Anxiety Disorders

These include Panic Disorder with or without Agoraphobia, Specific Phobias, Posttraumatic Stress Disorder, Acute Stress Disorder, Generalized Anxiety Disorder, and Other Anxiety Disorders.  Chronic anxiety is often very disabling, much more than is commonly thought.  A recent English study found chronic anxiety as disabling as chronic depression and more disabling that any medical condition except stroke.

Vitamins and minerals have not been researched much with anxiety disorders, but based on the depression research and for general medical reasons, I would recommend all patients with anxiety difficulties take folic acid 800-1600 mcg per day, and fish oil two-three capsules per day.  For individuals over 50, B-12 500 mcg every other day should be taken whenever folic acid is taken.  There is one study with selenium which found it helped anxiety.  A single positive selenium study also exists for selenium and I really like the health benefits of selenium which I recommend at 200 mcg once a day.

My favorite anti-anxiety medication is hydroxyzine.  It is non-addictive, cheap, and has few side-effects.  When this doesn't work, various anti-depressants should be tried.  I like to start with fluoxetine for young women or children or nortriptyline for everyone else.  Imipramine is well researched with many studies showing positive results.  While atypical anti-psychotics have been found to help, they are best a back up medication. 

Depending on the patient and the symptoms, cognitive-behavioral and behavioral therapies are often as important or more important than medication. 

Chronic Anxiety Disabling: A UK study of 20,921 residents looked as anxiety, depression, and medical conditions. Depressive and anxiety disorders have a profound impact on functional health that is independent of chronic medical illness. Chronic anxiety is associated with physical health limitations in excess of those associated with chronic depression or any of the physical health conditions considered, except for stroke. Functional health status, chronic medical conditions and disorders of mood. Surtees PG, Wainwright NW, Khaw KT, Day NE. Br J Psychiatry. 2003 Oct;183(4):299-303

Norepinepherine Hypothesis of Anxiety: NE neurons in locus caeruleus involved. Clonidine alpha-2 agonist is anxiolytic. These neurons stimulate Ach, CRF, and Glutamate while inhibiting GABA, and serotonin, and NE by negative feedback through efferent projections with projections to spinal cord, and limbic, prefrontal and cingulate gyri. High MHPG turnover in panic disorder. CRF/ACTH/cortisol fluctuations are abnormally uncoupled from NE feedback. Amygdaloid activation with hippocampus memory function. Somatosensory stimuli affect amygdala.

Adenosine A2A Receptor Gene Polymorphisms May Increase Anxiety Risk: Amphetamine is thought to produce its stimulant effects mainly via the dopamine system, but its effects may also be influenced by other systems. Dopamine D(1) and D(2) receptors exist as heterodimers with adenosine A(1) and A(2A) receptors, which modulate their responsiveness. In a study of one adenosine A(1) and three adenosine A(2A) receptor gene polymorphisms for the interindividual variability in amphetamine response in 99 healthy volunteers who received placebo or d-amphetamine (10 or 20 mg), the 1976C/T and 2592C/T(ins) polymorphisms of the adenosine receptor gene were associated with increases in anxiety at both doses. This is consistent with recent observations indicating a role for adenosine A(2A) receptor gene polymorphisms in anxiety. Interindividual variation in anxiety response to amphetamine: Possible role for adenosine A(2A) receptor gene variants. Hohoff C, et al. University of Muenster, Germany. Am J Med Genet B Neuropsychiatr Genet. 2005 Aug 23

GABA Protein Kinase C Epsilon Receptor Involved: Benzodiazepines work on GABA receptors. Mice with PKC-epsilon gene knockouts are much more sensitive tocalming effects of GABA substances like neurosteroid allopregnanolone. J Clin Investigations 10/02 UNC.

