Benzodiazepines (BZDs) are useful medications for the acute treatment of seizures, severe muscle spasms, tremors, alcohol withdrawal syndrome, anxiety, and insomnia (Harvard Health Publishing, 2019). Though short-term administration can be efficacious and pose minimal risk, long-term administration causes physical dependence, resulting in withdrawal syndrome when abruptly discontinued. BZDs are generally recommended as a short-term option for acute anxiety or while pending a response towards antidepressants, since they have a rapid anxiolytic and sedative/hypnotic effect (Tanguay Bernard et al., 2018). Assuming that KT meets the criteria for GAD, first-line therapy to recommend would be cognitive behavioral therapy (CBT)/ cognitive therapy (CT) to help her evaluate and cope with her anxious thoughts through cognitive restructuring, problem solving, worry exposure, and applied relaxation (Powers et al., 2015). KT might also want to consider pharmacologic therapy along with CBT/CT, such either an SNRI or an SSRI, approved therapies including Venlafaxine XR, Paroxetine, or Escitalopram (Powers et al., 2015). These medications are as effective and safer for long-term administration than benzodiazepines for GAD, while also reducing the risk of dependence (Harvard Health Publishing, 2019).

Assuming WD meets the criteria for MDD, recommendations to help him cope with his recent life-alternating event (suffering from an MI) and resolve his depressive symptoms to return to a euthymic state is the goal. Interpersonal and CBT would be recommended for first-line therapy, along with pharmacotherapy, as combination therapy is helpful for patients with psychosocial stressors such as WD (Chisholm-Burns et al., 2019). SSRI’s would be most appropriate for first-line pharmacotherapy, however, precautions on which medication to prescribe must be taken considering WD’s past medical history. A dose related elevation in BP can occur with the SNRI’s venlafaxine and desvenlafaxine, and due to WD’s HTN, these would not be recommended (Chisholm-Burns et al., 2019). Additionally, the SSRI paroxetine has mild anticholinergic effects, and with WD’s severe uncontrolled narrow angle glaucoma, this medication would also not be recommended. According to the Cleveland Clinic (2019) there is a link between and heart disease and depression; these patients should adopt a healthy lifestyle including regular exercise, proper sleep, a healthy diet, and may also benefit from the SSRIs sertraline (Zoloft) and citalopram (Celexa) which have been deemed effective and safe in patients with heart disease.

Given JM’s current circumstances, I would first recommend that she improve her sleep hygiene. Ways that she can improve her sleep hygiene include: keeping a consistent routine before bedtime, allowing 30 minutes for winding down before sleep, dimming the lights in the room, unplugging from electronics 30-60 minutes before bed, cut down on caffeine, don’t eat late in the evening, get daylight exposure to help with circadian rhythm, exercise but not within a few hours of going to sleep, and restrict in bed activity (such as reading and watching TV) (Vyas & Suni, 2020). JM is also suffering from psychosocial issues, her abusive relationship with her boyfriend and unemployment. CBT/CT would be helpful and aid in coping with these recent life stressors. Moving on from an abusive relationship and gaining employment may help reduce the stress she is currently experiencing. JM is currently taking a benzodiazepine, Restoril 30mg HS, and this dose was recently increased. The increased dose may be helpful while JM is working on improving her sleep hygiene and her psychosocial stressors, but it is not recommended for long-term use. Though JM would benefit from antidepressant therapy, SSRI’s and SNRI’s may cause insomnia and worsen sleep quality, and since JM is already experiencing poor sleep, other options may want to be considered (Aiken, 2019). Although quetiapine (Seroquel) should not be used for primary insomnia, it is appropriate to be used for antidepressant augmentation, as it is not just sedating, it also improves the deep, restorative phase of sleep (Aiken, 2019). Another drug that may be considered for JM is buproprion; though it can increase daytime energy, it causes no more insomnia than SSRIs and has neutral to positive effects on overall sleep (Aiken, 2019). Overall, JM has many psychosocial factors that are likely influencing her ability to sleep and once she improves upon her relationship, employment status, and sleep hygiene, her sleep will likely improve.

