And open my Red Bull necessity. What? My Red Bull. Oh, your Red Bull.
I heard Bread Bull.
I just heard you say Red Bull twice. What was the other thing that you heard?
Opening up your Bread Bull.
Mm-hmm. Well, you know, that's a San Francisco treat.
I don't think it would make for a good podcast, though.
A little chowder. You're saying that people don't want to hear about a bread bowl full of steaming hot clam chowder on a podcast? I think that's crazy. But how would it impact you? I don't think we have a... What?
I think a red bowl gets you amped up. It gets you aggressive and disagreeable. I don't know what a bread bowl does to you. I would think it gets you lethargic.
Yeah, it's calming, right? It's soothing. Maybe if you have a lot of anxiety, you'll cool down a little bit and you'll have a little less anxiety. Maybe we should start prescribing bread bowls.
I think you'd be a lot more agreeable on the podcast if you did bread bowls.
I think we'd be giving people about as much diabetes risk as most of the antipsychotics if we did that.
I will say, after one of the podcasts, my partner was like, is Dr. Fu drinking coffee or something? He's aggressive. This is one of the older ones.
Is it really? Oh, the older ones. Yeah, I think there was definitely a more of a tinge of that in the past. But I think that's also depends on the topic, you know, and I can't say I'm very excited about today's topic, which I believe is anxiety medications. And the reason for that. Is as you probably heard from the last episode, I'm not necessarily such a believer in many of the named anxiety disorders in the DSM being a thing in itself.
I do think that GAD is its own disorder in a sense, but that the criteria is too loose and that too many people are being diagnosed with it when we should probably tighten up the criteria and capture a smaller proportion of the population.
You're an anxiety denier.
I mean, some people would say that. Thankfully, I don't think people are quite as passionate about anxiety as they are about certain other diagnoses. By the way, I'm not anti-anxiety medication. I just think that what often happens is that people will take the medications. They will take the medications at high doses, which is generally needed for someone with a primary anxiety disorder or a serious anxiety disorder.
And then they will get good enough And then they will not do any of the psychological treatment, which is fundamentally the most important part to treating anxiety and growing for the vast majority of patients. So that's my problem with medications. They are a convenient mandate, and the work of treating anxiety can be so difficult That adding medications doesn't necessarily help people get better in the way that adding medication does help getting better in something like a major depressive episode.
Well, so I guess what you're saying is that they're useful when done in the correct way and with the correct psychoeducation. Is that what you'd say?
They're useful across the board. I would say that. I just think there is a higher risk in anxiety disorders compared to others. in sort of removing the drive or motivation for psychological treatment and if you can remember from last episode listeners um anxiety can be interpreted as an activation right as a higher level of sort of psychological energy. And if you decrease it, remove it, or suppress it entirely as you would using a benzodiazepine, that will slow or stop motivation itself and treatment change in the psychotherapies.
So it just really depends. I think we'll drill down to the details today.
Well, if you wouldn't mind to start off, would it be okay if I did the basics and the flow chart of starting?
I think it's a good framework. I think you should lead the charge here and they'll kind of riff on it.
And I feel like I hope we are kind of doing this for most of the different diagnoses. I think it's super important that you learn the absolute basics and you have a super basic flow chart for how you prescribe, especially when you start. And that it's like, I start with this. If that doesn't work, I do this. If that doesn't work, X, Y, Z. I feel like...
There was like a Reddit picture recently where it's like, if you're an idiot, you think this. If you're like in the middle, you think differently. And then once you're an expert, you go back to thinking the same thing you thought when you were an idiot.
It's the bell curve mean. If you're familiar with the bell curve mean. It reminds me of a saying growing up that my mother would say. I don't know if it's a real one, but it's like when you're a child, you see a mountain as a mountain. When you're an adult, you see that a mountain is not just a mountain. But when you're elderly and wise, you see that the mountain is a mountain again.
It's literally that. Beautiful. Um, but I think most people don't use the meme as a progression of psychology or understanding. They use it to denigrate people.
So, um, beautiful quote. Um, yeah, the gist is that when you start out, um, I'm thinking of residency. We had the most basic flowchart for how to prescribe which medications. I've said this before. You get Zoloft if you're depressed. If you're bipolar, you get lithium. If you're psychotic, you get Risperol. That's the entirety of the hospital algorithm. And I was furious at this. I thought it was embarrassing that we used such a few medications.
And then by fourth year... If someone was depressed, I used Zoloft. If someone was bipolar, I used lithium.
Obviously, it gets a little more complicated. You've got to know your algorithm. If you don't know your algorithm, you won't know when to deviate. You won't be able to have it in your head immediately and ready to use. There's been some discourse, I think, on Twitter these days about crystallized knowledge. Is it important to have rote memorization or crystallized knowledge in education? I've come to the... part, the conclusion that, yes, it is important.
And for the fact that if you do not have readily accessible crystallized knowledge in your head, you won't be able to be creative with it because it won't be there for you. You know, we can't rely on references and lookups all the time.
The healthy developmental progression is your parents teach you how to live and then you become a teenager and you rebel against it. You say, my parents are idiots. And then you turn, as you get older, you return back to your parents' ways of living.
It's the hero's journey, isn't it? The hero's journey. Joseph Campbell. Okay, we're really getting caught up here.
So to start, you're assessing how severe the anxiety is. And an important part is that mild anxiety can forego treatment entirely. That means that back in the old days, if you came in, people who were seeing psychiatrists were bedridden, were acutely catatonic. Nowadays, it's not uncommon for me to get patients that I finish the assessment and I go... You've got nothing wrong with you. If you want, you can start.
