Dr. Jill Sisselman presents the case of an 80 year old patient with high anxiety manifesting with constant worry, agitation, poor sleep, and tearfulness. Dr. Sisselman seeks feedback from the group on the use of benzodiazepines versus SSRIs in this patient given her age and anxiety. Dr. Mary Kate Christopher then gives a didactic presentation on pharmacological management of anxiety. She discusses different anxiolytics including how to choose the right medication, safety considerations, and common patient questions and concerns.
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Case Presentation Case Discussion Didactic Presentation Didactic Q&A to the audience of their discussions of unlabeled or unapproved drugs or devices. Faculty disclosure summary may be found in PowerPoint slides. Thank you. And without further ado, I would like to turn over to dr Jill cinnamon from the cinnamon medical group who is going to be presenting a case for us today, Dr Cecillon take it away. Hi. Thanks for having me. Um I am a family practitioner that practices in Long Island and this was a great forum because we are really seeing almost a third of our cases each day um with mental health issues. So it's really become a forefront of primary care, especially since covid and especially since it is virtually impossible to get people in in a timely manner to therapists and psychiatrist and psychologists. So more and more it's falling on us. So I thought this was an interesting case because it combined a couple of things with age and anxiety and what medications do we use and the pitfalls that we have in prescribing them so you can start the slides for me. So this is an 80 year old female who is um Medicare patient and she does live alone and she's retired. She is not somebody that I typically see in the practice, but in january in the middle of all macron came to see me and we were actually doing parking lot visits at the time. If you came in with some any symptoms of being ill. We would come out to the parking lot, see you examine you and decide what kind of testing you needed. So she initially presented with um cough and some low back pain and proceeded to tell me that she has this whole heart thing going on that she's in the midst of and could not elaborate further. So at the time she had a history of hyper lipid e. Mia and hypertension. And at that moment I did not know about the aortic aneurysm. So that will come into play a little bit later. And initially she was on um load up in val certain baby aspirin Lipitor and premed own. She does have an essential tremor for which she takes the premed in for. And she seemed to be a very nervous person. So her first visit was a virtual visit about the um all the whole heart issues that she's having and the cough. So we proceeded to talk about her symptoms and I didn't really want to do much for her until I figured out what the whole heart issue was. Um And you know she agreed and she just wanted to know that her cough was okay And I had told her to take an anti histamine and some felonies at the time. And then a week later she presented to come to the parking lot to be seen still discussing her heart issues. Not aware of what they were but that she knows she's seeing a surgeon and that she's going to need heart surgery. So I still had no information despite trying to call her cardiologist and get that information over. I had no information on that. And when we talked about her cough and the anti histamine that she was taking, she continued to just go over her symptoms over and over again and it was very hard to finish the visit with her. She never seemed to be well assured. So we continued to talk about that. I needed the cardiac information on her to be able to better assess what was going on with her. And then I received the information and now still about five days later. So this is her third visit in two weeks. She comes to the office telling me that she has to have heart surgery. She has this back pain and she's meditating and praying and listening to music and she still wakes up full of anxiety that this heart issue came out of nowhere and she has to have surgery. And she was a complete nervous wreck. So we talked about the normalcy of those feelings and I did try to couldn't comfort her with the fact that you know with going through surgery and it coming out of the blue that she is okay feeling that way and and understanding how she felt that way. And did she want to start anything that could help her. So I'm not a big Benzo fan for anybody, but especially for this age population, I feel that even at a low dose they're at risk for falls. She lives alone. It can alter you. Um And I just don't like starting those medications on this age population. And she had agreed with me because she said she needed to keep her wits about her and she didn't want to be off balance. And we decided to start her on an Ss Ri. And I chose Lexapro because she was in such high anxiety dire straits. And in my experience Lexapro does work one of the quickest. I feel that it does help people within a few days to two weeks where some of the others take a little bit longer. So I agreed to and she agreed to go on the Lexapro. And then two days later I find out that she's in the hospital due to hyponatremia. So she actually wound up going to the emergency room for anxiety and feeling her heart racing. And it turns out that she was hyponatremia. So she had only been on the Lexapro for two days and I was concerned about that being a side effect of the S. S. Ri. And I had followed up with her after the discharge tried to follow up with her because I wanted to keep close management on her electrolytes. And we had some trouble getting in touch with her and I found out that she did end up in the hospital to have her aortic aneurysm repair. So I lost her for about a week or so and then after her discharge, she did a virtual visit with me with her daughter there and she was a mess. She was a mess for several reasons and she was very difficult to comfort and only wanted to talk about her experience in the hospital. So she had a very poor experience in the hospital where she was not getting enough sleep and they come in every so often to take vitals and were bothering her and then they put her to rehab and the same thing happened so she was exhausted, she couldn't sleep and she felt that she needed help in that respect. So we talked about keeping her on the Lexapro versus the hyponatremia and I wasn't really sure if that was the cause of the hyponatremia. So we did keep her on the Lexapro, I checked her sodium again and she ended up dropping her sodium again on the Lexapro. So she actually ended up back in the hospital due to hyponatremia and nuance at a fib And interestingly enough, one of the things we talked about when she first had presented with the anxiety was, could there be a reason, an organic reason for this anxiety? You know, when do you decide is this person really anxious or is there an underlying cause? It seemed to come out of the blue and be out of character for her. So we had done a whole work up on her and everything was fine and now she has this a fib that's contributing to her anxiety. So she ended up back in the hospital which was actually a good thing because she ended up seeing a psychiatrist there. I had spoken to the hospitalist who had admitted her for me and I told her about all the anxiety and the need for some kind of medication. And I wasn't sure if the hyponatremia was linked to the S. S. Ri but the patient didn't really want to come off of it. So they had given her some Benzos in the hospital but she really didn't like how she felt on it and she was still getting agitated. So she is discharged on the Lexapro still. And the psychiatrist did add Remeron for her. So which was a very nice way of getting her hooked up with a psychiatrist. But had she not, My question remains, do you keep somebody like this on an Ss Ri where does the hyponatremia come in? And what else or what in place could we have used for this? So in my experience I don't use a lot of the other antipsychotics. Um they're not as comfortable and familiar in my wheelhouse as things'll like the S. S. R. I. S. Or the snr eyes or Wellbutrin beause bar those type of things. Um So I don't think that I would have been comfortable adding something else to her and then would she have been able to get help from a psychiatrist as quickly as she did in the hospital. So you did you did you want us to show any of the other pieces you can slip, go over to the other slide. So part of the her history that becomes difficult to decide which part of anxiety and which part of her personality comes into play was when you wanted to speak with her and you wanted to try and help treat her. She just wanted to continually keep telling her story. And if you tried to redirect her, she would say that she wanted to please let me tell my story. And this came into play in the office. And this came into play on the virtual visit when she was so upset after the hospitalization and the rehab and her experience and being sleep deprived. And prior to this, she had no family psychiatric history that we know of and