References

Aiken, C. (2019, May 22). Sleep problems can guide antidepressant selection. Psychiatric Times. https://www.psychiatrictimes.com/view/sleep-problems-can-guide-antidepressant-selection

Chisholm-Burns, M., Schwinghammer, T., Malone, P., Kolesar, J., Lee, K. C., & Bookstaver, P. B. (2019). Pharmacotherapy principles and practice (5th ed.). Mcgraw-hill Education / Medical.

Depression & heart disease management and treatment. (2019, April 29). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/16917-depression–heart-disease/management-and-treatment

Harvard Health Publishing. (2019, March 15). Benzodiazepines (and the alternatives). Harvard Health. https://www.health.harvard.edu/mind-and-mood/benzodiazepines_and_the_alternatives

Powers, M., Becker, E., Gorman, J., Kissen, D., & Smits, J. (2015, July 2). Clinical practice review for GAD. Anxiety and Depression Association of American (ADAA). https://adaa.org/resources-professionals/practice-guidelines-gad

Tanguay Bernard, M.-M., Luc, M., Carrier, J.-D., Fournier, L., Duhoux, A., Côté, E., Lessard, O., Gibeault, C., Bocti, C., & Roberge, P. (2018). Patterns of benzodiazepines use in primary care adults with anxiety disorders. Heliyon, 4(7). https://doi.org/10.1016/j.heliyon.2018.e00688

Vyas, N., & Suni, E. (2020, August 14). What is sleep hygiene? Sleep Foundation. https://www.sleepfoundation.org/articles/sleep-hygiene

Benzodiazepines are sedative-hypnotics that provide quick relief for anxiety and insomnia symptoms. Regardless of their usage period, long-term or short-term, benzodiazepines are known to pose various adverse side effects (Hashmi, Han, French-Rosas, Jabbar, Khan & Shah,2018).

Anxiety is one of the main symptoms of many psychiatric disorders; its prevalence in the U.S is at least 4%. According to Bachhuber, Hennessy, Cunningham and Starrels (2016), though benzodiazepines are efficacious in treating anxiety, insomnia, and panic disorder, the efficacy is lost in 4 to 6 weeks of usage, and the patient becomes dependent. This particular risk significantly increases with the duration and dose of the treatment. Benzodiazepines are a short-term treatment. The long and safer shot includes psychotherapy, non- pharmacological interventions, and drug management. Moreover, situational insomnia cannot be managed without addressing underlying issues such as stress, depression and practicing good sleep hygiene.

Benzodiazepines are widely prescribed, especially in the western regions. The use of these drugs increases with age and is prolonged by its addictive nature. Therefore, a medical practitioner needs to apply a professional and evidence-based approach in prescribing (Kennedy & O’Riordan,2019). It can be done through a comprehensive assessment of the patient, offering an acute description of alternative treatments in a long-term case, amongst others.

For the first scenario involving KT, I would conduct a thorough assessment in order to exclude a substance, medical, or psychological condition as the causative factor of KT’s anxiety. Next, I would assess the severity and span of her symptoms. Having passed the criteria for GAD, I would recommend KT an individualized multimodal therapy that consists of psychotherapy, and non-pharmacological management. In the event that psychotherapy alone doesn’t prove successful, I would follow the treatment algorithm for GAD and prescribe an SSRI such as Lexapro 10mg QD and up-titrate the dose accordingly. Additionally, I would add a two to three week course of a BZD such as Xanax as a short term adjunct during the initiation phase of the SSRI therapy.

Delving into WD’s case, form the background information provided, it would seem as if he’s experiencing a bout of situational depression although it could also be attributed to his CAD. Following a thorough physical, psychiatric evaluation, medication regimen, and lifestyle assessment, I would evaluate him for the presence of any other psychiatric comorbidities as this would guide the selection of the right ATD agent. Moreover, I would assess his adherence to medications and any history of previous depression as this may indicate a trial with a different ATD drug. Given that he has a history of refractory HTN, I would look into his current medication list for any use of propanolol or clonidine as these drugs cause depressive symptoms. In order to help WD out, I would suggest psychotherapy and if needed, a course of a first line ATD such as an SSRI namely Celexa 20mg QD or Prozac 20mg QD and up-titrate accordingly. If necessary, a 2 to 3 week course of BZDs may be added until effects of ATD are reported.