I mean, I think therapy would be smart for you. You have the option to just watch and wait.
And I say that. So worried well, they're referred to, right?
Yeah. So you move to treatment when it's severe enough that it's impacting their function. And you can choose CBT or medications or both if it's particularly severe. If a patient can engage in therapy, I think that they should be engaged in therapy before medications. When do I use medications first? First, if they're too symptomatic, that they're not able to engage in therapy. And second, patient autonomy. So the patient knows both options exist, but for whatever reason, they don't have the time, they don't have the energy, they don't have the resources, they don't want to engage in therapy.
It's reasonable to start medications as an alternative.
And one thing I want to mention here is that I don't know if every psychiatrist is, and certainly not every primary care doctor, is actually going over the adverse effects and side effects and risks of these medications enough. I think there are some clinicians out there who aren't talking about it at all. And I think a part that gets lost in the conversation here is that even if one medication carries the same risk across the population, that risk becomes more salient.
when the condition you're treating is either less serious or less responsive to that medication. And on the same token, even if a medication has severe side effects and problems, if the alternative is hospitalization, incarceration, and the gradual decay of your rational mind, then you must accept those side effects. You must take the medication. That element, I think, is not addressed enough.
Yeah, that's a great point. And, you know, with every patient, even someone who's, you know, they've been on Prozac three times before, it worked great, they just want to restart it. I go, listen, I'm just going to give you the spiel once more time. I don't assume that the patient remembers the side effects and the problems and all those things. So for medications, what do you start with?
Start with an SSRI. I prefer Zoloft or Lexapro. More recently, I usually pick Zoloft first. And someone helped me to explain. I just came to it because I felt like it was patients responded to it more consistently. I think early on, I had a few patients who just had really bad responses to Lexapro. It actually makes sense. So... Zoloft is highly variable in its metabolism, whereas Lexapro is really just broken down by 3A4 and 2C19.
I always zone out once I start hearing the SIP stuff, but this is pretty simple. If someone has 2C19, there's a lot of variants. There's rapid metabolizers and poor metabolizers. For Lexapro, if someone's a poor metabolizer, typically Asian or oceanic, that means that they're going to get a lot, at the lower doses, they can still have a lot of side effects. Whereas the ultra-rapid metabolizers tends to be the European and African population, they will need higher doses to get the same effect.
So the gist is that because Zoloft is broken down by a bunch of different things, it doesn't really matter if they're a rapid or poor metabolizer. They'll have a similar effect because there's other pathways. So Lexapro, you do see a more variable effect than Zoloft. I do think Lexapro is a little bit more effective, but I just tend to go with Zoloft first.
I actually don't think it is a little more effective. I know there's a little evidence saying that, but it's too individual. They're both good. I think they're both fine choices because on top of the things that you just mentioned, they tend to have, relatively speaking, less interactions of other medications. Even if someone's young, you never know if they're going to have to add another medication for some kind of a new medical condition down the line.
I'd like to start with these. One other reason that I think Zoloft is a little bit more versatile than Lexapro, though I use plenty of Lexapro, is that you can kind of step a little bit easier with small steps in Zoloft. Because roughly speaking, 50 milligrams of Zoloft is roughly like... five milligrams of Lexapro. Not true really, but basically true. It's hard and annoying to get people to even find five milligram Lexapro or cut it in half.
Two and a half is kind of ridiculous. Whereas totally normal to have 25 milligram tablets of Zoloft. So you can play with the dose a little bit more. So yeah, similarly, I was initially more of a Lexapro enjoyer. Today, my first line is usually Zoloft unless I find another reason to use another agent. Yep.
In terms of prescribing, just because surprisingly not talked about that often, I start it on average. There's obviously differences depending on the situation, but I'll start at 25 milligrams for a week and then move up to 50, stay there for a month, and then negotiate an effect. I usually will prescribe 30 of the 50 milligrams and say break the first four and a half. And at the first week, if it's tolerable, move up to 50.
If it's not tolerable, continue it for another week. Moving on to, let's say they start that, they don't have a response. I'll taper it and try a different SSRI. If I see a partial response, I usually augment with Buspirone. If... Or if a buspirone doesn't work or a patient doesn't want it, then I'll do gabapentin. An important point here is, and I think we can talk about this in more detail later, I don't use PRN medications unless there's an exception.
What are your thoughts on that?
I'm totally with you. I am anti-PRN for anxiety. I know people are not going to like this. Why am I anti-PRN? No, it's not because I want people to suffer. It's because PRNs are not a good treatment plan. Okay. What you are really doing with a PRN for the vast majority of cases is that you are adding a safety signal to that can be used and you're forcing the safety signal to be a medication.
It is completely possible to start to use different safety signals or behaviors, right, in the course of a psychotherapy. You can introduce a variety of different tactics for an individual to manage their anxiety or to attenuate their anxiety response. And it doesn't have to be medication. Let's face it, unless you are mainlining Bursad, most medications you take by mouth actually have an onset of usually at least 30 minutes.
Now, you're going to start feeling something right away because the body and mind are quite powerful and you're going to get your placebo or nocebo effect right away, especially for anxious patients. But that's not actually the medication. So if it's the psychology working, we can treat it without a medication. We can treat it with some kind of a lifestyle change, psychotherapy skill, anything.
Yeah. And going back to your first point when you started the podcast is that if you give a PRN, you're going to reduce the important teaching point. And I think the important teaching point for improving with anxiety is being able to trust that you'll be okay and trust that you're able to handle something. And when you use a medication, you're validating that I need something external to reduce this anxiety.
