Venlaxine needs extra caution due to potential higher suicide risk and overdose fatality links.

Okay, lots to consider there. Finally, let's wrap up with some quick therapeutic tips for our listeners, things to keep in mind for practice.

Sure. Remember, short-term interventions like relaxation can be useful adjuncts. Short-term benzo use, maybe up to 6, 8 weeks max, can help acutely or anti-depressant initiation.

Don't judge effectiveness too early.

Exactly. Assess effectiveness only after an adequate dose and duration. Using those self-report scales can help track progress objectively.

And if the first drug doesn't work,

switch to another firstline agent if ineffective or not tolerated. Augmentation comes later for partial response to an optimal dose, usually with specialist input.

Great summary. This has been really comprehensive, super helpful for PEBC candidates. And remember everyone, you can refer back to those table 3, four, and five and the algorithms in the CTC reference for quick reviews.

Definitely keep those handy and always stay updated with current guidelines.

Okay, time for our quick quiz question based on today's deep dive. Which of the following SSRIs is generally avoided during pregnancy due to a potential association with congenital cardiac abnormalities? Is it a certuline, b acetalopram, c per proxitine or d fluxine?

Thinking back to our discussion, the answer is c peroxitine.

Correct. Proxitine is the one to generally avoid in pregnancy due to that potential cardiac link. Well, this deep dive into anxiety disorders for Canadian pharmacy PBC candidates was brought to you by Pharma Board Group based on the CTC reference. Thanks so much for tuning in.

Yeah, thanks for joining us. Hope it was helpful.

Definitely check out further resources and guidelines for the full picture and to leave you with something to think about considering just how common anxiety disorders are and their impact. How can you as a future pharmacist proactively contribute to earlier recognition and better management right there in your daily practice?

اختلال وسواس جبری
Welcome to the deep dive. Today we're tackling obsessivecompulsive disorder, OCD. And I for those of you gearing up for the Canadian pharmacist PBC exam, really understanding the therapeutic choices here is well, it's critical.

Absolutely. And this deep dive comes to you from the Pharma Board Group using the CTC reference as our guide. Our mission today is basically to pull out the must know info on treatments, those medication algorithms, the tables, all the essential tips for OCD management. Think of this as your focused guide. We want to give you that clarity, the accuracy, and you know, the practical insights you'll need not just for the exam, but for practice, too. It should hopefully provide some peace of mind.

Definitely. So, let's dive in. Therapeutic choices for OCD. Where do we begin?

Okay, so the foundations, what are the first line options?

Well, the evidence is really solid for two main approaches.

Specialized cognitive behavioral therapy or CBT and farmotherapy, specifically with SSRI, selective serotonin reuptake inhibitors.

Right. Both strong ly backed by research.

Exactly. High quality studies support both.

But um I gather CBT, the specialized kind, is often seen as the preferred starting point for most. Why is that?

Yeah, that's generally true. The main reason is the risk of relapse when medication is stopped. SSRIs work, no doubt, but stopping them often leads to symptoms returning. Specialized CDT aims for more lasting change.

So it equips patients, but as longterm

precisely, especially exposure and resp response prevention, ERP. That's the core of specialized CBT for OCD. It helps break that cycle of obsessions and compulsions.

That makes a lot of sense. But, you know, finding a therapist who really specializes in OCD, CBT, that can be tough, right? Access is an issue.

It absolutely can be. And that's why starting with an anti-depressant like an SSRI while someone is waiting to get into specialized CBT is seen as a pretty reasonable approach. It bridges that gap.

Okay. A practical step then. And I see there's work being done on setting standards for therapists doing this work?

Yes. Developing knowledge and competency standards. It's important to ensure quality specialized care.

Now, with the medications, how do we know if they're actually working effectively? Is there a specific measure?

Yeah.

In the drug trials, yeah, a clinically meaningful response is usually defined as getting at least a 30% reduction on the YBOCS score. That's the Yale Brown obsessive compulsive scale.

30% reduction.

But interestingly, in the CBT world, there's more talk now about um achieving wellness and recovery, like getting scores down. into the range you'd see in the general population.

A higher bar in a way. Let's dig into that specialized CBT a bit more. ERP, how is it different from the CBT someone might get for say general anxiety?

That's a great question. Specialized CDT for OCD, particularly ERP, is very specifically focused. It involves helping the person gradually face their feared thoughts or situations, the exposure part, and crucially resist performing the compulsive rituals, the response prevention part.

So, it's very targeted. very behavioral.

Exactly. It's not just about challenging thoughts like in some other CBTs. It's about directly confronting the fear and breaking the ritualistic behavior cycle.

And the results seem pretty good.

They do. Meta analyses show something like 65% of patients getting substantial symptom reduction. We're talking an average of 50% improvement at around 15 months.

Wow. Okay. And remission rates

also encouraging. Around 59% right after treatment, which takes maybe 14 15 weeks on average, and still holding at about 57 % at that 15-month follow-up.

That's impressive. But it's not always just ERP, is it? Sometimes more is needed.

That's right. Some individuals have more complex issues like uh metacognitive problems, problematic beliefs about their thoughts. They might need extra cognitive therapy techniques added on.

Beliefs about thoughts like having this thought is as bad as doing it.

Exactly. That kind of thing. And we're also seeing specialized protocols being developed for different OCD subtypes like contamination fears versus hoarding versus symmetry obsessions. They need slightly different approaches. tailoring the treatment makes sense. And the intensity matters, too.

It can. Yeah. Some people need more frequent sessions or longer ones. Sometimes having the therapists actually assist with ERP practice out in real world, you know, in their home or workplace is key.

Right. Where the triggers actually happen.

Exactly. And specialized OCD centers that offer these more intensive, tailored, longerterm programs often report even better outcomes, higher recovery rates.

So for pharmacists or other professionals in areas maybe without that deep expertise, What's the advice?

The guidance is clear. If you lack expertise, refer to or at least consult with someone who is an expert in specialized CBT for OCD. Get the patient to the right care.

Okay. What about things like guided self-help? Is that a good starting point?

Um, unfortunately, the evidence for lowintensity CBT, like guided self-help, isn't very strong for OCD. It doesn't reliably beat doing nothing.

So, not recommended as a first step.

Not really. Internetbased CBT is showing some promise which is good for access but this idea of stepped care starting with self-help and only moving up if needed that's not evidence-based for OCD there's a real risk of undertreatment maybe even making symptoms worse

that's a really important caution what about related disorders like hoarding or BDB do they have their own CBT

yes they do there are specific evidence-based specialized CBT protocols developed just for those conditions as well

okay now shifting gears a bit what about treatments for people who haven't responded to these first line options, the more experimental stuff,

right? For treatment resistant OCD, there are brain stimulation therapies being looked at. One is RTMS, repetitive transcranial magnetic stimulation. It uses magnetic pulses on the surface of the cortex.

And the results,

some preliminary evidence suggests it might offer benefit for up to about 12 weeks. Then there's DTMS, deep TMS, which can reach deeper brain areas,

deeper stimulation.

Yeah. One trial showed a 45% response rate compared to 18% with a sham treatment. The main side effect seems to be mild headache, which is pretty common.

Okay. And even more invasive options.

There's deep brain stimulation or DBS that involves surgically implanting a device, a neuro stimulator into specific brain regions targeted for OCD.

That sounds quite serious.

It is. Meta analyses show about a 50% response rate in severe treatment resisting cases, which is significant. But full remission, getting completely better, is less common, maybe around 8%. Adverse effects are usually mild. But they are common

and neuroblation making lesions in the brain.

Yes, that's another approach creating small irreversible lesions. Openle label trials show response rates around 54 62%.

But and this is crucial the risk of serious side effects is much higher potentially 5 21%.

So these are really reserved options.

Absolutely reserved for patients who haven't responded to optimized CBT and multiple medication trials. And honestly we still need more rigorous control trials for all these techniques.

