Welcome. To tonight's webinar on. Sorters the use of evidence-based, treatment. My. Name is dr. Jeanne you I'm a GP and medical advisor at NPS, medicine, wise and tonight. I'm joined by an interdisciplinary panel. To talk about the recognition. Assessment. And management. Of anxiety, and primary care with, a particular focus on psychological. Treatment, we. Really appreciate, you taking time out of your busy schedule, to join us today we'd. Like to hear about what you would like to know about anxiety, so. If you've got a question please, feel, free to ask just. Type it in the message box in the bottom right, corner of, the screen, tonight's. Webinar is also a CPD, event, at the, end of the webinar there will be a link for you to access, a CPD, certificate. Should, you need it now let's. Get started, so. Anxiety, disorders, are the most common, of our mental health disorders, they, affect 14, percent of Australians, aged 16. To 85, with, a lifetime, prevalence of one in four. So. Whether you are a GP, a pharmacist. A nurse, a psychologist, or a psychiatrist, you. Will undoubtedly be seeing and managing, patients, with anxiety. Tonight. We have clinical psychologist, dr. Sarah Edelman, GP. Dr. Louise stone and, psychiatrist. Dr. Lisa Lampe with us so. Sarah if you just like to introduce yourself, hi, I'm Sarah, Edelman I'm a clinical, psychologist and. I, predominantly, see people with anxiety. Disorders in my practice and. Louise hi, everyone I'm Louise Stone I'm a GP in Canberra, and I. See lots of patients with mental health conditions and. Lisa hi. I'm, Lisa lanty I'm. A psychiatrist. In academic. Practice and also clinical. Practice specializing, in anxiety. In. Tonight's webinar we, will be discussing how to best recognize assess. And manage, patients. With anxiety. This. Will include the, recognition. And assessment, of anxiety, symptoms, including. Their impact and severity, the. Role of evidence-based. Psychological. Treatments, such as cognitive behavioral. How. To engage patients, in treatment decisions, and discuss realistic, expectations. And when. Medicines, may be indicated I. Know. We've had a lot of interest in tonight's webinar from, a wide range of health professionals, so. For, our first poll question which. Profession. Do you belong to. Well. Good so we're starting to get some responses. Back so, I can see that we have. Quite. An even split between GPS. And, pharmacists. And, a lot of nurses with us tonight a. Few, psychologists. And some. Other health professionals, as, well. So, it's it's good to see. Participants. From all over different. Areas. Of practice with us tonight because really that's one of the key things about effectively. Managing anxiety is that we do need to work, together and we all have different roles, so. Let's. Start by, exploring the symptoms, and experiences. Of anxiety, so so, Sara how, would you describe the, symptoms of anxiety and, what is the difference between everyday. Anxiety. And an anxiety disorder. Well. In, terms of intensity, it really is about it's something that's on a continuum. Everybody. Experiences anxiety. At times but. For some people the, anxiety, is frequent. It's intense, it may be ongoing, and it, interferes with, their ability to function so, it interferes, with work or with ability.
To Function as a parent, or socially, and, according. To the DSM for usually lasts, for about at. Least six months in order to be classified. As an anxiety disorder, just. A little bit to explain what anxiety, is, anxiety. Starts, with perception, of threat so a brain, perceives, threat and once. We have that experience it, has an immediate effect on the body so. Physiologically. Our immediate response is. What we we all know to be the fight-or-flight response. We get arousal. We get an increase in heart rate breathing, rate, oxygen. Consumption, muscle, tension and other changes, in. The in the longer, term if we have continuing, or ongoing anxiety. We tend to experience more. Somatic. Symptoms so people will end up with headaches, with. Dizziness. With, nausea, with. Tremor, with, all sorts of other unpleasant. Physiological. Sensations. The. Third aspect of anxiety, is that it actually impacts, on behavior, so, our motivation is, to try and make, us of safe we engage in safety, seeking behaviors, which, sometimes can be a good thing because it can motivate us, to. Follow. Up on some goal it, can motivate us to study hard if we're anxious about an exam it can help us to focus and be energized, in achieving, the things that are important, however. If, we are feeling overwhelmed by, anxiety a lot of the behaviors that we see are unhelpful. And involve, things like avoidance. Or lots of safety seeking, behaviors, which. Unfortunately. Reinforced, the perception, of threat so, in the diagram, that we. Could see on the screen we can see that relationship between, cognition, through, perceptions. Physiology. And behavior. And, those three things interact, with each other so for example, as our, anxiety. Increases, we get more physiological. Arousal our, brain then starts to perceive threat, on a higher level and. Then. We sort of tend to avoid. Things even more so it kind of feeds on itself in. The longer term anxiety. Can or anxiety, disorders, can lead to extensive suffering. They. Can impair, our functioning. They cause often. Enormous, fatigue, and find people find it difficult to to work to, concentrate. And, on top of that they experience a whole lot of really unpleasant physical. Symptoms which most, people find very distressing. Thanks. So much for that, Sarah, I think that. Anxiety. Is a very common, experience and we've, all had that experience from from time to time but there, is quite a big difference between feeling, anxious and something, which is a full.