Lastly, in regards to JM, as expected I would conduct a thorough physical, psychiatric evaluation, medication regimen, and lifestyle assessment. After ruling out any underlying conditions such as OSA, RLS, CRDs, Parasomnias, or Narcolepsy, I would counsel her on non-pharmacological therapy such as start practicing better sleep hygiene (behavior changes such as stopping caffeine consumption by 5pm, exercising or eating no more than 5 hours before retiring to sleep, and using her bed only for sleep and intimacy) and refraining from any stressful situation, i.e. abusive boyfriend. She also needs to reduce and ultimately discontinue her use of temazepam as it may be causing the lack of sleep due to loss of efficacy. In the event that her insomnia persists despite behavioral, environmental, and lifestyle modifications, I would prescribe her a course of a Z-drug such as Ambien with a starting dose of 10mg QHS, as it has shown to induce and sustain sleep. Similarly, a course of Mirtrazapine 15mg QHS could be considered as it is commonly used for insomnia and concomitant depression.

References

Bachhuber, M. A., Hennessy, S., Cunningham, C. O., & Starrels, J. L. (2016). Increasing benzodiazepine prescriptions and overdose mortality in the United States, 1996–     2013. American journal of public health, 106(4), 686-688.

Hashmi, A. M., Han, J. Y., French-Rosas, L., Jabbar, Q., Khan, B. A., & Shah, A. A. (2018).

Benzodiazepine use and abuse. Psychiatric Annals, 48(8), 360-365.

Kennedy, K. M., & O’Riordan, J. (2019). Prescribing benzodiazepines in general practice. Br J

Gen Pract, 69(680), 152-153.

Psych Disorders Discussion

Benzodiazepines are a class of medications often prescribed to treat insomnia, anxiety, and seizures among other disorders.  These medications are highly effective, as they have a rapid onset, crossing the blood-brain barrier, where they increase activity at neurotransmitter gamma-aminobutyric acid (GABA) (Soyka, 2017).  As this transmitter decreases the activity of neurons, the resultant effect is rapid decrease in the fight or flight response feeling of anxiety.  While benzodiazepines do have a place, their use should be for short-term relief, less than 2-4 weeks, while waiting for medications that potentiate the reuptake of serotonin to reach therapeutic levels.   Benzodiazepines are considered safe medications as they have low toxicity, but are very addicting and have high potential for abuse.  As such, these medications should not be prescribed for patients with a history of polysubstance abuse, except in short-term detox settings.

Generalized anxiety disorder (GAD) is a disorder which is characterized by chronic incessant worry, poor concentration, irritability, and decreased level of social functioning (Stein & Sareen, 2015).  This disorder is also often associated with somatic complaints such as back pain, stomachaches, and headaches.  Women are diagnosed with GAD twice as often as men (Kato et al., 2018).  As GAD is chronic, the persistent anxiety must last for 6 months or longer in order to meet the criteria.  A diagnosis of GAD must meet DSM-V criteria, and can be assessed utilizing different screening tools such as GAD-7 or the Penn State Worry Questionnaire (Spitzer et al., 2006).  The GAD-7 is an 8 question self-answered diagnostic tool that helps a clinician assess the level of anxiety and the overall effect on the patient’s life. Treatment of GAD requires a stepped approach and should also include cognitive behavior therapy as pharmacological interventions are not a “cure” for anxiety, but rather they suppress activity in the amygdala and pre-frontal cortex (Abejuela & Osser, 2016).

KT is a young adult female who is experiencing anxiety related to a generalized adjustment disorder.  Utilizing DSM-V criteria, KT has been given a diagnosis of Generalized Anxiety Disorder.  The first line therapy for GAD is a selective serotonin reuptake inhibitor (SSRI) (Abejuela & Osser, 2016), although a serotonin and norepinephrine reuptake inhibitor (SNRI) such as duloxetine is also an option, especially if KT had more somatic symptoms such as pain.  In KT’s case, given her age, a few options to consider would be fluoxetine or escitalopram (Kato et al., 2018).  As both medications are generally well tolerated with few side effects, either would be beneficial.  SSRIs reach therapeutic levels in 6-8 weeks, with a patient seeing the first signs of improvement in sleep, appetite, and energy within the first 2 weeks, and significant improvement in anxiety in 2-4 weeks.  In the interim, KT could be prescribed an as needed medication that would help decrease the uncomfortable feelings of anxiety such as hydroxyzine, propranolol, gabapentin, or clonidine.  If her anxiety was not manageable in the short-term with these medications, then a small dose of a benzodiazepine, such as clonazepam, could be considered for the first 2 weeks (Stein & Sareen, 2015).  KT should follow up in 4-6 weeks.  If she has not achieved a 50% decrease in her symptoms at that time, it would be time to re-evaluate medications and either consider an increase in dose, a medication change, or an addition of another medication (Kato et al., 2018).