Serotonin Transporter Gene May Affect Anxiety: (serotonin transporter) is a genetic factor that determines how responsive a center in the brain is to stress. The gene is called SLC6A4, and it codes for a protein that transports the neurotransmitter, or message-carrying chemical, serotonin from one brain neuron to another. Weinberger, NIMH, Science 7/18/02

Anandamide Reduces Anxiety: Natural neurotransmitter helps. Current research on inhibitors of anandamide breakdown enzyme underway. 12/2/02 UC Irvine

Anxiety Diathesis. The following are notes from a lecture at the American Psychiatric Association 5/16/99: Two-thirds of panic patients have depression, many have substance abuse and personality disorders and avoidances. Persistent anxiety, vigilance, avoidance, unemployed, lost work days. Treatment may increase productivity at work. Anxiety patients are 5-8 times more likely be high utilizers of medical treatment. More chest pain, shortness of breath, irritable bowel, dizziness = the big four with overlap with med symptoms. Increased premature mortality. 2-3 fold increase in sudden cardiac death and more suicide. Rx=SSRI, TCVA, MAOI, Atyp, Both cognitive and behavioral symptoms improve and about equally. SSRIs first line agents. All 5 SSRIs have studies showing of benefit. Start Rx with lower than standard doses, e.g. 10 mg fluoxetine or 25 mg Sertraline. Bring up to full doses after adjustment. A DB PC study for 10 weeks of 243 patients with 10 mg/day fluoxetine almost as good and placebo getting 2/3rds of the benefit and ¾ decr in total disability. Higher dose minimally more effective. Benzodiazepines have been used for panic disorders but they cause sedation, are addictive, do not help depression, and may make depression worse. They have often been used in combination with anti-depressants. Exposure therapy very helpful. Cognitive-behavior therapy by therapist or self-help manuals has often been helpful. Gabapentin, valproate, beta blockers, and buspirone have been used. Combination with TCAs. Anafranils, nefazodone, inositol reported helpful and kava-kava. Treat for at least 1 ½ year before stopping meds. Sometimes multiple augmentation strategies in same patient. SSRIs are approved for treatment of children.

Tana Grady-Weliky: Pre-Menstrual Syndrome reported by 29 million women with mild to moderate symptoms and Pre-Menstrual Dysphoric Disorder (PMDD) reported by 2.5 million who experience very severe premenstrual dysphoria. Mood changes, cravings e.g. choc, salt, carbohydrates, back pain, bloat, water retention. PMDD has marked depressed mood, irritability, lability or anxiety in the luteal phase with at least 4 symptoms for list of 11. It causes significant distress and interferes with functioning. It is not an exacerbation of an underlying disorder. Symptoms remit within 1-3 days of menses. The diagnosis requires prospective daily ratings for 2-months. The progesterone rise is very marked in the luteal phase and there is some increase in estrogen. Patterns of PMDD 1) depression for 7-10 days before menses is called late luteal phase disorder 2) symptoms mild at ovulation and then again late luteal 3) onset with ovulation and remit with menses 4) onset with ovulation and persist until after menses although this group may have underlying disorder. Serotonin modulates mood and appetite and impulsivity and some abnormal 5-HT measures those these have not been consistent. Treatment with SSRIs but also with m-CPP M-chlorophenylpiperzine. 5-HT antagonists made worse. Diet, exercise, calcium, carbohydrate-rich beverages and cognitive therapy can help milder cases and use while having keep a calendar. Eliminate caffeine and salt. Supplement of calcium helped in one study. 1200mg/day Tums. One study with cognitive therapy found benefit. Rx: 1) Hormonal: BCP often used before going to psychiatrist and sometimes help. Progesterone not benefit in DB studies. GnRH agonists lupron very effective. If add in progesterone and estrogen while blocking innate with lupron can recreate PMS symptoms. TCAs and SSRIs have helped. Fluoxetine throughout cycle and 20mg as good as 40. Intermittent dosing does work too at 20mg. Sertraline study of 243 found good benefit. Intermittent dosing did just at well or better. As was the case with fluoxetine. Paroxetine found helpful. Clomipramine intermittent helped. Citalopram helped with intermittent best. If family history bipolar might consider valproate. St Johns wort is popular with patients but no research. SSRIs more effective than maprotiline. No single Rx found effective for all symptoms. Women with higher education have more symptoms on average.