Anxiety, Disorder, so. That's, very helpful to to get things started. We know that anxiety is, a common, clinical presentation. And so we'll have our next poll question which. Is for what proportion. Of patients in your practice would. You identify anxiety. As a key, problem. So, while we're just seeing. How our, participants. Respond. To that perhaps we'll turn, next, to anxiety in in general practice. Louise. What. Are the challenges of diagnosing, anxiety, in a general practice setting, because sometimes it's not that straightforward. One. Of the difficult things always in general, practice is that the first, way. People often present is with some of those somatic, symptoms, that Sarah's described, so people, are much more likely to present to us talking about they're particularly fatigued but. Also pain headaches. Muscle, tension, and abdominal. Symptoms particularly. Things like an. Irritable bowel type picture, so for us we. Really have, three jobs in general practice and our first one is always to. Examine. Thoughtfully. The symptom that is in front of us because, patients. Need to understand. That we take them seriously and, that we we, validate, their concerns, so often. With anxiety, disorders we might be initially, starting, from that somatic, symptom and then, perhaps working, more broadly of course, the number of our patients will have chronic disease and sometimes we'll find that anxiety. Is a manifestation, of, that illness so for instance particularly. Respiratory. Disease will often find when with spirit or diseases out of control that anxiety is quite common and. Medications. Of course those of our patients, who are on steroids those, doctors, in the room will know that steroids. Can cause just about anything and there's a number of other, medications. That can raise people's level of anxiety but, apart, from making that physical, diagnosis. And making sure we're covering things obviously we, also need to take into account psychiatric. Diagnosis, which may cross over and I I know a little later that we'll be hearing from Lisa talking, about some of those things and. Particularly. At the moment with alcohol, and we're the ISO epidemic, particularly, in. Rural communities ice, is particularly. Challenging. For rural doctors and so, we'll often find that substance abuse is mixed up in the mix I think. In. Terms of what the GPS need to do they need to make that physical diagnosis, they need to make a psychiatric, diagnosis, but, they also need to have an understanding of, why this person is unwell at this time and that's, not just about, why, they've come anxious but, what sorts, of things we may be able to leverage in order to help their recovery so, things like sleep and diet and exercise, and understanding. Things that might be going on that might be triggering, their anxiety, at this time it's terribly important, so, those three things the physical, diagnosis. The psychiatric, diagnosis, and also getting an understanding of the, psychological formulation. Of why person is unwell at this time yeah. So there's, a lot to, actually having. A, comprehensive. Assessment of someone that's presenting. With anxiety, or presenting, in another way where, it turns out that anxiety is the primary issue as. Usual as GPS, we've. Got more than one thing to think about yes. And I think patients, are often very, aware. Of the stigma and we'll be talking about that a little later but they're, very anxious not to be seen as neurotic there's a very, high.
Level Of stigma and often. Patients have that sense that they'll be discounted, or not taken seriously so terribly. Important, to examine the patient it's, one thing that's very, important. That you don't leap to a conclusion, too quickly that, you actually listen to the heart feel the tummy do what you have to do in order to make that diagnosis, because, their impatience understand, that they've been taken seriously well. Thank you very much for that Louise. We've had results, come in from our second. Poll question and. Anxiety. Is certainly, very. Relevant, to the clinical practice of many of our audience, members, tonight. About. 45% of our respondents would. Identify. Anxieties. A key problem in 11 to 25, percent, of, their patients, so. It is very relevant and, in fact the next biggest group twenty, two and a half percent, would. Identify anxiety, as a key problem in 25, 26, to 50 percent of their patients, so this, is you know tonight's topic is very relevant so. Lisa. We've. Heard a lot about what. Anxiety, symptoms. Are, and, what, constitutes, an anxiety disorder and about, the complexity, of diagnosing. Anxiety, in general practice, how. Disabling, are our anxiety, disorders. That's. A good question, because I think that they're often underestimated. In their impact and in. Summer sex that might be part of the the stigma of anxiety. Is well on the side of the. Health professional. In that. It, can be underestimated. So. This. Slide that you can see now aims, to. Create, some comparisons. Between some. Reasonably, common chronic medical, conditions, and some. Anxiety. Conditions, so this is actually, Australian, data but it's actually been repeated, around, the world which. Shows, that anxiety, slots. In around, other. Types. Of disorders. With. That measure being a composit. Of the. Physical. Burden of illness and the mental burden of illness and this. Is a table you don't want to be at the bottom of in numbers, because the lower the number in fact the more. Disabling. The condition, is so. Impact. On functioning it. Is, one. Of the things that we consider in, terms of the. Burden. Of illness or anxiety. Disorders, and as. Sarah, mentioned, they. Can also be extremely distressing, so, in, terms of, trying. To estimate the severity we would of course think about, the level of personal, distress that. People are experiencing. Any. Disability. Or impairment they. Might have but. There's also a category, where, people, just can't live their life the way they want to live it they, can't do the things they'd like to do or they, can't do them in the way they'd like to be able to do them and, I think all those things are important to take into account. So. Anxiety. Can certainly have a major impact it has a major impact, at a public health level and. Very much so at the individual. Level. Clinically. Speaking we. Know that often. Anxiety. Doesn't present in a pure form but, we see, a mixture, of symptoms.