I need something outside of me. And If you don't use a PRN, then you start to develop other coping skills. You know, like I personally, if I'm starting to feel increased anxiety, I need to go outside for a little bit. I do like to do a little bit of a Wim Hof. We talked about that earlier. You don't like that. You know, do... Various breathing techniques. Breathing techniques.
Going, you know, like taking a bath, doing something to calm down. And over time... Talking to somebody.
Talking to somebody.
Big one. Huge one. And then after you talk to someone... What I was worried about wasn't that big a deal. Over time, you use those techniques and you learn, oh, I can handle things. And that major trigger of anxiety, I'll be like, if I can ride it out. And you're destroying that process when you add a PRN. You're not allowing the natural progress of, I can handle this.
I might have to use something that works to calm myself down, but I'll be okay in an hour. You're destroying that process.
A funny note, though, the way you frame it is kind of just a bit different from me. You talk about how it's sort of coming to a realization that you're good enough and strong enough. Let's say you can disagree with that formulation if you want. The way I sell it is I'd like you to get used to accepting suffering. There's a minimum level of suffering and anxiety that you have to live with.
And if you accept that, you won't make it worse. Much more pessimistic in the way I talk about it. It's really the same process that we're referring to with different words. You have more of the Eastern tradition, the Buddhist that life is suffering. Yeah, it's very Buddhist. That's one of my upbringing.
I have the more Western tradition that we are great.
Optimistic.
We will conquer.
That's right.
All right. So then in terms of the, you know, so your SSRI don't work, doesn't work. Talking about Buspar and Gabapentin. I've started using Buspar more since we've been talking and have liked it and seen it be more effective at the higher dose range than I was using before.
Yeah. It's deceptive because it comes in seven and a half, right? Makes you think you should start there. But really that's where titrating up once you're already at the starting dose of 30 a day. and divide the doses naturally.
So yeah, tell me what you see with buspirone, what doses you tend to start to, you'd like to get patients to and how, you know, the effect you see.
Yeah, everyone's a little different. I think, actually, even before I talk about Busforum, something we should have mentioned, with any medication, you really need to emphasize a couple of things. First of all, especially for anxiety patients, we are not going to expect these medications to remove your anxiety entirely. If something removes your anxiety entirely, something has gone terribly wrong. You are supposed to have some degree of anxiety in your life.
You may have a personality that means that you're going to have more worry and anxiety compared to the average person no matter what, unless you undergo wholesale personality change, which is a long-term process and not something that medication is going to cause. Secondly, when you start a medication on an anxious patient, I think anxiety patients, especially anyone with a little more tendency towards somatic symptoms, needs to know how long it actually takes for the medication to even get to a reasonable level in the body after you take it.
What are the real effects that you expect from this medication and how long it takes to start working? Because in my experience, through no fault of their own, many anxious patients will naturally have a very anxious reaction to these medications, will have a paradoxical reaction, basically a nocebo effect right after starting the medication, and that can cause medication to fail. So it's important to head that off at the pass and discuss those things.
Now,
uh, for the views bar, I don't necessarily use this as a augmentation agents, great augmentation agent. I totally suggest it to be used that way, but I'll often just use it alone. Um, but whether or not you're using it as augmentation or alone, you want to start at minimum 15 in the morning, 15 at night. That's the starter dose. Now, what I do say to patients is that if this happens to make you very sedated, then cut the morning dose in half or stop it.
And then past that, I just sort of assess how tolerated it is, mostly in terms of sedation, how effective it seems to be. And I will rapidly go up to a total of 60 in steps of either 5 or even 15, depending on the clinical situation.
Going back to what you're saying with anxious patients, you do see more side effects, and there is a period that you almost need to grind through with the anxious patient to start seeing the effects, because it is very common for them to have a ton of side effects. And I intentionally reinforce in my little spiel with anxious patients. I say... The side effects are going to be certain side effects are going to be as bad as they're going to be when you first start the medication.
And it takes about three days for it to kind of level out. And usually about one week until you start to feel a little bit normal. That's expected. And there oftentimes you will hear at the end of the month like, oh, the first week was awful. And I, you know, I had all these things and then I started feeling a little bit better. A lot of patients, a lot of people will consider probably more older psychiatrists would use benzodiazepines for this period.
I try to avoid that, but I'm not inherently opposed to it for the right patient.
Yeah, it can definitely work for the right patient, especially because... A certain personality type that tends to have an anxiety disorder is probably the lowest risk for addiction habituation with benzodiazepines. It's the medication hater. It's the person who does have strong placebo effect and negative emotional relationship with medications, right? Those patients are not going to get addicted to benzodiazepines. They will barely take what you want to prescribe to them.
But I'm going to say this. It is not a reliable... assessment in trying to determine in advance whether you have that patient or the patient who finds that their anxiety is totally suppressed on the benzos and then sticks to that as the only solution. And then you have a problem with your hands. So yes, I don't do the classical thing of benzos with the first couple weeks of the SRI.
I don't do that. If they want a PRN, they need a PRN for some reason, I still encourage against it. I'm not going to not use it if the clinical situation is right for it. I'll use gabapentin or hydroxyzine. Should we have talked a little bit about SNRIs as a subcategory? I grouped them together for this algorithm. But what do you think? SNRIs.
You know, I have a tough time with SNRIs because they're shown to have just a very marginal improvement in effect. And it's important to keep in mind that a lot of patients have a really tough time getting off of them. And especially with Effexor, withdrawal can be really, really difficult. So I think I like SNRIs a little bit less than I think most of my colleagues do.
