Dr Alex Williams, a GP at St Thomas's Health Centre in Exeter, describes the management of anxiety in primary care
Objectives * To revise physiology and symptoms of anxiety * To know when anxiety should be treated * To understand the drugs used in its management * To be aware of dependence issues * To be aware of alternative approaches
Anxiety is extremely common. It has been estimated that there are between 50 and 120 presentations per 1,000 patients per year. Over 7 per cent of people who consult their GP do so for a mental illness.1
Anxiety may be an element in many other consultations and it is perhaps important to decide when anxiety becomes a problem. Anxiety is a response to stressful situations and is probably suffered by most people at some stage in their lives. Patients tend to seek help when the symptoms of anxiety start interfering with their life. These symptoms can include irritability, restlessness, sleep disturbance and difficulties with concentration.
An overactive autonomic nervous system can produce several somatic responses including dry mouth, tachycardia, palpitations, tremor, bowel and sexual disturbances. It is these symptoms that commonly prompt a patient into seeking help. Anxiety often co- exists with depression so it is important to assess whether there is any mood disturbance, feelings of worthlessness, apathy, poor concentration or thoughts of self-injury or self-harm.
Mild anxiety is a common occurrence with examinations and life crises, and these symptoms may be short-term. However, chronic anxiety can be an ongoing problem in patients whose personalities have not developed sufficiently to cope with life's stresses and uncertainties. It is important to consider that other psychiatric illnesses, as well as depression, may be lurking beneath the surface and to consider concurrent drug and alcohol abuse. The patient may have tried to mask or control his or her symptoms with excessive use of these agents, but they may simply be exacerbating the condition.
Having recognised that anxiety symptoms are significantly troublesome to interfere with daily life, what are the treatment options available?
Benzodiazepines
These drugs can be effective as anxiolytics, although there has been a tendency in the past to prescribe them to almost anyone with a stress-related illness or unhappiness. Benzodiazepines should be limited to the lowest possible dose and for the shortest duration of time. The Committee on Safety of Medicines suggests that benzodiazepines should be used only for short-term relief of symptoms, in anxiety that is severe, disabling or subjecting the individual to unacceptable distress, possibly occurring in association with insomnia.
Benzodiazepines should only be used as hypnotics when insomnia is severe, disabling and subjecting the individual to extreme distress. Dependence is particularly likely in patients with a history of alcohol or drug abuse and in patients with marked personality disorders.
Benzodiazepines have been erroneously labelled minor tranquillisers. This term is inaccurate and misleading, not only because they differ in chemical make up from the major tranquillisers but also because they can be highly addictive and cause significant side-effects.
The choice of benzodiazepine depends on the required duration of action (long or short) and whether it is being used as an anxiolytic or hypnotic (see table). The shorter acting drugs have a greater risk of withdrawal symptoms. My personal preference is to use diazepam in the dose range 2-10mg three times daily for a couple of weeks and then try to reduce the dose over the ensuing two to four weeks. If I were looking for a hypnotic effect, I would probably use temazepam 10-20mg at night, although increasingly I am using zopiclone, which is a cyclopyrrolone. Although not a benzodiazepine, zopiclone works on the same receptor. It has a short duration of action and little or no hangover effect.
Beta-blockers
If the patient is experiencing excessive somatic symptoms of anxiety, such as palpitations and tremor, I would consider adding a beta-blocker. These drugs have different affinities for beta 1 receptors, found mainly in the heart, or beta 2 receptors found in non-cardiac tissue. The beta-blockers used in anxiety, propranolol and oxprenolol are non-cardioselective.
It is important to find out if there any reasons why patients should not take these drugs. In particular anyone with a history of asthma or obstructive airways disease, uncontrolled heart failure, marked bradycardia or hypotension and any degree of heart block should not be prescribed these drugs in primary care. If I prescribe a beta-blocker I usually use propranolol, starting with 40mg three times daily and sometimes increasing the dose to 80mg three times daily, providing there are no side-effects. These can include bradycardia and possibly postural hypotension, exacerbation of both intermittent claudication and poor peripheral circulation with cold hands, excessive fatigue and sleep disturbances, and impotence.
The advantage of beta-blockers is that they are non-addictive and can help patients who subsequently need to withdraw from benzodiazepines.
I rarely use beta-blockers first line, for example in calming nerves before a stage performance, but propranolol 40mg daily or 80mg daily by sustained release, is used in situational anxiety.
Buspirone
Buspirone belongs to a class of drugs known as the azapirones, which are chemically and pharmacologically distinct from other anxiolytics. It is thought to act at specific serotonin (5HT1a) receptors. Buspirone has low dependence and abuse potential, but is licensed only for short-term use (two to three weeks).