Of Depression and, anxiety, what. Is the relationship, between these, two conditions and, what what difference does it make to, know which is the primary, diagnosis. Um. It's, an interesting question. I think it's is important. To have recognized, the very close relationship, between anxiety, and depression and that, relationship, is particularly, close, for generalized, anxiety disorder, which is the the worry condition. Where, people worry all the time about everything, and they know it's, out, of proportion to, what's. Warranted by, the situation, but they just can't help it they can't control it and. They. That, shares, a lot of. Genetic. Vulnerability. With depression, and it. Does seem that most people who have generalized. Anxiety disorder, at some stage in their life will probably have at least one episode of, depression so. I'd like to encourage GPS. That when you see depression ask. About anxiety and. Certainly. We knew the anxiety, be alert for depression. Developing, in, that sense. It doesn't necessarily. Matter what's. Primary. Except. Insofar as if, a. GP, recognizes. Depression, and treats it appropriately, and I think chip is very good at identifying, and. Treating, depression now, if. There, is a comorbid. Anxiety condition. Or indeed if the anxiety condition. Was there first and then the person got depressed, then. When. The depression, treatment is discontinued. The anxiety, will probably, come back and, the. Person, themself, may, think they're back to normal, because. Anxiety, is, such a chronic. Problem in their life so. I would really encourage GPS. When they do treat people for depression, get. Them back later when, they say the depression, is better and just assess whether, there might be some, anxiety. In. Terms of other conditions, of, significance. Other comorbid. Conditions, it's, probably, more the case that patients, who, have other mental, health conditions, may. Well have anxiety as well because. Anxiety is, a very, very common. Concomitant. To. Other conditions. Such as bipolar. Disorder schizophrenia. Eating. Disorders, ADHD, it's. Just extremely. Common that there'll be some anxiety, there as well which. Might actually benefit. From some, targeted. Treatment, so, sometimes, the anxiety, component, won't automatically, get better when, the underlying, illness. Is treated, and.
So That's the value of thinking. To assess, whether someone also has anxiety it. Could make a difference to how you manage, that patient from what she said yes and it could make a difference to, the functional, outcome and the whole of their life that the person experiences, in the long term so. Lisa, you. Know as as we've discussed successfully. Managing, patients with anxiety, is certainly a team-based, effort. When. Would you recommend, obtaining. A psychiatric, opinion for example if you're a GP for a patient, with an anxiety to sort your, think might be an anxiety disorder. Well. I think a patient who doesn't respond, to the treatment that's, initiated. In the way that the GP. Is expecting, it, might be beneficial to. Discuss, the case with the psychiatrist, or even refer them to a psychiatrist. With. The caveat that we'll talk about a. Bit later as how what. Time frame one should expect see improvement, within that that's probably something to consider I would also suggest that very complex, presentations. Where there is an Associated, personality. Disorder. Where, there is associated, substance. Misuse or, where, there are comorbid. Conditions, could be worth getting an opinion, about. Well. The thing thank you very much and I believe, that we've had some questions. Come, in from our audience, so. I've. Got here the first question. Is. About, cognitive, behavioral therapy but I think that that's a topic, that we're going to come to next. So. In relation to. We've. Got a question here which. Is about the relationship, between anxiety. And. Physical. Conditions. So, how. Do you go about realistically. Recognizing. And treating anxiety when, there are serious lung conditions. So perhaps, that Louise would would you have something to to say to that well. I guess in general practice one, of the things that we often have to do is manage things in parallel and one. Of the things that's terribly, important no matter what the comorbid, condition, is whether, it's. Chronic. Obstructive Airways disease or it's cancer, is that you have to optimize the treatment of the physical illness at the same time I think, it's very important, to differentiate, between the patient, who is understandably. Anxious about. A new diagnosis. And you've, broken bad news about something, and they they have concerns of course they do and you. Might see that for instance in a woman with a with an IVF pregnancy, is a classic example and people naturally, become quite anxious but, I think it gets to the point of function, that's the that's, the critical, moment when, patients.
Find That they are no. Longer able to manage what they need to manage in order to. Pursue. Their lives and that's the point at which I think anxiety, disorders, Colleen in. General practice one of the problems we have is that health anxiety is quite common and those. Are the patients who will present this week worried, about a lump in the neck and next week worried about a spot on the arm and the week on next, after worried, about a cough so, frequent, presentations. And that, requires, a very, delicate. Handling, but gradually, helping, patients to understand, what's. Going on and that there may perhaps be an, anxiety disorder underlying, that presentation. Okay. Well we've, got a range of other questions that have come through and hopefully, we'll get the opportunity. To explore some of those as we go but. Let's, move on to our. Next, section which is really, focusing, on the management. Of anxiety. Are through psychological. Treatments. So. Louise. When, a patient, has been. Identified as, having an anxiety, disorder. What. Is your approach to explaining, this to the patient and how do you help them make sense of of that diagnosis. I, think. The first thing that's terribly, important is to understand, the social world in which the patient, lives and the. Social world in which patients live. Has. A high level of stigma around exile, disorders, and that makes life very difficult for patients with anxiety, because they, often feel that they're they're, seen as as, having their symptoms are not real that, their people, are assuming it's all in their head and that has all sorts of loadings so it's, terribly, important, particularly in general practice to, start with establishing, empathy, and validation, and to start with trying. To take a history that is holistic, because. The one thing you don't want to do is chase down the cardiology, side of things and then turn around and say there's nothing cardiological, it must be anxiety, disorder because that's a disaster patients. Really, do feel very letdown. Patients. Will often help you patients, will talk. About stress they'll talk about words. That indicate to you their model of the way the mind and body interrelate. And in, general practice it's very important, to listen to, those words because, often. You can hook into that model and although, patients may not straightaway get the connection they, will occasionally take, two or three consultations. Before you they say to you you know I've been thinking about what you said doctor and actually yes I do think stress is playing into this it's, been a really difficult time, and, I do think. That perhaps my gut symptoms might be related, to you. Know my anxiety and that's your chance to. Give, written material, to to. Explain. However. The patient will take. The message on board that the mind and body obviously occupy. The same space and, there's, various ways of doing that but it depends. Very much on the patient's, point of view so the explanation, that I would give to a miner in Broken Hill is going, to be completely different to what I would do with a lawyer in Canberra and you have to be flexible. Enough to make that connection the, one thing that I think is terribly, important, is trying, to get to a shared understanding before. You try and start treatment because. If I refer to someone like Lisa or someone like Sarah before a patient accepts, that, patients. May never come back to me I mean it's, you they have to get to that point where.
