Here you will find a detailed algorithm for treating anxiety in patients with a history of chemical abuse and/or dependence. Much of the information applies to patients with anxiety disorders who do not have this comorbidity: the principle difference is in the placement of benzodiazepines in the algorithm. Most clinicians will find more opportunities to use benzodiazepines in uncomplicated cases.
Chemical abuse and dependency are common in patients presenting with complaints of anxiety. According to the National Comorbidity Survey, among patients who meet DSM-III-R criteria for any anxiety disorder, about 15% also have a substance use disorder during the previous twelve months.¹ The use of pharmacotherapy in such patients presents some special problems that have not been addressed systematically in previously published algorithms for the treatment of anxiety disorders.(2-4) The authors decided to pool their many years of clinical experience working with dual diagnosis populations, survey the literature and expert opinion, and prepare a series of algorithms for these patients. They were presented at the American Psychiatric Association Annual Meeting in Toronto in 1998.
This algorithm is part of the portfolio of applications in the Harvard Psychopharmacology Algorithm Project described in the May, 1999 issue of Psychiatric Annals. (Osser DN, Renner JA, Bayog R. Algorithms for the pharmacotherapy of anxiety disorders in patients with chemical abuse and dependence. Psychiatric Annals 1999;29(5):285-301.)
The use of this algorithm is predicated upon the clinician making a criteria-based DSM-4 diagnosis. Since this is an evidence-based as well as consensus-informed algorithm, it is important to note that almost all the published research studies in modern psychopharmacology (over the past 15 years) utilize DSM criteria as the basis for entering patients into the studies. Hence, if the clinician uses more vague or alternative criteria, this may reduce the validity of the recommendations to be found in this algorithm. A central premise of the approach to treatment outlined in this program is the primary importance of treating diagnoses, not symptoms. The vast majority of the evidence basis for psychopharmacology practice comprises information about treating patients with particular diagnoses, not symptoms independent of diagnosis. Many treatment errors arise from treating symptoms without identifying their cause. It appears to be one of the primary causes of polypharmacy and resultant toxicity from drug interactions and compounded side effects.
In crafting this algorithm, the goal was to propose a plausible, supportable, possibly cost-effective sequence which could be a "default" method for the optimum psychopharmacological care for an average case of these often complicated and treatment-resistant patients. We tried to address some of the nuances that may affect the prescribing decision of the psychiatrist, nuances which may differ depending on the setting where the patient is being seen (outpatient or institutional care, for example).
There is a relative paucity of research directly relevant to this effort. Much of this was summarized in the March 1998 issue of Psychiatric Annals, which was devoted to "the anxious person with an addiction." Those articles strongly advocated minimizing the use of benzodiazepines in this patient population,(5) but the editorial comment questioned if passion on this issue had obscured the quest for balance.(6) The controversy over the role of benzodiazepines was a central issue that had to be addressed in the development of the present algorithms, and a quest for balance was considered essential if the final product was to be useful to physicians facing real-world exigencies.
We want to stress that in proposing this educated guess of what constitutes reasonable practice, it was not our intention to discourage innovation. Creative new thinking often leads to significant advances. Innovators need only explain why the new approach might be better, and then try it. Ultimately, those innovations which pass the test of time and replication can replace these initially proposed benchmarks. Collection of patient outcome data over the Internet, using algorithm-recommended or alternative treatments, may enable determination of which innovations should lead to a change in the primary recommendations of the algorithm.
The Help sections after each question provide some pointers about the mechanics of using this program.
References:
1. Kessler RC, Nelson CB, McGonagle KA, Edlund MG, Frank RG, Leaf PJ. The epidemiology of co-occurring mental disorders and substance use disorders in the National Comorbidity Survey: implications for prevention and service utilization. American Journal of Orthopsychiatry. 1996;66:17-31.
2. Sussman N. Interactive treatment algorithms for anxiety disorders. Primary Psychiatry. New York: MBL Communications; 1997:16-80.
3. Stein DJ, Jobson KO. Pharmacotherapy algorithms for anxiety disorders. In: Fawcett J, ed. Psychiatric Annals. Thorofare, New Jersey: SLACK; 1996:190-232.
4. Jobson KO, Potter WZ. International psychopharmacology algorithm project report. Psychopharmacology Bulletin. 1995;31:483-507.
5. Longo LP. Non-benzodiazepine pharmacotherapy of anxiety and panic in substance abusing patients. Psychiatric Annals. 1998;28:142-153.
6. Fawcett J. Science, balance, and passion. Psychiatric Annals. 1998;28:116-117.
Many of the questions and recommendations have a clinical confidence rating icon in their windows. These give an indication of the scientific strength of data supporting the use of the recommendations and distinctions made by the questions. Confidence ratings have three levels:
Your feedback and your clinical experience are most valuable to help us refine this algorithm.
The "Feedback" button takes you to our automatic system for sending observations to us. Recent feedback of interest to users is posted regularly in the "Users Comments" section.
Our addresses are:
Dr. David N. Osser
% Mental Health Connections, Inc.
21 Blossom St.
Lexington, MA 02173
E-mail: dno@world.std.com
This program is designed to supplement and enhance the expertise of the psychiatrist. However, management of any individual patient is the responsibility of the prescribing physician. Recommendations from this program should only be used in the context of your overall knowledge of the patient.
End of Introduction.
Painted by Carolyn Crocker, used by permission.
Here are listed updates and additions to this program. They are listed by date, with the most recent first.
June 12, 2003. Completion of updating of all components of this algorithm. Though there were no major changes in recommended sequences, there are more alternatives at many points and many new literature citations supporting the decisions. This updating was done to prepare the files for transporting to the software of the new Version 4 of these algorithms.
January 21, 2002. The use of atypical antipsychotics as adjunctive therapy in PTSD is increasing, especially chronic combat-related PTSD in veterans, even when there are no psychotic symptoms. Separate poster sessions at the 2001 New Clinical Drug Evaluation Unit conference in Phoenix, Arizona described studies using risperidone, olanzapine, and quetiapine for this purpose. We have integrated this information into the PTSD algorithm at suitable points, with commentary.
January 14, 2002. Update in prescribing information about nefazodone, reflecting boxed warning about liver toxicity that was added in December, 2001. Nefazodone has also been removed as a prominent option in social anxiety disorder, PTSD, panic disorder, and generalized anxiety disorder. Discussion of this medication now reflects the new labeling which says that this product should be used only after the patient has not responded to or has been intolerant of other medications.
November 1, 2001. Some updates to the algorithm for social anxiety disorder.
February 14, 2000 Updated the link to PubMed's new site. Further refinements of the treatment trial reporting process.
November 4, 1999 Many refinements of the drug trial reporting process have been made. Clinician and patient versions of a Patient Functioning Questionnaire have been added.
October 3, 1999 The drug trial reporting form has been improved and recommendations have been numbered so the user can easily identify the appropriate recommendation for reporting.
September 1, 1999: Program completed.
