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Dr. Bob is Robert Hsiung, MD,
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Posted by herpills on September 9, 2011, at 21:47:22
Psychiatric News September 2, 2011
Volume 46 Number 17 Page 20
© American Psychiatric AssociationClinical & Research News
Antipsychotics Increasingly Prescribed for Anxiety
Jonathan Wolfe
Researchers find a significant rise in antipsychotic prescriptions for patients diagnosed with anxiety disorders, despite limited studies on safety and efficacy of the medications for these disorders.
Antipsychotic medications that have been approved for use in treating serious mental illnesses such as schizophrenia and bipolar disorder are increasingly being prescribed by office-based psychiatrists in an off-label use for patients with a range of common anxiety disorders.
This finding, published online July 28 in AJP in Advance, may signal psychiatrists' increased willingness to explore alternative medication regimens for patients resistant to more conventional forms of treatment for anxiety disorders, noted study authors Jonathan Comer, Ph.D. of Boston University's Center for Anxiety and Related Disorders; Ramin Mojtabai, M.D., Ph.D., of the Mental Health Department at Johns Hopkins Bloomberg School of Public Health; and Mark Olfson, M.D., M.P.H., of Columbia University's Department of Psychiatry.
However, the researchers also encouraged psychiatrists to monitor their nonapproved use of antipsychotics and called for further studies investigating the risks and benefits associated with this form of treatment for anxiety disorders.
The dramatic increase in atypical antipsychotic use in anxiety disorders in the absence of FDA approval for these indications is surprising in view of the many medications for which there is both evidence of efficacy and FDA approval, said Charles Nemeroff, M.D., Ph.D., chair of the Department of Psychiatry and Behavioral Sciences at the University of Miami's Miller School of Medicine. Considering the significant side-effect burden of atypical antipsychotics, and their cost, decisions of their use for non-FDA-approved indications, including anxiety disorders, should be made with careful risk-benefit evaluations.
Using data from the National Ambulatory Medical Care Survey of office-based physician visits from 1996 to 2007, the researchers studied a random sample of 4,166 outpatient visits to psychiatrists that resulted in the diagnosis of traumatic stress disorders (including posttraumatic stress disorder and acute stress), panic disorder/agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder (OCD), phobias, or other anxiety disorders.
In comparing visits to office-based psychiatrists made from 1996 to 1999 with visits made from 2004 to 2007, the researchers' analysis showed a 4.5 percent increase in visits resulting in an anxiety disorder diagnosis, an increase of nearly 9 percent in the number of all visits leading to the prescription of an antipsychotic medication, and an approximate doubling of visits for the specific treatment of anxiety disorders involving the prescription of antipsychotics (from 10.6 percent to 21.3 percent).
Patients diagnosed with panic disorder or other anxiety disorders were more commonly prescribed antipsychotics than were those with other diagnoses in the anxiety spectrum.
The researchers also noted that the number of prescriptions written for second-generation antipsychotics in the treatment of anxiety disorders rose by nearly 17 percent between the study's two time periods, while those for first-generation antipsychotics decreased by nearly 5 percent. Specifically, patients prescribed antipsychotic medication for traumatic stress disorders were most commonly treated with quetiapine or risperidone, while individuals receiving antipsychotics for OCD were most frequently treated with olanzapine.
Additionally, the study found that new psychiatric patients saw the most significant comparative increase in antipsychotic prescriptions for anxiety disorders. Individuals with private insurance also experienced a rise in prescriptions for antipsychotic medications.
In reviewing their findings, the researchers acknowledged a lack of information about patient treatment and medication history, prescription dosage, and the observed results of antipsychotic use in treating anxiety disorders of patients during the study period.
As for reasons why the study found such a considerable increase in off-label prescribing of antipsychotics, the researchers suggested several possibilities, including physicians' increased focus on symptom reduction and the availability of new antipsychotic medications with less troublesome side-effect profiles than the earlier versions of these drugs.
The researchers also noted that some physicians consider second-generation antipsychotics to be less problematic than benzodiazepines (which have traditionally been prescribed as second-line alternatives for treatment of anxiety disorders) when it comes to cognitive side effects, withdrawal, and potential for abuse. Others have cited the antineurotic qualities of antipsychotic medications as weighing in their favor for patients with anxiety disorders.