They Come to understand, and I. Would really encourage the, GPS in the audience to have a look at different explanations. And talk, to some colleagues about the how they explain anxiety, so you've got some metaphors, and, understandings. That that patients may be able to use and some resources to, help them to come to that sort of understanding. Yeah. So I, mean as you've mentioned. Sometimes. Part, of the process is going to be referring. To colleagues and of course, having. That shared basis, for. What's to come is, essential, for success. For, that patient, sometimes. However it can be a bit of a wait before they get to see the psychologist they've been referred to or the psychiatrist. That you've referred to as well as. GPS is there anything that we can do to help those patients while. They're waiting, absolutely. If a patient is in poor health they're in poor health and it doesn't matter what their symptoms are so, before. We get to the e mental health question I think there's all those questions, about diet and exercise, minimizing. Alcohol, and definitely, sleep and you, can always make a difference, in terms of lifestyle, you know it's not unusual for me to see a patient who has much, more coffee than I do for instance and can. Be presenting, with palpitations, so there's often a lot of things you can do that are very sensible, and, also, streamlining, occasionally. Patients, will have drifted into anxiety, because they're working you know a 70, hour weeks so it may be about, giving them some space but, there's certainly some resources, that you can obtain that you can help, patients, access. And we'll, help them come to an understanding, not. Every patient is going to respond, to an eventual health resource there are patients who don't have access to the Internet may not have the digital literacy, or or even, the written literacy, to understand, but. For patients who, do there's, a option, for them to come. To an understanding, of the basics, so that when the psychologist starts, working, they're, already ahead of the game and I, often will encourage patients, to go to head to health because it's a curated site and the. Patients, particularly, adolescents you can say go, to head to health and have a look at the resources and tell me which ones you like and then, that makes, them feel empowered it, gives them an option and they'll come back and tell you what they don't like but they will occasionally tell you what they do and I, think that then gives them a sense that they've got some say in their own recovery I think that's a very important, thing so, on the heads health site you'll see all those examples of evidence-based a mental health treatment tools and you, can search for them which makes it much easier. So. Let's, come to our next poll question then, because online, CBT, programs, are a relatively. New development arm. Over the last 10 years we'd. Like to know whether that's something that you recommend, to, your patients, so, how. Often do you recommend online, CBT programs. To patients, with an anxiety disorder. So. Let's find out a little bit more about psychological. Treatments, so. Sarah, of the, different, psychological. Treatment, options that are available for anxiety. Why, is CBT, the most commonly recommended. Well. CBT, has the greatest, evidence base both. In terms of good, quality randomized, controlled trials, and also meta. Analyses, that consistently. Show that the, outcomes, are as, far as we know superior, at this stage to other models so. It's, generally. Considered the gold standard. In. Terms of what it actually involves and you want me to talk yes. So. The aim. Of cognitive, behavior therapy is, really to change the. Meanings, that people give, to their both their, environmental. Situations. But also their own internal, symptoms. Including, anxiety so, it always starts, off with an assessment trying. To make sense of what's going on for this particular patient, and then. Followed, by a formulation. Which is used to guide treatment but. Also shared with the patient so that the patient understands, what's. Happening what's initiated. This anxiety what's, maintaining, it and what sort of things they can do to, to. Address it cycle. Education, is a really core component. Of CBT. Treatment. For, all things that for all disorders, including anxiety disorders. And once. The patient, understands. Some. Of the key features of what, they're going through it actually helps, to guide them in. Managing those symptoms as a GP. Some, of the useful, things that you may talk, about in, session, might. Include things like anxiety. Effects. The, way that our mind works, so, when, we're anxious, we experience a cognitive, bias towards, threat so.
Our Thoughts are not if, not often, are not a reliable indicator, of danger, when, we're in a highly, anxious state, and sometimes just understanding. That that just, because I'm thinking this doesn't necessarily mean it's true can be quite useful, also. Explaining, to patients that the things that we, do to try and make ourselves safe often perpetuate, the problem is. Also really helpful so. Outlining. Things like avoidance, and safety behaviors, which might. In the short-term feel like they reduce anxiety but, in the longer term increased. Feelings of vulnerability and. And, threat, cognitive. Reframing is. That, that whole process of teaching people to be aware of their. Thinking and some of the reasoning, errors that they're making I mean most most notably, catastrophic. Thinking or predicting. Catastrophe. But also things, like black and white thinking, mind-reading. Taking. Things very personally, when it's not about not, about us and teaching. Patients, to, to challenge, some of those unhelpful. Thinking patterns that, perpetuates. Anxiety. Some. Of the key features of. Treatments. For anxiety are, the behavioral. Treatments. And that includes behavioral experiments. And graded exposure, and, behavioral experiments, involve, directly. Experimenting. In, order to discover, that the beliefs that we have are incorrect, so for example for a patient, with social, anxiety they. Might. Expect. Me. Ting people will laugh at them or ridicule, them you might do a behavioral, experiment to get the person, to speak up in a meeting and to, learn experientially. That the things that the the things that they worried about or the assumptions, that they're making are, incorrect, so, behavioral, experiments, can be particularly powerful because, patients have an aha, moment when. They discover. That the things that they expected. Are not necessarily, things that happen, with, graded