Understood. Just to clarify, ECT electrocombulsive therapy that's not for OCD itself.

No, generally not help for OCD symptoms directly.

It's really only considered if someone has severe comorbid depression, for example, where ECT might be used for the mood disorder.

Okay, let's pivot back to pharmarmacothotherapy. Super important for the PBC candidates listening. You mentioned figure 1, table 3, table four in the reference material. Let's break down those firstline drugs from table three, right? The SSRI. So, we're talking about cyolopramopramoxy fluoxamine, peroxitine, and certuline. Those are the go-tos.

And the key thing to remember about time frame,

it takes time. You might see about 80% of the benefit within 6 weeks, but you really need to give it up to 12 weeks, maybe even longer sometimes at an adequate dose to see the maximum effect.

12 weeks for a full trial. And what if someone isn't improving much early on, say at 4 weeks?

That's actually a decent predictor.

Yeah.

If there's less than about a 20% improvement on the YBOCs at 4 weeks, the chance of them responding well by 12 weeks drops quite a bit maybe only a 20% chance

okay so that 4-we mark is a point to reassess

definitely whereas if they have shown more than 20% improvement at 4 weeks their chances of responding by 12 weeks jump up to over 50%.

Is any one SSRI clearly better than the others

you know the evidence doesn't really support one being consistently superior across the board for OCD but individuals can respond very differently one person might do great on search lane another might tolerate fluoxitine better or find fluoxamin works best. Tolerability varies too.

And dosage that seems really crucial for OCD, maybe more so than for depression.

Yes, that's a critical point. Higher doses of SSRIs are often needed to get good control of OCD symptoms compared to what you might typically use for depression.

But higher doses mean potentially more side effects.

Exactly. It's always a balance between efficacy and tolerability. The usual approach is start low, maybe for the first week, then gradually increase the dose. You want to get to the maximum tolerated dose and stay there for at least 6 weeks before deciding it's not working or switching.

Maximum tolerated dose for 6 weeks,

right? And sometimes specialists might even carefully push the dose beyond the standard approved maximums with the patients informed consent of course. But you have to be cautious especially thinking about risks like seizures or uh QTC prolongation with citr and esopram at very high doses.

Okay. So if that first SSRI trial even at a good dose for enough time doesn't work out. What are the options then?

Generally, you'd think about three main paths. Switching to a different SSRI, maybe trying that super therapeutic dosing if it wasn't already attempted and seems feasible, or adding something else on augmentation strategies.

Let's talk about switching first. What about other monotherapies, second line choices?

Okay, so second line monotherapy, you're primarily looking at venaxine, which is an SNRI or clomoprain, an older tricyclic antidepressant.

Venlaxine, how does that work?

It inhibits both serotonin and norepinephrine reuptake. Its benefit in OCD is thought to come mainly from the serotonin part. It might be a good option if the patient also has say chronic pain or major depression. Though switching from an SSRI to ventilaxine might sometimes be less effective than just trying another SSRI

and clomopraine.

Clomopraine is actually quite effective similar efficacy to SSRIs. The big issue is tolerability. It has more side effects anticolinergic effects like dry mouth constipation plus sedation from antihistamine effects. And a major concern is that it's dangerous. is an overdose.

Okay, so significant drawbacks there. What about morttazipene?

Mertazzipene, the evidence for it as a standalone treatment for OCD is pretty weak. It might be considered if someone cannot tolerate SSRIs, maybe due to sexual side effects or potentially as an add-on treatment, an augmentation agent, but it often causes weight gain.

Right? So, let's talk more about augmentation. If an SSRI isn't cutting it alone, what gets added?

The agents with the best evidence for augmentation are actually antiscychotics. Specifically, Piprizole and Respperadone. They are dopamine receptor partial agonists or antagonists.

Antiscychotics for OCD.

Yes. Used as augmenting agents. They seem to help maybe around 30% of people who have an inadequate response to SSRIs. You usually titrate them up to a middle dose and check for benefit around the four-week mark.

And side effects to watch for.

With these, you need to monitor for things like metabolic syndrome, weight gain, changes in blood sugar or lipids, and potentially movement disorders. though may be less risk with arapiprazil. Olanzipene and quitipene have also been studied but the data supporting them is more mixed.

Okay. And beyond the antiscychotics you mentioned glutamate modulators earlier.

Yes. For more refractory cases if SSRIs plus dopamine antagonists haven't worked or weren't tolerated drugs like lamatrodine meantine to pyramate amantadine adding these onto an SSRI might help some people.

How's the tolerability generally?

Generally they're reasonably well tolerated with the exception of top which can sometimes cause has cognitive side effects or other issues. Lemmitrine and meantine might be common next steps after trying respirone or aeroprizole augmentation

and things like ketamine.

Ketamine is definitely being investigated. Lots of research interest, but it's not really in standard clinical practice for OCD yet.

What about anicylcysteine? I've heard about that.

Yeah, NC. It's a neutrautical. There's some well some mixed but emerging evidence that adding it to serotoninergic meds might be beneficial possibly more for the compulsions needs more study though.

And just to be clear, benzoazipines, lithium,

generally not helpful for the core symptoms of OCD. They might be used if someone has severe coexisting anxiety or mood issues that need managing, but not for the OCD itself.

Okay. So, tracking progress is key. You mentioned the YBOCS.

Yes, the YBOCS is the gold standard. Or sometimes a shorter version like the BOCS is used in clinical practice. You'd ideally use it to monitor response at key points, maybe 4 weeks, 12 weeks. And when Whenever you're making a treatment decision

and if a treatment is successful, how long should it continue?

The general recommendation is for at least a year of continuation treatment after achieving a good response.

A full year. And what about stopping medication?

That's tricky. Relapse rates after stopping medication monotherapy are unfortunately quite high. The decision to stop really needs to be individualized. Usually waiting until the person has been stable psychosoccially for a prolonged period. And if you do stop, Taper the antid-depressant very gradually to minimize discontinuation symptoms and watch closely for any signs of relapse.

It sounds like medication alone often isn't enough to get people fully well.

That's a really important point. Most patients don't reach minimal symptoms with just medication. That's why combining pharmarmacologic treatment with specialized CBT, especially ERP, whenever possible is so crucial. It really optimizes outcomes.

Adding ERP improves things significantly.

Yes. Substantially improves the response rate compared to meds alone. And And it seems to make people less susceptible to relapse later on.

What about people who do CBT first? Can they sometimes come off meds later?

Yes. There's evidence suggesting that individuals who complete successful CBT while on an SRI might be able to maintain their stability even after carefully tapering off the medication with ongoing monitoring of course.

And combination therapy might be particularly helpful for certain folks.

Definitely people who are maybe more treatment resistant, perhaps those with poor insight into their illness. or really strong beliefs about their obsessions, overvalued ideas, or just very high levels of distress, combination therapy can often be beneficial for them.

Okay, let's summarize some of those key therapeutic tips from the guidelines. What are the highlights?

Number one, get specialized CBT started as soon as possible. If someone's on an SSRI and they feel improved or much improved after 6 weeks, keep going for the full 12 weeks. Don't switch too soon.

And if they haven't improved by 6 weeks,

first check adherence. Are they actually taking as prescribed, then consider pushing the dose up to the maximum tolerated level before thinking about switching meds.

Right? And those higher than standard doses,

they can be considered if someone's tolerating a high dose well. But again, be cautious, especially with citroetalopram and QTC prolongation risk.

What if the first SSRI even optimized doesn't work or isn't tolerated?

Then switching to another SSRI or perhaps clomopraine makes sense.

And when does augmentation come in before switching.

Good point.

If the first SSRI only gives partial improvement, the guidelines suggest considering augmenting with respodadone or air piperole might actually be better than just switching to a second SRRI right away.

Interesting. Augment first if there's some response.