Posted by Phillipa on September 9, 2011, at 23:51:30
In reply to Antipsychotics Increasingly Prescribed for Anxiety, posted by herpills on September 9, 2011, at 21:47:22
I see private insurance as so expensive. The drug companies still dictate to docs it seems. I would cold turkey before taking one for anxiety that is me. Phillipa
Posted by Christ_empowered on September 9, 2011, at 23:56:16
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety » herpills, posted by Phillipa on September 9, 2011, at 23:51:30
This is disturbing, but not surprising. In the 60s-70s, docs used antipsychotics for anxiety often. Then in the 80s they started getting TD lawsuits, and the practice became less common. Now, with Big Pharma pushing antipsychotics for everything and a new generation of benzo-phobic doctors, everybody and their mother is on an AAP.
I *have* to take an AAP. Its not always pleasant, but its what keeps me out of a mental hospital. I would not use heavy medication like this on people who didn't *need* such treatment; that sort of prescribing strikes me as irresponsible.
What we need is a new benzo. Even if its a schedule IV like all the others, if Big Pharma pushes it hard enough, everybody will be on it.
Posted by jono_in_adelaide on September 10, 2011, at 4:11:59
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety, posted by Christ_empowered on September 9, 2011, at 23:56:16
Yeah, i think its the fear of benzodiazepine dependence that is pusshing this, that and the hard sell by drug companies.
I think Atarax needs to become popular again, its safe, effective and not habit forming...... but its off patent, so noone pushes doctors to prescribe it, noone advertises it
Posted by Dinah on September 10, 2011, at 17:20:05
In reply to Antipsychotics Increasingly Prescribed for Anxiety, posted by herpills on September 9, 2011, at 21:47:22
Maybe it's because it works so d*mn well.
I have access to both Risperdal and Klonopin and I almost never use Klonopin. Klonopin brings a totally different sort of calm. One that seems centered in my head, and that affects my wakefulness. It doesn't quite make me groggy, but it can make me feel sleepy. Risperdal can affect my brain in that it frees me from obsessive thinking in a way that Klonopin just can't. But mostly it affects me at a bone deep level. It calms my jangling nerves. Klonopin impairs my ability to work. Risperdal enhances my ability to stop obsessing and work, and it stops the electrical feeling of anxiety.
Don't condemn the use of antipsychotics. For some people it is by far the best choice of antianxiety medication.
Posted by floatingbridge on September 10, 2011, at 18:25:26
In reply to Antipsychotics Increasingly Prescribed for Anxiety, posted by herpills on September 9, 2011, at 21:47:22
http://www.psychiatrictimes.com/display/article/10168/54151
I found this discussion interesting. Made me question, just question why I am in such a big hurry to dump my benzos.
Bseside memory loss, and escalation, depending on the benzo, which varies greatly in effect, the sides are more known unlike possible endocrine interference of AAP's.
I want to add that in this last year I discovered something
important: I now refrain from telling any prescriberva medication 'feels' good. Some find that pleasure itself indicative of pathology. I will freely say if something feels bad, though.I use a small amount of risperdone which I like.
I also use Xanax XR since a forced cold turkey this summer, and find there is no pleasure left in it's usage.
Tenazepam is for sleep, but I find that just another yucky benzo.
In order to get anxiety releif I have wanted to try Nardil. I mean, anxiety is really intolerable to those that have it bad enough.....
Posted by linkadge on September 10, 2011, at 20:46:11
In reply to The religion of benzodiazpines; an article » herpills, posted by floatingbridge on September 10, 2011, at 18:25:26
Just changed from clonazepam to ativan. I much prefer this medication to any atypical antipsychotic. I can think just fine on lorazepam. I would be completely wonked out on an AP.
Linkadge
Posted by floatingbridge on September 10, 2011, at 21:01:36
In reply to Re: The religion of benzodiazpines; an article, posted by linkadge on September 10, 2011, at 20:46:11
Link, I wished I like Ativan. I feel edgy inside. Strange, eh?
In general, I think just fine on benzos. The risperdone needs to be taken (by me) before bed.
Posted by sleepygirl2 on September 10, 2011, at 21:01:45
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety, posted by Dinah on September 10, 2011, at 17:20:05
Dinah,
You manage to take the risperdal only prn?
How often do you take it?
Thanks,
Sleepy
Posted by Phillipa on September 10, 2011, at 21:02:01
In reply to Re: The religion of benzodiazpines; an article, posted by linkadge on September 10, 2011, at 20:46:11
Link the one time was put on one was totally out of it couldn't talk the words wouldn't leave my mouth. Benzos relax feel the muscles twitch as they unwind. And then lights out and sleep. Don't take during day anymore. Have cut down to such a tiny piece of xanax probably .125 and 7.5 of valium. Will go lower as don't notice a difference. I'm with CE on the new benzo. In the 70's it was valium "Mother's little helper". But worked marvelously for panic. Phillipa
Posted by Dinah on September 10, 2011, at 21:09:04
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety » Dinah, posted by sleepygirl2 on September 10, 2011, at 21:01:45
I say maybe ten a month, but my prescription of thirty seems to last forever, so maybe I don't use that many. Or maybe I do sometimes but not others. I've got no sense of time. None. At all.