exposure, exercises. We, encourage, patients to confront. And repeatedly, confront, some of the things that they're particularly worried about so, a patient with social anxiety might. Deliberately. And. Repeatedly. Confront. Scituate, social situations, starting from low. Threat social, situations, and gradually moving on to more high threat situations, or for someone with Aggra phobia, or with panic disorder it may involve just. Starting. Off with going for regular walks then, going, to cafes, and coffee shops, and then gradually, go into supermarkets, and busy public places and it's the repeated, exposure, to those places that, actually help to help. The anxiety, to reduce, and habituate, over time so. Greated exposure sera seems, to be a very important. Aspect. Of of, CBT, and maybe it's something that perhaps, it certainly is GPS where, we're less familiar, with would that be correct it may be not them and I think some some cheapies are familiar with it and I think that the the. Granite. Exposure is particularly, powerful because. It actually, is creates experiencial, learning, so sometimes people will say look I logically. Know. That, going to the supermarket isn't going to kill me but, I just don't feel it it feels scary. And so sometimes you actually need the experience, and the repeated, experience, and sometimes go into the supermarket and if you're feeling overwhelmed, just sit on the bench outside the supermarket stay, there for a little while then go in walk, around have that experience and then and then, leave. And then go back again next, day next day next day and gradually, the threat perceptions, that are associated with those situations, reduce, and people, start to relax and the behavioral. Stuff is particularly, powerful in, terms of reducing, fear and helping people to to. Discover, experientially. That nothing terrible happens. So. Lisa from, your point of view is, the behavioral. Experiments, and graded exposure are they an important, part. Of good. CBT, I mean how do we know what good CBT, looks like well. It looks like that I. Mean, it's. Really essential, that. CBT, package, that, the person. Received. Has, all of those components if, they're, not doing homework between. Sessions. Practicing. Things working. On things so. I guess I often say to the patient, did. You keep a bit of a workbook or a record of what, you worked on, that's. A good way to check but, we just want to ask that the treatment they they got had all the components, that that, Sara's just listed, and that they, went more, than full, of once a month I guess that's the other thing is the frequency, of sessions, it's a bit like if you, want to see, a personal, trainer to get fit and you're coming from a position not being fit at all just, seeing them once a month isn't going to achieve anything, it. Might be fine for booster, sessions, but, that's the other thing I'd like to know that the person saw the.
Psychologist. Or whoever else was doing the CBT, frequently. Enough that it was likely to have built up some momentum and, that it had all those components. Well. Thank. You very much because I think sometimes, a, says, GPS, we refer, to, our psychologist, colleagues for CBT, but we don't necessarily know, the right questions to ask when our patient comes back. So. We've, had some responses, to our poll question about, online CBT, programs. And roughly. About 45%, of, our audience would. Either always, often, or sometimes, refer, for online CBT, so, it seems that there is certainly a type, of resource, that's recommended often. So. If we now turn to the, question, of interdisciplinary. Communication. We've referred to that a number of times the importance, of working, with a team. The. Question is what does good interdisciplinary. Communication. Actually look like so. Perhaps if I could start with you Sarah um when. A GP, refers, a patient, to you what are some key things that you'd like to to. Know, about that patient well, I'd like to know the. The. Medication, that they're taking, any medical, illnesses, that might be relevant and if the GP, is aware, of something sort of very specific, that may, not come out in, the initial assessment it's. Useful for them to mention that as well what. I don't, really need my think what most psychologists, don't need is is very detailed. It's about diagnosis. And so on because we do a very thorough assessment. So. A lot, of most of that information actually comes out I guess the other thing that, I, that. I sometimes get in mental health treatment plans is very prescriptive, treatments. So sometimes. GPS, will say can you teach this person. Progressive. Muscle relaxation or. Can. You can, you, treat. This person for social anxiety disorder, and yet when I do a more thorough assessment. The person may be dealing with complex, trauma and social. Anxiety may, be one, of the many symptoms, of that disorder so I. Guess, personally I prefer when people say Q know could. You please assess. And advise and make recommendations, and then, we sort of collaborate, rather, than very prescriptive treatments. Yes. Because of course when, you see the patient you have, the knowledge and expertise, but also the time to really delve in and, to. Understand fully what's happening and, if we, typically, spend an hour per session we have, the opportunity to get a lot more information about what's, really going on for that patient and, and. So Louise as a GP, when you hear back from a psychologist, that has seen a patient you've referred what. Do you want to hear, yeah. It's, interesting in general practice um one of our many roles of courses is like, being a matchmaker of trying to find the right person. To. Help with the patient, and I, often. Find it helpful for the psychologist, to give me a rough, outline of what it is that they're actually doing. It's. It can be a little tricky because we're not all across all the three-letter abbreviations. That we can come across with DVDs, and CDs and so on but. It, helps me to ask the patient what's, happening. And I. Think if I can know that the other thing that really helps, me a lot is when. Patients get stuck because. You will get patients, who do a few sessions with a psychologist, and really. They are so, unwell that. Their cognitive, slowing, is such or their their cognitive capacity, is such that, really we should be also considering, whether we should be using a medication. I find, it incredibly, helpful if, I'll get that feedback back, from. A psychiatrist point of view it's always very helpful to have a few options of where, we can head because many of us, it.