Exactly. And similarly, if a second SRRI is ineffective, consider augmenting with respadone or aapiprazole before jumping to a third SRRI monotherapy trial.

And after that point,

that's when you might start thinking about those glut modulating agents like lamontrigyny or meantine as augmentation options.

It's also important to distinguish technical failure versus actual failure.

Yes, technical failure means maybe the dose wasn't high enough or the trial wasn't long enough. Actual failure is when an adequate trial truly didn't work. Big difference.

Okay, really crucial points. Now, let's touch on pregnancy and breastfeeding. This comes up a lot.

It does. And unfortunately, OCD symptoms, especially obsessions about harm coming to the baby, can sometimes worsen during pregnancy. It causes immense distress

and it's important to reassure them.

Crucially important, reassure them they are not at higher risk of actually harming their child. These are intrusive thoughts, part of the OCD often leading to guilt and depression.

And screening is vital.

Absolutely. Many people with psychiatric issues don't seek help during this time. So screen for OCD and other symptoms before conception if possible, definitely during pregnancy and postpartum. And always screen for mood symptoms and suicidality if there's significant stress referral to a psychiatrist might be needed.

Can treatment be offered before pregnancy?

Yes. If someone has significant distress or impairment from OCD, preconceptional treatment, maybe with CBT. It's definitely something to consider.

And during pregnancy itself, what are the options?

Well, the good news is psychological treatments, especially specialized CBT are considered safe and beneficial throughout pregnancy. That should be a primary consideration.

And medications, SSRIs,

for severe impairing symptoms during pregnancy, SSRIs are considered appropriate. You'd follow the general principles for managing depression in pregnancy. Just note that peroxitine has been linked with slightly higher risks compared to other SSRIs. So, it's often avoided if possible.

Okay. What about after the baby is born during breastfeeding?

Postpartum OCD can be really tough. Severe anxiety, disrupted sleep, loss of confidence. In really severe cases, those tormenting harm thoughts can lead a mother to avoid caring for her baby, which is an emergency needing urgent psychiatric help.

So, again, non-drug options first.

Yes, prioritize CBT if possible for breastfeeding mothers, but if medication is necessary, esetalopram and certuline are often preferred because they seem to pass into breast milk in minimal amounts. Always consult specialized resources on medication use in pregnancy and lactation.

Excellent. Lastly, let's quickly walk through figure one, the drug therapy algorithm, just the key steps.

Sure. So, generally, it starts with an SSRI, optimized dose and duration.

If that doesn't work, no response. You typically switch to another SSRI or maybe an SRI like benlaxine or clomoprain.

Okay. Switch if no response. What if it's a partial response?

If the first SSRI gives only a partial response, the algorithm suggests augmenting with respirone or aeraprizole.

Augment if partial response,

right? And then if you've tried a second SRRI and still have an inadequate response, the next step is usually augmentation again with respirone or aeroprizole before moving on.

Then after that,

that's where you might consider adding one of the glutamate modulating drugs. Lamar's gene, meantine to permate, amantadine and just remember the shortand SDA usually means those serotonin and dopamine antagonists like respperadone and SRRI includes SSRIs, venolithaxine or clomop preman.

Perfect. That algorithm provides a really helpful visual road map. This has been uh incredibly thorough. It's so clear that really getting these therapeutic choices, the algorithms, the nuances, it's just essential for PBC candidates.

Absolutely. And remembering that it's not just about drugs. That combination of pharmacologic and non-farmacologic options, especially specialized CBT, is often the key to the best outcomes.

Definitely encourage everyone listening to really go over those tables, table three, table four. Look at the dosages, the side effects, the interactions, and review figure one, the algorithm.

They're invaluable summaries for exam preparation.

Okay, time for a quick check-in. Here's a multiple choice question based on what we've discussed. Which of the following is generally considered the firstline psychotherrapeutic treatment for obsessivempuls of disorder. Is it A relaxation therapy, B psychoanalysis, C specialized cognitive behavioral therapy, or D group therapy?

And the answer, hopefully clear by now, is C, specialized cognitive behavioral therapy, specifically ERP being a core component.

Exactly. We really hope this deep dive has provided that clarity and confidence boost you need. Summarizing this critical info should offer some peace of mind as you study. Remember, this knowledge isn't just for the exam. It's fundamental for providing Excellent patient care.

Keep up the great work with your preparation. Stay curious and always remember that treating OCD effectively often requires that careful, individualized approach, combining strategies to best meet each patients needs.

اختلال استرس پس از سانحه
Welcome to this deep dive from Pharma Board Group. If you're getting ready for your Canadian pharmacy PBC exams, well, you're definitely in the right place.

That's right.

Today, we're focusing right in on post-traumatic stress disorder, PTSD. We're pulling out all the key information from the CTC reference that uh you really need to know.

Exactly. Think of this as your essential guide.

We'll cover the um the core diagnostic stuff, therapeutic choices, medication details, you know, the important tables and tips, all streamlined to help you feel confident for the the exam.

Absolutely. PTSD is uh a really important area for pharmacists. Understanding how to manage it is vital for patient care and of course for the PBC. We're here to break down the key elements for you.

Okay, let's dive in. Starting with the basics. How is PTSD actually defined? What's the framework?

So, the DSM5 puts PTSD under the umbrella of trauma and stressor related disorders.

Okay,

it's in there with others like uh reactive attachment disorder, acute stress disorder, adjustment disorders, all linked to experiencing stressful events,

right? And what specifically triggers PTSD? What criteria need to be met? And um is there a timeline?

Good questions. The core thing is significant distress or problems functioning lasting at least a month after the trauma exposure.

A month. Okay.

And the exposure itself,

yeah,

it could be directly experiencing or witnessing things like actual or threatened death, serious injury, or sexual violence.

Right.

But also includes learning about these things happening to someone close like family or a good friend or um repeated exposure to the grim details like first responders might face

ah so it's not just about personal experience that's important now what about the symptoms I know they fall into different groups

that's right four main categories you'll find these in table one in the reference material first up is intrusion symptoms

intrusion

yeah this is where the trauma keeps coming back so like intrusive memories just popping into their head bad dreams flashbacks where it feels like it's happening again.

Wow. Yeah.

And getting really upset physically or emotionally when faced with trauma reminders.

That sounds incredibly disruptive. What's the second category?

Second is avoidance.

Basically trying really hard to stay away from anything connected to the trauma.

Avoiding how

it could be internal things. Trying not to think about it, not wanting to feel those emotions

or external avoiding people, places, conversations, activities, objects,

anything that reminds them. People might really change their lives to avoid trigger. Okay. Actively steering clear. What's the third group of symptoms?

Third is negative cognitions and mood. This covers a lot actually, like distorted thoughts about the cause or consequences, blaming themselves or others unfairly, trouble remembering important parts of the event,

feeling persistent negative emotions, fear, horror, anger, guilt, shame,

and often losing interest in things they used to enjoy, feeling detached from others, not being able to feel positive emotions, just a generally negative view of things.

Okay. And the last Number four is arousal and reactivity. Big changes here too.

In what way?

Things like being hypervigilant, constantly on guard, jumpy, an exaggerated startle response, problems with concentration, trouble sleeping.

Sleep issues are common, right?

Very. Also, irritability, angry outbursts, reckless or self-destructive behavior, just a general state of being keed up or on edge.

So, for our PBC candidates listening, how many symptoms from each category are needed for an adult diagnosis? Let's clarify. verify that,

right? For an adult PTSD diagnosis, you need at least one intrusion symptom, at least one avoidance symptom, at least two negative cognition mood symptoms, and at least two arousal reactivity symptoms.

One, one, two, two. Got it.

And crucially, these symptoms have to cause significant distress or impairment in their life, socially, occupationally, and last for more than one month.

And we're focusing on adults today, right?