no history of trauma that could have brought on the anxiety other than the diagnosis of the aneurysm next slide. So she did get diagnosed with anxiety. Um and the psychiatrist did not add any other diagnosis is to that. Um and then these other symptoms came into play to heighten her already existing anxiety where she had the constant worry about the surgery, the agitation of her experience in the hospital and the rehab facility and her inability to sleep while she was there were certainly contributing to it next slide. So at the time, her treatment plan was the Lexapro and she continued to stay on that until the hospitalization which just happened a few days ago and the Remeron got added for her. Um And she's I'm gonna follow up with her for the hospital and she will continue to have a social worker that will engage with her post hospitalization and and as as an outpatient and her daughter is very involved with her and you can see that sometimes she gets frustrated but she is there helping to take care of her. So again my question is you know at what point does a benzo work even in this age population to help with the high anxiety but where it doesn't put a patient at risk and can an ss ri given enough time really help a patient like this. Okay thank you so much. Um I just wanted to know if you could clarify before we jump in and ask others for input the dosage for the Lexapro and the Remeron if you're aware. So I started her on um five mg of Lexapro for a week to ease her into it because she was when people are very nervous about starting it and side effects, I like to start them at the five mg and then in a week if they're tolerating it go up to 10 mg. So she never really made it there before she ended up in the hospital but she did get discharged on the full 10 mg and I would have to um look for you quickly to find the dose of Remeron? Thank you. Um Thank you so much for presenting this case. Um You know, and really appreciate sort of the history and all of the pieces of the journey. She's been on this since january that you shared um dr cheung uh you have a question, would you like to ask it yourself second? Okay. See me. Yeah. All right. So she's 80 years old. Could be she has another primary doctor, another family doctor. Maybe you get a lot of information from him or her because she complains like this now, she must have been doing this the last 80 years she might have been. Um but when I say she hasn't been seeing me, she has been seen in the practice by some of the other providers. So she doesn't really have a lot of any documentation of high anxiety and I do believe that perhaps she had it underlying with her personality, but this trauma of having the heart surgery and the fear of what could happen to her, brought out the anxiety along with it great. Um I wanted to see if um dr Christopher if you have any thoughts or suggestions or anyone else from the hub team before we take more questions from folks in that. Yeah, I think this is a really great case to present because it definitely, you know, brings up some challenges that we have in treating our geriatric patient population. Um And and it's always a good idea to get those baseline labs to see is this the Lexapro or you know, was there something going on before this? I think the addition of Remeron was a good choice and it may be that Remeron can be used solo, you know in replace of the Lexapro because it does carry less of a risk of S. A. D. H. Although you know the risk is still there, you know, so it it can be problematic using our medications. Um I'm wondering about gabapentin tin, if there was any thought about using that you know in lieu of R. S. S. R. I. S. Or. Yeah I try to avoid, especially in this age group things that can make you dizzy, lightheaded and I do feel that people have you know at a decent dose of gabapentin tin, it does get um you know those side effects of dizziness, lightheadedness, fogginess. So always come concerned with this age population and this happens a lot as people age they get depression or anxiety and I'm always struggling to find the right medicine for them. They generally do well on S. S. R. I. S. But um you know again with the fall risk and a lot of them still do live alone. I feel that God depends in you know it maybe it could be a great choice but it's something for me in my comfort. I don't love when people who live alone have that risk of falling. Right. Right. No, I think that that's fair and you know, it's one of those medications that comes in the 100 mg capsule. You know, it's hard hard to dose lower with that. And certainly there's that ataxia and sedation component to it. Yeah. I guess if I started 100 mg and titrate and you know, to the lowest dose that they feel okay then perhaps they won't have those side effects. You know, the other 100 mg cause that with some of our older people. So it's a tough call. It really is. I can understand the struggle here. Yeah. And you know the struggle in primary care where she is a perfect example of is that the virtual visit For her after she came out of the hospital was 35 minutes. So you know, I was lucky enough that I didn't have a pile up because of it. But you know again because she was so insistent on saying let me speak, let me tell she had to go through her entire hospital stay and experienced that in rehab. Where it was very hard to cut her off and I don't really want to cut her off because her visit is for me to help her. But that's where psychiatry or a psychologist comes in so much better because they have that 45 minutes to really dedicate to a patient where I don't and that sounds callous, but that's the reality of it. Um I wanted to also um Note, you said that she was engaged with a social worker after her discharge, and um, if it's somebody who can provide that support to her to give her the time to tell her story, I think that's wonderful. You know, I wonder with this 80 year old, like, we don't know, I'm assuming she's widowed. Um Right, so, we don't know, for example, you know, did her husband die of heart issues? And so here she is, at the age of 80 diagnosed with heart issues, and she's going to have surgery, and, you know, maybe some of this is she's frantic about dying. Um and that's where I think seeing a social worker who might be able to delve into that um is really helpful. The other thought I had, you know, if I were the social worker talking with her as I'd want to talk to her daughter, who may be pulling her hair out with a mother. You know, this woman may have leaned on the side of anxiety, but again, a d and hard issues, you know, she just may be really frantic and good for her to talk to somebody and good for her daughter. Absolutely, because for her, I think part of the care and part of her treatment is being able to talk, and I think the suddenness of the heart diagnosis was what was so worrisome to her, but, you know, she absolutely would benefit from somebody to give the time and I don't know if those type of social workers that get given in home discharge planning are those counseling type or are they just coming in, you know, continually assessing her in the home? Right. I mean if it's a social worker who came through like a certified home health agency, they'd probably be with her one or two times and who knows? But dr system in certainly this is the type of patient that care management can talk to by phone, you know, to give her some time to really process what's going on. So, you know, I know I'm a broken record on some in some of these meetings, but you know this is this is somebody who you know, if she would want to talk with us by phone um please refer her to us and we'll reach out to her and her daughter. I'll definitely do that and that would be great. And you know, that's the problem with these times where you know um old enough to know the times when a patient got discharged from the hospital, the primary care doctor was involved in discharge planning. So that would have been something that could have helped set up before she got discharged and um you know, so now I have to go after the fact and talk to the home health agency and see if we can get that for her, But discharge planning at the time would have been great. Sure. Sure. But feel free to to um to refer to us and I can put in the chat uh our email address. That would be wonderful. Thank you. Thanks judy. Um Dr Gorman, do you want to ask your question about S. S. R. I. S. Um And the risk sort of in the context of bleed? Oh yes. Um So I'm one of the rehab docs here. So we use a lot of like SRS in our patients. But how do you guys feel in like the the non traumatic or traumatic bleeds? Um Do we see an increased risk um realistic, increased risk of intracranial bleeds? Um in patients who already have bleeds especially this population. Is it something that we may not want to start SRS for? I'm not sure. So yeah, someone could answer that. Not me. Yeah. There's it's something we've thought about a lot I think and there's sort of a lot of talk around it, you know, I think in in the psychiatry world um definitely important to get, you know, a platelet level. And I think when I was at Sloan we wouldn't do SSR eyes with