Ketamine’s efficacy for treating depressive disorder has led to interest in its use as an anxiolytic. One study found a beneficial effect on anxiety symptoms with oral ketamine use in adults enrolled in hospice care (Garakani et al., 2020). Another small, open-label study found improvement in patients with refractory GAD and/or SAD with administration of subcutaneous ketamine given once or twice weekly over 3 months (Garakani et al., 2020). Currently, there are no known ongoing trials evaluating ketamine for GAD, SAD, or PD. Further research is needed to further understand whether ketamine has a role in management of anxiety disorders. PH94B PH94B is an investigational, synthetic neurosteroid administered as an intranasal aerosol. It’s currently being studied for acute treatment of SAD. In one double-blind, randomized, placebo-controlled trial, 91 patients diagnosed with SAD were assigned to receive either PH94B or placebo nasal spray 15 minutes before a public Various medications and substances can induce symptoms of anxiety. When assessing a patient with complaints of anxiety symptoms, a medication history must be recorded and evaluated for medication-induced anxiety. A medication history is particularly important in patients with new-onset symptoms or an exacerbation of pre-existing anxiety. This history should include asking the patient about over-the-counter medications, dietary and herbal supplements, and illicit substances. In most cases, medication-induced anxiety is treated by discontinuing the causative agent. However, with antidepressant- induced anxiety, symptoms are usually transient, although a dose reduction or switch to alternative agent within the same class may be necessary. Examples of agents that may cause drug- induced anxiety include: ● Antidepressants. ● β 2-agonists, such as albuterol. ● Caffeine. ● Corticosteroids. ● Dietary supplements and herbal substances, such as guarana. ● Illicit substances, such as cocaine. Case study BD is a 33-year-old who presents with complaints of “anxiety.” When asked to elaborate, he states, “I feel extremely agitated and irritable most of the time. I’m very disturbed by current events in the world. I’m not sleeping well; I wake up most nights and can’t fall back asleep.” BD does not identify any specific triggers that lead to symptoms, and that he has experienced them “for nearly two years now,” stating he has delayed seeking help during the COVID-19 pandemic. He states he exercises “two or three times a week,” and says, “I try to do yoga to be mindful and relax but I’m not sure if it’s doing anything for me.” BD’s medical history is positive for asthma, for which he uses as-needed albuterol. He has a family history of heart disease and high cholesterol, but his most recent lab workup shows all values within normal limits. BD does not report illicit drug use, which is confirmed via urine drug screen. He does report drinking “five, six, sometimes seven cups of coffee per day”; he states his work as a software engineer can be demanding and, “I need to stay alert to get my work finished every day. It’s really hard for me to focus on my work with everything going on.” Questions 1. Are there medications or substances which may be contributing to medication-induced anxiety in BD? If so, Conclusion Anxiety disorders are the most commonly diagnosed psychiatric disorders, including generalized anxiety disorder (GAD), panic disorder (PD), specific phobias, agoraphobia,
speaking or social interaction test in a controlled setting. Of the participants assigned to the PH94B group, 75% were “responders,” meaning their symptoms were “much improved” or “very much improved” as measured using the Clinical Global Impressions-Improvement (CGI-I) scale (Garakani et al., 2020). By comparison, 37% of persons who received placebo achieved these same results. A second study assessed PH94B in “real-world” settings: 22 patients diagnosed with SAD were randomized to receive either PH94B or placebo nasal spray (Garakani et al., 2020). Patients were instructed to administer treatment 15 minutes before a perceived distressing social interaction or performance, up to a total of four doses per day. Researchers found PH94B superior to placebo in decreasing social anxiety symptoms, measured using subject-reported subjective units of distress (SUDs) (Garakani et al., 2020). Adverse effects reported to date have been relatively benign, with headache and gastrointestinal distress being the most commonly reported ADRs. ● Nicotine. ● Methylxanthines, such as theophylline (Theo-24). ● Thyroid hormones. ● Psychostimulants, such as methylphenidate (Ritalin). ● Sympathomimetics, such as pseudoephedrine. Healthcare Considerations: “Hidden” Caffeine Sources: When discussing anxiety symptoms and attempting to elucidate potential causes, it’s important to consider “hidden” sources of caffeine—or caffeine intake the patient may not be aware of. Go beyond asking patients indirect questions, such as “How many cups of coffee do you drink per day?” This excludes other sources of caffeine, such as teas or energy drinks. It’s not unusual for over-the-counter workout supplements to contain caffeine—sometimes in doses of 600 mg per serving. Word your questions so that they’re direct, and present potential for education—“do you consume caffeine? If so, do you know about how much you take in per day, on average? Are you aware of other sources of caffeine besides coffee?” what recommendations regarding their use would you make to BD? 2. Which anxiety disorder does BD seem to be displaying symptoms for? Discussion 1. BD reports use of as-needed albuterol for asthma and also reports drinking 5-7 cups of coffee per day. Both albuterol and caffeine are known as potential causative agents for medication-induced anxiety. Given that albuterol is used as-needed, and that BD acknowledges drinking 5- 7 cups of coffee daily, caffeine seems a more likely culprit than albuterol. BD’s anxiety symptoms may benefit from decreasing his caffeine consumption. 2. BD’s symptoms appear consistent with generalized anxiety disorder (GAD). He is experiencing excessive anxiety and worry, which he has difficulty controlling and which has lasted for more than 6 months. He reports issues with sleep, irritability, and difficulty concentrating—which may contribute to his high caffeine consumption. BD would likely benefit from reducing his caffeine consumption. He may also be a candidate for cognitive behavioral therapy (CBT), especially if reducing caffeine intake does not have a noticeable impact on his symptoms.
MEDICATION-INDUCED ANXIETY
social anxiety disorder (SAD), and separation anxiety disorder, among others. Recommended treatment for anxiety disorders includes both psychological modalities, such as CBT, as well as
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