Yes, exactly. This discussion is centered on adult PTSD for the PBC context.

Perfect. That's a very clear picture of the diagnosis. So once someone is diagnosed, what are we aiming for with treatment? What are the goals?

The main goals are uh pretty straightforward but really important. We want to reduce how often the symptoms happen and how bad they are. We want to decrease the disability caused by the PTSD.

Makes sense.

We also aim to prevent relapse, stop the symptoms from coming back strongly later on. And a big one is treating any other conditions that are present, what we call comorbid conditions,

right? Like depression or anxiety.

Exactly. Treating those alongside the PTSD is often key to getting a good overall outcome.

Okay. Let's talk about how we get to that diagnosis, the investigation process. It sounds like it needs to be handled carefully.

Absolutely. Starts with really exploring the traumatic event and how it's affected the person. Sensitivity and patience are paramount here.

Yeah, I can imagine.

It can be incredibly difficult for someone to talk about these things. Building trust and maybe over several visits is really key to getting the full picture. So definitely not something to rush. What specific things does a clinician focus on during the history taking?

They'll look closely at the symptoms themselves. What are they when did they start? How much are they impacting daily life, work, relationships? And are there other medical or psychiatric issues going on? Co-orbidities are common.

You mentioned coorbidities. Are there tools to help screen for PTSD itself?

Yes, the CTC reference mentioned several useful tools for a quick screen, especially in primary care. There's the PCPTSD5. It's just five questions.

Okay, quick chair.

Then there's the PCL5. That's a self-report questionnaire so the patient fills it out.

It's good for tracking symptoms over time and can help with a provisional diagnosis.

And the gold standard

that would be the CIPS5. It's clinician administered more in depth. Takes maybe 20 40 minutes, but it gives a really thorough assessment.

CAPS5. Good to know. Is there a physical exam component, too?

Yes, a physical exam is important. Helps rule out medical conditions that could mimic some symptoms and also to check for signs of substance misuse.

Ah, good point.

And it's just generally good practice as people with psychiatric disorders can have higher rates of other medical problems.

For substance use specifically, something like the Inia, a quick screen can be helpful.

An idea quick screen. Okay. What about lab tests? Are any routinely done?

Yeah, several labs can be useful. Things like a CBC, electrolytes, glucose, liver function tests, including GGT, which can hint at alcohol I'll use

GGGT

also thyroid function test, kidney function test, maybe ferotin, B12 and ECG to check the heart. It's about getting a complete picture of the patient's health.

Okay, that covers diagnosis. Now, the really crucial part for us, therapeutic choices. Figure one in the reference is the algorithm. What about initial management right after a trauma?

This is a really important point. In the first few weeks, say up to four weeks, most people exposed to trauma won't develop PTSD.

Oh, really? Most people.

Yeah. So usually psychotherapy or medication including benzo isn't needed right away. In fact, something called psychological debriefing shortly after the event within 2 weeks is actually discouraged.

Discouraged what

evidence suggests it doesn't really help and might even interfere with natural recovery. The focus early on should be more on support, normalizing the acute stress reactions which are common and encouraging the person's own coping skills and support networks.

So let natural resilience work first. Exactly.

And there's not much evidence that giving medication immediately prevents PTSD from developing later. Now, if someone is severely overwhelmed or really impaired in that first month, then supportive therapy or maybe medication could be considered.

Okay, so mostly watchful waiting and support initially, what about treating established PTSD? Is there a general approach?

Yes, treatment usually follows phases. Often starts with stabilization, making sure the person is safe, then psychoeducation, helping them understand PTSD. learning about it,

right? Then teaching anxiety management skills.

Then the core part, trauma focused psychotherapy. After that, relapse prevention strategies and planning for ongoing care.

Sounds structured. What about those comorbidities you mentioned?

Crucial to address those. If there's severe depression or another major mood disorder, that often needs to be prioritized. Managing chronic pain, sleep problems, substance use, that's all part of the picture, too. Sometimes needing referrals.

The reference really highlights trauma focused psychotherapy. be as first line. Can you talk more about that?

Absolutely. It's generally the recommended starting point before medication if possible and if the patient is willing.

But medication is also first line.

Yes, phicotherapy is also considered first line. It's a key option if say therapy isn't available or the patient prefers medication or maybe if they need quicker stabilization. Some evidence suggests meds might be particularly helpful for military or combat related PTSD.

Interesting. What about doing both together? therapy and meds.

There isn't a clear recommendation to always combine them initially. Studies haven't shown a huge advantage of combination versus either one alone. Generally speaking,

so it comes down to the individual.

Exactly. Offering patients a choice considering their situation, resources, preferences, that's really key for adherence and getting good results. We need to support that shared decision-making.

Makes sense. Let's dig into the non-farmacologic options then. Table two lists some. What should PBC candidates know? Well, CBT cognitive behavioral therapy is effective, but the trauma focused therapies tend to work even better for PTSD specifically,

like which ones?

There's prolonged exposure or PE that involve carefully confronting the trauma memories and reminders either in imagination or real life in a safe way,

facing the fear essentially,

in a controlled therapeutic way. Yes. Then there's cognitive processing therapy, CPT, that focuses more on identifying and challenging the unhelpful thoughts and beliefs that arose from the trauma. changing the thinking patterns,

right? And then EMDR, eye movement desensitization and reprocessing. That involves focusing on the trauma memory while tracking an external stimulus like the therapist's finger. It's thought to help the brain process the memories differently.

EMDR. Okay. What about just supportive talk therapy?

General supportive therapy without directly addressing the trauma hasn't been shown to be better than just being on a wait list for active treatment. The trauma focus seems important.

Good distinction. Any other approaches? There's emerging stuff like adaptive disclosure intervention especially for moral injury which can be a factor in military PTSD dealing with guilt or shame over actions taken.

Moral injury. Okay.

Also really important before starting intense trauma focused work. The patient needs to be reasonably stable. If there's active suicidality, self harm or psychosis that needs addressing first. Starting too early might worsen things.

Stabilization first makes sense. What if therapy isn't easily accessible?

Internetbased C PT is an option to consider if there are delays or barriers to in-person or virtual therapy. And don't forget, lifestyle exercise can actually help reduce both PTSD and depression symptoms.

Exercise, good tip. Okay, let's switch gears to medications. Table three territory. What are the go-to first-line drugs?

First line phicotherapy is primarily the SSRI's selective serotonin reuptake inhibitors. Specifically, fluoxitine, peroxitine, and certillene have the best evidence.

SSRIs any others first line

in the SNRI venifaxine Serotonin nor neuropinephoprin reuptake inhibitor. These are all shown to help reduce symptoms across those four clusters we talked about.

Okay. SSRIs and venlaxine. What if those don't work well enough? What are second line options?

Second light agents include another SSRI fluoxmen. Also mockamide which is an RIMA and phenylene an older MAOI though used less often due to restrictions and retazzipine.

Martazipine. I know that one's often used for sleep and appetite too.

Exactly. It can be quite useful if the patient also has significant depression, insomnia. or weight loss. Often used as an add-on, though an important point, continuing antid-depressants for up to a year seems to help prevent relapse.

Good to know about duration. What about adding other types of meds? The reference mentions antiscychotics,

right? Augmentation. Second generation anticychotics like aapiprazole, quipene, alanzipene might be considered with an anti-depressant if the response isn't adequate.

So not on their own.

Generally not as monotherapy for PTSD. No, it's more for boosting the antid-depressant. effect especially if hyperarousal or reexperiencing symptoms are really prominent

and we need to watch for side effects with those

definitely metabolic side effects weight gain blood sugar changes cholesterol need careful monitoring azrazole might have a bit less weight gain risk ketapene often causes more sedation things to consider

okay now what about bzzoioipines people often think of them for anxiety where do they fit in PTSD

uh generally they're not recommended as a primary treatment or monotherapy be for PTSD

not recommended. Why not?