Comorbidity common between OCD, PMS, PTSD, and Panic and all benefited by SSRIs.

David Dunner, U Washington APA 5/16/99: Dysthymic disorder. Major depression usually persists 2 years and dysthymic disorder often starts earlier, persistant. MDD in partial remission is where MDD is first but only partially responded. Therefore four patterns. Not all depressions that are mild are dysthymic disorder. Question if axis I or II. Half of pts with dysthymic develop double depression and is familial with MDD. Response to pharmacotherapy is good but not to psychotherapy. 3.1% prevalence. People don’t come in for Rx readily because assume that it is normal. Depressed more days than not for 2 years or more. B criterion=2 or more of 6 items with poor appetite and sleep problems less common and low energy, low self-esteem and 2 others. Can’t be well for more than two months. Mean of euthymia is 8 days with range 2-30 days. Some get hypomanic at times. Look for MDD. Social withdrawal, pessimism, guilt, irritable, ICD-10 requires 3 of 11 with less talkative, often in tears, and inability to cope. MDD=depressed mod and 4 or more of 7 other symptoms. Only 25% of pts with atypical features. Same Rx as MDD and says TCAs are poorly tolerated. Requires long treatment. 3 DB fluoxetine studies found benefit. Large study (450 pts) found imipramine did a little better than sertraline! Both better than placebo. Imipramine with 200 mg average although a higher dropout rate. Fluoxetine better than cognitive therapy although both improved. Need a high dose of psychotherapy. One study found placebo did better than fluoxetine probably due to small size of study allowing just a couple patients to have a big impact.

See: Psyc meds: hydroxyzine; Many studies with benzodiazepine show some benefit but addictiveness a problem with worsening on withdrawal. Other meds similar to buspirone researched in other countries with similar benefits. Many studies with buspirone showing of benefit, but cost of buspirone is high.

Escitalopram (Lexapro) Helped Generalized Anxiety Disorder Somewhat: In a 315-patient, 8-week DB PC study, escitalopram (10 mg/day for the first 4 weeks and then flexibly dosed from 10-20 mg/day) resulted in a HAM-Anxiety score decrease using a last-observation-carried-forward (LOCF) approach of -11.3 for escitalopram and -7.4 for placebo (P<.001). Response rates at Week 8 were 68% for escitalopram and 41% for placebo (P<.01) for completers, and 58% for escitalopram and 38% for placebo LOCF values (P<.01). Escitalopram in the treatment of generalized anxiety disorder: Double-blind, placebo controlled, flexible-dose study. Davidson JR, Bose A, Korotzer A, Zheng H. Duke University. Depress Anxiety. 2004;19(4):234-40. Ed: This small superiority over placebo is hardly worth $1000 per year. I prefer to start with hydroxyzine pamoate 50 mg. three times a day. If this doesn’t work, there are several low-cost anti-depressant medications in low doses that work just as well as Lexapro. As can be seen in this study, the inferior LOCF analysis makes the active drug look better than it really is. That’s why drug companies prefer it and rarely report an "intention to treat" analysis.

Fluvoxamine Helps Kids and OK Long-Term: 8-week placebo-controlled study, the Research Units on Pediatric Psychopharmacology Anxiety Study, 127 pt 7-17yo, documented beneficial effects of fluvoxamine in the treatment of pediatric social anxiety, separation anxiety, or generalized anxiety disorders. 6 month f/u found improvement generally maintained. John Hopkins, Treatment of pediatric anxiety disorders: an open-label extension of the research units on pediatric psychopharmacology anxiety study. Walkup J, Labellarte M, Riddle MA, Pine DS, Greenhill L, Fairbanks J, Klein R, Davies M, Sweeney M, Abikoff H, Hack S, Klee B, Bergman RL, Lynn D, McCracken J, March J, Gammon P, Vitiello B, Ritz L, Roper M; The Research Units on Pediatric Psychopharmacology Anxiety Study Group. J Child Adolesc Psychopharmacol 2002 Fall;12(3):175-88