Objective improvement can be seen during the first week of treatment, followed by a progressive rate of symptom response. Reports suggest that it produces less sedation and psychomotor impairment than the benzodiazepines. It does not appear to interact with alcohol or other CNS depressants.
Buspirone does not alleviate the symptoms of benzodiazepine withdrawal, so the latter should be withdrawn gradually. It is thought advisable to withdraw benzodiazepines before starting buspirone.
Counselling
This can be a very effective treatment for anxiety. Counselling can occur whenever a friend or parent offers advice and support. Many GPs are able to offer effective short-term counselling to patients they know well; they can listen, understand, provide sympathy, empathy and support. However, if longer term counselling is required, it may be necessary to refer to other agencies including psychologists and counsellors attached to the community mental health team.
A useful resource in our area is an anxiety management class, which concentrates on offering patients strategies to deal with anxiety provoking situations. Some practices have counsellors with formal training who offer short-term intervention. In our practice we have a counsellor who is able to offer up to eight one hour sessions and many patients find this resource valuable.
Exercise
There is a growing body of evidence that regular exercise is a valuable treatment.2 Taking 20-40 minutes of aerobic activity results in improvement in anxiety and mood that persists for several hours. This can occur whether individuals have normal or elevated levels of anxiety.3 There have been a number of theories as to how exercise may help and possible mechanisms may be: 1. Lower catecholamine concentrations, which can be anxiolytic, after endurance exercise.
2. Measurable increase in circulating beta endorphins after vigorous exercise; these have been shown to be powerful analgesics.
3. There may be psychological factors, such as a sense of achievement in completing a period of exercise properly or simply having time out from a stressful situation at work. The exercise could take the form of a regular brisk walk or could be more formal in a gym, swimming, running or a team sport.
Dependence
Despite the CSM advice about short-term use, some patients do become dependent on benzodiazepines used to manage a generalised anxiety disorder. GPs will also have patients who have been on benzodiazepines for many years and this group may find it particularly difficult to withdraw from their treatment. It has been suggested that withdrawal should be gradual as abrupt abstinence may produce confusion, convulsions, toxic psychosis or a condition representing delirium tremens. The withdrawal reaction may occur some time after stopping benzodiazepines - anything up to three weeks - but can occur in a few hours with short acting drugs.
Some of the withdrawal symptoms can mimic the underlying condition that is being treated. It is recommended that benzodiazepines are reduced by about one-eighth of the total dose every two weeks and, if symptoms recur with dosage reduction, maintain the patient on this dose for a bit longer. It may take up to a year to withdraw completely off the drugs and patients can still exhibit withdrawal symptoms for several weeks afterwards.
Antidepressants
Antidepressants may be useful for patients with both anxiety and depression, as some antidepressants also have a significant anxiolytic effect. These drugs are particularly useful if there is insomnia or other symptoms of depression.
The tricyclics are anxiolytic and also cause sedation. All have significant anti-cholinergenic effects and should be used with extreme caution in patients with glaucoma, urine retention and prostatic hypertrophy. Significant risk of cardiotoxicity occurs in overdose (see C&D, Pharmacy Update, January 12, p21-24).
I would normally prescribe a two to four week course of antidepressant drugs then review the patient to check for any unacceptable side-effects. It is also useful to give a structured follow-up to patients with any mood disorder, particularly if there are thoughts of self-harm. I frequently refer patients on to the community mental health team.
The selective serotonin reuptake inhibitors (SSRIs) citalopram and paroxetine are licensed for the management of panic disorder. Although the SSRIs are considered to be less sedating and have fewer anti-muscarinic and cardiotoxic side- effects than tricyclic antidepressants, they do have potential side effects ranging from nausea, vomiting, abdominal pain and diarrhoea to anorexia and weight loss. Some patients with anxiety experience an unpleasant and paradoxical hyper anxiety state. This has been linked to the surge of serotonin in the body - the serotonergic surge. This can be covered by a short-term prescription for benzodiazepines.
In the long term
My experience is that anxiety is a very common condition in primary care. Although ideally short-term treatment should be offered, many patients have chronic and disabling long-term anxiety that requires a multi-disciplinary approach. This includes both drug therapy and counselling. Regular consultations with the GP form an integral part of their long-term management.
References 1 McCormick A. Morbidity Statistics from General Practice: The Fourth National Study 1991-2; HSLO 1995 2 Petruzzello SJ et al. A Meta-analysis of the Anxiety Reducing Affects of Acute and Chronic Exercise. Outcomes and Mechanisms. Sports MED 1991;11: 143-82. 3 Raglin JS. Exercise and Mental Health. Beneficial and Detrimental Affects. Sports MED 1990;9: 323-9.

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