Takes A long time for us to get a patient into particularly public psychiatry, so it's, always incredibly helpful for me if a. Psychiatrist, is able to offer me a range of options and I can start with option, a and then move, on if the patient doesn't respond, to a certain category so, I think, giving, me some sort of assessment of how unwell the patient is I think is very helpful I need. A diagnosis. Often from either of you, particularly. In circumstances, where I need to interact with someone like centerlink, because. From. A policy. Point of view we. Need psychiatry. And psychology backup, in, order to ask for things like Disability, Support pension so, having, that diagnosis. Set, in, a letter is, terribly, important to us and. Lisa. Do, you have any suggestions, for how to effectively, communicate with, our psychiatrist. Colleagues, well. I guess we. Are particularly interested, in what. Investigations. Have been done, because. Then we can relax a bit and. Say. Okay well important. Medical, causes, for the things I have identified. Or excluded. Or whatever. It might be so that's probably, the most important, thing for us because like Sarah. We're going to take a pretty. Comprehensive. History. Of course anything the GP is aware, of such. As the comorbidities. The. Complex trauma was a good point I didn't, mention that before but that would be another reason why you might particularly, want an opinion so anything. The GP. Knows. Or, thinks is, relevant, but I guess in particular the. Medical, tests, and also, any medicines, that have been tried and. Ideally. What dose and for how long. So. It's always useful to know what has happened beforehand, so that that background, so that you can pick things up from from, there very. Helpful so. We've. Got a few questions from. Our audience and, a few to, explore. Those questions, one. Of our questions is from Wendy saws and she, asks, a GP. Is able to access guidelines, for helping, patients increase. Their own capacity. To manage, their symptoms as they, work on graded, exposure. So. Any, any suggestions, about resources. To, help patients help themselves if you like I, think. As a GP, one of the things that we need to be really careful of is that we don't work in opposition or, in, parallel, to a psychologist, and, we. All know that there are many and varied ways that you can achieve the same outcome, in something like CBT, so. I think. If. Possible. It, would be for, me I would be ringing the psychologist, to find out what the psychologist, is doing on what methods, they have suggested, so that I can back the psychologist, in that sense because, the one thing you don't want to do is give, the patient, activity. Or an exercise that will. Be. An, additional, burden and not be heading in the same direction I, think. Often, the psychologists, have already provided this information and the patient has forgotten so it's, easier for us I think if we can actually head that way we. All use methods, of relaxation, we all do that in many different ways because, we have to every time we take a blood test from someone with needle phobia for instance so, it's not that we're not used to doing that work but I think, it's, so easy for, mental healthcare to get fractured, and for.
People To be doing all sorts of bits and for the patient, to get confused, so. I would, definitely in, that circumstance, be ringing and asking the psychologists, what resources they prefer. All. Right well thank you very much for that we've. Had a question from dr. Arum or Aimie who, asks is, online, CBT better, or face-to-face CBT. So Lisa. Or Sarah I. Thought. I personally, think that online, CBT, can be a really good adjunct. To, -. Face to face CBT, and I think if someone perhaps has. You. Know moderate. To low levels of anxiety and is very. Self-aware. And really open to learning they can actually do really well but I don't think it necessarily works for everyone I know the evaluations. Of the online therapy are generally, pretty good but in my experience. People. Often, respond. More effectively when, you actually tailor treatment, to. Their situation, but. I think the online treatments. Are an excellent, form of additional. Information cycle, education. And sometimes, you, know further suggestions. So. In other words research tells us that they're equivalent but it still comes down to the individual, in front of you yeah yeah, and I ask the question of how patients, prefer to learn you. Know do you when you're trying to learn about something new do you go, to the internet do you ask someone, do you prefer it written down and then, tailor it that way one thing that I will say is I would far rather give, them head, to health and give them Google. So. You. Know I will default, to giving them an evidence-based. CBT, resource just because I know it's, a safe home for them to go to but I would do that with you, know asthma. Or diabetes or. Anything else to to give them somewhere safe to go because Google is dangerous. For someone with anxiety, disorder yes indeed, can, be dangerous for him but for many of us but particularly in anxiety. So. Look we've got another question here. And I think this is a really important one so it's. Not one which has an easy answer necessarily. The. Comment is that tonight. We seem to be only highlighting. Referrals. To psychologists. For the treatment of anxiety, but. There are many different types of mental. Health professionals, including. Mental health nurses. Mental. Health social workers ot speech pathologists. It's not just, psychologists. So. I wonder perhaps ELISA would, you have any comment to make about the role of the broader. Interdisciplinary. Team in mental health, I. Think they can be very important, and particularly, in areas where, resources, are limited but, I would say that no, matter who is implementing. The therapy, if it doesn't, have the elements, of a, cognitive behavior, therapy package. That. Have, been shown. In research. Trials to be effective, then. It's. Unlikely, to be as effective, as therapy. That includes, all those, elements, so. Um, if, somebody's, been trained in it and they. Had, the expertise, and the experience, then. That's. Fine that. You know to implement, an evidence-based, treatment. So, we've had a few questions about. Medications. And antidepressants, and also, the role of the pharmacist, so I think we might move to, our next section where. We talk about when. Medication. Is needed, which. Ones and how best to use them, so. Lisa. When, is medication, needed. And warranted for the management of anxiety. In. The clinical, practice guidelines, for, anxiety. That, I recently released, by the Royal. Australian and New Zealand College, of Psychiatrists, it's. Recommended. For. Severe. Levels and anxiety. However. Having said that it, can, be medication can. Be used I should, specify, antidepressants. Are recommended, as first-line treatment, but. They they can be offered it at any level, of severity. I've. Given the effectiveness, of of cognitive. Behavior therapy in, the desire of many, patients to avoid medication. You. Might choose to reserve them for more severe levels of anxiety or at least it to offer them at more, severe levels, of anxiety, and. How are you characterizing. Severe. Anxiety and, in this kind of context, patients, who are extremely distressed, I, would. Recommend, considering. Medication, for patients, whose anxiety. Has been going on for so long and is so severe that they're quite demoralized, but and, any. Patient who's quite depressed. Because. It affects your thinking, and people, become quite negative, in their thinking and they not be able to do more, cognitive, aspects, of a treatment like coloristic behavior, therapy until, their depression, is, actually, responding, so those are other patients in whom you, might think about using an antidepressant soon. Rather than later you might. Want to add to those things Louis yeah.