Fluvoxamine of Minimal Benefit in DB: In a large 300-patient 12-week DB PC study of Social Anxiety Disorder, patients improved only 37% on fluvoxamine and 28% on placebo.  This very small difference was statistically significant only because so many patients were in the study.  However, such a small benefit is not very impressive. Univ. Utrecht. Netherlands. A double-blind placebo-controlled study of controlled release fluvoxamine for the treatment of generalized social anxiety disorder. Westenberg HG, Stein DJ, Yang H, Li D, Barbato LM. J Clin Psychopharmacol. 2004 Feb;24(1):49-55. Ed: The study was undoubtedly funded by the manufacturer. The authors claim the study shows fluvoxamine is "efficacious" and safe.  In fact, the study shows fluvoxamine is only slightly better than sugar pills!

St. John’s Helps Somatiform Disorder: Psychopharmacology (Berl) 2002 Nov;164(3):294-300.151 pt DB PC Germany, Placebo 15 to 11 v 15 to 6 with St. John on HAM-A somatiform items. Helped CGI, depression, anxiety.

Anxiety Helped by Trazodone or Imipramine Slightly More than with Benzodiazepine: In a 230-patient DB PC 8-week study of generalized anxiety disorder, diazepam (Valium) patients (average dose 26 mg) improved the quickest.  However, by the third week, imipramine (average dose 143 mg) and trazodone (255 mg) were catching up.  Among completers, moderate to marked improvement was reported by 73% of patients treated with imipramine, 69% of patients treated with trazodone, 66% of patients treated with diazepam, but only 47% of patients treated with placebo.  While the antidepressants caused more side-effects, drop-out rates were equal. A placebo-controlled comparison of imipramine, trazodone, and diazepam. Rickels K, Downing R, Schweizer E, Hassman H. University of Pennsylvania. Arch Gen Psychiatry. 1993 Nov;50(11):884-95

Paroxetine Slightly Better than Placebo: 566 GAD pt 8 weeks DB PC with paroxetine 20mg/d vs 30mg/d vs. placebo. Response 62% and 68% vs. 46%. Remission in 30% and 36% vs. 20%. U. Penn. Paroxetine treatment of generalized anxiety disorder: a double-blind, placebo-controlled study. Rickels K, Zaninelli R, et al. Am J Psychiatry. 2003 Apr;160(4):749-56

Pregabalin (Lyrica) Helped Anxiety: In a 4-week DB PC study of 276 adults with generalized anxiety disorder, pregabalin (150 mg/day or 600 mg/day), lorazepam (6 mg/day), or placebo. Fewer patients given lorazepam (59%) completed the trial than placebo (73%), 600 mg/day of pregabalin (71%), or 150 mg/day of pregabalin (90%). Hamilton anxiety scores decreased 9.2 with150 mg/day of pregabalin, 10.3 with 600 mg/day of pregabalin and 12.0 with lorazepam vs. 6.8 for placebo. There were no serious adverse events reported by patients given pregabalin, and no withdrawal syndrome was associated with pregabalin treatment. Pregabalin in generalized anxiety disorder: a placebo-controlled trial by Pande AC, Crockatt JG, et al. Am J Psychiatry 2003 Mar;160(3):533-40. Ed: Pfizer is developing this new medication.