platelets under 50 I think, but I'm forgetting. Um But the risk is from what I've seen pretty minimal, especially if patients have, you know, platelet level within normal limits. Um And it's just you know because of the serotonin ergic properties within platelets. we worry about bleeding risk there but I wish I had more for you. I haven't thought about it in a little while. No problem, thank you. I appreciate it. And dr Christopher you know that's something that we can touch based on after if you wanted to kind of provide an update, we can certainly circulate that around as well in case similar questions. Right? Because next next month I'll be doing another lecture. So that's when I could definitely highlight. For sure. Thank you. Other questions or suggestions for dr system and particularly around her. Um You know, specific conundrum around, you know, when when might you go the benzo route versus not. I'm also wondering about the use bar which is a partial serotonin ergic agonist. I don't think it carries the same risk, you know, similarly to Remeron. Um As R. S. S. R. I. S. And S. N. R. I. So possibly substituting Lexapro with abuse bar could be something to consider. Yeah I've seen that my, one of my nurse practitioners is a fan of boost bar, you know we all become accustomed to what we use over the time. Um And I do think it's a nice alternative to the Benzos for people who are overly anxious. I think it works well. Can you use it as a PRN or do you need it more daily? I've heard some patients say that as a Prn it works but really you know it's one of those that we think works best using daily and it is typically B. I. D. Dozing. Um But it's generally well tolerated doesn't carry as intense side effects as the S. S. R. I. S. Or S. In our eyes. I just uh this is dr Cornwell, just sharing my experience. I'm definitely not an expert but I have had many patients like like this and hi judy hi everybody. Uh So again so I at times I moved from queens to Manhattan I found you know many many elderly um on bends of the ice opinions. But the other thing that my concept you know in acute events uh you know using low doses and for a very short period of time uh doesn't make the cut on the risk benefit analysis. Um You know if if you know and sometimes I do approach it like that like considering as as the colleague said that you know perhaps you have another week til it kicks in or two weeks even in the best case scenario. So I I do consider and I I have used uh the lowest dose possible and trying to bring the patients of like 96 week, 96 hours a week after starting and see where we are. Um You know it is a fear but it's also part of the treatment now and then there's like the couple of people that can tolerate uh accessorize and summarize I mean and and there are some that can tolerate or non response. So it is complex. So I just wanted to put back on thank you thank you. You know I'm a I'm a person who and maybe this is a very too strict of a line of thinking but I feel that for me, once I start people on the Benzos I can't get them off. They all like the sedated, feel they all like the tranquility of it. Um and I find that once I start it is hard to get them off. So I try not to start it. There are very few times that I will and have them you know strictly say that they can just take it at night or if they're going to stay home in the high time of panic and say I'll only give them short supply to know that it's not going to be renewed and I'll set that straight from the beginning. But like you I have a lot of people who have come to me already on Benzos even two and three times a day and I've had to work so hard to taper them off of it and they actually will sometimes you know often say they feel better off of it. This patient have like quantifiable amounts of like panic attacks or like any like cadence or any kind of way we can quantify that. No just um you know her voicing of her high anxiety and panic and and her blood pressure going high while she was in the hospital and rehab. And to the point where they considered her agitated and put her on out even in in the hospital. Um but she didn't really have anything like that. Um She felt much better after our last virtual visit and she got a good night's sleep and had the Lexapro um and you know, everything was over. So I do think the situation was a lot of it, but I didn't see any elements of panic or any other symptoms like that. Okay, I'm sorry if you mentioned that that she had like regular like issues with insomnia or sleep on a nightly basis. Okay. Yeah. I think I would probably maybe get creative and like try abuse part first and rather than the Benzo if there is a concern of like dependency though, you know, I would be a proponent of like a short term short term benzodiazepine in like the interim of getting used to the ss ri if somebody had panic and then giving them a limited supply maybe for the first 2 to 4 weeks. Um and then trying to quantify how often or how frequently the panic episodes occur and then um if somebody's having insomnia, trying to avoid the use of that as like a bedtime agent. Just because then there might be better sleep associated with that and maybe a higher likelihood of asking for more. Thank you. Um Dr cheung you had another question. Would you like to ask it? I was just thinking if anybody in the hospital did an M. R. I have a brain because it seems like a pretty drastic change from a person who didn't have panic attacks and anxiety and didn't talk about the same thing over and over again. So now this person can't get loose from the ideas of her suffering. Maybe she had a stroke and she has some kind of frontal frontal lobe problem that she's this is all a brain problem. Not really an anxiety problem. I'm just thinking maybe maybe something's there. Yeah I'll look back through the records and see that but I don't recall seeing any brain imaging on her. Were you out of curiosity, were you able to recall the Mortaza pin dose? Okay let me know. I didn't want to give some insight because it has like an inverse relationship with the dose so oftentimes especially in like a 7.5 mg dose might be heavily to dating. If that ends up being a route you take then maybe consider actually starting at 15. So it has serotonin ergic and nora ephron ergic effects and um at lower doses or very low doses it might be overly sedating whereas 15 there might be a better balance between the Norwegian ergic and serotonin ergic effects 7.5 mg nightly. Okay. Did she experience any of the exhibition or feeling too dated in the next day. I have she got that in the hospital. I haven't seen her, She was just discharged a few days ago and she didn't make her follow up appointment is next week. I see. Okay. So just be curious to see if that's something she might be feeling in case you're worried that like aside from the hyponatremia CDH if if maybe if she's feeling overly sedated or maybe you want to give that a shot and see how she responds that maybe 15 might be a little bit more, it's counterintuitive but actually more conservative. Okay. When um when we did her I didn't do her non face to face but um someone in my office did and she didn't report anything back about that. So I don't know that she asked it directly but she didn't report any issues that she was having. I just want to note also going back to dr chung's question about any kind of, you know, vascular event that may have been associated. Um Dr Gorman also noted kind of where is the bleed? Um and sort of the need to potentially understand that um any other questions or suggestions for Dr cisa Leman, other folks perhaps on the call that have similar patients or similar questions that come up in your practice that you know you're recalling or this is resonating that you might have some suggestions from experience to share. I imagine the Benzo versus not struggle is not an uncommon one. Um in primary care, particularly to Dr Layman's point when patients ask for it or asked to stay on it. Um So if there's anything folks want to share, that might be a useful suggestion for Dr Simon, I would appreciate. Yeah, I think it's it's always a tough risk benefit um scenario. And with our elderly patients I I definitely more hesitant to prescribe benzodiazepines, I always try to set limits in the beginning and set a plan in the beginning. You know, I'm I will prescribe this for x amount of weeks and then, you know, we'll go to like maybe three times a week and then we'll think about coming off, so just kind of being very boundary around it and letting them know like we're sticking with the plan, this is what we're doing type of thing. Um can be helpful and in the long run may help the patient, you know, to to not remain on these medications. Alright, thank you. Um I also just another suggestion, you know, given that she's uh an older adult who lives alone, I don't know if there are um educational or support oriented groups, particularly if they're offered virtually, I wonder if that might help her um you know, I know that those are hard to come by and harder to access. Um But I know that sort of a setting where she doesn't have to be alone with these problems and she can