In fact, his overall improvement was dramatic. He was able to joke about his previous “hypochondriasis,” and when thoughts about health concerns entered his mind, he was able to quickly dismiss them and reassure himself. At the outset of treatment, it had not been unusual for Mr. A to make several phone calls daily to his psychiatrist seeking reassurance about his general health. During such calls, anything shy of 100% certainty would exacerbate his anxiety. Definitive reassurance would comfort him for anywhere from 1 hour to 3 days. In contrast, on nortriptyline 125 mg/d, Mr. A felt well and would go several months between appointments. His contact with his psychiatrist during those intervals was limited to phone calls to request prescription refills. His phone messages frequently included jokes about whether the psychiatrist was lonely without the frequent phone contact.
How do your patients with complaints of anxiety respond if you suggest treating them with antidepressants? How do you reassure them so they stay the course?
Dr. Carter’s observations
Educational messages and compliance strategies can have a positive impact.5 A little time invested in patient education early on can reap big rewards by reducing frantic telephone calls about side effects and the risk of a demoralized patient who discontinues medication prematurely.
For patients who feel every peristaltic wave, knowing that nausea from the initiation of a medication is likely to be gone by the end of the first week of treatment can be pivotal. Such differences are critical in achieving medication trials of adequate duration, which is particularly relevant in GAD.6 This finding may account for Mr. A’s variable early response and more robust subsequent response to nortriptyline.
The importance of educational messages is also relevant to patients’ reactions to use of antidepressants to treat their anxiety. This is not a trivial, semantic point. Patients who at first did not even perceive a need for treatment finally recognize that they have anxiety, and you are going to prescribe an antidepressant? Without a lucid explanation, be prepared for an indignant patient who thinks you are ignoring his or her stated concern. Especially with patients accustomed to the immediate effect of diazepam in acute treatment, the expected time course with antidepressants is a critical lesson.
Regarding specific medications, Mr. A’s history again illustrates a typical scenario: benzodiazepines for acute symptoms and buspirone when he eventually presented to a psychiatrist. With typical comorbidity, however, the use of broader-spectrum antidepressants—selective serotonin reuptake inhibitors or serotonin/norepinephrine reuptake inhibitors—represents a more logical first-line choice. Head-to-head trials between venlafaxine XR and buspirone further support this position.7 With the emergence of sexual side effects with sertraline in this particular case, the switch to a different category of antidepressant is sensible.
I support the use in GAD of antidepressant dosages comparable to those used to treat major depression. I can recall discussions about how anxiety disorder patients cannot tolerate full doses of antidepressants and do not need them anyway, but dosage response studies and clinical experience would argue otherwise. Compliance is a crucial factor with anxiety patients, and nothing fosters compliance like robust clinical response. In treatment of GAD, the data are clear: Use antidepressants at full dosages.
Complications: hypochondriacs get ill, too
Mr. A remained well for 8 months, but then became more concerned about an increase in his resting heart rate to 90 bpm, some heartburn, and a slight decrease in his libido.
At Mr. A’s request, liver function tests (LFTs) and an ECG were obtained. The latter was normal, but his LFT scores remained elevated (ALT=121, AST=73) without significant change from premedication results (130, 64, respectively).
Three months later, Mr. A continued to report that he was feeling well, but he now noted distress related to long-term memory deficits that had emerged, in retrospect, relatively early in this nortriptyline trial. His dosage was decreased to 100 mg/d.
At a routine physical examination the next month, Mr. A’s internist noted the persistence of elevated LFT scores. The internist had been advised of Mr. A’s anxiety-ridden response to any discussion of possible medical illness and agreed to simply recommend that Mr. A discontinue his vitamin A and D supplements with periodic administration of LFTs.
A year later, however, with advancing knowledge about chronic hepatitis, the internist found that Mr. A did indeed have hepatitis C. Mr. A handled this news relatively well initially, but 4 months later his defenses began to break down. His previously lighthearted humor assumed more morbid tones, as he attempted to joke about how he would probably die from liver cancer while he worried about a hangnail. He became dependent on his wife’s reassurance again and required her presence during appointments so that she could retain information from those meetings and later use it to reassure him.