I share your feelings on Effexor. I actually don't use it at all unless someone is coming to me already on it because how bad the withdrawal is. You know, I remember a case where I saw elderly woman coming in for what was basically delirium and it ended up being because of Effexor withdrawal. You know, it can be pretty bad. So I don't use Effexor. Christique's great, but my patients, their formulary won't cover it, so I can't use it.
I guess I don't use it as a third line going like, oh, you failed some SSRIs. Let's try SNRI. No, I don't find it to be at all more effective than the SSRIs. When do I reach for SNRI? I will do it first line if I see a comorbidity where there may be an indication. Chronic pain, migraine disorder. What I would caution, though, is that, oh, and in some cases, true ADHD.
We're not going to get into that today. True ADHD might be a little bonus with the norepinephrine. But I have seen in some patients that the norepinephrine action seems to worsen nightmares if they have a nightmare problem. So just be cautious.
Yeah, the two bird, one stone. So it's got two mechanisms of action, and I typically use it when it's got the comorbidities. Like you said, pain disorders, migraines, fibromyalgia. I think they're a little bit better in hot flashes. Oh, yeah.
Are they better? Well, they're a certain choice.
Now... Let's talk a little bit about the gabapentinoids. Now, one thing I do see is it's important to remember that typically it's for anxiety. I like to go a little bit higher. I see a lot of people use like 100 milligrams or 300 milligrams. Typically, it's more effective at the like 900 to 3,600 milligrams per day range. And It's important to remember that gabapentin has, quote unquote, nonlinear pharmacokinetics, which is just a fancy way of saying that like, you know, 2400 sounds like a mega dose, but significantly less is absorbed as you get to the higher doses.
So that's per dose. We need to emphasize per dose. So if you separate the dose timings, then the absorption kind of resets in a sense.
yes so it has to do with like the absorption gets saturated and yes so that it's there's less getting like it'll uh bottleneck how much gets absorbed so 900 milligrams like only like 540 milligrams is getting absorbed as you get higher it's even lower so like 2400 you're looking at like close to a little over 800
milligrams yeah though are you ever giving people 2400 at once
I'm not, but I have seen patients at much higher doses.
Yeah, I try to cap it at 1,200 personally. I feel like, what are you doing at that point? Just separate it out into a different dose. Do I give a lot of gabapentin for anxiety disorder? No, but I'm not opposed to it. We have to understand that we're starting to get into the territory of just broad suppression of neurons and that there could be habituation. I've never seen it with my patients on gabapentin.
It's certainly been written about. I guess if you're not using gabapentin for sleep support only, And if you're using it for the direct treatment of an anxiety problem, then, yeah, like BUSPAR, you should probably be doing it at least twice a day. Uh, morning and night, you might be able to get away with that. Now I wouldn't be starting people on high doses like that. I would be getting to those doses eventually because I just find that people are quite variable in their apparent effects.
Maybe it's an absorption issue. So I usually start at around 300 and have people let me know if it's too much or too little and we'll increase accordingly or decrease.
Yep. And start at nighttime and then add the, uh, morning or evening doses. Yeah. How about Lyrica? I know you... So Lyrica does have more evidence in anxiety.
There is... We have to remember, people want us to use the generic names, pregabalin. Pregabalin.
So it does have more evidence in anxiety. Typically how it's thought of is gabapentin might be a little bit more tolerable and less abuse risk and... I know that you're a much bigger fan of gabapentin than Lyrica.
Yeah. And that's simply because Lyrica is too effective. The absorption, speed, and amount is sufficient to make this a possibly habit-forming drug. And, of course, that also means that the risk of withdrawal effects are higher. and dependency both psychological and physiological but it works you know if you tolerate it and it works for you it works i don't like to use this medication this is definitely a medication um solidly in the category of will park a patient where they are forever instead of allowing them to move towards long-term improvement but for refractory cases Sometimes that's what you need to get people living a good life.
So for me, Lyrica is for refractory cases. It is a serious medication. It is just one step below the benzodiazepines.
You also mentioned hydroxyzine. When do you use that?
I don't love hydroxyzine, but I will hand it out because it's a low-risk medication, generally speaking. Some people just seem to like it. I think the main dividing line is how sedated you get on it. Some people just get way too sedated on hydroxyzine. It's not a good choice. But this is a perfectly acceptable choice in anxiety for PRN, for schedule, for sleep. But I don't think this one really addresses the underlying issue quite as much.
I think it, like the beta blockers, is manipulating one element of physiological arousal so that then downstream people can calm themselves a little bit more. Not too bad, hydroxyzine. Feel free to use at any stage in the anxiety treatment.
And then I guess, you know, just a little, it's the one used in psychiatry tends to be hydroxyzine pomoate, which is viscerol. And that's in comparison to hydroxyzine hydrochloride, which is atarax, which is better for allergy. The exact reason isn't entirely clear. So viscerol might be a little bit more lipophilic. So it crosses the blood brain barrier. So it's getting more of the brain effects. Yeah.
But in psychiatry, I thought this was debunked, this little difference.
It's one of those things. Do we know anything about pharmacokinetics at all?
Yeah, I suppose. But, you know, it's theoretical. That's kind of the traditional theory. You can subscribe to it if you like. I really pay zero attention to it and have not found a difference in my practice. I just prescribed. I don't even know what I'm clicking on. And in my opinion, from what I reviewed in the past, and I didn't review it very long, there was no evidence to show a difference.