talk it out with other folks that are experiencing similar things That might give her more space to kind of express this stuff that she otherwise brings to you. Um So that might be worth, particularly if you connect with care management, um judy something that we might explore um to see what options there may be around it. And then one other suggestion before we switch gears and go to the didactic. You know, I'm struck by her daughter is now involved in her care. I don't know if she attends appointments with her or not. She's only had virtual since the hospital, so her daughter does attend the virtual with her and I'm not sure if the one next week is in person or not. Okay. You know, just thinking about, you know to dr chung's question about how much of this is new, what maybe other precipitating factors that the patient hasn't articulated. You know, the daughter may be able to fill in some puzzle pieces that might give you a little bit more information um that potentially might affect you know how you move forward, right? I'm hoping that if I hook her up with somebody that they'll be able to delve into that more. So sure. Yeah, well thank you very much doctor system and I hope this was helpful. I hope you're taking away some food for thought um and things that potentially, you know, maybe actionable as well. Um any other questions that you have before we switch onto the didactic? No but how could it not be helpful by having all these great minds together all at once to sit and care for my patients with me. Thank you. Thanks so much. Thanks everyone for your help, I appreciate it. Thank you. Um Okay so then without further ado um I will switch over to the didactic portion of this evening's session um If we could just pull the slides up. Oh dr Christopher you're doing that right? Yeah yeah so I will do that now. Okay okay sorry I'm just kidding it. Can you see that? Yeah we can see that. Um While you're getting the setting to how you like, are you good to go? Um I think so. Okay I just wanted to introduce you really quick dr mary kate Christopher is consultation and liaison psychiatrist who splits her time between the center for stress resiliency and personal growth which is a space that Mount Sinai health system is established specifically for the mental health of our own employees. Um As well as she also spends some of her time at the post covid center. Um Really excited to have her here. She's also part of our hub team. And so I'm really excited for this talk. Um dr Christopher do introduce any other aspects of yourself that I have left out. Thank you very much. Um everyone and it's I'm really happy to be here? Um I am a constant liaison psychiatrist. So my main area of interest within psychiatry is working with medically complex patients and also interfacing with the medical teams with providers such as yourself. And I really appreciate that case presentation we just went through um and appreciate all of your thoughts on that. So I'm going to be discussing effective treatments to manage anxiety through the use of psychotropic medications. Um And our case was really a great starter to this presentation first. I do want to highlight these two resources. So successful psychopharmacology by steven sobel and then essential psychopharmacology. Prescribers by guide by Stephen stall their books that I've used throughout my time in psychiatry. Their user friendly information is nicely organized and easy to access information on specific medications. Okay so I'm going to frame this presentation through a patient case that may be typical for one in the primary care setting. Um We have here a 31 year old woman. She's living in new york city and employed full time as a nurse. She has a medical history of asthma and a psychiatric history of mild anxiety currently engaged in weekly therapy. And she presents for her annual physical exam during which time she reports worsening anxiety in the context of psychosocial stressors including her work as an E. R. Nurse during the pandemic. So she reports the following symptom Atala ji excessive worrying, irritability, poor concentration, restlessness, fear that something awful might happen. Poor sleep with difficulty falling asleep and staying asleep. And she also notes that she had a panic attack last month. Since that time she's been worrying about having another panic attack and avoiding settings which might trigger a panic attack. So you deliver the generalized anxiety disorder rating scale the God seven and she scores a 14 out of 21 indicating moderate to severe level of anxiety. So first we have to consider etiology. We review the patient's medication regimen as you might recall. The patient has a history of asthma. So it would be important to ask her if she's using her inhaler more frequently as this could be contributing to some of her panic symptoms. We review her lab work. We check TSH and T. Four because we know that hyperthyroidism can precipitate anxiety. We check Cbc and vitamin B. 12. The symptoms of anemia can mimic panic symptoms as can electrolyte abnormalities and hypoglycemia. It's also important to ensure that kidney and liver function are within normal limits. As doses of medication may be altered depending on functionality, I get a lipid panel and an A. One C. As some of our medications are weight precipitating. And if the patient presents with chest pain and palpitations we might also want to do a cardiac work up. I always recommend a baseline E. K. G. And then we might consider cardiac enzymes or even a dime or to rule out pe. So as we rule out organic etiology. We also want to screen for psychiatric comorbidities. We want to do a thorough substance use screen. Is the patient experiencing alcohol or benzodiazepine withdrawal? Is the patient using a stimulant, cocaine or ingesting more caffeine than usual. Also marijuana, while patients often think about marijuana as a calming agent, we know that it can precipitate anxiety and even paranoia. And some people, we also want to make sure to screen for depression. So two thirds of patients with generalized anxiety disorder also have major depressive disorder and screen for depression can be made simple through the P. H. Q. To which we can deliver with the Gods Seven. So I also screened for trauma. Did our patient experience a recent traumatic event or do they have a history of childhood trauma? Both of which may be contributing to their presentation. Screening for trauma is important as it may inform our treatment plan. A psychotherapy is a crucial part of the successful treatment of PTSD. And really psychotherapy is an important treatment modality for any of our anxiety disorders. As the combination of psychotherapy and medication is more effective than either treatment modality alone. So we should offer referral information for CBT if available. So our patient reports that she's not been using her inhaler. Her lab work is within normal limits and cardiac work up is negative. She denies any substance use except for the occasional glass of wine. She also denies any recent feelings of depression. She notes that her work in the er has been incredibly stressful and at times emotionally taxing but she does not characterize her experiences as traumatic. She does report a history of childhood adversity within a score of three. So our patient already came to us engaged in weekly therapy yet she's still experiencing a significant level of anxious distress. So we can be confident in our decision to utilize medications to augment this patient's therapeutic intervention. So the question becomes which medications do we want to utilize? And first line agents for anxiety disorders regardless of diagnostic specificity, are going to be antidepressants. So for generalized anxiety, panic, ptsd social anxiety or O. C. D. The first medications we want to consider our our S. S. R. I. S. And S. N. R. I. S. So these medications modulate the activity of the serotonin system which in theory rains in an overactive amygdala, the brain region which is the site of fear and when excessively activated dr symptoms of anxiety. When you suggest an antidepressant, your patient maybe confused, you know, I'm not depressed, I'm anxious. So it can be important to reassure patients that these medications can just as easily be classified as angle itics as most are FDA approved to treat some form of anxiety disorder. But since a majority of patients with anxiety are also experiencing depression it is to our advantage that these medications are effective in treating both conditions. Um and we consider these agents first line because they're generally safe well tolerated, not habit forming and effective. They're difficult to overdose on. Um one disadvantage of these medications are they're delayed onset of action so it can take up 3-4 weeks to affect mood. Um but we can address this through the use of adjunct medications which I'll talk about a little bit later. As you can see there are a number of Srs and srs. So the question becomes, which one do we use? Which one's the right one for our patient. So we can approach this choice by using four sequential factors. The first thing you want to think about always