Transcript: Managing Anxiety in Primary Care for New Nurse Practitioners

Liz Rohr: Anxiety is a really common chief complaint in primary care in general, but especially timely right now. This is a topic that not many new nurse practitioners feel very comfortable with, so what I'm going to be talking about is how to assess anxiety, how to determine if it's actually anxiety or if it's actually something else, and then the general steps of management in primary care, the first line, second line, third line, that kind of stuff. And I made a cheat sheet to go along with this video because I'm a very visual person, and I'm also trying to pack a lot of information in here, so hopefully you find that really helpful. Definitely download that here if you haven't grabbed it already.

And I want to make a disclaimer that there are psychiatric NP programs for a reason, and the ideal world is that somebody who has a psychiatric illness is going to be cared for by a psychiatric provider, but the real world, which that's what I'm all about here is this, the real talk of the real world, is that primary care providers are providing psychiatric care for patients because of lack of resources, lack of access, patient preference, things like that. If you are a psych provider or a psych NP student and you have feedback for me, I welcome it. Thank you so much.

If you're new here, I'm Liz Rohr from Real World NP and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. I'm going to be sharing my screen with you. Again, I'm a visual person. I find it really helpful, so hopefully, you find it helpful too, and let me know if you have any questions or concerns or other topics you want to hear about because I could go on and on about anxiety, but I'm going to really stick to the main high points here.

Background

All right. The situation you're probably in is that patients are calling with just feeling super anxious. The main things you're probably thinking about are generalized anxiety disorder, which is this excessive, persistent worrying that's hard to control and it's there for most days, most every day for at least six months, and it's just a general worry about things in general, compared to specific things. Adjustment disorder is a sudden onset in the last three months in response to a specific stressor. The treatment is overall the same, but just something to think about in terms of the expectations of improvement, right? Adjustment disorder's typically a stressful response that will generally get better sooner versus a generalized anxiety disorder's typically a persistent situation.

Assessing Anxiety in Primary Care

I think a really important thing to start with is that it's very easy, especially as a new grad nurse practitioner, patients will walk in or call on the phone and say, "I'm really anxious and I need a medication to help me," right, or they come in for some specific reason with seeking some specific thing from you. And that may be the case. Totally, totally. But the thing to think about is that in this new role that you're in compared to being a nurse, now you're a nurse practitioner, you need to maintain this healthy skepticism of what else could be going on and making sure that you're covering yourself and covering the patient and making sure that there's nothing else going on.

Approach to Anxiety Differential Diagnosis

And so I just wanted to get into that first. When is it anxiety and when is it something else? The first thing to think about is underlying medical conditions, not that generalized anxiety disorder is not, but I'm just using it as a bucket category of ways to think about it. What are your medical differential diagnoses here? Arrhythmias is something that's come up a handful of times in my practice. Not super common, but just something to think about. I had a patient who was drinking a ton of caffeine-related to her stressful job, was a very petite woman, had multiple coffees per day, and then when she came in, her heart rate was in the 160s and she was actually in super ventricular tachycardia. And I also had another patient who had that that was not caused by caffeine. It was just there. And she ended up going to cardiology and had an ablation.

And so these are just handful cases, but just something to think about that that's a possibility, right? Hyperthyroidism is the most common one to think about in terms of ruling out. It's not a very common condition, but it's slightly more common than someone walking in with an arrhythmia. But the way you differentiate that is, again, your history, right? Do they have weight loss, [inaudible 00:03:54], palpitations, diarrhea, things like that?

Another really important thing to think about is the medications that they take. Are they taking anything over-the-counter? Are they taking any supplements? Do they take things like Adderall, weight loss medications, things like that and again, supplements and diet. Do they take any herbal supplements? How much alcohol do they drink? Are they in alcohol withdrawal and that's what's giving them anxiety because they're drinking consistently and then in the mornings, they have really bad anxiety? For example, tobacco again makes your heart race. It's a stimulant that can cause anxiety to be worse, and then again, caffeine, like the example that I gave.

Other rare conditions, so typically when I'm assessing a patient in my personal practice and the practice I see for many clinicians is that common things appear commonly, right? And so if the story matches up that it sounds like it's a generalized anxiety disorder or an adjustment disorder versus an underlying medical condition, starting with that, starting their treatment and then reassessing and if they're not getting better thinking about going further. And so again, you don't necessarily have to think about all of those rare conditions, but just thinking about what are the red flags that you would think about medically that would be apparent to you versus, "I really just feel like I'm worried all the time and nothing else physically is going on with me."

Two other clinical scenarios to think about is that in menopause with the hormonal shifts that happen, it's a time of hormonal chaos and sometimes that can cause a new onset anxiety. And it doesn't necessarily mean that you have to give someone hormone replacement therapy. It's just really important to think about the patient holistically in that scenario of do you want to treat anxiety? Do you want to treat the other conditions that are going on? Things like that.