Selenium Helped Anxiety in HIV+ Drug Users: DB PC 63 pt 200 microg/d. At the 12-month evaluation, participants who received selenium reported increased vigor (p = 0.004) and had less anxiety (State, p = 0.05 and Trait, p = 0.02), compared to the placebo-treated individuals. No apparent selenium-related affect on depression or distress was observed. The risk for state anxiety was almost four times higher, and nearly nine times greater for trait anxiety in the placebo-treated group, controlling for antiretroviral therapy, CD4 cell decline (> 50 cells) and years of education. U Miami. Psychological burden in the era of HAART: impact of selenium therapy. Shor-Posner G, Lecusay R, Miguez MJ, Moreno-Black G, Zhang G, Rodriguez N, Burbano X, Baum M, Wilkie F. Int J Psychiatry Med. 2003;33(1):55-69

Sympathyl Herbal Remedy Reportedly Helps Mild to Moderate Anxiety: A 264-patient 3-month DB PC study from Paris reports that an herbal preparation containing Crataegus oxyacantha,  Eschscholtzia californica, and magnesium helped more than placebo in treating mild-to-moderate anxiety disorders (Generalized Anxiety Disorder) with associated functional disturbances, under usual general practice prescription conditions. Benefit was modest and side-effects were minimal (1.8% more had side-effects than in the placebo group). Double-blind, randomised, placebo-controlled study to evaluate the efficacy and safety of a fixed combination containing two plant extracts (Crataegus oxyacantha and Eschscholtzia californica) and magnesium in mild-to-moderate anxiety disorders. Hanus M, Lafon J, Mathieu M. Curr Med Res Opin. 2004 Jan;20(1):63-71

Trazodone Better than Clorazepate (Tranxene) for Cancer and HIV Adjustment Disorder Anxiety: 2 small studies of roughly 20 patients each. Difference not significant unless combined. 86% vs. 61% helped. Both Belgium. Comparative study of the efficacy and safety of trazodone versus clorazepate in the treatment of adjustment disorders in cancer patients: a pilot study. Razavi D, Kormoss N, Collard A, Farvacques C, Delvaux N. J Int Med Res 1999;27(6):264-72; Efficacy and safety of trazodone versus clorazepate in the treatment of HIV-positive subjects with adjustment disorders: a pilot study. De Wit S, Cremers L, Hirsch D, Zulian C, Clumeck N, Kormoss N. J Int Med Res 1999 Sep-Oct;27(5):223-32

Venlafaxine XR (Effexor) Slight Benefit for Generalized Anxiety: In five DB PC trials of 1837 patients with Generalized Anxiety Disorder, Wyeth drug company employees in France report that their medication did better than placebo for both 8 weeks (57% vs. 41%) and in two trials for 24 weeks (66% vs. 41%). Pooled analysis of venlafaxine XR efficacy on somatic and psychic symptoms of anxiety in patients with generalized anxiety disorder. Meoni P, Hackett D, Lader M. Depress Anxiety. 2004;19(2):127-32. Ed: While venlafaxine is an effective medication for anxiety, so is virtually every other available antidepressant.  Venlafaxine might be the perfect match for some patients, but in general it has no advantages over much less expensive medications.  It has a high rate of discontinuation due to side-effects. Also, the immediate release version should soon be available as a generic at a much lower price. 

Venlafaxine Modest Benefit for Generalized Anxiety: In a 28-week, 386 patient DB PC study of generalized social anxiety disorder (GSAD), venlafaxine ER fixed low dose (75 mg/day), or venlafaxine ER flexible higher dose (150-225 mg/day) had a 58% response rate compared to 33% for placebo ( P<0.001); remission rates were 31% and 16% ( P<0.01). There were no differences in outcome according to venlafaxine ER dosage. Efficacy of low and higher dose extended-release venlafaxine in generalized social anxiety disorder: a 6-month randomized controlled trial. Stein MB, Pollack MH, Bystritsky A, Kelsey JE, Mangano RM. University of California San Diego. Psychopharmacology (Berl). 2004 Jul 16

Venlafaxzine Better Than Placebo: Generalized anxiety disorder patients treated for 6 months. Remission in 61% v 43%. Relapse 6% v 15%. J Psychiatr Res 2002 Jul-Aug;36(4):209-17

Venlafaxine Slightly Better Than Placebo: In a DB PC study of 377 patients treated with 75, 150 or 225mg/d venlafaxine for 8 weeks, HAM-A (24 at baseline) decreased 9.5 points for patients on placebo vs. 11.2-12.4 for venlafaxine groups. Only highest dose significantly better on all outcomes. Rickels, Am J Psychiatry 00;157:968