is safety. So as our patient taking any other medications depending on the patient's medication regimen, we might want to consider using an ss ri such as Lexapro or an S. N. R. I. As these have less drug drug interactions if the patients elderly Lexapro is a good choice because it's well tolerated in this patient population and they're more likely to be on complex medication regimens. Is the patient pregnant breastfeeding or intending to become pregnant. If so we want to avoid prescribing Paxil because it's category D in pregnancy and consider a safer option such as Zoloft the second faction factor to take into consideration is efficacy. So we want the medication that we choose to work you know with these medications it can take some trial and changes it works for one patient may not be effective for another but we want to give it our best shot on the first go around. So in an effort to do this we should ask patients if they've ever been prescribed an antidepressant in the past, Was it effective? Was it ineffective? We should also ask if any family members have been prescribed an antidepressant as biologically the patient may respond in a similar way, but ultimately the most effective S. S. Ri or S. N. R. I. Is the one that the patient is going to take. If our patient is concerned about a specific side effect, we should choose a medication that's less likely to cause that side effect. For example, if our patients concerned about weight gain, we might want to avoid Paxil as this medication is more likely to cause weight gain. On the other hand, if our patient is struggling with weight loss we could use this side effect to our advantage. And the last thing to consider is availability. Some of our newer antidepressants um like Trent Felix or press teak are more costly and therefore not a realistic option for some of our patients. Okay so now I'm gonna take you through the different S. S. R. I. S. And S. In our eyes that we commonly prescribe and highlight some of the advantages and disadvantages associated with each medication um I'll briefly touch on side effects. Um But next month's lecture is dedicated to side effects. So I'll talk about that more then and I'll talk about drug drug interactions, discontinuation syndrome and tapering strategies during that time. Um But all of rss rss and snR eyes can cause G. I. Issues, insomnia or sedation, headaches, dizziness, tremors. These side effects are generally transient and they'll remit within the first 1 to 2 weeks on the medication. But more persistent side effects include sexual dysfunctions. So low libido, difficulty reaching orgasm, erectile dysfunction in males and sweating. It can be important to let patients know that these side effects can be persistent while on the medication. But after the medication is discontinued these effects will go away so they're not permanent. Some more serious side effects include serotonin syndrome, risk of bleeding, um even precipitating hypomania, mania or manic episode. And we can talk about that more next time. And lastly we want to reiterate to patients that these classes of medications are not addictive. So the first medication I want to highlight is Zoloft, it's a medication that I commonly use because it seems to be well tolerated by patients and it works really well for anxiety disorders. It's not overly sedating or stimulating. So generally it's kind of middle of the road. The dose range here is 50 to 200 mg daily. Um I start with 25 mg. So half of the lowest dose for 1 to 2 weeks. To minimize side effects when starting on the medication And then I increase to 50 mg daily if the patient is medication naive I'll hold at the starting dose and then follow up within 3-4 weeks. If the patients having having a good effect in terms of mood I'll hold here. Um but if not then I'll increase the dose for a better therapeutic effect. And this is going to be true of all of our antidepressants. We want to see at least like a 30% improvement in mood within 3-4 weeks. And if we're not seeing that we should increase the dose. So the advantages of Zoloft specifically it's the safest choice for pregnancy and breastfeeding. It's also saved for patients with recent M. I. Some disadvantages here. There's more G. I. Side effects when starting on Zoloft. Compared to our other ss ri notably diarrhea, there's also a longer dose hydration. So the dose range here is broad from 50 to 200 mg. So it could take longer to get to a therapeutic dose. The next medication I want to highlight is Lexapro. Um So this medication's FDA approved for generalized anxiety but commonly used for all of our anxiety disorders. It's dose ranges 10 to 20 mg daily. I start with half of that at five mg and then I'll titrate up from there. Of note for our geriatric patients doses should not exceed 10 mg daily. And that's because there's data indicating that the benefits of going higher than that don't outweigh the risk of possible Q. T. C. Prolongation which I'll talk about in a minute. Um advantages of Lexapro. It's rss ri with the fewest drug drug interactions. So it's good for our elderly population. There's shorter tight rations to max therapeutic dose and it may be among the best tolerated antidepressants. Also of note it may cause less sexual dysfunction than our other ss rs some disadvantages here. Um Some patients report they find a little more sedating and there is this possibility of increasing the risk of Q. T. C. Prolongation. So in the U. S. And Canada this warning is not on the label but it is in the U. K. So we do want to be mindful of it. Um Next we have CeleXA, this is another S. S. R. I. F. D. A. Approved only for depression but commonly used for anxiety. So I did want to highlight it. It's an Ananta more of Lexapro. So they work similarly. I tend to choose Lexapro over CeleXA because Lexapro is less sedating generally better tolerated. Doesn't carry that warning in the U. S. And Canada of the Q. T. C. Prolongation and you can reach max therapeutic dose more quickly. Um But notably with CeleXA there are reports that it reduces agitation in patients with dementia. So you might see it in that setting. But a big thing here is the risk of Q. T. C. Prolongation. Um For all patients we shouldn't exceed doses of 40 mg. Um And then for geriatric patients we shouldn't exceed 20 mg. It's also mild histamine properties. So it can be more sedating. Then we have Paxil. This medication is commonly prescribed. It's FDA approved for all of our anxiety disorders. Those ranges tend to 60 should be taken at night because it's sedating. Some patients report they experience a quick relief of insomnia and or anxiety after starting on this medication compared to our other S. S. R. I. S. It's also available in a controlled release formulation which is usually better tolerated and mute. But there's some major disadvantages with Paxil. Um One sexual dysfunction may occur more commonly. It can also cause dry mouth and constipation because it has some anti Colin ergic properties. And then it's category D. In pregnancy due to an increased risk of cardiovascular malformation. It causes weight gain. It's also a potent two D. Six inhibitor. So there's gonna be drug drug interactions here and there's more discontinuation effects than with their other SSR eyes. So patients typically have a harder time coming off of Tax cell. Then we have PROzac. So PROzac is FDA approved for panic and O. C. D. But again prescribed for all of our anxiety disorders dose range here is 20 to 80 mg and it's best tolerated when taken in the morning because it has an activating stimulating effect. Um The advantage here it has a long half life and it can be prescribed is actually a once per week dose. So it's good for patients who have issues with compliance works well for O. C. D. Also good to prescribe for patients who have co morbid bulimia disadvantage because it's more activating and stimulating than other S. S. R. I. S. It can actually worsen anxiety when starting on on it. Um But if patients report like good previous effect on it it's okay to utilize. I would just start at a low dose and go up slowly and again. This also has interactions with their sip for 50 system. So you'd want to be mindful of multiple medications here and then we have blue box. So this is a good medication for O. C. D. Dose range. Here is 100 to 300 mg often given at night. Do desiccation like Paxil patients report early relief of insomnia and anxiety after initiating on this medication. Um Less likely to cause weight gain and there are reports that it has anti inflammatory properties. It's being studied in the acute covid setting and also the post covid setting disadvantages. There's a longer dose titrate nation more gi side effects and this is our ss ri with the most drug drug interactions. So you're definitely gonna want to check your patient's medications against loot box before prescribing it. So now we'll get into the S. N. R. I. Serotonin norepinephrine reuptake inhibitors. Um Generally I like to start with an S. S. R. I. And then if they're ineffective I move to the SnR eyes. But if I have a patient with co morbid pain, Cymbalta could be a good place to start. And that's because