NEW ORLEANS — Though anxiety disorders such as panic disorder, agoraphobia, and generalized social anxiety disorder are the cause for many office visits, not all primary care physicians and internists recognize them, according to a presenter at the American College of Physicians Internal Medicine Meeting.
“Anxiety is the most prevalent condition in primary care, but the majority of patients with anxiety do not present saying ‘I have anxiety.’ They come in presenting with nonspecific medical concerns,” Heidi Combs, MD, an associate professor at the University of Washington, told Healio Family Medicine. “There are lots of great screening tools such as GAD Anxiety Test and PHQ for anxiety, but only if you use them.”
She also encouraged PCPs to ask questions and listen for certain medical conditions to assist in the diagnosis process.
“If they’re complaining about fatigue, experiencing insomnia, talking about there being stomach upset -- consider anxiety. You should also ask the patient: ‘Do you spend a lot of time worrying? Do you consider yourself someone who worries a lot? Do you have anxiety when you’re in groups of people and feel uncomfortable about that?’”
Once the diagnosis is made, there are several treatment options, Combs said.
“Any selective serotonin reuptake inhibitor or serotonin and norepinephrine reuptake inhibitor can be used,” she said. “If they’re going to be using benzodiazepine, try to avoid alprazolam since it is more habit-forming than some of the other benzodiazepines.”
“I have a pearl when prescribing medications to patients with anxiety — start them at a half dose of what you would start for someone with depression. And then have the patient titrate up as they are ready. Put them in the driver’s seat about moving up the antidepressants because if they have exacerbation of their anxiety, knowing that they’re controlling when they’re actually going to increase their medication can be helpful,” she added, noting that a combination of these medications with cognitive behavior therapy may also prove beneficial.
Combs acknowledged office visits are finite, but the root of the patient’s problem must be found.
“One of the things that’s a challenge for all providers these days is time. And then the other thing they struggle with is time and then the third thing they struggle with is time. But these patients are struggling and suffering and they will come see you again and again and again until you actually identify what’s going on,” she said.
“Engage in interventions on these disorders earlier to get these patients feeling better and on their way. Then it actually ends up saving you time and it certainly saves illness burden and suffering on the part of the patient,” she added. – by Janel Miller
Combs H. Psychiatry for the nonpsychiatrist: depression, anxiety, PTSD and ADHD. Presented at: American College of Physicians Internal Medicine Meeting; April 17-21, 2018; New Orleans.
Disclosure: Combs reports no relevant financial disclosures.