Look I would say the same thing I've. Worked in rural and remote and there are communities where it's extremely difficult to get anyone, in the multidisciplinary team to see patients and I will, say that we often have to resort to medication more. Earlier. Mm-hmm, because, of lack, of access to services. I will. Say that the. Thing that's the greatest barrier, from my point of view is again, and I know I keep saying this but in general practice it's. The early days and patients, come in with all sorts, of misinformation. About, medication. And it's rare for me to be able to prescribe, a medication, first. Consultation. It takes a couple, of consults for patients to come around to the idea to, understand, how it works to, not be terrified that it's going to turn them into a zombie or they're going to be addicted, or they're, going to change, their personality, or that you must think I'm mad doctor if you're offering me an antidepressant so, that's, another delicate, conversation and. Particularly. With people with anxiety disorder, they're automatically, going to read the product inserts, and the product, inserts are slightly terrifying, so I, will say that before, you write a script it's. Very important, to get the patient, to a point where the patient is asking, to, start a medication and not try and make. That, move, too fast. And. So, once you've gotten, to that point where a patient is open to that option. Often. We. Think of SSRIs, as. First-line. Lisa, or, SSRIs, still the best choice and if we use that group. Of medicines, how, is prescribing, for anxiety different, to prescribing for depression. SSRIs. Are still the most widely recommended. First-line. Treatment. For anxiety. Across. Guidelines, across the world. The, SNR, eyes also, have, a good body of evidence but. Probably, the largest body of evidence is for, the SSRIs, and, some. Guidelines recommend, SSR. Is over, SNR, eyes because, of the side effect profile. But. They both have a very solid evidence. Base there. Are some important, differences from, prescribing, for, anxiety as Louise, has alluded, to and also Sara anxious. Patients, are often extremely. Sensitive. To physical. Sensations. And they. Tend to worry. About them and to worry that something. Seriously. Wrong is happening so. Because, of that hyper, vigilance, and hyper sensitivity, it's. Usually, wise, start. At half the usual, dose that you would use for a patient, with depression and also. To allow, the person, time. Before. You suggest they build up the dose because if they get, scared and don't take it at all they're, not going to get the benefit, whereas if you take a little bit longer to get up to a therapeutic, dose then. That. Means. They're more likely to take it to. Other points, to note, there. Is an there, is an. Idea, perhaps, more prevalent among psychiatrists. That you need higher doses, to treat anxiety, that's. Not automatically. The case but. You do need to give the, antidepressant. Longer to work so, whereas you might expect, a response between. 10, to 14 days in depression it, much more commonly takes at least four, to six weeks and anxiety. So we, don't want to panic too soon and think the patient's not responding. And either, escalate, the dose with. A greater risk of adverse effects. Or start. Swapping, and changing, and thinking, it hasn't worked so give. It time to, work, mm-hmm. Thanks, very much so it's the the, old, adage we and particularly. Appropriate. Anxiety, to start low go slow, and take your time yes, okay. Thank, you very much, we. Might turn to our next poll question which. Is which. Medicines, do you initially, prescribe, or recommend, for a patient, with, an anxiety disorder, and you can select more than one of the options, that are available. So. While, our, attendees. Are thinking. About that one Lisa. SSRIs. Are the most commonly, prescribed, medicines, for anxiety but not the only one so is there a place for other types of medicines, there. Is a place. For other types of medicine never say never in medicine. However. There. Are some that we don't recommend, as first-line. They include, beta blockers and, antipsychotics. Or, benzodiazepines. So those three classes are not recommended, as first-line. Beta. Blockers while they may slow, the heart rate and reduce tremor, in, conditions. Like generalized. Social. Anxiety, disorder for, example the evidence is quite clear that they're not better than placebo. Antipsychotics. Have so many potential, adverse, effects that, they're, not recommended. And. Benzodiazepines. We're, aware of the problems with them so as I said not that there's no place but that place should be well, down the line and perhaps that's when you, might want to consider consulting, with the psychiatrist. And. What. You're saying looks. Like it's many, of our audience are in agreement with that so, the most commonly recommended, class.
Of Medicines is SSRIs. That's it's 60%. Next. After that is SNR, is at 10%. And. Then a, few, would consider. Recommending, some. Of the others we've mentioned, benzodiazepines. Beta blockers, and. Antipsychotics. Okay. So. What. Why don't we turn now to, how. Successful our, treatments, are and and what we can do to to maintain the the gains. That are made so, Lisa. How. Successful, is, CBT. And I had a psychological treatments, compared with medicines. They're. About equivalent, as a matter of fact so they're, both very effective treatments. Certainly. In trials, of cognitive behavior therapy about. 50%. Of participants. Would no longer meet criteria, for an anxiety disorder. But. I guess it's important, to. Be. Aware that the. Long-term gains tend, to be maintained, and so, one other point about using, me Oshin is that it should always be accompanied, by advice, to, confront, the situations. That, patients. Fear or perhaps, have been avoiding. So. It's not only about medication. Even if that's the mainstay, of your treatment. Okay. Luiz, so. With. Patients some who are not improving. Or not responding, the way that you expect, what's. Your approach to that situation. Well. I think the first thing you have to do is go back to square one and see what lifestyle, factors, are coming into play because we'll. Often find that patients, will be, seeing their psychologist, perhaps may not necessarily be, putting in the practice that they need to put in they. May or may not be compliant, with their medications, for a whole lot of reasons including that they're terrified, that something might. Not. Be as valuable, so for instance we don't necessarily hear, about the sexual side-effects we just hear, that patients stop their medication, so it's, very important, for us to understand, what's going on underneath but, also to understand. That you. Know a patient who's working, 80 hours a week and still drinking, and still, you, know in quite a toxic, situation. No. Amount of SSRI, and CBT, will necessarily drag. Them out of that unless you can actually problem-solve. So I think it's terribly, important to understand, the patient holistically, but if. You feel that things are going well and you're not winning with a medication. Then you've got a few choices, you can either change. The medication, or increase it so three. Options of course are change increase, or augment, and that's. Often worth a, psychiatrist, conversation, at least so, that you know what you might do and also, to consider some, patients spaced out their psychology to the extent, that it is unhelpful, so, as, you. Said leads the you know doing CBT, once a month may, not be beneficial I must, say occasionally with some patients, I'll alternate, so they see this I call it psychologist. One week me, the next so, that we can actually space, that will be required to do and I can encourage. Adherence, particularly. In young people, who might be a little, bit more nervous so. I think keeping. An eye on what's, actually happening, is. Really, important, and going back to square one and making sure that. Patience looking after themselves I think is always very important, and making, sure of course it's a GP that they're not you, know miss, managing, their diabetes or, they're not using you, know too much ventolin, or any of those other things that go with mobility. Thank. You Louisa and, and, Sarah what kinds of general strategies, for maintaining good mental health can.