it helps treat fibromyalgia, neuropathic pain, chronic musculoskeletal pain, migraines. Those range here's 30 to 60 mg daily. Some disadvantages dry mouth constipation can increase blood pressure mildly and um in rare cases it can cause urinary retention and then the last antidepressant I'm going to talk about is effects er another SnR I it comes in an extended release formulation which has a lot less side effects than our immediate release. So I'd always go with the extended release. Start with half of the starting dose so 37.5 mg for 1 to 2 weeks and then titrate up advantages minimal drug drug interactions with a fixer and it could be good for co morbid A. D. H. D. Because there are reports that it helps with concentration and focus. A major disadvantage here is it can increase blood pressure. So not a great option for patients with hypertension and you want to get a baseline blood pressure before starting this medication. It can be more activating than rss our eyes. It can cause more gi side effects and it has a short half life. So there's more discontinuation effects when tapering off of effects are so I do want to highlight the geriatric patient population and it was great that were coming off of a you know a challenging geriatric case. Um Generally S. S. R. I. S. Are better tolerated in the geriatric patient population than S. N. R. S. We want to consider drug drug interactions and Lexapro maybe our safest option here. Keeping in mind that there is this risk of Q. T. C. Prolongation. We shouldn't exceed doses of 10 mg on Lexapro or 20 mg on CeleXA. Also notably the risk of S. I. D. H. In the elderly population which can precipitate hyponatremia. I recommend after starting one of these medications to follow up. Um More closely because of this risk. There's also a risk associated with S. S. R. I. S. With osteoporosis. So if someone's on them for a long time you know the risk of osteoporosis can increase. This brings us to bus bar so BuSpar is a partial serotonin agonist. Um It's an alternative first line agents to S. S. R. I. S. Or S. N. R. S. It's a good option for patients with mild to moderate range anxiety with no co morbid depression. Um And for a patient who may be concerned about side effects like there's no sexual side effects associated with use. Bar. Um less weight gain and discontinuation of this medication is generally well tolerated. It doesn't really need to be tapered. So we can use this solo to manage anxiety disorders or we can use it to augment or S. S. R. I. S. Or S. N. R. S. For better therapeutic effect Disadvantages here because it's a partial agonist, it might be less effective than our antidepressants and it carries that same delayed onset of action. So it can take up 3-4 weeks to start. Okay so circling back to our patient, we recommend that she started on Zoloft 25 mg daily with a plan to titrate the dose up as tolerated and indicated we engage her in a conversation about the medication, outlining its method of action, risks, benefits and common side effects. We inform that this medication is not addictive and that it needs to be taken on a daily basis for it to be effective. The patient expresses understanding and is amenable to starting on the medication. But she asked some common questions including how long will I have to be on it? Is this medication forever? It's important to reassure our patients that this medication is not intended to be a forever medication. General guidelines recommend that we treat with these medications for approximately one year and then we can trial off the medication while monitoring for recurrence of symptom Atala Ji, we should inform patients that abruptly stopping antidepressants can lead to discontinuation symptoms. This is different from withdrawal. It's not a life threatening syndrome but it can be uncomfortable and I'll talk about this more during our next lecture but it's important to note that our antidepressants with the most discontinuation effects include Paxil effects er and one of our newer antidepressants. Press teak. So during the course of our conversation, the patient notes that she was previously prescribed non Extra Flying and she's been taking this medication a few times over the past month, prior to taking the subway to avoid having a panic attack on the train. So this is not an uncommon scenario and it is okay to utilize Benzodiazepines on a Prn basis to mitigate anxious distress or panic attacks. They can also be used on a standing basis short term to mitigate anxiety while our first line agents take effect. And it can be important to utilize them because as I mentioned are antidepressants sometimes can worsen anxiety in the first few weeks while the patients getting used to them. So this brings us to our benzodiazepines. It would be important to highlight the risks associated with this class of medication, including addiction potential and respiratory depression. When combined with alcohol or other sedating medications we should use with extreme caution in patients with obstructive sleep apnea due to the respiratory depression. Um It's not recommended in pregnancy. And for our geriatric patients there's an increased risk of falls and fractures. There can be a paradoxical dis inhibitory effect and there could be risk of cognitive impairment. But these medications are effective and they have a rapid onset of action. So they can be important to use on a short term basis to provide patients with more immediate relief of symptoms. Um Benzodiazepines commonly prescribed for anxiety include Valium Klonopin Ativan and Xanax. So Valium is our longest acting Benzodiazepine and Xanax is our shortest acting. I tend to avoid Valium especially in the elderly population because of its long half life. It can accumulate in the body and it increases the risks of psycho, motor impairment, cognitive impairment sedation falls. I also tend to avoid Xanax because of its short half life. There can be more rebound anxiety which can potentially eight habit forming behavior. So I tend to stick in the middle with either Klonopin or even Klonopin has a bit of a longer half life with a slower onset of action. So theoretically it could be less addictive. A devon is another option. Some patients describe it as less sedating than Klonopin and it's often used in the hospital setting as it can be given I. V. Or injection um With either of these medications I use the lowest possible effective dose for the shortest possible period of time and I assess the need for continued treatment regularly as risk of dependence increases with those and duration of treatment. So this brings us to some alternatives for adjunct including Neurontin. Also known as Gaba Penton. It's not FDA approved for our anxiety disorders but it's used off label commonly and that's because there's a mild side effect profile. Few drug drug interactions. It can be used for sleep. It's helpful with neuropathic pain. Um It can be used standing in three divided doses or on a prn basis from 100 to 600 mg. I tend to stick with 100 mg. Side effects here. As we noted during our case sedation. Ataxia tremor G. I issues. Another option is at Iraq's um this is an anti histamine and FDA approved for anxiety. It can be taken up to four times a day. I find it to be helpful with sleep and there's also no abuse. Potential disadvantage here can cause confusion in the elderly. It can be delirious genic and should be avoided in dementia pay sections And then we have beta blockers. So this class of medication can be helpful for panic symptoms because they target autonomic hyperactivity. They're often prescribed for performance anxiety and they're given like 90 minutes before intended performance. They can be utilized on a prn basis for panic attacks or standing to mitigate more chronic panic symptoms. We have a 10 a. Law which is a selective beta blocker and propranolol which is non selective attention. Lol has an advantage and that its once daily dose ng. Um And with propranolol we want to keep in mind some disadvantages it crosses the blood brain barrier so it can worsen depression and it's contraindicated in patients with asthma and severe COPD. So it can inhibit bronco dilation. Also important to note certain S. S. R. I. S. Can increase the level of beta blockers due to two D. Six inhibition like PROzac does this. So it's important to be mindful of that and then this brings us to sleep. So patients with anxiety typically have issues sleeping as our patient did. Um And I like to use Prn AD Iraq's transindo nor gather Penton um to start with and then also off label process in for pTSD related nightmares is very effective with traZODone. It would be important to inform males that there is a risk of priapism and then some takeaway points before we finish up when the patients presenting with anxiety. We want to rule out organic etiology screen for comorbidities. Our first line agents are antidepressants and juice bar. I like Zoloft and Lexapro Zoloft because it's well tolerated effective Lexapro same thing. And then there's the added benefit of safety and geriatric patients or patients on multiple medications. And then Cymbalta can be a good choice for our patients with