Venlafaxine Better than Placebo: In a DB PC study of 150 mg or 225 mg/d for 238 patients with generalized anxiety disorder without major depression within past 6 months, only 41% of patients completed the 6 month trial! 52% on venlafaxine and 65% on placebo withdrew. HAM-A decreased 13.4 for venlafaxine and 8.7 for placebo. Gelenberg, Univ. S. Carolina, JAMA 00;283:3082

Venlafaxine Better than Buspirone Which was Better than Placebo: In a DB PC study of 365 patients treated for 8 weeks with venlafaxine XR 75 or 150 mg/day vs. buspirone 10 mg t.i.d. vs. placebo, venlafaxine did best. Duke. Efficacy, safety, and tolerability of venlafaxine extended release and buspirone in outpatients with generalized anxiety disorder. Davidson JR, DuPont RL, Hedges D, Haskins JT. J Clin Psychiatry 1999 Aug;60(8):528-35. Ed: Buspirone has always been a disappointment and makes an easy target for the manufacturers of venlafaxine.

Testosterone Helped Hypogonadism with Anxiety: 34yo with GAD not helped by relaxation or biofeedback, helped by buspirone 30/d but d/c. Hx unilat orchiectomy for undescended testicle. Testosterone level low. Testosterone enanthate 200mg IM q2weeks improved concentration, libido, orgasms and relieved anxiety. Cooper, AJP 00;157:1884

Neither Valerian Nor Kava Helped Anxiety or Insomnia in Large Internet Study: It had to happen.  In the first internet-based, 4-week DB PC study of 391 adults with anxiety disorders from all across the U.S., neither those assigned to kava nor valerian did any better than placebo on tests for anxiety and insomnia. An internet-based randomized, placebo-controlled trial of kava and valerian for anxiety and insomnia. Jacobs BP, et al. University of California-San Francisco. Medicine (Baltimore). 2005 Jul;84(4):197-207 

Kava Helped Anxiety in DB: vs placebo for anx. 101 outpt with agoraphob, gen anx disorder, adjustment disorder with anx Rx 25 wk DB placebo multicenter with Hamilton Anx. Kavalactones 70mg tid. 75% vs 51% improved at 24 weeks. Claim no evidence of tolerance. Kava better than placebo after 8^th week. Also better on Clinical Global Impression and self-report symptom inventory. Adverse events rare and same in both groups. Author favors kava over tricyclics and benzodiaz. Hans-Peter Volz, Jena Univ, Germany, Pharmacopsychiatry 1/97 30:1-5; In J Am Coll Health 5/98 46:271-6. Wong says fr South Pacific. Neuroprotective in animals and anticonvulsive. May help anxiety. 100-200mg of kavalactones in divided doses or HS. Long term at 400 mg may get scaling.

Kava Helped Anx in DB: 58 pt non-psychotic anxiety Rx 4 wk 100mg TID or placebo. Benefit measured on HAM-A from 1^st week significant. Also on CGI benefit. Kinzler, Artxneimittelforschung 6/91;41:584. Another similar study of 58 pt by German researchers in 1996 mentioned in Kava: Nature’s Stress Relief by Kathryn M. Connor, M.D., Avon Health: New York 1999. "Recent" German study of anxiety 38 pt DB by Germans kavain 200mg tid vs oxazepam 10mg bid with no diff and 65% improving. E. Lehmann 1996 Phytomedicine 3:113-9 ‘96: 58 "anxiety not from mental disorders" pts DB 100mg standardized (70mg kavalactones) 4 weeks with kava doing better. Y.N. Singh 60 pt DB 4 week 60mg kavalactones bid found kava superior. South Sea islanders consume 750-2000mg/day when drinking it. Supposedly a study of 40 individuals in 1993 found no harmful effect on driving tho Connor advises caution. May help pain. Found useful to decr UTI pain by numbing bladder lining. Some anti-inflam properties.