Well, there's a lack of good evidence for long-term effectiveness. Plus, there's the risk of dependence and high rates of substance use disorders often co-occur with PTSD.

Right. The coorbidity issue again.

Exactly. So, while they might be used very cautiously short-term for severe acute anxiety or insomnia while the person is getting proper evidence-based treatment like an SSRI or therapy,

routine or long-term use is discouraged. Definitely avoid them if there's a substance use history.

Okay. Okay. Strong caution there. Sleep is such a big problem. You mentioned nightmares too. Any specific meds for those?

Yeah. Trazetones is often used for insomnia. If non-drug approaches or treating the PTSD itself doesn't solve it.

Trazadone for sleep.

And for nightmares specifically, protocin is commonly used. It's an alpha 1 blocker.

Prozocin. Does it work well?

The evidence is a bit mixed in trials honestly, but a meta analysis did suggest it helps with nightmares, hyperarousal, and sleep quality. It might work better for people with signs of high adrenaline levels or more unstable PTSD. Need to watch for dizziness, especially when starting.

Good practical point. What about things like medical cannabis? Is that used?

Well, there's a lot of interest, but currently the research supporting cannabis for PTSD or other mental health conditions is quite limited,

limited evidence.

Yeah. And there are potential risks, too. Concerns about increased risk of psychosis, maybe suicidal thoughts in some individuals. So, given the limited evidence and known risks, it's not recommended as a standard treatment for PTSD. right now.

Okay, that's clear. Let's move to another really important area. Managing PTSD during pregnancy and breastfeeding. What do future pharmacists need to know?

This is critical. PTSD symptoms can definitely flare up or come back during pregnancy. So, screening for PTSD and anxiety before conception and during pregnancy and postpartum is really important.

Screening is key

and check for mood symptoms, thoughts of self harm, especially if distress is high. Severe symptoms might need a referral to psychi ry if treatment is needed before pregnancy that's an option too.

What about treatment during pregnancy?

Psychotherapies like CBT are safe throughout pregnancy. Relaxation techniques can also be helpful.

And medications

if meds are necessary because symptoms are severe and impacting safety. SSRIs are generally the choice. Lowest effective dose shortest needed duration.

Which SSRIs?

CAMAC guidelines favor citellopregalopreg and certillene as first line in pregnancy. Peroxitine is usually avoided due to a small potential risk of cardiac issues. Avoid beroxitine. Okay. Any risks near delivery?

Using SSRIs in the third trimester can sometimes cause temporary withdrawal symptoms in the newborn. Something to be aware of. Benzos are generally used cautiously due to debated risks.

What about breastfeeding?

Again, non-drug options first if possible. If medication is needed, certuline, isatelopram, or citr are preferred because very little gets into the breast milk.

Certillene, acetatelopram, citopram preferred for breastfeeding. Got it. These are really vital points. Okay, let's circle back to some general therapeutic tips, quick takeaways.

Right. So, reiterate, trauma focused psychotherapy is preferred first line if feasible, but meds are also first line, especially with co-orbidities.

Always consider the patient's view.

Absolutely. Patient preference and expectations matter hugely for adherence. When starting a med, give it enough time at a good dose, usually four or six weeks before judging effectiveness. Use those scales like PCL5 or CPS5 to track progress.

And if the first drug doesn't work.

Try switching either within the same class like another SSRI or to a different class like venal vaccine. If a second one fails, consider switching classes again or adding an augmentation agent.

Okay. And don't forget the family.

Definitely. PTSD affects families. Consider referring partners, kids, or others for support or counseling if needed.

Great tips. We've mentioned the algorithm figure 1 a few times. Can you just briefly walk us through the flow again?

Sure. It starts with assessment and diagnosis. Considers those initial management strategies for acute trauma. Then for established PTSD, the main branches are trauma focused psychotherapy, pharmicotherapy, SSRI, SSNRIS, or maybe both

decision points,

right? Then it guides what to do if the first approach isn't working, switching, augmenting. It highlights managing coorbidities, depression, sleep, pain, substance use. And finally, relapse prevention and maintenance

provides a clear pathway. Lastly, for the petty C focus, let's hit the highlights from the drug table. Table three, what's most It's important there.

Okay. For the key drugs listed like proozosin, the SSRIs, venlaxine, mtazzipene, the antiscychotics used for augmentation.

What should candidates know?

Know the typical starting and maintenance dose ranges are usually oral. Be very familiar with key adverse effects for counseling and monitoring. No major drug interactions to watch out for.

So side effects interactions.

Yes. And understand their main role in PTSD prizen for nightmare sleep. SSI for poor symptoms, SGAAS for augmentation, and any special comments like presosin and floppy iris syndrome risk before cataract surgery, mortazzipene for sleep depression, how long SSRIs take to work, the need to taper off,

key clinical pearls.

Exactly. Focus on the clinically relevant points for safe and effective use.

Fantastic. This has been a really comprehensive runthrough of PTSD management for our PBC candidates. Key takeaways: Accurate diagnosis is crucial. Remember, both therapy and meds are first line. manage those coorbidities and always involve the patient.

Couldn't agree more.

And all this info distilled from the CTC reference is brought to you by Pharma Board Group to help you prepare

and hopefully this understanding helps you feel more confident not just for the exam but for your future practice.

Absolutely. Now to test your recall on what we've covered, here's a multiple choice question for you.

Which of the following is generally recommended as a firstline pharmacologic treatment for PTSD in adults? A. Benzoazipene monotherapy pres Tot C search certuline D atypical antiscychotic monotherapy

think about what we discussed regarding the evidence and guidelines

take a moment on that and we really encourage you to go back to the CTC reference and other resources to solidify your knowledge

yes definitely review the source material remember your role as the pharmacist in supporting patients with mental health challenges like PTSD is incredibly valuable

well said that brings us to the end of this deep dive thanks so much for joining us

ترانسکریپت مبحث اضطراب
Welcome to the deep dive. If you're gearing up for the Canadian pharmacy PBC exam, you uh you definitely know how much material there is to cover.

It's a lot.

Yeah, a mountain. So, today we're tackling a big one. Anxiety disorders,

a very common and important topic.

Exactly. And we've really tried to distill a key resource for you. Uh this deep dive is brought to you by Pharma Board Group and it's based on the CTC reference.

Right. We've pulled out the essential therapeutic choices, medication algorithms, those key tables, and you know, practical tips you really need for the exam and for practice.

Think of it as maybe a focused review, helping you feel confident you've got the critical stuff covered in this area.

That's the goal, a concise, clear summary. We know that feeling prepared brings peace of mind, and that's what we want to help with.

And it's so relevant for Canadian pharmacists, isn't it? The numbers are pretty staggering.

They really are. Lifetime prevalence estimates are about what, 31% and maybe 24% of Canadians saying they've actually experienced an anxiety disord. order.

Wow. So, you will see this in practice frequently.

Absolutely. And what's also concerning is that they're often underdiagnosed, undertreated even,

which means there's a real role for pharmacists here.

A huge opportunity. Yeah. To help with recognition, support, guiding patients.

So, it's more than just exam prep. It's about good patient care down the line. Okay. So, what's the roadmap for this deep dive? What are we covering?

Well, we'll start with the basics definitions. DSM5TR classifications, then uh goals of therapy. What investigations might look like. Okay. The main part will be the treatments, non-farmacological and pharmacological options.

We'll also get into special populations, pregnancy, breastfeeding, kids, adolescence,

crucial areas.

Definitely. And we'll wrap up with some practical therapeutic tips you can actually use.

Sounds like a solid plan.

Yeah.

Let's jump right into therapeutic choices then. Uh starting with the non-farmacological side. What about psychoeducation? How important is that?

Oh, it's foundational really empower. ing patients with knowledge about their condition, what it is, treatment options, what makes it worse, how to spot early warning signs,

so they understand what's happening.