chronic pain. Adjuncts should be used in the short term to mitigate anxiety when starting on our first line agents. It can be used long term as augmenting agents but we should try to avoid benzos as a long term adjunct sleep. I like to use Transit don't add Iraq's or Gava Penton and then length of treatment here is one year and then we taper and monitor for recurrence and then that brings us to our Q. And a um section of the presentation. Thank you so much dr Christopher um anybody have questions for dr Christopher after that incredibly informative and comprehensive. Um Talk. Um hi this is Tyree a social worker and I just wanted to thank you for that presentation. I wish there was some way to briefly condense that with patients uh when they meet with PCP because we have a lot of patients in the older adult category who do have anxiety and the number one fear is side effects, right? And and just really being able to understand um you know, what's common, what's not common, what's to be expected, what's what's the most effective based off of the demographics? Um A lot of the patients uh that I talked to um the sleep is one of those things. And so you you kind of laying out, you know what's best, you know, for generally for the most common, you know, scenarios. I think it's great and I wonder if there's some, you know, I know every case is unique but I wonder if there's some way to kind of uh uh you know, package this presentation in a way that it can be digestible for patients and social workers who have to to interact with a lot of these patients. That's a great point. Um Tyree dr Christopher. And if you want to say something, I have a thought, but I'll let you go ahead. I was just gonna say that, you know, all of the slides and recordings of mind matter sessions are available on the behavioral health page for M. S. Hp. So tired when you're working with the patient as questions come up. If there's anything that you can use as reference from those materials it's always available. Um And then more importantly we frequently take the content that are incredible didactic speakers provide and package them into materials that can be circulated and used as reference. Um You know that's likely something we will attempt to do with dr Christopher's talk both today as well as next month because there is value to your point around reference materials that are easy that are condensed that can be used as needed um in patient care. I hope that answers your question I hope that will address. Um But you know if you have suggestions for practical tools we're always happy to do what we can to make it easier on the clinical practice side with the information that we have from experts at Sinai including dr Christopher. Hi I have a question more of a comment. Thank you. I think I've attended all of these Mind Matters sessions and I find them all excellent. I think tonight was the best of course especially the case presentation which was excellent. But I just I I honestly don't know who she is but she's an excellent presenter but just to reiterate I think you know mental health right now is so incredibly important the pandemic has really you know magnified mental health right now and so many of our patients even if it's not there presenting complaint there are certainly associated complaints and so many people we see and so many of these people are not getting care from a mental health specialist, they're using their primary care. So the more tools we have to be able to help these people the better. And I'm just so grateful for all of you for doing this and taking your time and presenting this information, which is just so incredibly important. So it's not really a question. It's a thank you, thank you. And as I said before, you know, we modeled mind matters after the project echo format because um input from folks in the field is much more valuable right than anything else. And so I really appreciate that you attend every month because it does help us build that community where folks can provide support and receive support because we all have tough cases that right, like that throw us off from time to time, so really appreciate it. Thank you for for everything that you guys do, it's just so important. Thank you, appreciate hearing that. Um dr cui no, you have a question about th C. U. S and Ss Rs jennifer Queen. Oh, did I say that right, I apologize if I'm mispronouncing your last name, I can read the question out. Perhaps it's um um do you hear me? Yes, please go ahead, Okay. I have a population that uses, I have a younger population that tends to use THC as a treatment for anxiety and one of the things that I've been reading is that if, you know, if a person is actively using THC ss ri are contra indicated um What is your opinion on that? I mean, how do we? And I don't see that it's effectively actually treating their anxiety that ST ta see that's not medically, you know, prescribed. Um I'm finding that there's I had a patient and ended up in a whole psychosis being admitted to the er because of, you know, the whole THC us. Okay. Right. Yeah, that that's a good point and that's why I wanted to highlight it in the beginning of my presentation because a lot of people consider marijuana and T. S. A. To B. You know, an angry elliptic. Um But for some people it's precipitates anxiety and you're right, it can lead to paranoia and psychotic episodes, especially in our younger adults. Um I'm not aware of a contra indication between the two of them. Um But I just think psycho education becomes really important, you know, giving our patients the information and then kind of going from there. It's not easy. Okay, thank you. Would also just add particularly with younger folks um you know, if they are amenable to listening to, you know what we know physiologically to be the reaction of marijuana in our body. Um You know, it might be helpful to also just take the opportunity to distinguish between when you smoke it versus when you consume it as edibles. Um you know, sometimes folks, they don't put those pieces together. Um I, I personally have had a patient who insisted that she never has any adverse effects to marijuana, never has any symptoms of panic or anxiety after. Um and it was when you kind of sat down and considered typically you smoke it this time you happen to take an edible, like there's a difference in the way your body processes metabolizes that. Um you know, kind of the pieces clicked in her head. Um she was able to make some adjustments, just would uh, add to what you said. Dr Christopher about psycho education to just really get a flavor for what are they actually doing when they talk about marijuana? Um dr cheung, you have a question, would you like to ask it? So a typical response when you try to put a patient on anti anxiety, antidepressant is all, I don't want to be a zombie. All my friends, they said I'm gonna become a zombie. So my personality will change, my emotions gonna change. I don't want that. So how do you get them over that barrier? Um yeah, that's actually a common question. I hear that a lot. Is this going to change who I am. Um sometimes our antidepressants can lead to some emotional flattening. Um, but I don't hear that commonly from patients and I think the ideas here, we're using these medications to mitigate all of these symptoms that you're telling us negatively impacting your life. Um and they'll work to kind of mitigate those symptoms so that you can be more yourself. I also always stress to patients, you know, if at any point you're not comfortable being on this medication, you don't like the way it's making you feel we can take it off, you know, when we can do that in a safe way and I just reassure them around that so they don't have to feel like they're locked into this medication. And you know, I say they're really probably isn't much harm to give it a try if you're experiencing, you know, these these profound mood symptoms. That's a great, great question. I'm glad you asked dr Cheung, I'm curious, I'm dr Christopher on that note, if you could talk about kind of, you know, you you you mentioned you don't have to be on these medications forever, which is, you know, another element of it um as well, which commonly people assume or expect almost. And so um and then we obviously we see an over prescription problem as well, Right? Um and so I'm curious if you could speak to kind of the right, not the right. I know it's difficult to speak about it broadly, but, you know, kind of how do you how do you provide that education to patients about what they can expect in terms of the process of reaching therapeutic dose, But also then like how long you keep them on it and then when you start to pull them off it. Yeah. So the general recommendation and this is for depression and anxiety is that after symptoms remit or have substantial improvement, we remain on the medication for a year um and then we trial off of the medication and we taper the dose down slowly to avoid discontinuation. And there's also been reports that tapering down slowly also reduces the time to recurrence. Um And that's really the recommendation across the board. If patient has experienced