But there's some theories.
I mean, I guess in terms of like hard differences, Visteril's a capsule and Atarax is a tablet. Yeah. Yeah.
Use either. That's what I was saying.
All right. So where do we move to next? I guess we can talk a little bit about one I see being used more and more propranolol.
Yeah, it's funny. I noticed there are Reddit ads.
Oh, that sexy man who's cool as a cucumber.
Really? I was remembering like an anxious man. Well, maybe it depends. See, I think maybe the Internet algorithm recognizes your propensity towards optimism and mine towards pessimism and directed the appropriate ads on us. But no, there were these telehealth companies specifically promising like some kind of wonder drug for your performance and general anxiety. And it was just a telehealth company dedicated to getting you propranolol. Okay, ridiculous, completely ridiculous.
This is something that any primary care doctor can prescribe for you and will prescribe for you if you feel that you have some anxiety. And after I mentioned this to my primary care buddies, they were like, you don't use that much propranolol? We love propranolol. It works great. It's awesome, which I found interesting.
Yeah, the ad, I mean, maybe just the, we're probably seeing the same ad, but it's just like a, it seems like a thing that like young, cool hip people do. And it says like adrenaline blockers to cool your nerves. Like it just feels like a, you know, like, you know, just a cool hip thing. Like, yeah, just be cool, be chill.
Now I've seen multiple ads for it. So there's definitely different models that they're using. By the way, I'm not opposed to Propranolol, but I just don't really use it so much for primary anxiety. I want to see some kind of evidence of upregulation of the fight or flight system. So I do use it for trauma disorders, and I certainly use it for echithesia because it's low risk and effective.
I'm not opposed to using it if anyone wants to try it. I just don't think it's quite as effective in the long term for a primary anxiety disorder compared to the SRIs, for example, or, of course, psychotherapy. I do wonder if its popularity for the primary care doctors and in the general population is because I tend to see a more ill population. My population is more serious in terms of the severity of their conditions compared to maybe some other doctors.
So that could be why I have this bias.
Yeah, where I see it useful is, I feel like it was a test question in medical school. It's indicated for performance anxiety. And I do think it's reasonable for patients who have a fear of public speaking, fear of performing, don't need to use it that often. And there, I'll typically use like 20 to 40 milligrams of propranolol, tell the patient to use it an hour before the performance or whatever the anxiety provoking situation is.
And what it tends to do is it just really suppresses that autonomic response. So the bodily anxiety of the increased heart rate, feeling a little bit shaky, feeling sweating, it decreases that. Again, the mechanism, it's a beta blocker. Remember, it's a non-selective beta blocker, so it blocks both beta 1 and beta 2. The little mnemonic I remember from med school, one heart, two lungs, so beta 2 impacts the lungs.
So you want to be careful with patients that have any sort of asthma or lung conditions.
That's right. Be careful.
Yeah, I was surprised when I was searching on, you know, sometimes I'll search for just like a general opinion of medications by searching Reddit on it. Patients are loving propranolol. There's a lot of like, I was surprised I opened up like four threads and it was just filled with people raising it.
Yeah, apparently people like it. I think, again, if you have a non-serious and environmentally provoked anxiety problem, it's a good choice. But it is also giving an effect that you could do yourself if you learned how. because it's essentially treating the perception of physiological arousal as a threat. If you can perceive physiological arousal as non-threatening, relatively speaking, or even as excitement instead, you will be able to modulate your body response.
It's not something you can do overnight. It's not something you can do by just deciding it, but it is something you can do with practice. but it's also a low risk medication. I'm fine with it. I don't like psychiatrists who just give it as a PRN, as an as needed medication for all anxieties. I think it should only be given as a PRN if you have a environmentally provoked, scheduled and known situation like performances, right?
That's fine. What else can you give it for? Again, people of trauma disorders, comorbid, also people of essential tremor. Or even hypertension, uh, not a great agent for primary hypertension, but.
And of course.
Yes.
So, yeah, you know, reviewing what we've gotten to so far. Typically, I use an SSRI. That doesn't work. I'll switch to another SSRI. We're talking augmenting agents, considering buspirone or gabapentin. If their patient's still unresponsive to, you know, a bunch of these things, you can start kind of going off patient characteristics. If there's a lot of sleep issues, I'll consider mirtazapine. A lot of sexual problems, you know, marketing plays a big role in this, but I have seen that Vilazodone and Vortioxetine are the two meds that are marketed as slightly lower sexual side effects.
I have had one patient that Vilazodone did work without the sexual side effects.
Speaking of sexual side effects and the avoidance of them, I think it's worth mentioning Wilbutrin at this point, because Wilbutrin is actually effective in anxiety disorders, but you have to get over the hump of the initial part. It's more activating and anxiety-provoking for anxious people at the beginning, but if they can tolerate it and stay on it, the data does show that it's effective in anxiety disorders, and in my experience, it is.
So that is an option if the other medications are not being tolerated or not appropriate for some reason. I also wanted to mention that we had talked about pregabalin, Lyrica before, because we were already talking about gabapentin. But to me, that is a method of last resort that I even placed beyond, and I will try before that, the tricyclics. And that's actually the traditional answer to what to do with someone who is having a primary anxiety disorder, who's not responding to your SSRIs, SNRs.
You should be using tricyclics.
I mean, what would be your first line one? It's probably imipramine, right?
