• Think twice about prescribing a benzodiazepine.
• Provide psychoeducation about anxiety. "A lot of the bite of anxiety is defanged if you just understand what anxiety is. It’s not going to kill you. It’s a set of alarm systems in your brain that helps you survive by responding to threats at the cost of making you miserable. That’s all it is. If you can get that across to a patient and the family, that’s a crucial part of getting well and staying well," Dr. Lenze said.
Physicians often don’t have a lot of time for patient education in the office, and patients might not remember much of what was said anyway, because they were stressed out about the visit. So recommendations for good self-help books are useful, added Dr. Lenze.
• Start low and go slow in elderly patients – but go slow. "Starting low is a good exercise in graduated exposure for these patients so they feel more comfortable. But get them up to the same doses of SSRIs (selective serotonin reuptake inhibitors) and SNRIs (selective norepinephrine reuptake inhibitors) you use in younger adults as quickly as you can for their level of comfort. Ten weeks of escitalopram at 2.5 mg is not the way to treat these individuals," he continued.
• Arrange for frequent follow-up within the first month of starting therapy or a dose change in order to monitor response and encourage adherence. "This is really important," he said. "They get anxious about treatment, scared of medication, and frequently stop therapy."
• For first-line therapy, stick to what you’re used to prescribing. You’ll project more confidence when a patient calls back about side effects.
• Consider augmentation and switch strategies for inadequate responders.
• Provide maintenance therapy. "An area where many in our field make errors is in letting people drop out of long-term treatment. Antidepressants have maintenance benefits. That means they prevent relapse if you keep taking them. One place where we can all do better is in continuing to remind our patients of the benefits of maintenance treatment," Dr. Lenze emphasized.