Major Depressive Disorder (MDD) is characterized by pervasive feelings of sadness, loss of interest, hopelessness, and trouble completing activities of daily living (Depression, n.d.).  One tool clinicians use when evaluating depression in patients is the Hamilton Rating Scale for Depression (Sharp, 2015).  This is a series of either 17 or 21 questions to evaluate symptomatology of depression including sleep, social functioning, quality of life, and feelings of hopelessness.  SSRI’s are considered the gold standard for treating MDD, but other medications such as SNRIs or bupropion, a norepinephrine dopamine reuptake inhibitors (NDRI) may be used (Kato et al., 2018).  As with medications for GAD, these medications take 6-8 weeks to reach maximum therapeutic levels, with patients generally endorsing decreased levels of depression within the first 2-4 weeks.

WD, a 49-year-old male, with underlying health conditions, recently suffered a myocardial infarction, and is noted to be depressed. As criteria for major depressive disorder (MDD) has already been established, it is in WD’s best interest to start an anti-depressant.  Given WD’s medical health, an SSRI such as fluoxetine or sertraline would be a first-line treatment.  These medications are generally considered safe in patients with hypertension and glaucoma (Kato et al., 2018).

Most people struggle with insomnia at some point in their lives.  For many people, poor sleep hygiene can be a component.  Additionally, studies show that 50% of people endorsing insomnia have an underlying untreated mental health condition (Winkelman, 2015).  Insomnia has different components such as difficulty falling asleep, difficulty staying asleep, and early morning awakening.  Cognitive behavioral therapy with improved sleep hygiene are the first line treatments for insomnia.  However, many people also require temporary pharmacological interventions.

JM, a 42-year-old female, with poor sleep hygiene, in conjunction with depression, is endorsing continued insomnia despite her current regimen of temazepam 30 mg at bedtime.  JM should be counseled regarding the poor lifestyle choices that she is making, such as high caffeine intake, lack of exercise, and high emotional stress levels.  While a pharmacological intervention should be initiated, if JM does not make lifestyle changes and seek CBT, the interventions will not be as effective.  As JM is endorsing depression as well as insomnia, an addition of trazodone or low dose quetiapine before bed would be beneficial (Winkelman, 2015). Temazepam should be considered only as a short-term hypnotic for sleep and be discontinued.  As JM is struggling with daytime alertness and depression, she would be a good candidate for bupropion (Cipriani et al., 2018).

References

Abejuela, H., & Osser, D. N. (2016). The psychopharmacology algorithm project at the harvard south shore program. Harvard Review of Psychiatry, 24(4), 243–256. https://doi.org/10.1097/hrp.0000000000000098

Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., Leucht, S., Ruhe, H. G., Turner, E. H., Higgins, J. T., Egger, M., Takeshima, N., Hayasaka, Y., Imai, H., Shinohara, K., Tajika, A., Ioannidis, J. A., & Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. The Lancet, 391(10128), 1357–1366. https://doi.org/10.1016/s0140-6736(17)32802-7

Depression. (n.d.). Retrieved September 22, 2020, from https://www.nimh.nih.gov/health/topics/depression/index.shtml

Kato, T., Furukawa, T. A., Mantani, A., Kurata, K., Kubouchi, H., Hirota, S., Sato, H., Sugishita, K., Chino, B., Itoh, K., Ikeda, Y., Shinagawa, Y., Kondo, M., Okamoto, Y., Fujita, H., Suga, M., Yasumoto, S., Tsujino, N., Inoue, T.,…Guyatt, G. H. (2018). Optimising first- and second-line treatment strategies for untreated major depressive disorder — the sun☺d study: A pragmatic, multi-centre, assessor-blinded randomised controlled trial. BMC Medicine, 16(1). https://doi.org/10.1186/s12916-018-1096-5

Sharp, R. (2015). The hamilton rating scale for depression. Occupational Medicine, 65(4), 340–340. https://doi.org/10.1093/occmed/kqv043