Yeah. What's interesting is that that's just because that was the one that was researched the most back in the day. So, you know, you can go for imipramine. But really, it's whatever tricyclic is tolerated. I believe nortriptyline is usually... one of the classically better tolerated ones so yes if i have to go to the tricyclics and that's very very very rare for me to do uh yeah but yes if you're if you're treating an anxiety disorder with a tricyclic i would go for either
desipramine or nortriptyline yeah you know going back to wellbutrin um as you said the data does show it i think it's especially with like anxious depression it can really help it can help with anxiety I now, I feel like with patients, I feel like there have been a bunch of anxious patients I've had that I've taken it off and seen improvement. So I feel like when I first started out, I thought I was crafty and being like, oh, I know the data shows that it's actually not that much worse for anxiety.
And now I do try to tend to avoid it if anxiety is the predominant problem. If it's depression with anxious features, I think it's great. But if it's mostly generalized anxiety disorder, There's a pull for when a patient comes in and says, hey, doc, I don't want the sexual side effects. I don't want the weight gain. And I need my anxiety treated to be like, oh, I.
More recently, I still I won't go to Wellbutrin.
You know, I think that's wise. It's just how you should be doing things. You don't treat using the algorithm. You're aware of the algorithm, but you need to adjust for the particular situation. And not just Welbutrin, any of these agents can potentially cause agitation or worsening in certain patients. Even ones that don't have a bipolar disorder, there are some people who just seem to get agitated or activated on the antidepressants and just don't use those.
Use Buspar. use gabapentin or use psychotherapy. Do not use the SRIs or especially Wellbutrin if someone just seems to be getting worse. You need to be actually looking at the patient's overall clinical picture. Awesome.
How about MAOIs?
How about MAOIs?
MAOIs are one of those things I want to pretend that I use them and I wish I used phenelzine for anxiety and I haven't.
Well, you know, there's this whole trend of methylene blue. Have you caught on to that?
I know that it is an MAOI and it was like the original thing that made them discover I think it was the backbone for something, but I haven't actually seen it.
Yeah, the chemical structure is the basis for a lot of the MAOI and other antidepressants, I believe. I don't know a lot about this. I've only just kind of caught it on the side. The impression I'm getting is that certain groups on the internet are getting very into methylene blue, even though they're the same people who would wholly reject traditional psychiatry. It doesn't make any sense to me.
You're trying to take... like just the pure MAOI, which is like the end of the road for the treatment in terms of side effects and risk. It's strange. But anyway, don't be shy if you are an experienced or under good supervision clinician and you're reaching the end of the road of pharmacological agents for anxiety for a patient. You can consider an MAOI. Same thing for your depression patients, right?
I would say that in terms of tolerability and ease of use, the selagulene patch, is not a bad choice. But if you do the appropriate dietary counseling and risk counseling with patients, you can use any of the typical ones.
Yeah, and I recommend com to learn more about the MAOIs. Ken Gilman's a very nutty man. I spoke to him a few times. He's an odd duck. I'll just say that. But an incredibly nice guy. And he's a big proponent. So I believe selegiline is technically selective and only at the much higher doses is hitting both MAO receptors. And the patch... Because the patch is absorbed systemically and not through the gut, there's a much lower risk of the tyramine reaction.
That's right. Theoretically, and I think it's still recommended to follow the diet, but theoretically, there's less risk of the hypertensive reaction from tyramine-contained foods. The other one last thing, I don't want to talk much about the benzodiazepines, but I just want to reassure.
I just want to have to talk about them. We have to write there. They're probably the first thing patients, primary care doctors and traditional psychiatrists, older psychiatrists think of when they talk about treating anxiety. I believe there are several that are actually FDA indicated for anxiety. Isn't that right? Yep.
Yeah.
Yeah. Now, we aren't Italian here. Are you aware of that group from Italy that publishes all those papers about how benzos are actually really safe and awesome and they should use them?
No, I haven't seen those papers.
There is actually a group that does that. Uh, you know, I think I'm at least receptive to hearing the argument that today people like us are being overly cautious with benzodiazepines, but I just really hate anything that causes withdrawal and physiological dependence for patients. I think it's an awful thing to do to somebody when there are other options, you know, um, Will I never give it? No.
I remember when I was in medical school, I saw a patient who just presented for a regular medical catch up checkup. I said catch up. That's interesting. It was a regular medical checkup. I was at my primary care rotation. And this lady was like her physiological baseline was basically the most anxious person I've ever seen times three just throughout. She was just at a regular thing. And this was like basically your top one percent of physiological anxiety.
I'm open to the possibility that some people just have this extremely upregulated anxiety problem that is more biological. And for those patients, if that's what it takes for them to function, I will give them some benzos. It reminds me of the hairdryer debate. Do you know about the hairdryer debate and OCD? Did we talk about that? Where did that come from, that story?
The hairdryer debate?
You're not familiar with this? Okay. There's like a famous for OCD treaters story about there is some patient, high functioning, and one obsession was that If I leave this hairdryer at home before I leave for work in the morning, it's going to burn down the house. OK, so half of the treatment team thought that the treatment has to be ERP, ERP, ERP regarding that particular exception. Sorry, obsession, exposure and response prevention.
And then one of the treaters, if I recall correctly, was like, hey, why don't you just unplug the hairdryer and take it with you to work? Leave it in your car. Just the car burns down. And then the patient was like, whoa, that works perfectly. and was far more functional. Okay. So, you know, we can be curious about treatment and treatment theory and treatment recommendations, but I think in the end, we should be practical too.
And we need to consider what's reasonable for a patient's values, goals, and their functioning.