Exactly. And pharmacists can point them to great resources like uh Relief or Anxiety Canada, good websites, good info to supplement what you provide.

Makes sense. An informed patient is usually a more engaged patient.

Totally. More likely to stick with the plan, feel more in control.

Okay. What about actual therapies? We hear about C CBT exposure therapy.

Yeah, psychotherapy is a cornerstone for the PBC. The big ones to know are cognitive behavioral therapy, CBT exposure therapy, and mindfulness-based approaches. They've all got strong evidence.

CBT seems to come up a lot.

It does. It helps patients identify and change those unhelpful thought patterns and behaviors. Often considered firstline psychotherapy for many anxiety disorders.

What if someone can't easily get to facetoface therapy? Are there alternatives?

Yes, and this is increasingly important. delivered CBT or ICBT.

ICBT. Yeah.

Yeah. There was a big Cochran review showing it's definitely better than being on a weight list. And interestingly, when it includes the support, it seems pretty comparable to traditional face-to-face CBT for a lot of people.

That's really good to know, especially for accessibility.

Huge benefit for access. Yeah.

What else? Beyond formal therapy, lifestyle things.

Definitely. Stress reduction techniques are helpful things like relaxation exercises, deep breathing, even just better time management can help people feel less overwhelmed. and exercise.

Aerobic exercise can certainly have a positive effect on mood and anxiety. Probably not a standalone cure for a diagnosed disorder, but definitely supportive,

right? What about things people consume? Caffeine,

alcohol,

key area for counseling.

Reducing or at least monitoring caffeine and other stimulants is important. They can really ramp up anxiety symptoms.

And alcohol, some people might use it to cope.

Yeah, but it's a tricky one. It can actually worsen anxiety in the long run. And it really messes with sleep quality. So, minimizing or avoiding it as a coping tool is crucial. Plus, withdrawal itself can cause anxiety.

The bad cycle. What about elicit drugs?

Big no. No. Things like cannabis, cocaine, hallucinagens, even anabolic steroids. They can all trigger or worsen anxiety, they really should be stopped.

And if someone's struggling to stop,

referral to addiction services is the way to go. And underlying all this is just, you know, emphasizing a balanced lifestyle, healthy sleep habits, sleep and anxiety are so tight. linked.

Okay. So, a real whole person approach needed on the non-farma side. Let's switch gears to medications. Pharmacologic treatments. When do we usually start thinking about meds?

Generally reserved for moderate to severe anxiety disorders, especially when symptoms are really interfering with daily life, quality of life, or you know, if non-drug approaches just haven't been enough.

And the main players here, the go-to drug classes,

uh, the selective serotonin reuptake inhibitors, SSRIs, and the serotonin Epinephrine reuptake inhibitors, the SNRIs, those are generally your first line choices.

Why them compared to older ones like TCAs?

Mostly tolerability and safety. They just tend to have a better side effect profile and are safer in overdose compared to say the triccyclic anti-depressants or the MAO inhibitors.

Got it. Are the doses for anxiety similar to depression doses?

Generally, yes. The target doses often overlap, but the key difference is how you start. For anxiety, you really want to start low and go slow.

Start low. so slow. Why is that?

To improve tolerability, titrate up gradually, maybe every week or two, until you hit that target dose. Helps minimize those initial side effects that can sometimes feel like increased anxiety,

right? And what's the most important thing to tell patients about when these meds will start working for anxiety.

This is absolutely critical for adherence. They need to understand it takes time. It's not like taking a painkiller.

Not instant relief.

Not at all. It can take anywhere from, say, 2 to 8 weeks to really start feeling the benefits. Sometimes longer, maybe 8 to 12 weeks for the optimal response.

Wow, that's a long time. Dentrol,

it is. And crucially, they might get side effects before they feel better. So setting those realistic expectations right from the start is vital. Otherwise, they might just stop taking it too soon.

That makes sense. What if someone tries one, say an SSRI, gives it a good shot, adequate dose, enough time, and nothing or not enough improvement?

Good question. If there isn't a significant response, and we often look for at least maybe 50% improvement on a standard anxiety scale. The usual next step is to switch to a different anti-depressant.

Switch rather than add something on.

Generally, yes, switch first. Could be another SSRI or maybe switch to an SNRI. Sometimes people respond to one but not another even within the same class. Augmentation, adding another drug usually comes later if needed.

Okay. And how long do people typically stay on these once they are working?

Good question. For relapse prevention, after someone's achieved remission or significant improvement. The recommendation is usually at least 12 to 24 months of continued treatment.

A year or two.

Yeah. And when it's time to stop, it absolutely has to be tapered gradually over several months. Usually stopping abruptly can cause withdrawal symptoms and anxiety can bounce back.

Super important counseling point. What about safety warnings, particularly for younger people?

Yes, very important. Health Canada has warnings about a potential increased risk of suicidal thoughts and behavior in patients under 18 taking anti-depressants

under eight.

Right.

So, But while these meds are still used and can be very helpful, they need careful prescribing, close monitoring, strict follow-up in that age group, interestingly, that risk doesn't seem to apply to adults.

No increased risk in adults.

Doesn't seem so. And some data even hints at a possible protective effect in adults. But still, monitoring for mood changes is always wise across all ages.

Okay. What about benzoazipines? We hear about Valium, Activon. Where do they fit in?

Uh, benzo. They work fast, very effective for acute anxiety, panic attacks, agitation. They can be useful initially when starting an anti-depressant, kind of bridging that gap until the SSRI kicks in.

There's always a butt with benzo, isn't there?

There is big butts. Risks of abuse, sedation, thinking problems, dependence, withdrawal issues, and falls, especially in the elderly,

right?

So, because of all that, they're considered second line, best used short-term if possible, and generally avoided in anyone with a history of substance use problems.

Okay? Second line, short-term. Are there other medication options besides SSIS and benzo?

Yeah, a few others. Things like pregabalin and gabapentin. Their calcium channel modulators have shown some effect in some studies.

Pregabin

lica, right? But there are growing concerns about misuse potential, especially with pregablin and particularly in people with substance use history. Definitely avoid pregablin if someone has current or past opioid use disorder.

Good point.

Any others? Well, there's less strong evidence for agents like Busperone, Martazipene, Velazadone, hydroxazine, trazadone. Some antiscychotics or anti-convulsants might be used as add-ons in really tough treatment resistant cases, but side effects are often limiting.

So, it sounds like the best choice really depends on the specific type of anxiety disorder someone has.

Exactly. The evidence base and even remission rates can differ. Panic disorder, for instance, often responds well to treatment. GAD that starts in adolescence can be more chronic. Separation anxiety often fades in adulthood.

And Thinking about therapy versus meds is one generally seen as better overall.

It's a good question. The evidence suggests both psychotherapy, especially CBT, and medications are effective for most anxiety disorders. Their overall effectiveness is often comparable.

Comparable.

Yeah. Some big analyses, meta analyses, might show a slightly larger average effect size for meds, but it's close. Interestingly, combining them doesn't always yield better results initially for all disorders. Oh, how so?

Well, for example, for GAD, starting with both meds and therapy isn't strongly supported right off the bat. But for panic disorder, combination therapy often works better than therapy alone. It varies.

When would medication definitely be the preferred starting point?

Usually, when symptoms are really severe, significantly impairing function or especially if there's any suicidal thinking. Also, in cases that haven't responded to other approaches, treatment resistant anxiety, that's when a psychiatric consult is definitely needed to.

Okay. Okay, let's get into those specifics then. Starting with panic disorder. What meds work best here?

Right. And remember a lot of the studies mix panic disorder with or without agorophobia. So panic disorder those recurrent unexpected attacks and the fear of having more. Yeah.

For meds SSRI are first line. Cityloprm, acetylop, fluxine, fluoxamine, peroxitine, certuline all have evidence and the SNR venaxine too. No SSRI seems clearly better than others.

