I. Principles of treatment
(I) Principle of matching with psychotherapy
According to the biopsychosocial medical model, psychosocial factors play an important role in the development of anxiety disorders. Both medication and psychotherapy are effective for generalized anxiety disorder and panic disorder. Patients with first-onset anxiety disorders can choose their treatment according to the degree of their condition and accompanying symptoms. Patients with mild cases may only need psychotherapy, and when symptoms are severe or psychological intervention is not available, pharmacotherapy should be considered. Of course, medication and psychotherapy can also be applied in combination during the acute onset, which can enhance the therapeutic effect, and one treatment modality can be used to maintain treatment after the symptoms have subsided. We found that some patients with anxiety disorders take medication for a long time, even though the effect is not obvious, but they hold the wrong idea that “taking medication is better than not taking it” or “there is no other way”. Therefore, it is not unreasonable for some psychotherapists to oppose the use of medication.
As for the relationship between medication and psychotherapy, we believe that psychotherapy, together with appropriate medication, is more suitable for most anxiety disorder patients. The role of both medication and psychotherapy in the treatment of anxiety disorders can be likened to the process of learning to swim. Medication is like a swimming ring that can easily float on the surface without sinking as long as it is placed on the body, and can facilitate learning to swim. In other words, medication can shorten the course of psychotherapy, especially making the initial psychotherapy easier. Patients with severe anxiety are fidgety and inattentive, and conversation is difficult to go deeper. Medications can make the anxiety symptoms lessen a bit and facilitate the conversation, as well as enhance the patient’s confidence and trust in the doctor. And psychotherapy is like learning to swim; if you don’t learn, you may sink as soon as you take off the swimming ring. If psychotherapy is actively carried out, patients can gradually master the way of mental health and take the initiative to improve their mental state, so that they can lose the “swimming ring” of drugs in due course.
(2) The principle of adequate amount and course of treatment
Generalized anxiety disorder and panic disorder are both chronic diseases and prone to recurrent attacks (at least 50% of patients with generalized anxiety disorder will have a second attack after the first attack), so the principle of adequate dosage and full course of treatment should be adhered to. After treatment remission or symptom elimination, a certain period of maintenance treatment is required to reduce relapse and restore social and occupational functions.
(iii) Principles of individualized medication
The effect of medication depends on the pharmacological effect of the drug, individual differences of the patient and the patient’s compliance with the medication. In the course of drug treatment, patients with anxiety disorders may mistake the adverse effects of drugs, such as tachycardia, dizziness, dry mouth, and abdominal discomfort, as manifestations of disease symptoms. Patients’ somatic anxiety symptoms may worsen during the initial phase of antidepressant treatment. Patients with anxiety disorders tend to be more sensitive to adverse drug reactions than other patients.
Therefore, when deciding on medication it is important to.
(i) Understand the patient’s age, previous treatment response, the possibility of drug overdose or risk of self-inflicted suicide, the patient’s tolerability, the patient’s personal preference of choice, and the burden of drug costs on the family;
(ii) Consider the patient’s possible combination of physical illness, drug interactions, and the presence of complications;
③Special attention should be given to drug treatment during pregnancy and lactation, and the potential risk of fetal and infant exposure to the drug must be weighed against the inherent risk to the mother of not taking the drug.
In general, selective 5-HT reuptake inhibitors (SSRIs), 5-HT and NE reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs) have fewer cardiovascular side effects and are more easily tolerated by patients with cardiovascular disease; they are less toxic and safer for patients with suicidal tendencies. However, SSRIs and SNRIs often cause sexual dysfunction, irritable bowel syndrome, and may aggravate migraine, etc. For these patients TCAs are more appropriate. SSRIs and SNRIs have no sedative effect, and patients with tension or insomnia may need additional tranquilizers or sedatives.
(iv) Other principles
1. Explain to patients and their families the nature, effects, onset of action, duration of treatment, possible adverse reactions and countermeasures, risks and countermeasures of discontinuing medication, and seek their active cooperation so that patients can take medication regularly as prescribed to improve compliance with treatment.
