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Review ArticleClinical Review

Brief Intervention for Anxiety in Primary Care Patients

Peter Roy-Byrne, Jason P. Veitengruber, Alexander Bystritsky, Mark J. Edlund, Greer Sullivan, Michelle G. Craske, Stacy Shaw Welch, Raphael Rose and Murray B. Stein
The Journal of the American Board of Family Medicine March 2009, 22 (2) 175-186; DOI: https://doi.org/10.3122/jabfm.2009.02.080078
Peter Roy-Byrne
Department of Psychiatry and Behavioral Sciences (PRB, JPV, SSW), University of Washington School of Medicine, Harborview Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations (CHAMMP), Seattle
MD
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Jason P. Veitengruber
Department of Psychiatry and Behavioral Sciences (PRB, JPV, SSW), University of Washington School of Medicine, Harborview Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations (CHAMMP), Seattle
MD
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Alexander Bystritsky
Department of Psychiatry and Biobehavioral Sciences (AB), University of California, Los Angeles
MD
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Mark J. Edlund
Department of Psychiatry (MJE, GS), University of Arkansas for Medical Sciences, Little Rock
MD, PhD
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Greer Sullivan
Department of Psychiatry (MJE, GS), University of Arkansas for Medical Sciences, Little Rock
MD
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Michelle G. Craske
Department of Psychology (MGC, RR), University of California, Los Angeles
PhD
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Stacy Shaw Welch
Department of Psychiatry and Behavioral Sciences (PRB, JPV, SSW), University of Washington School of Medicine, Harborview Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations (CHAMMP), Seattle
PhD
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Raphael Rose
Department of Psychology (MGC, RR), University of California, Los Angeles
PhD
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Murray B. Stein
Department of Psychiatry (MBS), University of California, San Diego
MD, MPH
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Article Figures & Data

Figures

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  • Figure 1.
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    Figure 1.

    Cycle of anxiety.

Tables

  • Figures
  • “In the past year … ”01234
    1) How often did you have a drink containing alcohol?NeverMonthly or less2–4 times a month2–3 times a week≥4 times a week
    2) How many drinks containing alcohol did you have on a typical day when you were drinking?1 or 23 or 45 or 67–9≥10N/A (If #1 = 0)
    3) How often did you have 6 or more (≥4 for women) drinks on one occasion?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyN/A (If #1 = 0)
  • Overall Anxiety Severity and Impairment Scale (OASIS)

    1. In the past week, how often have you felt anxious?

      • 0 = No anxiety in the past week.

      • 1 = Infrequent anxiety. Felt anxious a few times.

      • 2 = Occasional anxiety. Felt anxious as much of the time as not. It was hard to relax.

      • 3 = Frequent anxiety. Felt anxious most of the time. It was very difficult to relax.

      • 4 = Constant anxiety. Felt anxious all of the time and never really relaxed.

    2. In the past week, when you have felt anxious, how intense or severe was your anxiety?

      • 0 = Little or none. Anxiety was absent or barely noticeable.

      • 1 = Mild. Anxiety was at a low level. It was possible to relax when I tried. Physical symptoms were only slightly uncomfortable.

      • 2 = Moderate. Anxiety was distressing at times. It was hard to relax or concentrate, but I could do it if I tried. Physical symptoms were uncomfortable.

      • 3 = Severe. Anxiety was intense much of the time. It was very difficult to relax or focus on anything else. Physical symptoms were extremely uncomfortable.

      • 4 = Extreme. Anxiety was overwhelming. It was impossible to relax at all. Physical symptoms were unbearable.

    3. In the past week, how often did you avoid situations, places, objects, or activities because of anxiety or fear?

      • 0 = None. I do not avoid places, situations, activities, or things because of fear.

      • 1 = Infrequent. I avoid something once in a while, but will usually face the situation or confront the object. My lifestyle is not affected.

      • 2 = Occasional. I have some fear of certain situations, places, or objects, but it is still manageable. My lifestyle has only changed in minor ways. I always or almost always avoid the things I fear when I’m alone, but can handle them if someone comes with me.

      • 3 = Frequent. I have considerable fear and really try to avoid the things that frighten me. I have made significant changes in my life style to avoid the object, situation, activity, or place.

      • 4 = All the Time. Avoiding objects, situations, activities, or places has taken over my life. My lifestyle has been extensively affected and I no longer do things that I used to enjoy.

    4. In the past week, how much did your anxiety interfere with your ability to do the things you needed to do at work, at school, or at home?

      • 0 = None. No interference at work/home/school from anxiety.

      • 1 = Mild. My anxiety has caused some interference at work/home/school. Things are more difficult, but everything that needs to be done is still getting done.

      • 2 = Moderate. My anxiety definitely interferes with tasks. Most things are still getting done, but few things are being done as well as in the past.

      • 3 = Severe. My anxiety has really changed my ability to get things done. Some tasks are still being done, but many things are not. My performance has definitely suffered.

      • 4 = Extreme. My anxiety has become incapacitating. I am unable to complete tasks and have had to leave school, have quit or been fired from my job, or have been unable to complete tasks at home and have faced consequences like bill collectors, eviction, etc.