That's a wonderful little story. And I feel like it really, like, very easy to be one of those on that high horses. Like I never prescribed benzos and I never give PRMs and there's no, and then there's just clinical reality. And as you say, like the point is to focus on functionality. It's not to live by some, you know, Platonian ideal of how you should be prescribing and using things.
Yeah. I like using more, I guess I would say that the more creative things in terms of just improving people's lifestyle.
Yeah. So I guess for the benzos, I want to say be aware at the outset and make your patient aware that there are side effects. There are problems of executive functioning. Sorry.
Before before you jump in, I will. I do want to give the because I feel like this is a related to your hair dryer story. It's very easy to be like I remember when I was in. So just for the first two years of residency or inpatient, the third year is outpatient. And I remember saying, you know, my first two years, like all my benzo patients, I'm going to taper them all off the benzos.
I'm going to, you know, I'm going to get them on, do lifestyle interventions. I'm going to get them on better medications for long-term. And then I inherited my patient load and three quarters of them are on standing benzos. And the reality is I emotionally couldn't, the tapering that many people off of benzos is, was, it just wasn't, it's not humanly possible. Um,
And it's not practical either. And it's not good care, you know, especially when someone has been on longstanding benzos. We have basically induced iatrogenically as physicians. We have doomed them to a state of physiological change that may be permanent. They just have to be on those benzos. OK, it's not a good thing. That's why I don't like to do it. But yeah, if someone has that as their standing regimen, be careful, be slow, get a lock collaboration first.
Yeah. And, you know, so the important thing there is really patient buy-in. And there was like a recent big study that showed that there's a higher mortality in patients who discontinued long-term benzos. So it's, you know, there is genuine risks in tapering patients off of benzos. And those need to be genuinely considered. It's not all patients, you know, longstanding daily benzos are bad and they should all be tapered off.
you really have to consider the patient in front of you and consider the risks. And remember that there are serious risks of tapering someone off of a standing bed zone.
Yeah. And that's one of the risks that I want to make sure a patient knows before we start using that in the treatment plan, right? You're going to be on a controlled substance that causes addiction, withdrawal, executive functioning problems, memory problems, sedation, and it probably slows your ability to improve yourself in the psychotherapy as well. And I might be happy to give this to you, but I can't say that if you have to change doctors.
And what if you run out and suddenly you don't have health insurance? There's not going to be a single urgent care emergency doctor who's going to prescribe you an amount that's going to last until the next year. You're going to have to have a horrible withdrawal. It's a method of last resort. It should be a method of last resort, I think. Anyway, so you need to make sure the patient is well aware of these risks and then do not use it for PRNs, especially long term.
Don't use the short acting ones because that's going to make the possibility of forming addictive behavior worse. Personally, I would either do clonfin or valium if I'm treating an anxiety disorder with benzodiazepines.
It's another important point. You should be thinking of treating the anxiety as a standing medication and not as a PRN. It's not like, oh, take this Xanax to reduce your anxiety. There are patients who will pull you and they will desire that and you provide the psychoeducation that that's not the most effective long-term treatment of anxiety.
Yeah, and again, the purpose of the medication is not to obliterate the anxiety, right? If you're doing that, something's wrong. The purpose of the medication is to improve function and to lead the patient towards some kind of a recovery or at least prevention of decompensation. So look at the function. Examine the functioning and activities of the patient and titrate medication accordingly, not based on reported subjective experience of anxiety.
And, you know, I'm just going to keep you. I you'll think that, you know, patients had previous prescribers. They know all these things. I've had I've taken over patients who have really good providers. And when I provide the psychoeducation on this stuff, the patient had no idea that that was the case. You know, there are a lot of patients like you. I think once you're in the field for so long, you kind of think some things are second nature and like, oh, everyone knows that.
X, Y, Z. Everyone knows benzos have addiction risk. Everyone knows, you know, and it's not the case. So even if the patient like it's super important to provide the psychoeducation to everyone.
Yeah, I've had enough patients tell me that I'm the first doctor to have even told them this stuff of the risks that I do believe that people aren't talking about this stuff with patients before they give a treatment. At the same time, I've had patients where I have talked about this, have documented talking about this. And when I revisit the topic at later dates, they go like, you never talked about that.
I don't remember this. So it may be a memory issue too. It's a lot of information. You know, you can't expect anyone to remember this stuff. This is our field. It's our duty to be informing patients and reminding them of it and monitoring for the problems.
I guess that's a great point. And I want to emphasize that don't fall... As a provider, especially with the increased intakes on people requesting certain medications, it's not healthy to be burnt out and roll your eyes if a patient requests a benzodiazepine. You don't want to set up a hot... When patients, let's say if a patient says like, hey, doc, can I have Xanax? I take them not as trying to manipulate me, not as trying to get this drug.
I take them as an innocent person who heard that Xanax is helpful for anxiety and calmly lay out my reasoning as to why I don't think it'll be helpful long term and why we won't be going that route. And When I was early in my career, I would kind of get a little annoyed at them or be frustrated and think that, oh, you just want the easy way.
And it's not the case. And you'll set up more problematic dynamics if you approach it as they want this bad thing. And you'll treat so much better if you take them as their word in that they're just trying to get better. And they don't know why certain medications are good or certain medications are helpful and some aren't.
Absolutely agree.
It wasn't too, uh, eloquent in that, but I think the point.
Yeah. Did we miss any particular medication strategies? I don't think so. Antipsychotics. Oh, no, no, no.
I think it's important that we talk about it because we see it used.
OK.