Posted by Dinah on September 10, 2011, at 21:11:09
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety » sleepygirl2, posted by Dinah on September 10, 2011, at 21:09:04
This has been ok'd by my pdoc or it would make me anxious to use. But the best combination for me with regard to work productivity is a Risperdal and a Provigil taken at the same time.
I still feel a bit guilty about that.
Posted by floatingbridge on September 10, 2011, at 21:13:28
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety » Dinah, posted by sleepygirl2 on September 10, 2011, at 21:01:45
> Dinah,
> You manage to take the risperdal only prn?
> How often do you take it?
> Thanks,
> SleepyUmmm. O. K. What does PRN stand for?
I think it means as needed, yes?
Posted by floatingbridge on September 10, 2011, at 21:19:31
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety » sleepygirl2, posted by Dinah on September 10, 2011, at 21:09:04
> I say maybe ten a month, but my prescription of thirty seems to last forever, so maybe I don't use that many. Or maybe I do sometimes but not others. I've got no sense of time. None. At all.
______________That's kinda nice that way, Dinah. Is it?
I've been instructed a few times to take nightly and steadily. .5mg per night. Tried to fly the 'as-needed' by pdoc, but didn't
like that for me.I'm curious about the sense of guilt expressed over in your other post about ripsperdone and provigil.
Posted by Dinah on September 10, 2011, at 21:19:50
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety » sleepygirl2, posted by floatingbridge on September 10, 2011, at 21:13:28
Posted by Dinah on September 10, 2011, at 21:58:31
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety » Dinah, posted by floatingbridge on September 10, 2011, at 21:19:31
I would prefer more of a sense of myself as a single continuous individual existing through a steady flow of time. I don't really have that.
I feel like that combination is combining uppers and downers. Though technically speaking, Risperdal doesn't feel much like a downer.
The Risperdal helps with the anxiety and obsessions and the Provigil helps with wakefulness and focus. It really does seem to work, though I use it sparingly. I'm afraid using it regularly would dilute the effect.
Posted by floatingbridge on September 10, 2011, at 22:47:38
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety » floatingbridge, posted by Dinah on September 10, 2011, at 21:58:31
> I would prefer more of a sense of myself as a single continuous individual existing through a steady flow of time. I don't really have that.
>
> I feel like that combination is combining uppers and downers. Though technically speaking, Risperdal doesn't feel much like a downer.
>
> The Risperdal helps with the anxiety and obsessions and the Provigil helps with wakefulness and focus. It really does
seem to work, though I use it sparingly. I'm afraid using it regularly would dilute the effect.Dinah, now that you've explained it, I feel little dense for not understanding more w/o your explanation. I used to say my older daily treatment was a 'speedball', something that made the ex-pdoc uncomfortable. (Me too!) Legal or not, it was how I felt, and still do. Xanax, risperdone (though ostensibly for other reasons), plus Emsam is reproducing a similar effect. It's my tightrope walk between depression/lethargy and anxiety.
I feel badly that I asked you to spell out your discomfort. Online is not irl. Online, you have to me a real steady sense.
Btw, progivil is an odd med. I found it intolerable. I'm glad you have these tools in your kit.
fb
Posted by linkadge on September 11, 2011, at 15:38:42
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety, posted by Dinah on September 10, 2011, at 21:11:09
It depends on the person and the type of anxiety I guess. I was on such a merry go round for anxiety before my doctor finally tried benzodiazapines.
We came to the conclusion that I really don't have GAD, its more of a periodic anxiety attack thing - also with a lot of insomnia etc.