anxiety depression for the first time, if they experience you know, multiple subsequent episodes, then the recommendation becomes more long term treatment with these medications. But especially when patients are coming in medication naive first episode. It's really important to let them know that we want to stick to their that recommendation and after a year you know it is important to try to come off of these meds. Great, thank you. I'm dr Austin. Do you want to ask your question? I've just heard about a new long acting LORazepam called Laure Eve and I want to know if that has any special benefit or use uh and chronic anxiety patients. I'm actually not familiar with it so I can't can't speak to it but I don't know if anyone else has had any experience with it. La reve spelled L O R E E V doesn't sound like others on the call happy to look into it. Um Dr Austin as well. Oh Tyree this isn't I don't have an answer to that question. Listen to the question. Um What I guess this is um an open question in terms of what's your um your take on homeopathic approaches because one of the other concerns that patients always have again um of the you know, the psychotropic side effects and and maybe you know, it's a deficiency issue uh and wanting to explore um you know, more natural approach to some of the symptoms of the anxiety um and treating it that way. Do you feel that it's it's more it's effective. It's not as effective. Um I've read studies that melatonin maybe isn't the best thing for sleep issues. Um And so just trying to get some feedback on kind of addressing some of the symptoms individually as opposed to kind of them as a group. Uh So I'm always you know, a proponent of melatonin if patients find that it works and they find that it's helpful, it's a good place to start. Um I think I'd have to have a better understanding of which homeopathic, you know, regimens people are talking about, it is really important to let patients know that if they are taking like herbal supplements to inform us of that because that if they aren't an antidepressant, they can have, you know, severe adverse reactions. So just you know, making them aware that they should let us know about any kind of homeopathic regimens they're taking or interested in trying. Thank you. Um dr Jill cecil man had a question about whether traZODone is best used nightly or whether it can be used. Prn um it can be I use like it better pr and actually because I find that you know, the less people are using it, the more effective it is. Mhm. Thank you any other questions. I also want to mention the conundrum when people say I don't want to start on something daily, I don't think I need something daily. I just want the Xanax for now and then. But they end up using the Xanax three times a week or so. And you know, why is it that that stigma of being on an ss ri date? Really, I don't know if it gives them more of a feeling that they have a true diagnosis and you know, it just seems that Xanax or a Benzo is so much more socially acceptable. Everyone's like, yeah I take Xanax but they don't like to disclose that they're on PROzac or Zoloft during any kind of S. S. R. I. Yeah, I I think that's a great point and it is something I commonly come across. So I think just you know, providing educations on the risks that come with Benzodiazepines and really rss our eyes are much safer in terms of risk benefit profile. And I also try to de stigmatize you know the diagnosis and the need for medication. Like if you had high blood pressure you'd be on a medication daily and you know would that be bothersome for you? And we can think of you know our brain as an organ like any other organ in our body. And you know sometimes we need to treat issues with medications. Um So again I just try to educate and de stigmatize as much as I can. I actually take that approach as well to try to tell the medicine Oregon as well. Um So thank you. Thank you. Um dr Coleman, you wanted to ask you a question about FLUoxetine. Yes. Um I haven't I think you mentioned that we could possibly dose FLUoxetine weekly. I haven't used that approach. How do you normally approach that? Um yeah it can be, it comes in like a one capsule that can be used once a week and I think it come it's like 90 mg. It's because the half life is so long that it stays in the system for a week when it's at that dose. So you know I tend to like to start um you know with daily dozing but if a patient has an issue with compliance but they've tolerated the medication well you know you can go to that once a week Dozing. Okay. And do you see like more side effects or adverse events with that larger weekly dose. No. So I actually had one patient on once a week dozing and she tolerated it really well, no adverse effects. And she was an older patient too. So I personally haven't seen anything but I can look into that for the next lecture to if there is any difference, thank you. Um And then we can end with this question from Dr Cheung about how you message um you know, the value of getting on medications to your patients. Dr Cheung if you wanted to share it. Well sometimes it's hard to convince those patients to take any medicine at all. And then you try to say, well you go to therapy and I don't wanna go to therapy. So they're just like stuck. So I try to tell them that uh well if you take this medicine maybe you'll be able to participate in therapy better and maybe you'll be able to work better and maybe you'll be able to get along with your family better and all those things together may get you to where you want to be. And so is that a good approach to to use for them? I've been saying that a lot. So if it's not good, you gotta tell me otherwise. I've been saying the wrong thing. No, I think that's a great, great approach. You know, and we do often see that when people's symptoms are are so intense they can't engage you know, as as well in therapy. So this kind of helps get to that point where they can utilize the skills, um, and make progress. So I think that's a wonderful point. I got one more question please follow on to. That is a lot of those patients will say, well how do I know that I'm getting better? You know, you'd think they would know that you feel better. But I I tell them that other people around, you may notice it before you, like their boyfriend, girlfriend or family and somebody starts to say, hey, you know, you're, you look a little different. Then they know that something's happening. So is that something that you see or that's something that's reasonable to say to them? Yeah, definitely. I I just had a patient last week being like my wife told me I'm much less irritable. Um, he's like, I don't know if I've noticed it, but she's mentioned that a few times And then also we can use those scales like the God seven. So if a patient comes, they can fill that out on initial appointment and then in a month or two, fill it out again. It's just a very tangible reminder to the patient of where things are. So you started at 14, 2 months ago now you're down to a four and it's just a visual representation of progress, which I think can be important when this is so kind of abstract. Um, those are great questions to kind of bring us full circle. I would also just note for those on the call that are not medical prescribers you know psychiatrists or primary care folks who are providers of therapy. You know looking out for that kind of conversation and kind of educating the patient in that way. And the way that dr chang described is actually a great way to get them to think about medications added to the therapeutic kind of relationship that you may be setting up with them or in the process of. Um so we're just about at 7:00 um you know really really appreciate everybody being so engaged sticking around till the end asking all these incredibly meaningful and relevant questions. I hope that folks found the case presentation and the didactic and the discussion after both to be useful and um you know applicable to your day to day practice is really what we want to make these sessions be. Um dr Christopher, thank you so much for such an informative and well condensed talk as I noted the recording from today's session as well as dr Christopher slides as well as the case presentation. The doctor system when presented presented earlier would all be available online on the M. S. H. P. Behavioral health page so that you can use it as as relevant to your work. Um Dr Christopher is also going to present again um at our next mind matter session in april that will be on Wednesday april 13th from 5 30 to 7 p.m. I look forward to seeing you all there and then I will just leave you with a reminder to please take a minute to complete the post survey that you'll get after this session, as I mentioned a couple of times before we got started today, we look at kind of matched responses and look to see what impact mind matters has on folks. We also read the comments and use all of that to continually improve the session so that it's um as as useful as it can be. So if you could take a minute to complete those post surveys, I would really appreciate it. Thank you everybody. We will see you next month be well.