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Anxiety Disorders: Guidelines for Effective Primary Care, Part 2, Treatment

(PSYCHIATRIC TIMES) - Most uncomplicated anxiety disorders can be treated in the primary care setting. Following the initial treatment, patients require ongoing care, which combines psychosocial and psychopharmacological therapies. Treatment of anxiety disorders can lead to improved interpersonal, social, and vocational functioning.

In the second part of this 2-part series, I describe the various treatments, with emphasis on those that are typically used in the primary care setting. In part 1 (CONSULTANT, March 2009, page 169), I addressed the clinical presentation, the relevant diagnostic studies, and the differential diagnosis.


Sequence of treatment. The management of an anxiety disorder depends on the specific diagnosis and the presence of comorbid medical and psychiatric conditions.1 If the presenting anxiety symptoms are secondary to a medical condition, treatment of the condition usually leads to remission of anxiety.1,2 Thus, comorbid medical conditions should be treated first, followed by the anxiety disorder. When a comorbid psychiatric condition is present, simultaneous treatment with the anxiety disorder is recommended.1,3,4

Comorbid substance abuse. The management of anxiety disorders in patients with alcohol or substance abuse disorders should be coordinated with a psychiatrist or an addiction specialist.3,5,6 Discuss the long-term risks of dependence, withdrawal, and abuse, as well as the intended course of treatment. In general, it is advisable to treat alcohol and substance abuse disorders before the initiation of pharmacological therapy for anxiety disorders.1-3

In a primary care setting, the following immediate steps can be instituted7:

•Perform an evaluation to identify a provisional diagnosis of an anxiety disorder.
•Assess the degree and the severity of personal, social, and vocational impairment.
•Educate the patient about the nature and origin of anxiety symptoms.
•Incorporate family and social support resources to encourage anxious patients to use their coping skills and problem-solving abilities.
•Suggest lifestyle changes as appropriate, including stress reduction techniques; avoidance of alcohol, caffeine, nicotine, and illicit drug use; and proper diet and regular exercise.
•Establish and maintain a therapeutic alliance that conveys a sense of understanding and empathy.
Resources for patients, including those that can provide referrals to specialists and self-help groups, are listed in the Box (page 237).

An urgent psychiatric consultation for the evaluation and treatment of anxiety disorders may be necessary under the following circumstances5,6:
•There is serious risk of suicide.
•The diagnosis is uncertain.
•Psychotic symptoms are present.
•Comorbid illicit drug or alcohol use is present.
•The anxiety symptoms are chronic, severe, and disabling.
•The patient is elderly or is a child or adolescent.
•The patient refuses to adhere to the recommended treatment.
•No improvement is evident after a period of initial treatment and follow-up.

The main difficulty in referring to psychiatric services is discussing the referral with the patient. The stigma attached to mental illness continues despite medical and community education programs. As a consequence, referral needs to be handled tactfully. Discussing emotional factors and illness, explaining and demystifying psychiatric services, and addressing patient fears and beliefs about psychiatrists are key elements in the process.5,6

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