And then another consideration is with elderly patients. And I should have said this actually at the beginning is that I'm really only talking about adults here because pediatrics, adolescents, and actually geriatric patients to kind of have their own considerations. I typically will ask for assistance when it comes to elderly patients because they have some more caveats related to treatment of mental illness. But something to think about is that it could be an early dementia, so just keeping that in the back of your mind.

And then some other psychiatric differential diagnoses you want to keep in mind, generalized anxiety disorder, like I said. Was this here before they had this recent stressful situation? Is it a brand new thing that they're responding to? Is it panic disorder? Panic disorder is a little bit more persistent panic attacks that are interfering with their life specifically and they change their life in response to a panic attack. And it's not necessarily anxiety-induced. They just kind of happen, whereas generalized anxiety disorder can also come with panic attacks, but it's typically caused by a stressor of a severe increase in anxiety.

The treatments are generally the same, but there are some other caveats about panic disorder. Depression. Is there also comorbid depression, or is it really depression that feels like it's causing anxiety? Again, treatment is very similar, but just there's certain caveats to think about. And then OCD is kind of a type of anxiety. It's its own condition, whereas generalized anxiety disorder is a general worry about things overall. OCD is typically specific to specific types of worries, like worries about harm to them or things like that.

And then there's compulsions that typically go along with it of needing to repeatedly do something to feel safe. Similar treatments, but there are some caveats to treatment. Bipolar is kind of ... Anxiety is a less common manifestation of bipolar, but something you want to think about because the treatment for anxiety can worsen bipolar. And obviously there are other psychiatric diagnoses that are possible. Anxiety can go with a lot of things, but those are the general things to be thinking about.

Approach to Testing in Anxiety

And again, when it comes to testing, okay, so there could be possible medical co-morbidities, there could be multiple psychiatric comorbidities. When you do testing or not, especially if you're doing telemedicine and you're trying to keep patients out of the clinic setting, this unfortunately comes down to clinical judgment based on your history, especially if you can't examine them physically. Does it sound like a situational or generalized anxiety or does it sound like they have other concerning symptoms where you want to rule out an arrhythmia or hyperthyroid or something else going on? And again, keeping in mind that common things appear commonly, and so do you want to attempt to treat them for their anxiety and then reassess if they're not getting better, if they're getting worse, if there's something else going on? It's really kind of up to you.

How do we assess them? That's kind of about the differential diagnoses, making sure that you're not just jumping to conclusions about, "Okay, it's anxiety. I'm going to give you medication," versus is there something else going on? How do you assess patients? And so OLDCART, I think we get really worked up in terms of putting that pressure on ourselves to know everything. And really, whenever you go back to OLDCART, it'll kind of help you out. It'll help you get a lot of information even if you don't know how to manage somebody. And I talk about that in that getting a patient history video, which I can link to down below, but just onset, location, duration and all that good stuff.

Medications and supplements. Again, doing a really good history for that. And again, I talked about this in a couple of videos, but if you're not sure what to ask, just go to that ROS and ask the entire ROS. When it comes to psychiatric, do you have hallucinations, visual or auditory? Do you have suicidal ideation, homicidal ideation? Just asking all the questions and going from there, and you can literally read it off a piece of paper and that's fine. People won't judge you. Maybe they will, but you're giving good care, so it's fine.

GAD-7, the generalized anxiety disorder screener, is a great questionnaire I love, especially if you're in the clinic setting will definitely help save you some time with getting a history. And it's also a good assessment tool because you can see where patients are now compared to where they are after they get treatment. Harder to do over the phone, a little bit more on time-consuming. The PHQ-9 is that patient health questionnaire, nine questions about depression. Not the only one, but definitely one that I appreciate that I also have translated in multiple languages at my clinic, which is really helpful. And then the mood disorder questionnaire is another really helpful one. It's not diagnostic for bipolar disorder, but it's one that you can use to help you in that direction of deciding whether or not they need further assessment and treatment.

Approach to Anxiety Treatment in Primary Care

That's the assessment, so treatment. This is kind of the last part is of the treatment pathways and then some cautionary advice about when to refer out of primary care. Treatment is therapy, specifically cognitive behavioral therapy, CBT, medication, or both. There actually aren't really head-to-head trials in terms of comparing them, which one is more effective, but in their own research trials, they're both shown to be equally as effective, if that makes sense. And so it really comes down to do they have symptoms every day or these occasional symptoms? Do they have a general anxiety where a daily medication would help bring it down or therapy would help bring it down or the occasional symptoms? Is it just that they can't sleep at night because they're so anxious a couple days a week or a couple of times a month? Because that kind of guides your treatment one way or the other.

And a note about the therapy is that the research trials typically have looked at 60 minute sessions of cognitive behavioral therapy, about 10 to 15 sessions, so it's quite a bit of therapy that patients commit to using that methodology to really help with it in terms of the efficacy. And it really comes down to patient preference in terms of whether or not they want to do therapy or medications, because patients typically have very strong feelings. And I actually never know. I guess whether or not someone's going to want medication and it always surprises me. I always just leave it open and they get to choose because it's their body, right?

