidence-based screening tools for substance use, including the DAST, AUDIT-C, and CAGE. While the screening tools set a clear framework for what to ask, it’s important to know how to ask — how to set the stage — so the patient’s answers are more likely to be reliable and valid. Setting the stage includes managing our own anxiety, mitigating the patient’s anxiety, and being mindful of the wording, order and form of the questions you are asking.

To begin, be aware of your own anxiety and fears about asking sensitive questions. What’s driving them? What feels uncomfortable about asking these questions? To quell their own anxieties, some people find it helpful to practice and to ground themselves in the reasons why the answers are so important. Asking sensitive questions eventually becomes more natural, but until then, take a minute to check in with yourself and what you need to feel confident.

The words you use to ask sensitive questions, and how you set up the structure of asking, is key. Where does asking about drug and alcohol use fall in your assessment? Your psychosocial assessment should have flow, and it can be helpful to ask less loaded habit questions before asking about drug/ETOH use. For example, consider asking about diet and exercise before asking about other habits around smoking, alcohol and drugs. Starting off with questions about more socially acceptable substances like caffeine, tobacco, and then alcohol can be helpful in normalizing this line of questions.

As you head into the more sensitive questions, it can be helpful to start off with close-ended or fixed choice questions. “Have you ever drank alcohol?” or “Have you ever used any drugs or Cannabis?” This can then be followed up by asking “How often do you use?”, “How much do you use?”, and “How do you use?” if appropriate.  Asking additional questions to identify potential harms associated with their use can identify potential areas of intervention and education. “How often do you use a fresh needle when you inject…never, sometimes, almost always, always?” Asking about access to Narcan is important if the patient is using opioids or methamphetamine which may have opioids like fentanyl mixed in.

Be careful to use words that are less loaded—don’t use the term “illegal” when referring to drugs, for example, and try to ask about each drug specifically. “Have you ever used cocaine” is better than “have you ever used street drugs.” When talking with patients, be careful too about terms that are defined by each of us individually, like “drunk,” “high,” “frequently,” etc. Ask specific, quantifiable questions.

After you have a thorough substance use history from your patient and it turns out they have some concerning use patterns, what do you do now? Behavioral interventions have shown effectiveness in reducing substance use in those who are at risk for developing dependence. Commonly used elements for engaging in behavioral interventions are described in the FRAMES acronym—Feedback of risk, encouraging Responsibility for change, Advice, a Menu of options, therapeutic Empathy and enhancing Self Efficacy. Motivational interviewing can help you engage with patients who have more problematic use, but who are not yet expressing interest in change, or are contemplating change but not stating a readiness to change.

Remember, you can always call the PCL for advice on what to do once you have determined a patient does have some concerning substance use habits. Many providers feel ill-equipped to treat substance use and mental health conditions and the PCL adult psychiatrists and addiction psychiatrists are there to support you in the care of your patient. Call us anytime – we are a part of your team!

Author
Jennifer Magnani, MSW, LICSW, is the Assistant Program Director of the Psychiatry Consultation Line.

Learn more
Screening, Diagnosis, and Medication Assisted Treatment for Alcohol Use Disorders (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) identify the current screening tools and recommendations for alcohol use disorders, 2) discuss what to consider in diagnosing alcohol use disorders, and 3) review the current medications used for alcohol use disorders.

What Are Some Behavioral Strategies to Help My Patient Stay Sober? (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) review the importance of behavioral strategies for relapse prevention, 2) describe which behavioral strategies can be incorporated, and 3) learn when to use these strategies in a clinical situation.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

Resources provide guidance on psychotropic medications

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Many providers who lack formal training in mental health or addictions find themselves caring for patients with behavioral health conditions, but prescribing medications for mental health and/or substance use disorders can be daunting. To help bridge this gap, the UW AIMS Center developed a summary of Commonly Prescribed Psychotropic Medications that providers can use to familiarize themselves with effective medication treatments used in primary care.

The AIMS Center also created a collection of Brief Medication Prescribing Directions for common psychotropic medications used to treat adult patients. The succinct protocols are organized into three sections — dosing information, monitoring and general information — and are tailored to the outpatient setting.

Both resources are intended to facilitate the best possible prescribing practices in the outpatient setting. They should always be used with discrimination and, where questions arise (e.g., as new prescribing information comes out about a medication), in consultation with a pharmacist, current FDA drug label guidelines and/or an on-call UW psychiatrist staffing the Psychiatry Consultation Line.