    5. In the past week, how much has anxiety interfered with your social life and relationships?

      • 0 = None. My anxiety doesn’t affect my relationships.

      • 1 = Mild. My anxiety slightly interferes with my relationships. Some of my friendships and other relationships have suffered, but, overall, my social life is still fulfilling.

      • 2 = Moderate. I have experienced some interference with my social life, but I still have a few close relationships. I don’t spend as much time with others as in the past, but I still socialize sometimes.

      • 3 = Severe. My friendships and other relationships have suffered a lot because of anxiety. I do not enjoy social activities. I socialize very little.

      • 4 = Extreme. My anxiety has completely disrupted my social activities. All of my relationships have suffered or ended. My family life is extremely strained.

    • View popup
    Table 1.

    Assessment and Treatment Approach, with Strength of Recommendation Taxonomy Levels A, B, C

    Clinical FocusSORT Criteria17Assessment and Treatment Approach
    Screening and AssessmentBFour anxiety disorder questions: ADD
    ATwo depression questions
    AAlcohol screen: AUDIT-C
    CPain: one question
    BSuicide evaluation: thoughts, plan, intent, reasons for living
    BBipolar disorder: MDQ good specificity, poor sensitivity
    Severity of AnxietyAGAD-7: symptom severity
    BOASIS: functional impairment plus global symptoms
    Treatment HistoryCSpecify response: little, moderate, a lot
    Engaging the Patient-Brief InterventionBExpectations for outcome: 0–10
    BExpectation for role in outcome: 0–10
    CUse these and MI techniques
    CHelp patient weight positives/negatives
    Education and SkillsCFocus on avoidance: make list of avoided activities
    CCognitive restructuring to help with exposure
    CBreathing techniques to help with exposure
    CExposure (easiest to hardest) over 8–12 weeks
    Initial MedicationASSRI/SNRI: start low and go slow, but go
    BBenzodiazepines: if >4 times per week, keep taking for 12 weeks, then taper slowly
    BBenzodiazepines: may use as monotherapy in select cases
    Treatment Resistant AnxietyCAdd another antidepressant or benzodiazepine
    BConsider in rare cases adding atypical neuroleptic
    Medication DiscontinuationCAfter 1 year of therapy
    CDepending on comorbid psych and medical illness, avoidance, ongoing stress
    • ADD, Anxiety Depression Detector; AUDIT-C, Alcohol Use Disorder Identification Test; MDQ, Mood Disorders Questionairre; GAD, generalized anxiety disorder; OASIS, Overall Anxiety Severity and Impairment Scale; MI, motivational interviewing; SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin-norepinephrine reuptake inhibitor.

    • View popup
    Table 2.

    Selective Serotonin Reuptake Inhibitor and Serotonin Norepinephrine Reuptake Inhibitor Antidepressant Options

    MedicationAnziolytic Efficacy*AdvantagesDisadvantages
    FluoxetinePanic,† PTSD*Generic available; long half life (no withdrawal)Most stimulating; longer half life
    ParoxetinePanic,† GAD,† SAD,† PTSD†Generic available; most extensively studied across these anxiety disorders; least stimulating; no P450 3A4 effectsMost sedating; shorter half life and worse withdrawal
    SertralinePanic,† GAD,* SAD,† PTSD†Well-studied across these 4 anxiety disorders; least P4502D6 effects; minimal P4503A4 effects; intermediate half life (less withdrawal)Most diarrhea
    CitalopramPanic*Generic available; no P450 effects
    EscitalopramPanic,* GAD,† SAD*No P450 effects
    Venlafaxine ERPanic,† GAD,† SAD,† PTSDNo P450 effects, pain effectsShort half life; withdrawal with missed dose or sudden discontinuation; increased blood pressure at >225 mg
    DuloxetineGAD†Pain effectsUnclear efficacy for other anxiety disorders; more stimulating
    • ↵* Randomized controlled trials but no Food and Drug Administration-approved indication.

    • ↵† Food and Drug Administration-approved indication as of January 2006.

    • GAD, generalized anxiety disorder; PTSD, posttraumatic stress disorder; SAD, social anxiety disorder.

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The Journal of the American Board of Family Medicine: 22 (2)
The Journal of the American Board of Family Medicine
Vol. 22, Issue 2
March-April 2009
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Brief Intervention for Anxiety in Primary Care Patients
Peter Roy-Byrne, Jason P. Veitengruber, Alexander Bystritsky, Mark J. Edlund, Greer Sullivan, Michelle G. Craske, Stacy Shaw Welch, Raphael Rose, Murray B. Stein
The Journal of the American Board of Family Medicine Mar 2009, 22 (2) 175-186; DOI: 10.3122/jabfm.2009.02.080078

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Brief Intervention for Anxiety in Primary Care Patients
Peter Roy-Byrne, Jason P. Veitengruber, Alexander Bystritsky, Mark J. Edlund, Greer Sullivan, Michelle G. Craske, Stacy Shaw Welch, Raphael Rose, Murray B. Stein
The Journal of the American Board of Family Medicine Mar 2009, 22 (2) 175-186; DOI: 10.3122/jabfm.2009.02.080078
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