Soyka, M. (2017). Treatment of benzodiazepine dependence. New England Journal of Medicine, 376(12), 1147–1157. https://doi.org/10.1056/nejmra1611832

Spitzer, R. L., Kroenke, K., Williams, J. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder. Archives of Internal Medicine, 166(10), 1092. https://doi.org/10.1001/archinte.166.10.1092

Stein, M. B., & Sareen, J. (2015). Generalized anxiety disorder. New England Journal of Medicine, 373(21), 2059–2068. https://doi.org/10.1056/nejmcp1502514

Winkelman, J. W. (2015). Insomnia disorder. New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/nejmcp1412740

Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders in primary care, although it is often underrecognized and undertreated Davidson, Feltner, & Dugar (2010). Generalized anxiety disorder is chronic, disabling and is linked with many order disorders or health issues. GAD criteria include these list of symptoms (restlessness, irritability, difficulty concentrating, muscle tension, sleep disturbance and being easily fatigued) Davidson et al. (2010) and duration of the disorder last up to 6 months. GAD onset is usually gradual but progresses to be recurrent and chronic and complete recovery are low.

KT is worried about her academics and if she is going to graduate with her friends. This is stressing her and causing her to experience poor concentration in her academics. The cause of GAD is not well known, but it is linked with genetic, environment reaction Davidson et al. (2010). Individuals with GAD always say that are worried about things extremely that they conceived are dangerous or threats without any evidence.

To meet up KT problems and issues, appropriate assessments are required with the use of: Generalized anxiety disorder 7-items. This assessment tool which assessments patient in 7 different areas within for 2 weeks rating it from: 0 for Not at all, 1 for several days, 2for more than half the days and 3 nearly every day. This tool looks at individual’s:

1.Feeling nervous, anxious or at edge

2.Not being able to stop or control worrying

3. Worrying too much about different things

4. Trouble relaxing

5. Being so restless that it is hard to sit still

6. Becoming easily annoyed or irritable

7. Feeling afraid as if something awful might happen.

Reviewing KT chief complaint, She fell into the 7-assessment tool, she is worried that she might not graduate with her friends. As a practitioner, more histories must be obtained, her family history, how she hands stress, sleep pattern and her coping skills. Coping skills include what she does to relax, recreational activities etc. KT could be started on Buspirone (Buspar), which is antianxiety at a scheduled dosage at a low dose and monitor patient two weekly. Follow up after initiating treatment to assess for adverse side effects. Encourage to take medication and attend to therapy as recommended. Therapeutic effects of Buspar is up to 2-4 weeks Wilson & Tripp (2020). There is no risk of dependency or withdrawal due to lack of effects on GABA receptors (neurotransmitter gamma-aminobutyric acid) Wilson and Tripp (2020) and has been approved by Food and Drug Administration (FDA) for the treatment of GAD both short and long-term basis. Patient will be referred counselling with a psychotherapist that will help her regulate her emotions Edmund (n.d.).

Benzodiazepines are among the moat prescribed drugs globally Guina, & Merrill, (2018). Benzodiazepines are sedative-hypnotic and are also used to relief anxiety rapidly. These group of medications are addictive in nature and have withdrawal effects. Evidence use of benzodiazepines are in the short term (2-4 weeks) treatments of panic disorder, general anxiety disorder, social anxiety disorder and insomnia. Evidence is against the use of benzodiazepines for patients with comorbid conditions for a long period without trying other first and second line of drugs Guina, & Merrill, (2018). Contra-indications for the use of benzodiazepines are depression, suicide ideation, psychosis, neurogenic disorders including traumatic brain injury etc.

Patients with cardiovascular disease (CVD) and affective disorders are common Mavrides, & Nemeroff, (2015). The prevalence of depression is between 17% and 47% in CVD patients Mavrides, & Nemeroff, (2015). Depression may make individual’s health condition worse due its effects on the proinflammatory factors, hypothalamic-pituitary axis, nervous system, and metabolic factors. It can lead to inactivity, overweight, smoking and poor adherence to medical treatments Katon (2011).