What about older drugs?

TCAs like omipramine and clom premine work. similar efficacy actually but they're second line because of side effects and overdose danger benzoazipines alrazole clinopam laurasipam dasipam also second line mostly for short-term or initial use

any preference among the benzos

clinosipam and laorazipam are often preferred over alprazilam and dasipam alprazoleum xanax seems to have a higher risk of rebound anxiety and tricky withdrawal

okay and third one

desopreine and phenylene and mai are way down the list due to limited data or side effects and restrictions and things like mortazzipene, mlobamide, bperone, tresidone, propranolol generally not recommended for panic disorder. Uh, table three in the CTC reference summarizes this well.

Great. Table three for panic disorder. Any special tips for starting meds and panic disorder?

Yes, patients with panic disorder can be really sensitive to initial side effects. So that start low, go slow principle, even more important here. Start really low, titrate very slowly.

Got it. What about agorophobia? That fear of situations you can't escape from. Is the medication the same?

Agorophobia, yeah, that fear of places or situations where escape might be tough if panic hits. Pharmacologically, the treatment is basically the same as for panic disorder, but the core issue in agorophobia is often the avoidance behavior. And medication isn't always great at tackling avoidance. That's where CBT, especially exposure therapy, really shines for agorophobia.

Makes sense. Okay, moving on to social anxiety disorder or social phobia. Fear of being judged first line. meds

again SSRIs and SNRIs are the treatment of choice. Essatalopram, fluoxane, peroxitine, certuline and venlaxine have good evidence. Fluoxitine's data is a bit more mixed for social anxiety.

What about the second line?

Pregobland is an option. It can work especially at higher doses but more side effects and anti-depressants might be better if there's also depression. Benzo like clonosopam, brisopam also second line. Same risks as before.

Other second line options

fenneline, citylopram, makabam IDE, Motazipene, Gabapentine. Some have less data though. Ketamine is maybe third line but not widely available and buserone disphenoline seem ineffective here. Check table four in the reference for this one.

Table four. Okay. Anything else for social anxiety like for performance situations, public speaking nerves?

Yes, good point. For that specific performance related anxiety, a low dose of a beta blocker like propranolol or atanol taken maybe an hour beforehand can help manage the physical symptoms. But not for general social anxiety.

No, generally not effective for the broader day-to-day social anxiety. Just for the specific performance situations.

Okay. What about a specific phobias? Fear of spiders, heights, flying. Meds useful there.

Not usually the main treatment. Specific phobias are really best treated with exposure therapy. That's the gold standard.

So meds rarely needed.

Rarely as a primary treatment. Some studies suggest maybe taking a short acting benzo like alpresolam or pregabbolin before a plant exposure session could potenti help some people manage the anticipatory dread and one study showed fluoxitine might help but really exposure therapy is key.

Got it. Therapy first for specific phobias. Lastly, let's cover generalized anxiety disorder, GAD. That excessive worry about everything.

Yeah, GAD. That constant uncontrollable worry about everyday things lasting 6 months or more. CT is highly effective here on the therapy side

and pharmacologically. First line

SSRIs and SNRIs again Opram, peroxitine, certillene, benlaxine, deluxitine, citylopram also has good data specifically in older emeralds with GA

my second line options for GA

a few validone but less long-term data brigoblin keeping the abuse risk in mind benzoazipene same limitations perman the TCA but side effects even bopropene showed promise in one study compared to a satellopram

any third line option

quapene XR an antiscychotic can work as monotherapy and reduces symptoms quickly but sedation weight gain metabolic issues are significant downsides.

What about things like hydroxazine or busperone?

Hydroxazine worked in one trial but isn't used much clinically because of side effects. Trazadone valpro have limited evidence. Busperone is comparable maybe to benzo but slow onset limited long-term data so not used that often.

SGAAs like alanzipene might be added in refractory cases but again side effects. Table five summarizes GA meds.

Table five for GAD. Excellent. Now shifting to really crucial are is for pharmacists special populations. Pregnancy and breastfeeding. This comes up all the time.

Absolutely critical. Anxiety disorders are common during pregnancy and postpartum maybe 15 20%. And untreated anxiety isn't good for mom or baby.

So screening is important.

Definitely. Preconception during pregnancy postpartum. For mild to moderate anxiety, therapy like CBT or IBT is first line. Relaxation techniques can help too. Severe symptoms might need meds, possibly referral to psychiatry.

Okay. What are the risks with meds during pregnancy? SSRI. It's complex. First trimester SSRI use might slightly increase spontaneous abortion risk. Peroxitine is generally avoided due to a potential link with cardiac issues in the baby.

Avoid peroxitine in pregnancy.

Got it. Yeah. Third trimester use of SSRIs can lead to a temporary neonatal behavioral syndrome than jitteriness, feeding issues. Peroxitine and fluoxitine might be more associated with this. Autism risk data is unclear. Contradictory.

What about SNR? surprise

less data but no clear signal for major malf for still a risk of that neonatal syndrome in the third trimester though

and benzoazipines in pregnancy

generally not linked to major malf forations overall but best to avoid in the first trimester if possible due to some conflicting older data there might be increased risks of other paranatal issues but confounding factors are possible avoid using multiple meds if you can

so the bottom line for severe symptoms

for severe symptoms where maternal or fetal safety is compromised SSRI S NRIs or maybe benzo might be needed. Lowest effective dose is key. If someone was stable on an anti-depressant before pregnancy, often best to continue it.

And if starting one during pregnancy,

citoprillene are often preferred choices based on safety data. Avoid peroxitine.

What about breastfeeding?

Again, non-drug options first if possible. If meds are needed, SSRIs like peroxitine and certuline are often considered preferred because they seem to pass into breast milk in a very low amount. Benzo while breastfeeding

generally best avoided if possible. They can accumulate in the infant, cause sedation, problems with temperature regulation. Always check up-to-date resources for pregnancy and lactation safety.

Absolutely. Okay. What about treating anxiety in children and adolescence?

Yeah, another important group. While some fears are normal in childhood, actual anxiety disorders are common. Maybe 20 30% lifetime prevalence reported in the US. Average onset around age 11

and treated anxiety in kids that can cause problems later,

big problems, impaired development, risk of other psychiatric issues later, even increased risk of suicidal thoughts or behavior, especially if depression is also present.

So, treatment is important. What's first line for kids?

For ages 6 to 18, mild to moderate anxiety, CBT is first line.

Therapy first.

Yes. For more severe cases, or if CBT isn't available, SSRIs or possibly SNRIs are considered. Sometimes combination therapy works best. SSRIs have the best evidence in kids.

Fluoxitine, fluoxamin, peroxitine, certuline have the most data, but and this is crucial, none are officially indicated for anxiety in kids, adolescence in Canada or the US. And they all carry that warning about potential increased suicidal thinking behavior risk.

The Health Canada warning applies up to age 18.

Yes, up to 18 in Canada, up to 24 in the US. So careful assessment, psycho education for the child and parents, and close monitoring are absolutely essential if using these meds.

What about SNRIs in kids?

Less data. Delloxitine and Venlaxine have the most. Delloxitine actually has a US indication for GAD in ages 717. Venlaxine needs extra caution due to potential higher suicide risk and overdose fatality links.

Okay, lots to consider there.

Finally, let's wrap up with some quick therapeutic tips for our listeners, things to keep in mind for practice.

Sure. Remember, short-term interventions like relaxation can be useful adjuncts. Short-term benzo use, maybe up to 6, 8 weeks max, can help acutely or anti-depressant initiation.

Don't judge effectiveness too early.

Exactly. Assess effectiveness only after an adequate dose and duration. Using those self-report scales can help track progress objectively.

And if the first drug doesn't work,

switch to another firstline agent if ineffective or not tolerated. Augmentation comes later for partial response to an optimal dose, usually with specialist input.