We Teach our patients well. I guess beyond, the the, various components, of cognitive behavior therapy if, we're looking at, maintaining. Good health or good mental health I always remind people that our mental health doesn't, stop at the neck that. What, that, the mind and the body are all part of one system and, anything, that's good for our body is also good for our mind so, we know that, regular. Exercise a. Healthy balanced diet just. Generally, healthy habits like not smoking and not drinking to excess are. Not only good for our physical health but also improve. Mental health good. Sleep hygiene is, also really important, getting into regular, good habits and knowing how to use. The light and not not nothing do it during the day and so on to make sure that you do, get adequate sleep is also important, we know that regular contact, social contact, is also very important for a resilience, building that, we are basically social, creatures, and we. Get. Comfort, from an enjoyment, from affiliating. And social. Connections, can help us deal with stressful life circumstances. They can provide assistance. During. Times of stress but they also, provide. A sort of an emotional, connection which, is part of our. Psychological. Needs the. Other thing specifically, for people with anxiety disorders is, to continue, to push the boundaries one. Of the things we do know is that people Things IOT disorders, even after successful, treatment are, at risk of relapse and, what tends to happen is people fall, back into old habits so, someone with social anxiety disorder who. May have made a significant, improvement may, fall back into the habit of not, taking, social risks, not making those phone calls not initiating. Social, connections, so, we always say keep pushing, those pushing. Those boundaries, make sure you continue, to. Move a little bit outside of your comfort zone, and that's one of the best protections. Against, relapse. Thank. You very much Sarah, so, we're, coming towards the end of our evening. We've, got a couple of evaluation. Poll, questions, so, the. First is have you learned anything new tonight about anxiety and, its treatment from this webinar. While. We're. Audience. Is responding, to that question, I'll, try and squeeze in a few more questions that we never have enough time to respond. To the questions that we're receiving we've had a lot of interesting. Questions tonight. A couple, of those have been, focusing. On the management of insomnia, which. Is such a common feature of anxiety. So. Does, anyone on our panel have anything, any. Keep athief point no points really about how to go about managing, insomnia, yeah I'd be happy to talk about a few things one is a regular, routine so, that you get up at the same time each day you go, out into the life early, in the morning to adjust, your circadian, rhythm, and try to go to bed at the same time each day the other thing I reckon. Remind. People is, when. People are very anxious they'll often wake up in the middle of the night and can't sleep and they end up with two problems, one is that they're not sleeping, but, the second, is anxiety. And distress about, the, fact that they're not sleeping and so. Just. Learning, that that whole mindful, acceptance. Principle. Which is just go, with it if you're, really, bored sometimes just listening to some music, or listening to something very calming, can be helpful in bed sometimes. It may be useful to to, get up and do some mundane, activity, for a little while and wait until you're tired and go back to sleep and, the. Other thing is never try to solve, problems, in the middle of the night or respond, to worry thoughts in the middle of the night when, we wake up anxious, at night our thoughts, tend to be catastrophic. Thinking. Tends to be distorted, one, of the best things to do if you're in that situation and, you're worrying about a specific problem, is write. Down just, write down the issue make, a note and say, I will deal with it tomorrow, and once.
We've Written it down we know that we're not going to forget about it we've still got control over but I'm not going to try and solve that problem now and very often by the time you look at it the next day in in the in. The daylight when you're in. A different state. You, look at that same problem and it doesn't seem to be as important. Or if it needs addressing, and it needs problem solving that is the best time to work on it that's. Fantastic Sarah, that's such practical, advice really that we can share. With our patients, we've, got one final poll question, so. How, likely are you to recommend this. NPS medicine were wise webinar, to a colleague we, do hope that you've gained. Some value out of it and that you would be, happy to to, share that with one of your colleagues, so. With, just a minute to go I'm afraid I'm going to have to wrap up there are so many questions I would have liked to have posed to. You tonight, but. We we really do, appreciate our audience, tuning in tonight and. I'd like to thank you Sarah Louise and, Lisa for. What has been a very engaging, and informative discussion, about, anxiety disorders, so. As. We said at the beginning this, is the CPD event, please, follow the link if you need to access the CPD certificate. We'll. Be in touch shortly with. You via an email with a link to our on-demand recording, of tonight's webinar should. You want to replay it again or should you want to share it with a colleague so. Thank you to everyone and. Good night.
2019-05-30