And so if you do a medication, if they have general symptoms every single day, SSRI or SNRI are the main first-line options. And this comes down to patient preference and typically for me, insurance, and I'll give you a couple of examples on the next slide, the next two slides. But in terms of as needed, so if somebody just can't sleep a couple of days a week because of anxiety at night, hopefully therapy will be really helpful for them, but if they are not interested or they're not available, if they don't have insurance or the resources, medications can be really helpful too. And a lot of people think about benzodiazepines or they come in asking for them. Typically, I personally avoid them and generally psychiatrists recommend avoiding them as well if we can because of certain risks associated with them.

But hydroxyzine is an anti-histamine. Atarax is another name. There's a couple of different names, but hydroxyzine is the generic name. And that can actually be used especially at night if patients are really anxious, and then pregabalin, also known as Lyrica, couple of other names as well. I have not used that personally myself because of insurance coverage typically, but hydroxyzine, I have had people have effect, and I typically use it at night because of the sedating effects, but you can use it during the day as well.

And so talking about SSRI and SNRI, the main principles of therapy are that you start at the lowest dose. It takes about four to six weeks, which you probably learned in school, but just to reiterate that, to take full effect. And then what you want to do is titrate to the max dose or whenever their symptoms are controlled. And there's two reasons for that. One is that side effects, it can take a while for their bodies to kind of get used to it, but also with anxiety, more than other conditions, those patients tend to be more sensitive to any effects of medications, just because their sensation is a little bit more heightened, I think.

If the patients don't have any response in four to six weeks ... or sorry, if they have no response and you've titrated up the medications, the recommendation is to switch an SSRI or SNRI, like switching into categories versus adding a second agent. Number one, just pick one and I'll talk about a couple of options in the next slide. Pick one. Titrate it up every four to six weeks. It depends on the medication profile and definitely look at each option in terms of how quickly you can titrate up, but just reassessing at least every four weeks. I have them come back in for a visit or a telemedicine visit to see how they're doing.

And then if there's some response but it's not enough and you get to the max dose and they're feeling fine, you can add a second agent. Buspirone is the next line option to add an addition to whichever SSRI, SNRI, and again, same thing. Takes about four to six weeks to see a full effect, so just having that conversation with patients, because I find that if I don't prepare them that, "Hey, this is going to take a little while," and most people need the max dose or moderate to high dose, which is true just anecdotally from my experience, they've typically gotten discouraged of, "What are we doing here? This feels like we're just chasing this around and it's not doing anything," versus setting the expectation from the beginning and seeing if they are willing to even do that, right?

And again, adding in those PRN medications if they need to, hydroxyzine, pregabalin and generally avoiding benzodiazepines. My personal take is that if somebody needs benzodiazepines to control their symptoms, then really they should seek a higher level of care, meaning a psychiatric referral first, because they can make sure that we've maximized everything else because of the risks associated with those medications.

And so options of SSRIs and SNRIs, so SSRIs. My first line is citalopram and escitalopram. The main notes about those, they're very helpful for anxiety specifically in the SSRI category. We want to think about QTC prolongation if they have any underlying heart conditions or if they're on other medications that also prolong the QTC, what insurance they have, and then the other thing that I find frustrating about citalopram is that there's a limited dose titration. Basically you either start at 10 or 20 and then the max dose in primary care is 40 milligrams, and so that's not really that much room to wiggle around versus sertraline, you can start at 50 milligrams and go all the way up to 200 feasibly.

Sertraline is another option. I don't have a lot to say about that. It's generally well-tolerated. Paroxetine is another one specifically for anxiety, but I don't prescribe this one typically because it has some anticholinergic side effects. Weight gain. It has a really short half-life, meaning that if they don't take their medication basically at the same time every day, they tend to have withdrawal effects in my personal experience, but I mean, it does have a short half-life.

SNRIs, venlafaxine or duloxetine are also options. I don't typically prescribe these typically because of insurance. Caution of when to refer. If patients have worsening symptoms, worsening depression, suicidality, they definitely need to stop the medication and then they need a higher level of care. They need a psychiatric referral, and if they're not able to go, I love cold calls and so you're welcome to call. I call. That's what I do all the time is I call psychiatrists that I have relationships with and ask for their advice, or the ones that are affiliated with our clinic. Luckily, I have one in my clinic now, so that's super helpful.

And then comorbidities, so if patients have comorbid substance use disorder, likely they're going to need more support than we're able to provide for them as primary care providers. And so typically those patients right off the bat probably should have a psychiatric prescriber and support and assessment and all that stuff. And I also, as an important note, always warn them about worsening symptoms, depression or suicidality before they even start taking the medication so they acknowledge those risks and let me know ASAP, as soon as possible if they get those kinds of symptoms.

And so that's it. If you haven't grabbed the Ultimate Resource Guide for the New NP, definitely head over to realworldnp.com/guide. I put together all my resources that are my favorite ones, and I'm continually updating it and I'm going to be coming out with anyone pretty soon. And you'll also get these videos sent straight to your inbox every week and bonus content that I don't share anywhere else. Thank you so much for watching. Let me know if you have any questions, and I'll see you soon.