Module summary
GPSI in mental health Dr Emma Nash discusses four cases involving patients presenting with anxiety and advises on the appropriate management approaches
Learning objectives
This case-based module will enhance your knowledge of the management of anxiety in general practice, including:
- Treatment options for someone experiencing crisis in anxiety disorder.
- Dealing with potential alcohol misuse in the context of worsening anxiety.
- Recognition of the different potential psychiatric presentations of anxiety, how to explore a specific diagnosis and how this affects management.
- Distinguishing panic disorder from panic attacks, and other underlying causes of related symptoms, and choosing appropriate treatment.
- How to escalate pharmacological treatment and support engagement in psychological therapy in patients with uncontrolled symptoms.
Note that all cases in this module are hypothetical scenarios developed for illustrative purposes only
Case 1. Woman presents with spiralling anxiety, requests sedative medication
You see a 35-year-old woman with a long history of anxiety in your emergency clinic. She has been on sertraline 50 mg/day for two years. She has had a lot of stresses lately in her work and home life and she feels like her anxiety is spiralling out of control and she can no longer cope. As a result, she is sleeping poorly and has started to drink more alcohol. She requests a course of diazepam and a supply of promethazine for night sedation – she says these have been very helpful in the past.
1. What is the role of medication like promethazine and benzodiazepines in the management of an ‘anxiety crisis’?
Promethazine is an antihistamine with sedative properties and is also licensed for short term treatment of insomnia. It is not a dependence-forming medication, although prolonged use is not recommended as cessation of treatment can result in discontinuation symptoms such as nausea, sweating, dizziness and insomnia. Due to its non-addictive nature, promethazine may be a good first-line choice in a case like this.
The NICE quality standard on anxiety disorders includes the quality statement ‘people with anxiety disorders are not prescribed benzodiazepines…unless specifically indicated’.1 Due to their association with tolerance and dependence, their routine use is not recommended. However, this is not a blanket exclusion. There may be some circumstances where they are appropriate, such as management of crisis in someone with an anxiety disorder. There is no defined criteria for anxiety disorder crisis, so a pragmatic approach is needed. Considerations include risk of harm to self or others – both by prescribing and not prescribing, degree of functional impairment and level of distress. Context is also important – where there is a history of dependence or suspicion of misuse, exploring alternatives first may be more appropriate.
2. Ideally, how are these situations best managed?
Evidence-based psychological interventions are recommended as first-line treatment, in preference to pharmacological treatments. However, the speed of access to therapy services, and gradual nature of benefit, means that they are often not useful acutely, on their own. Where patients have previously had psychological therapy, encouraging reflection on the session that they had, and reinforcing the benefits of the techniques they have learnt and the understanding of their psychological difficulties, can be useful.
Grounding techniques can be used to cope with overwhelming emotions and intolerable distress, and are a form of self-help. There are a wide variety of strategies to use, aimed at refocusing the individual on the present moment, diverting attention away from distressing thoughts. These including physical and mental grounding techniques and are widely available online. The Priory website has a helpful summary for adults,2 and Young Minds has an easily accessible blog aimed at children and young people.3
As well as looking at how the symptoms can be managed, it is important to have a discussion about any precipitating factors or triggers which might be amenable to modification. Life circumstances could be addressed, with the help of the wider primary care team such as social prescribers. It should also be explained that alcohol can worsen anxiety and reduce sleep quality, as it is often used to self-medicate these conditions, but actually makes them worse.
3. How can the complication of substance abuse, like alcohol, be managed in this situation?
It is not clear in this scenario whether the use of alcohol is at a harmful level or not. NICE is clear that non-harmful substance misuse should not be a contraindication to the treatment of generalised anxiety disorder.4 They go on to say that harmful and dependent substance misuse should be treated first, as this may lead to significant improvement in the symptoms of generalised anxiety disorder.
Although there may be challenges in engaging substance misuse services to work with someone while they are not stable, wider appreciation of the co-existence of, and interplay between, mental health conditions and substance misuse disorders means that collaboration between services to offer joint support is increasing. We should not preclude treatment for one disorder because of the presence of another, and general practice is particularly good at managing co-occurring conditions.
In primary care, we can deliver alcohol brief interventions. These are evidence-based, structured conversations that seek to motivate and support the individual to think about and plan a change in their drinking behaviour in order to reduce consumption and risk of harm.5
We also need to be mindful of the impulsivity that can emerge when intoxicated, and factor this into our risk formulation. This is particularly important in the context of her stating that she ‘can no longer cope’. Exploring what she means by this, and what strengths she has to help her cope, is part of this risk formulation and personalised management plan.
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Dr Emma Nash is a GP partner in Hampshire and clinical lead for mental health at Hampshire, Southampton and Isle of Wight ICB
In practice, promethazine, and similar drugs, are actually addictive.
Think back to when Benzodiazepins were heralded as the wonder drug for insomnia because they were not addictive, like barbiturates were.
A few years later, ‘Z-drugs’ were heralded as the wonder-drug for insomnia because they were not addictive, like Benzodiazepines were.
A few years later, Gabapentinoids were heralded as the wonder-drug because they were not addictive like the ‘Z-drugs’ were.
A few years later, antidepressants (like Mirtazepine) and antipsychotics (like Quetiapine), were heralded as the new wonder drugs for insomnia as they were not addictive like Gabapentinoids were.
And now we know that all of the above (even Quetiapine) are highly addictive, so we are moving onto a group people have forgotten about.
In the presence of alcohol addiction, there is a red flag already present for developing dependence to all drugs of the above groups, including Promethazine, which also encompasses the drug ‘Doctor’ and probably placebos too.
This makes choosing a non-addictive and temporary solution to the problem exceedingly difficult, and needs much better access to talking therapies and other measures to tackle situational and socioeconomic factors in anxiety, insomnia, and alcohol use.