Linkadge
Posted by Zonked on September 11, 2011, at 19:19:59
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety, posted by linkadge on September 11, 2011, at 15:38:42
How disturbing but not suprising. Years from now, this will probably be seen as a barbaric mistake, and I'd bet anyone 100 bucks the APA will say so, too. I understand that some people are happy with the results of AAP therapy, but the risks outweigh any potential benefit for me. I am aware long term benzo use carries some risks as well but I am okay with that. APs have entered my body twice, and made me feel like a drooling emotionless zombie both times. I'd also be afraid of EPS and diabetes. Xanax kills anxiety without making me feel unlike myself. If you go to askapatient.com and look at what patients have to say about these meds, or look up tardive dyskinesia on youtube, you might want to think twice before taking these pills for a nonpsychotic condition. I am less afraid of the Temodar chemotherapy drug my mom takes for brain cancer than I am of these drugs. At least she won't start having uncontrollable movements, develop diabetes, or feel restless. What really bugs me is that we have extremely safe and effective drugs available to treat anxiety disorders. I would support their use in nonpsychotic conditions only as last line treatment. And only if the patient were always made fully aware of potential side effects which I doubt is the case much of the time. I never thought I'd see antipsychotics advertised on TV for anything. One day we might consider these as revolting as old ads for Thorazine in medical journals to treat things like anxiety or ADHD go children. Yes, there were ads like that. My .002 -z
Posted by JONO_IN_ADELAIDE on September 11, 2011, at 19:52:50
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety yuck, posted by Zonked on September 11, 2011, at 19:19:59
In low doses (1mg per day) risperidone only hits the 5HT2 receptor, so it isnt realy an antipsychotic in thses doses. I think like most things, its the dose that matters.
And, for me, low dose risperidone + Xanax + antidepressants gave a much better result than Xanax + antidepressants.
Having said that, hydroxyzine (Atarax) would probably do more or less the same job.
Posted by Phillipa on September 11, 2011, at 21:32:00
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety yuck, posted by Zonked on September 11, 2011, at 19:19:59
A few years from now the error of over prescribing will become apparanent if hasn't already with weight gain, diabetes. Already they have increased and bet no studies done on that yet. A benzo has been around for half a century. Work fine Phillipa
Posted by hyperfocus on September 12, 2011, at 16:41:11
In reply to Antipsychotics Increasingly Prescribed for Anxiety, posted by herpills on September 9, 2011, at 21:47:22
The dosages of AAPs used to treat anxiety are much lower than typical neuroleptic dosages. Risperidone for example might rarely get over 1mg. So the risk of EPS and for weight gain and developing diabetes is less, but still greatly heightened.
When I took benzos for my anxiety I never felt that anything more than the surface anxiety symptoms were reduced. Like my body would relax and my startle response would decrease, and there would be a lot less sweating and trembling. But it's like the thoughts themselves would still be whirling around in my head. Only on ADs and AAPs have I ever felt that the thoughts themselves were decreasing. Also I never felt like I was getting 'better' on benzos; if I missed one or two doses the anxiety would be bad as ever. Withdrawing from years-long use was not fun. But still, after almost ten years of untreated anxiety Xanax felt like a miracle first-time I took it. It just didn't pan out as a long-term solution
For some anxiety conditions like panic attacks benzos should be first-line treatments, as well as for people with untreated debilitating anxiety. But for certain people with stuff like social phobia with the abnormal paranoid thoughts and neurotic (old fashioned term I know) thinking, APs might produce a better long-term response.
Posted by linkadge on September 13, 2011, at 20:06:54
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety yuck, posted by JONO_IN_ADELAIDE on September 11, 2011, at 19:52:50
Risperdal will hit the d2 receptors at any dose.
Yes, it has a higher affinity for the 5-ht2 receptors, but it still will block the d2 receptors (to varying extents) at all doses.
Linkadge
Posted by linkadge on September 13, 2011, at 20:11:55
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety, posted by hyperfocus on September 12, 2011, at 16:41:11
>Also I never felt like I was getting 'better' on benzos; if I missed one or two doses the anxiety would be bad as ever.
To each his own. I never felt like I was getting better on SSRIs or AP's. It just feels like my emotions are numbed and I'm not anxious because I don't care about anything. With the benzos, I still feel like me, and I don't feel like my regular drives are significantly lessened. For instacne, on SSRI's I don't care to play the piano any more. On a bit of lorazepam, I still enjoy playing the piano, and I can focus on it without the crippling anxiety.
>Withdrawing from years-long use was not fun.Neither is it for SSRI's. It took me a year for my brain to recover from getting off celexa. I experienced acute psychosis during withdrawl. Benzo withdrawl just makes me anxious, but it doesn't turn my world upside down.
>Xanax felt like a miracle first-time I took it. >It just didn't pan out as a long-term solution
SSRIs / APS's were not a long term solution for me either. I just became an apathetic zombie.
Linakdge
Posted by Phillipa on September 13, 2011, at 21:29:40
In reply to Re: Antipsychotics Increasingly Prescribed for Anxiety » hyperfocus, posted by linkadge on September 13, 2011, at 20:11:55
Agree benzos felt normal always. Phillipa
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