It is very important to treat WD 49 years old to reduce comorbidities resulting from Myocardial infarction and major depressive disorder to prove his lifestyle and reduce disabilities. Usually Clinicians should consider using psychotherapy, pharmacotherapy as it will suit the patient Cruz, Chionglo, Tran (2019).  Depression screening, blood pressure monitoring, AIC levels, and measure patient’s weight and BMI.  Antidepressants are made up Selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs).The TCAs are linked with arrhythmogenic activity which may be a result from the potent blockade of cardiac sodium and potassium channels and affect cardiac contractility and have even been associated to worsening of ischemic heart disease and sudden cardiac death, and thus should be avoided completely in patients at risk of a serious arrhythmia Pragle (2018). Studies have shown that the use SSRIs such as Zoloft, Lexapro, Prozac are safe and effective to be used on patients with heart diseases    in the treatment for MDD.

Insomnia is defined as difficulty with sleep initiation, duration, quality or consolidation, which results in impairment of daytime functioning. Insomnia is usually a chronic condition lasting from 1 year to 3 years Heesch (2014). Some of the benzodiazepine receptor agonists are approved by the Federal Drug Administrator, such as temazepam, estazolam, triazolam, quazepam and the non-benzodiazepine are zaleplon, zolpidem and eszopiclone Heesch (2014).  Restoril is a sedative-hypnotic drug that is used for the treatment of insomnia but is addictive and it acts on the central nervous system causing depression, individuals build tolerance and dependent to its uses.

Caffeine is an adenosine-receptor antagonist and affects the A1 and A2A receptors, which in turn are related to functions of the brain linked with sleep, arousal, and cognition O’Callaghan, Muurlink and Reid (2018). JM should be advised to gradually reduce the consumption of coffee.

The non-pharmacological treatments JM are cognitive behavioral therapy for insomnia (CBTI). This therapy aims at reducing factors that reduce sleep, adopt sleep hygiene, relaxation training and these last 4 to 8 sessions by a therapist. Using a diary to record number of hours of sleep. Awakening, and naps Siebern, Suh, and Nowakowski (2012).

• Sleep restriction: This limits the amount of sleep in bed. Sleep restriction therapy is effective because it strengthens sleep and wake system that is controlled by the endogenous circadian pacemaker Siebern, Suh, and Nowakowski (2012).
• Stimulus control is used is used to reduce the number hours one spends awake in bed. That patient goes to bed when sleepy i.e., using bed for sleep and sexual activities Siebern, Suh, and Nowakowski (2012).
• Relaxation technique during the day or before bedtime such as deep breathing exercises, watching relaxing movie, tensing and relaxation exercises Siebern, Suh, and Nowakowski (2012).
• Pharmacological drug that should be added to the non-pharmacological treatment for JM should be Trazodone. Start JM on a low dosage from 50mg to 100mg at night. Trazodone is an antidepressant but is widely used as a sleep aid. It an antagonist to serotonin type 2 (5-HT2) receptors Jaffer et al. (20170.

Reference

Aimee Pragle (2018) Depression and CAD. Retrieved from https://www.acc.org/latest-in-            cardiology/articles/2018/09/28/08/08/depression-and-cad

Austin De La Cruz, Alyssa Marie Chionglo, Thao Tran (2019) Current Updates Regarding             Antidepressant Prescribing in Cardiovascular Dysfunction. (n.d.). Retrieved from             https://www.acc.org/latest-in- cardiology/articles/2019 current-updates-regarding- antidepressant-prescribing-in-cv-dysfunction

Davidson, J. R., Feltner, D. E., & Dugar, A. (2010). Management of generalized anxiety disorder in primary care: identifying the challenges and unmet needs. Primary care companion to the Journal of clinical psychiatry, 12(2), PCC.09r00772.      https://doi.org/10.4088/PCC.09r00772blu

Generalized Anxiety Disorder 7-item (GAD-7). (n.d.). Retrieved from             https://www.hiv.uw.edu/page/mental-health-screening/gad-7

Guina, J., & Merrill, B. (2018). Benzodiazepines I: Upping the Care on Downers: The Evidence of Risks, Benefits and Alternatives. Journal of clinical medicine, 7(2), 17.     https://doi.org/10.3390/jcm7020017

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M.,   Danovitch, I., &             Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic           Review. Innovations in clinical             neuroscience, 14(7-8), 24–34.

Katon W. J. (2011). Epidemiology and treatment of depression in patients with chronic medical             illness. Dialogues in clinical neuroscience, 13(1), 7–23.