2. It is advisable to start with a small dose of the drug and increase it to a full dose (upper limit of effective drug) and a sufficiently long course of treatment (at least 4-12 weeks) according to the efficacy, adverse reactions and tolerability, etc.
3. It is generally not recommended to combine more than two kinds of anxiolytic drugs, but to use a single drug as much as possible. In case of severe anxiety or when drug replacement therapy is ineffective, the combination of two drugs with different mechanisms of action can be considered.
4.The changes in the patient’s condition and adverse reactions should be closely observed and dealt with in a timely manner during the treatment period.
5.Actively treat other somatic diseases that are co-morbid with anxiety disorders, substance dependence, depression, etc.
6.If the patient is concerned about their physical condition, they need to be given a comprehensive physical examination. The results of the examination should be discussed with the patient to clarify which symptoms are due to anxiety and which are caused by an underlying somatic disorder.
7. The goal of treatment is to help patients achieve a state of psychosomatic integrity without medication. However, a small number of patients with anxiety disorders do require long-term medication maintenance, including benzodiazepines, and it is short-sighted and unwise to deny these patients medications that can improve their quality of life.
8. Antidepressants are more effective than benzodiazepines and antihistamines for long-term psychiatric anxiety. When choosing antidepressant treatment for overly worried patients, benzodiazepines can be used in combination with severe anxiety, insomnia, or stressful scenarios that cause alertness and somatic symptoms.
II. Treatment strategies
Anxiety disorders are highly recurrent disorders, and full treatment is currently recommended for both panic disorder and generalized anxiety disorder.
(A) Pharmacological treatment strategies for panic disorder
1. The acute pharmacological treatment of panic disorder usually lasts for 12 weeks. Acute treatment medication should be adequate, full course of treatment, generally significant improvement occurs in the 6-8 weeks of drug treatment, and continues until the end of 12 weeks. After 12 weeks of acute treatment, if the treatment is effective, the patient no longer has panic attacks or fears of panic attacks, and fearful avoidance is significantly reduced, and the patient is transferred to maintenance treatment. There is less research evidence regarding the duration of maintenance medication. The general recommendation is to maintain treatment for at least 1 year after an effective acute phase of medication, and then consider tapering according to the patient’s clinical condition. Close observation of the patient’s condition is required during the drug reduction period, and drug therapy should be restarted immediately if relapse occurs.
2. Pay attention to psychotherapy to ensure patients’ compliance with medication.
3, the process of drug reduction should be carried out gradually, too fast may lead to rebound of anxiety symptoms, withdrawal symptoms or relapse of disease. It is generally believed that the medication reduction process should last at least 3 months.
4.Choose an appropriate treatment site. Patients with panic disorder have a high co-morbidity rate with major depression, and patients are likely to be at risk of suicide. Healthcare professionals should pay sufficient attention to this, and be hospitalized if necessary; patients with panic disorder also often have co-morbid substance dependence, and should be hospitalized for detoxification treatment if necessary.
(B) Pharmacological treatment strategies for generalized anxiety disorder
1. Acute phase treatment: Acute phase treatment refers to the period from the beginning of treatment to the relief of symptoms. The main purpose of medication in the acute phase of anxiety disorders is to control symptoms and strive to achieve clinical cure. Different drugs may have different mechanisms of action and the onset of action may vary greatly, generally starting to take effect in 1 to 2 weeks. In patients with severe anxiety disorder, the onset of action of medication may be extended to 2-4 weeks, and therefore a combination of two medications with different mechanisms of action may be considered. If the patient is still ineffective after 6-8 weeks of treatment with medication, it may be effective to switch to medication with other mechanisms of action, or to combine two medications with different mechanisms of action to control symptoms as soon as possible.
2.Consolidation phase treatment: It is generally believed that at least 2-6 months are needed for consolidation phase treatment, during which the patient’s condition is unstable and the risk of relapse is higher.
3.Maintenance phase treatment: It is generally believed that maintenance phase treatment is needed for at least 12 months to prevent relapse. At the end of maintenance treatment, if the patient’s condition is stable, the drug can be slowly reduced until termination of treatment, but early signs of relapse should be closely monitored.