Kava Helped Anx in Female Climacteric in DB: 20 or 40 pt Rx 8 week 100 mg TID or placebo for anxiety in "female climacteric." Improvement on HAM-A. G. Warnecke, Fortschrit Med /91;109:119. Also improvement in depressive mood, subjective diary, CGI. Benefit noted by 1^st week.; Heavy Kava drinkers on Tonga islands get pellagroid type skin rash. History of consumption predates European discovery of it in 1880. Consumed in cafes in South Sea Islands as a bitter but relaxing beverage and wide European use since 1920. From plant root. (Ed: Despite what these writers claims, there is good evidence both from the South Sea islands and from the U.S. that Kava is addictive. I would recommend it only as a last resort, since there are so many non-addictive alternatives.)

Carbamazepine Not Very Helpful in Benzodiaz Withdrawal: Klein, Israel, Am J Psychiatry ’94;151:1760

Benzodiazepines: The inability to move or speak for up to several minutes on awakening or just before falling asleep occurs at least once in a life-time for 6% of 8000 people interviewed in Germany and Italy. It was five times more common in people taking anxiolytics. Neurol ’99;52:1194-200

Alprazolam (Xanax) Causes Serious Driving Impairment: Alprazolam caused serious driving impairment, as expressed by a significantly increased SDLP (F(1,19) = 97.3, p <.0001) and SDS (F(1,19) = 30.4, p <.0001). This was confirmed by subjective assessments showing significantly impaired driving quality (F(1,19) = 16.4, p <.001), decreased alertness (F(1,19) = 43.4, p <.0001), decreased mental activation (F(1,19) = 5.7, p <.03) and increased mental effort during driving (F(1,19) = 26.4, p <.0001). Neuropsychopharmacology 2002 Aug;27(2):260-9

Social Phobia: Phenelzine or Cog-Behavioral Counseling Help: 12 week 133 pt DB placebo with placebo attention, both helped tho phenelzine (15/d to 90mg/d increaseed over 5 weeks) worked faster with 59% v 21% response after 6 weeks but 77% v 75% after 12 weeks. Both better than placebo with discussion groups. Other studies sho fluvoxamine, sertraline, paroxetine, clonazepam better than placebo but not atenolol, alprazolam, or buspirone. Three DB with phenelzine find 2/3 pt respond. Richard Heimber, Arch Gen Psychiatry ’98 55:1133-41 SUNY Albany

Excessive Work Can Increase Illness: Workers who do overtime were 61% more likely to become hurt or ill, once factors such as age and gender were taken into account. And working more than 12 hours a day raised the risk by more than a third, the University of Massachusetts found. A 60-hour week carried a 23% greater risk, the study of US records from 110,236 employment periods found. BBC News 8/17/05. Ed: It's probably more important whether you enjoy the work or not and whether it's voluntary or mandatory.

Substance Abuse Markedly Increases Anxiety in Affective Disorders: In a study of 260 adults in a supported socialization program, multivariate logistic regression analyses were used to determine the relationship between anxiety disorders and alcohol and substance use disorders among patients with severe and persistent affective disorders (i.e., major depression and bipolar disorder). Among patients with severe and persistent affective disorders, cocaine (odds ratio [OR] = 5.9), stimulant (OR = 5.1), sedative (OR = 5.4), and opioid use disorders (OR = 13.9) were all significantly more common among those with, compared with those without, anxiety disorders. This association persisted after adjusting for differences in sociodemographic characteristics and comorbid psychotic disorders. Significant associations between panic attacks, social phobia, specific phobia, and obsessive-compulsive disorder and specific substance use disorders were also evident. The relationship between anxiety and substance use disorders among individuals with severe affective disorders. Goodwin RD, et al. Columbia University. Compr Psychiatry. 2002 Jul-Aug;43(4):245-52.

Thomas E. Radecki, M.D., J.D.

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