Mavrides, N., & Nemeroff, C. B. (2015). Treatment of affective disorders in cardiac         disease. Dialogues in         clinical neuroscience, 17(2), 127–140.

O’Callaghan, F., Muurlink, O., & Reid, N. (2018, December 07). Effects of caffeine on sleep       quality and             daytime functioning. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292246/

Sara J. Edmund is a clinical assistant professor at the University of Arizona. (n.d.). The challenge            of generalized anxiety disorder in primary…: The Nurse Practitioner. Retrieved from             https://journals.lww.com/tnpj/FullText/2018/04000/The_challenge_of_generalized_anxie            ty_disorder_in.3.aspx

Siebern, A. T., Suh, S., & Nowakowski, S. (2012, October). Non-pharmacological treatment of    insomnia. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480569/

Wilson TK, Tripp J. Buspirone. [Updated 2020]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:          https://www.ncbi.nlm.nih.gov/books/NBK531477/

Pharm Module 4

Benzodiazepines have been prescribed for decades, but recent changes to prescribing information is taking a hard look at the safety, efficacy, and overuse of this class of drugs. Pennsylvania prescribing guidelines state that they are not a first line treatment for anxiety and are not effective in the long term use.(Huet, 2016) The guidelines list cognitive behavioral therapy (CBT) and the use of SSRI antidepressants as safer options. Benzodiazepines have had a 320% increase in prescribing and a 500% increase in deaths due to overuse.(Huet, 2016) I would be very cautious in prescribing these medications especially to anyone with a substance abuse history or the elderly.

With regard to KT, mental health issues among college age students is common due to a rapid time of change and often precipitates first onset of mental health issues.(College Students: Mental Health Problems and Treatment Considerations, n.d.)If KT meets the criteria of a GAD diagnosis and if a thorough history reveals no substance abuse issues I would start her on a low dose SSRI. Because the antianxiety effect is delayed by 2-4 weeks I would also consider a low dose benzodiazepine for short term relief of symptoms. (Chisholm-burns et al., 2019, pp. 622–623)  I would monitor her closely and advise CBT therapy.

WD is not alone in his new onset depression. Circulation reported in 2017 that “Depression among patients with acute myocardial infarction (AMI) is prevalent and associated with an adverse quality of life and prognosis.” (Smolderen et al., 2017) Due to his diagnosis of closed angle glaucoma and diabetes, I would suggest CBT and a support group. Because of his severe narrow angle glaucoma, I would not prescribe an antidepressant at this time until is determined that psychotherapy is not working.

JM needs a lot of education and counseling on sleep hygiene. The habits that she reports are probably the reason that she has insomnia. Caffeine, poor dietary habits, and depression need to be countered by relaxation training, better sleep hygiene, and stimulus control.(Chisholm-burns et al., 2019, p. 638) I would also begin a slow wean of her restoril. Restoril is a benzodiazepine which only has a recommended use of 4 weeks.(Temazepam, 2019) I would monitor her progress and encourage her to develop better sleeping habits.

References

Chisholm-burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., & Bookstaver, P. B. (2019). Pharmacotherapy principles and practice, fifth edition (5th ed.). Mcgraw-hill Education / Medical.

College students: Mental health problems and treatment considerations. (n.d.). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527955/

Huet, E. (2016). Benzo-for-anxiety-and-insomnia-final-002 [PDF]. http://www.overdosefreepa.pitt.edu/wp-content/uploads/2016/10/Benzo-for-anxiety-and-insomnia-FINAL-002.pdf

Smolderen, K. G., Buchanan, D. M., Gosch, K., Whooley, M., Chan, P. S., Vaccarino, V., Parashar, S., Shah, A. J., Ho, P., & Spertus, J. A. (2017). Depression treatment and 1-year mortality after acute myocardial infarction. Circulation, 135(18), 1681–1689. https://doi.org/10.1161/circulationaha.116.025140

Temazepam. (2019). nhs.uk. https://www.nhs.uk/medicines/temazepam/

Module IV: Psychiatric Disorders ( Depression, Anxiety, Sleep) Discussion

Benzodiazepines are relatively safe for short term use. It can be used in patients with many different illnesses, and overdose is almost never lethal. The most common side effect is drowsiness. Short acting Benzos may cause rebound insomnia the night after taking. Some benzos can impair memory and the ability to learn new things. The elderly are more susceptible to these side effects. It is best to avoid alcohol and opioids with Benzos due to alcohol potentiating the effects of these sedatives. Combining opioids and benzodiazepines can be unsafe because both types of drugs sedate patients and decrease respirations. Both prescription opioids and benzodiazepines have a black box warning on the label to warn of the dangers of using these drugs together.