So you do see it used, hopefully, for treatment resistant anxiety. Typically, Seroquel or Abilify. I think we're on the same page. Antipsychotics are not things I think it should be avoided in terms of should be last, last, last line.
Yeah, I don't do it at all for only anxiety. I think that we have insufficient to know evidence basis for antipsychotic augmentation of primary anxiety. Again, this is not counting OCD, which has been separated from the anxiety disorders since DSM-5. That's how I'm discussing this. I will use antipsychotic augmentation in some people with OCD. uh where can you use antipsychotic augmentation is when there's comorbidity okay comorbidity of a true bipolar disorder or of a true major depressive disorder with major depressive episodes recurrent okay or just severe that that is appropriate but other than that please don't do that
Oh, there's one other one that I wish I talked about earlier. Do you ever... Lavender or Silexan?
Ooh, yeah, we should have mentioned lavender. This is a very interesting choice now. I believe it's only over-the-counter. I don't know of any insurance-covered prescription version of it. But I kind of remember long before the studies of lavender on anxiety, we had a bunch of occupational therapists at our inpatient unit. who were using lavender, lavender scented pillows. They weren't only using lavender. They were also using a bunch of essential oils, almost in the way you would kind of suspect.
Did one of these people have a multi-level marketing thing going on with essential oil people? But they were going off of evidence still. And at least for the lavender companies, uh that one has played out and you can take lavender they have done studies on this and it does seem to have a physiological effect and a treatment effect for anxiety so yes we probably should have mentioned lavender um if they're willing the patient is willing and able to purchase lavender over the counter and take it as uh the studies try it i would probably rank that one around the range of the first to the second step, but I wouldn't say start with it.
This is probably good for patients who just have aversion to anything that isn't quote natural.
Yeah, and I've had really good effects. So just, I guess, in terms of usage and how to use it, it's like 12 to 15 bucks for 30 pills on Amazon. I typically use ComAid. I say start with one pill for a week and then you can move up to two pills. I think that's like 160 milligrams. In terms of the effect I see, almost everyone is like, oh yeah, it really helped me.
And it helps them for like the first month or two and then it kind of peters out. But... i have seen really good effects with it um i do use it uh yeah like you said close to after an ssri or if a patient doesn't want to use um they want something more quote-unquote natural um yeah side effects are pretty minimal uh the lavender burps lavender burps yeah lavender burps is the big one i have seen it could have some impact on female hormones um But other than that, you know, there's minimal sexual side effects.
Yeah. Too expensive. Not into it personally, but if someone wants to try it, it's perfectly fine. There's evidence for it. I just feel like for the effect size, this is not research finding, but for my perceived effect size as a clinician, I think I can get you somewhere similar abuse bar. So I'm not a huge fan.
I feel like there's less side effects. 12 bucks a month. Isn't too crazy.
Depends on who you are.
Depends on your population, of course. But for something with minimal side effects, it does help. I do like using it.
All right. Anything else?
I feel like we got most of the good stuff.
You know, I wanted to talk more about mindfulness. I think that's the ultimate treatment. If you can tolerate and engage with mindfulness practice, that's going to be a fast track to lowering and managing anxiety in the long term. And if that's not working for you, a CBT style Treatment for anxiety is quite helpful. And if that's not working for you, a psychodynamic type treatment for anxiety is also quite helpful.
I find that they're all pretty good in terms of bang for your buck. I say mindfulness and CBT. But in terms of long term full scale personality change, that's obviously going to be psychodynamic psychotherapy in my mind.
Yeah, and I think we should emphasize this was very specifically medications for anxiety. This is if you're going to use medications for anxiety. Now, yeah, let's use the last minute. Review your quick spiel about what mindfulness is or like what you tell patients.
Okay. Yeah, there's three necessary and sufficient parts to mindfulness practice. It's deliberate attention. paying attention on purpose, to the present moment, to what's going on right now, all of it, without judgment. Perceiving it, attending to it, and not layering on extra thoughts and judgment to it. And that includes not judging yourself for having judgment or failing to persist in any of those elements. When you practice mindfulness, there are like 100 or 200 ways of doing it.
Try out a bunch of different ones. Figure out what works for you that you can do for just five minutes to start. Schedule it a few times a week at a time where you're not going to be super bothered and you're not going to be particularly interrupted or unhappy. The purpose of doing mindfulness is not to feel better or get stronger. If you put that goal in your mind, you will subvert the experience and yourself.
The purpose of practicing mindfulness is to simply practice mindfulness. If you make the effort, you have already succeeded. Do that on a regular basis and you will probably find some kind of a longer term change. And if that doesn't work, consult with a professional that can teach you how to practice mindfulness.
Awesome. I'm a huge fan of mindfulness. We keep talking about doing a full episode and I keep kicking the can.
We'll do it someday, I hope.
Awesome. Anything else before we call it?
Nope, nope. I think that covers it. Remember, psychological change and personality change first.
Oh, actually, I have a decent ending to wrap everything up. Sure, sure. Reduced caffeine intake.
Okay. Yeah. You know, we should have started with that. When we talk about medication management, assess entirely for other physiological and medical causes, especially substances of anxiety.
Yeah. Yeah. And I mean, I guess that's should be that's just, you know, you started drinking a Red Bull. Standard psychiatric care. That is a low hanging, super easy thing. Patients often have no, very little, not patients, people have very little awareness of how much anxiety, how much caffeine can impact their anxiety and reduce, like, you know, it's very hard to get someone to reduce their triple espressos from Starbucks.
It makes a huge difference.
Yeah.
So bread bowls, not Red Bulls.
All right. Well, until next time.
you