Great summary. This has been really comprehensive, super helpful for PEBC candidates. And remember everyone, you can refer back to those table tools 3, four, and five and the algorithms in the CTC reference for quick reviews.

Definitely keep those handy and always stay updated with current guidelines.

Okay, time for our quick quiz question based on today's deep dive. Which of the following SSRIs is generally avoided during pregnancy due to a potential association with congenital cardiac abnormalities? Is it a certuline, b acetalopram, c per proxitine or d fluxine?

Thinking back to our discussion, the answer is c peroxitine.

Correct. Proxitine is the one to generally avoid in pregnancy due to that potential cardiac link. Well, this deep dive into anxiety disorders for Canadian pharmacy PBC candidates was brought to you by Pharma Board Group based on the CTC reference. Thanks so much for tuning in.

Yeah, thanks for joining us. Hope it was helpful.

Definitely check out further resources and guidelines for the full picture and to leave you with something to think about considering just how common anxiety disorders are and their impact. How can you as a future pharmacist proactively contribute to earlier recognition and better management right there in your daily practice?

دوقطبی
Welcome to the deep dive. Today we're zoning in on uh a really vital topic for all you Canadian pharmacy examining board candidates out there. Bipolar disorder. It's complex.

It really is.

We're working from this comprehensive chapter, bipolar disorder. And this deep dive comes to you from Pharma Board Group based on the CTC reference.

Yeah. And look, we know preparing for the PEBC means waiting through tons of information can be pretty overwhelming.

Definitely. So, Mission here is simple. Cut through the noise.

Exactly. We want to pull out the absolute mustnoss, the therapeutic choices, the logic behind the algorithms and tables, those practical tips you'll actually use.

Think of it as your high yield summary, clarity, accuracy, and hopefully a bit more peace of mind for the exam.

We're aiming for confidence. Really, this isn't just skimming the surface. It's about focusing on what's critical from this chapter so you don't miss those crucial details.

All right, let's jump in the basics. What does this chapter tell us about understanding bipolar disorder itself. What are the core things we need to know?

Okay, so first off, prevalence. It affects roughly 1 to 2% of the population. So it's common enough that you'll definitely encounter it.

Okay,

but the absolute core diagnostically speaking hinges on the DSM5 criteria.

You need evidence of a manic or hypom manic episode, right?

And this key part, an abnormal persistent increase in goal- directed activity or energy. It's that sustained drive or energy shift that's really telling. Got it. That persistent increase. And when we talk about mania specifically, what are those key symptoms we should be looking for?

Mania usually involves a noticeable mood change. It could be elevated, expansive, feeling on top of the world, or it could just be persistent irritability. That's important, too.

Okay. So, not always euphoria.

Exactly. Plus, increased energy, a decreased need for sleep, sometimes dramatically. So, thoughts might be racing, speech pressured, easily distracted.

And you often see that increased goal- directed activity. be taking on huge projects. Grandiosity, even psychosis can also occur in severe mania.

Now, flip side, bipolar depression. How does that tend to look? Especially compared to say unipolar depression. The chapter makes a distinction, right?

It does, and it's a really key one for pharmacists. While sadness is there, the chapter highlights that oversleeping or profound tiredness is actually super common in bipolar depression, much more so than insomnia sometimes.

Interesting. So, hyperomnia is a flag.

It can also pessimism, pulling away socially, cognitive foggess, and crucially, you still have to assess for suicidal thoughts or psychotic features, just like in mania. It's not just feeling blue.

Okay. The chapter then dives into the different types referencing table two. Can you break those down for us? Bipolar eye versus bipolar 2 seems fundamental.

Absolutely fundamental. Bipolar eye disorder requires at least one full manic episode. That's the defining feature. Whether they've also had hypomomania or depression doesn't change The bipolar eye diagnosis, the mania seals it.

Okay. One manic episode of bipolar eye. Got it.

Bipolar 2, on the other hand, involves a history of hypom manic episodes less severe, less impairing than full mania and major depressive episodes. Critically, someone with bipolar 2 has never had a full manic episode.

That distinction in severity and impairment between mania and hypomomania is key. Then

it's the core difference between I and two. Full mania and bipolar, it often signals a potential more severe overall course.

Makes sense. What about the other categories mentioned?

Right? There's substance or medication induced bipolar disorder. Here the bipolar symptoms pop up during or soon after using or withdrawing from a substance or medication. It's directly linked physiologically.

So a direct cause.

Yes. Similarly, bipolar disorder due to another medical condition.

The symptoms are a direct result of something else like a thyroid issue or a neurological condition. These aren't primary psychiatric bipolar disorders.

Always important to rule out about medical causes

always. Then you have other specified or unspecified bipolar disorders. This is kind of a catch-all for presentations that have some bipolar features but don't quite meet the full criteria. Maybe the episodes are too short, for example.

Okay.

And finally, psychothermic disorder. This involves chronic fluctuating moods, periods of hypomomanic symptoms, and periods of mild depressive symptoms, but never meeting the full criteria for either a hypomomanic or major depressive episode. It's more of a persistent instability.

Wow. Oh, okay. It really underscores how complex diagnosis can be, which the chapter flags too.

It absolutely does. The chapter emphasizes that getting the diagnosis right is challenging. It can look like schizophrenia sometimes or substance use disorders, definitely unipolar depression, that's a big one. Borderline personality disorder, even ADHD, especially in younger people.

It's coorbidities.

Coorbidities are common and muddy the waters further. So, careful assessment is crucial.

So, given all that complexity, what are the main goals of therapy? What are we aiming for?

Broadly, you want to control the symptoms of the acute episode, whether it's mania or depression. That's immediate,

right?

But long-term, the huge goal is preventing recurrence, stopping future episodes. You also need to address any co-occurring psychiatric issues, anxiety, substance use are common, and medical problems like metabolic syndrome. And

ultimately, the goal is to help the person get back to their best possible level of functioning, including cognitively, and stay there.

Okay. Let's shift to investigations. What should pharmacists really know about the workup for potential bipolar disorder?

A huge point the chapter makes and something pharmacists can really influence is the high rate of misdiagnosis as unipolar depression.

They mentioned that. Yeah.

So, the takeaway is always ask patients presenting with depression about any past history of hypomomania or mania. Don't assume it's just depression.

Proactive questioning.

Yes. And the mood disorder questionnaire, the MDQ, is mentioned as a helpful screening tool. It's not diagnostic, but it can raise a flag.

Good tool to be aware of. What else?

Collateral information. Talking to family or close friends, with the patients permission, of course, can be incredibly valuable. They might recall episodes the patient downplays or doesn't fully remember,

right? Getting another perspective.

And family history. Asking about mood disorders, substance use, or diagnosed bipolar and relatives is really important. Genetically, it runs in families.

Okay. What about lab tests?

Basic labs are recommended. CBC, electrolytes, kidney and liver function, and definitely thyroid function tests. Thyroid issues can mimic or worsen mood symptoms.

That's a key one.

Absolutely. And for women who could become pregnant, a beta hCG test before starting certain meds is essential.

And physical health parameters beyond basic labs.

Yes. The chapter stresses checking metabolic parameters at baseline weight, waist circumference, lipids, fasting glucose

because of medication side effects.

Exactly. Many mood stabilizers and antiscychotics can impact these. So getting a baseline and monitoring is critical. Brain imaging like a set or MRI isn't routine but might be considered if there are unusual symptoms, neurological signs or maybe if the first episode happens after age 40.

Okay, that makes sense. Now the big one, therapeutic choices, especially pharmacologic management huge for the PBC. The chapter highlights the team approach and canata's BD guidelines.

Right, the 2018 Canamata BD guidelines are the backbone here. They really stress collaborative decision-m talking with the patient, not just to them.

Shared decision-m

Yes.