Side effects to note when considering prescribing benzos to patients would be sedation, dizziness, weakness, unsteadiness, depression, loss of orientation, headache, sleep disturbance, confusion, irritability, aggression, excitement, memory impairment(Ansari & Osser, 2020). One must be mindful of the patients they are prescribing for, are they at risk for falls? Do they already become aggressive due to dementia? Are they suffering from depression?

Benzodiazepines sedative and calming effect will help anxiety and sleep for most patients in the short term. Its good to remember these drugs are for severe anxiety or insomnia that is disabling and causing distress. Benzos taken regularly for more than a few weeks and at higher doses, or taken by patient with a history of drug abuse are at a higher risk of becoming addicted(Hamzelou, 2019). While clinicians are prescribing fewer opioid pain relievers, prescriptions for anti-anxiety drugs are going up.  Doctors overestimate the benefits of benzodiazepines, as long-term use can not only cause dependance it can actually make insomnia, mood, and anxiety worse.

Benzos have their place in treating anxiety and insomnia as a short-term medication until the underlying cause can be fixed. The use of Benzos should be short term, or used just when really needed for severe attacks. Clinicians should avoid prescribing benzodiazepines and opiates together.

General anxiety disorder (GAD) is an anxiety disorder characterized by being in a chronic state of agitation and worry for at least 6 months without any outside reason for the agitation, and the anxiety is not caused by a medical condition, medication, or substances.

It has been determined that 24-year-old KT has GAD, and has presented to the clinic for treatment options. I would start KT on an antidepressant that will help her anxiety disorder. The three types of antidepressants are Tricyclics, SSR’s, and SNRIs. This drug can take weeks if not months to become fully effective. If KT is having distress that she feels can not wait for antidepressants to take effect, I would order a short-term benzo such as Ativan to help until the antidepressant began to be effective. I would suggest KT also try psychotherapy and cognitive behavioral therapy. Exercise and a good support system are also important to good mental health.

WD has been diagnosed with major depressive disorder and needs to start treatment. Do to WD having severe uncontrolled narrow angle glaucoma I would be very cautious in what I ordered for him. SSRIs and Tricyclic antidepressants can worsen narrow angle glaucoma(“Risk of Angle-closure Glaucoma with Antidepressants,” 2016). I might consider and older MAOI antidepressant such as Nardil or Parnate. I would also avoid Effexor as it can raise WD’s blood pressure further.

JM is having difficulty sleeping as well as depression related to an abusive relationship. Non-pharmacological treatment recommendations would be, decreasing caffeine intake especially later in the day, exercising earlier in the day, and stop eating at least 2 hours before bedtime. I would suggest winding down an hour or so before bedtime with a warm bath, and decreasing stimuli in the bedroom in order to fall asleep easier. I would increase the Restoril but only to 22.5 mg to see if it affective at that dose. Restoril is a drug that allows users to fall asleep faster and stay asleep longer(Jackson et al., 2018), so it would be a good choice for JM.

References

Ansari, A., & Osser, D. N. (2020). Anti-anxiety medicines and hypnotics. In Psychopharmacology (pp. 85–120). Oxford University Press. https://doi.org/10.1093/med/9780197537046.003.0003

Hamzelou, J. (2019). The trouble with benzos. New Scientist, 243(3250), 18–19. https://doi.org/10.1016/s0262-4079(19)31862-7

Jackson, E. A., Cardoni, A. A., McElnay, J. C., Jones, M. E., & Alexander, B. (2018). Temazepam (restoril, sandoz pharmaceuticals). Drug Intelligence & Clinical Pharmacy, 16(9), 650–656. https://doi.org/10.1177/106002808201600902

Risk of angle-closure glaucoma with antidepressants. (2016). Reactions Weekly, 1616(1), 6–6. https://doi.org/10.1007/s40278-016-20623-7