The Management of Anxiety in Primary Care

welcome back to the curbsiders I'm Dr Matthew Frank wad here with my great friend and America's primary care physician Dr Paul Nelson Williams Paul you ready to talk about some anxiety always it's one of my favorite topics we had a great guest for this one Dr Jesse gold and lot of practical stuff that we talked about she really I think the way that she talks to her patients about anxiety is really useful one of the things she told us is that when when she's talking to people and they say my anxiety or I feel anxiety she really says that's that's a symptom it can be a diagnosis but it's also just a symptom and you really need to clarify what they mean and what do they mean by their anxiety and really dig into how it's affecting their life so you can you can make the diagnosis we asked her about using things like the Gad seven score I think like most of the experts we talked to she kind of internalized that so she doesn't probably need to rely on a questionnaire but I I still rely on a questionnaire when I'm taking a history for anxiety and we asked her like how do you explain anxiety to patients I don't know about you Paul but I I never really thought about explaining to them why they have anxiety had you thought about this before no I I do my I've done my best to try to normalize it but in terms of actually talking about evolutionary Advantage I it was not a way that I considered framing it before yeah so she she frames it to the patients as okay when when at as we were evolving it it was somewhat of an advantage to be hypervigilant to have some anxiety have some healthy amount of fear so that you didn't get killed or eaten by something but now in the modern world that is not really playing to our advantage and a lot of in a lot of people it's miscalibrated where they're feeling anxiety and it's not helping them it's not making them safer it's making their life worse and so she kind of explains that to people and how she's trying to help them uh overcome that so so we'll talk about some of those ways and Paul I I always think about ssris as one of the first steps why she told us why why should why not go to s in our eyes as a first line yeah it's I I was glad we had this conversation because I I feel for whatever reason a little bit more comfortable with depression than do with anxiety but in any case uh Dr gold reaches for the ssris first in part because getting off of the snris if you need to sort of switch them can be absolutely miserable there can be fairly mean discontinuation effects to the extent that she's even had to sometimes Bridge patients with even a benzodiazapine to get them fully off of it so it's it's not the first one that she would reach for necessarily it's she thinks about it more if she's tried a couple of ssris and has not had efficacy or if there's a comorbid condition that might also benefit from the use of an snri in the same way that you might use a TCA for someone who has got migraines and anxiety she for an snri you know for someone who might have neuropathic pain say and anxiety that might be a a good medication to consider but rarely first line just because if it doesn't work out getting the patients off that medication can sometimes be a challenge yeah and she said lexine was one that was specifically difficult to get people off of um but Paul I've heard that buproprion should never be used in anxiety and if you give it you are a terrible doctor what what did we what did we hear about that one no I mean I probably am a terrible doctor but it's it's I it's one I've hesitated Matt to to prescribe to patients with anxiety or even comorbid anxiety like sometimes I'm a little bit nervous for someone who has depression and anxiety to prescribe Repro on because I worry you hear it's activating it might make things worse but Dr says that she's actually seen it work for some patients so she will consider it especially for those patients for whom the side effect profile um meets their needs so for someone who does not want to gain weight or for someone for whom sexual side effects would be really bothersome that person might be ow a child proon because it may actually work for them so it's not always the wrong answer um so her expert opinion you can try it and see how you do just with share decision- making and letting the patient know that they may they may not tolerate as well as other medications yeah and she she sees a lot of younger people students working professionals people that are really not wanting to gain weight uh and and that's understandable and so it's it's one of those things where she she said I will tell people look if you we can try it but if you get more anxious you know we might we might not be able to use this we might have to be used one of the first line agents that um that she's still she is still recommending the first line agents but they're they're just not willing to go along with it it was kind of we actually talked about mortaz aine during this conversation as well and it's kind of the flip side of that coin where she she shares you're going to have weight gain with it so it's you have to have that conversation with the patient if that's something they're willing to tolerate then great it might be worth a try but just you have to be upfront about the potential side effects and and know what the medications you're prescribing will do to patients yeah um and and I thought it was interesting because we asked her about you know benzodiazapines and she said she tries for her as needed medications for people who are maybe experiencing Panic or you know anxiety attacks she she will give them Propranolol 10 to 20 Mill like twice a day as needed which is a low dose I mean in primary care we use higher doses than that than uh you know for migraine prophylaxis or someone's still on it for thyroid or whatever you know there's it's still out there Paul I you see for pan all once in a while you inherit these patients that have been on it for 30 years yeah yeah but the reason she uses propanal is because she says some patients it's more the physical symptoms of anxiety that are bothering them and uh she can sort of calm down the physical symptoms with that and get by without needing to use Azo aspine but Paul what about the the thoughts can can we change people's Thoughts with medication I mean if you give enough of it I suppose that you can but I Dr gold made the point you know she can medicate away insomnia for the most part you can medicate away the the physical symptoms that manifest with anxiety which can be really bothersome so that's not nothing but it's you can't medicate away thoughts um and thought patterns so that's that's where cogni behavioral therapy can be especially helpful so it's great to make you can make the patient feel better with medications but you may not be able to get rid of the persistent bothersome thoughts and that's where therapy can be very helpful so most of these patients would benefit from therapy um if you can get them into the kind of therapy that can be helpful for them yeah I I completely agree with that but of course Paul we talked about so many great things with her but we can't recap it all in this video so please click on the link in the transcript if you would like to hear the full podcast episode and with all that until next time I've been Dr Matthew Frank Wad and this has been another episode of the C Ider is bringing you a little knowledge food for your brain hole and we'll just let that sit and I remain Dr Paul Nelson Williams thank you and goodbye [Music] [Music]