Use of benzodiazepines in a coronary care unit

Recognition and Management of Anxiety in the Intensive Care Unit

Anxiety is common among patients receiving intensive care. We discuss the signs and symptoms of anxiety in the intensive care unit. Appropriate treatment of anxiety should be initiated in a timely fashion so that patient compliance with treatment will be enhanced and the morbidity associated with critical illness can be reduced. Pharmacological and nonpharmacological strategies for management of anxiety are also presented.

Anxiolytic medication use is not associated with anxiety level and does not reduce complications after acute myocardial infarction

AIMS AND OBJECTIVES

To examine the association of anxiety level and anxiolytic medication use with in-hospital complications in patients following acute myocardial infarction (AMI).

BACKGROUND

There are conflicting data about the protective effect of anxiolytic medication used in patients after acute myocardial infarction. Examination of the interaction of anxiolytic medication and anxiety level may explain these disparate results.

DESIGN

This was a secondary analysis of existing data from a multisite, prospective study of the impact of anxiety on in-hospital complications in patients with AMI.

METHODS

Patients were primarily men, Caucasians, with Killip class 1 or 2, from the USA and Australia (n = 156). Anxiety level in the emergency department and intensive care unit and in-hospital complications were collected using self-report measures and medical record review. Logistic regression analyses examined whether the use of anxiolytic medication influenced the relationship between anxiety and in-hospital complications after controlling for demographic and clinical covariates.

RESULTS

In the ED, 31% of participants were very or extremely anxious; anxiolytic medication was given to only 5%. In the intensive care unit, nearly half of participants received anxiolytic medication. There was no association between anxiety level and use of anxiolytic medication. Anxiety was an independent predictor of the probability of in-hospital complications. The administration of anxiolytic medication did not alter the relationship between anxiety and in-hospital complications.

CONCLUSION

Use of anxiolytics in patients with AMI was not associated with anxiety level and did not reduce the probability of in-hospital complications.

RELEVANCE TO CLINICAL PRACTICE

Clinicians need to regularly assess anxiety and treat it appropriately. Regular anxiety assessment may promote appropriate use of anxiolytic medication. Clinical guidelines for the management of patients with an AMI should address anxiety assessment and appropriate use of anxiolytic medication to improve patients' outcomes.

Recognition and treatment of depression and anxiety in patients with acute myocardial infarction

The objective of this study was to determine the ability of providers (medical residents and nurse practitioners) on inpatient cardiac units to recognize and appropriately treat patients with clinically significant depression and anxiety among a cohort admitted with acute myocardial infarction. Patients within 72 hours of acute myocardial infarction underwent screening with the Standardized Clinical Instrument for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition module for major depressive disorder (MDD), the Beck Depression Inventory (BDI-II), and the Beck Anxiety Inventory (BAI). In addition, the study psychiatrist and a treatment team clinician independently assessed whether they believed that patients had clinically significant depression or anxiety. Prescription of antidepressants and benzodiazepines during hospitalization was recorded by chart review. Assessments were completed for 74 patients. Providers identified < 15% of patients with current MDD or with a BDI score > or = 10; 11% of patients with current MDD had appropriate treatment with antidepressants. There was no significant correlation of providers' assessment of depression with current MDD, BDI scores, or psychiatrists' clinical assessment of depression. In contrast, providers identified 31% of patients with a BAI score > or = 10 and 50% of patients who were assessed by psychiatrists as anxious; > 80% of patients with high anxiety received benzodiazepines. Providers' assessments of anxiety were significantly correlated with BAI scores and with psychiatrists' clinical assessments. In conclusion, medical residents and nurse practitioners routinely under-recognize and undertreat depression among patients with acute myocardial infarction on inpatient cardiac units. Recognition and treatment of anxiety is substantially better, up to 50% of patients who are found to be anxious by psychiatrists after acute myocardial infarction remain unrecognized.

Management of psychiatric problems in critically ill patients

Critical care units have become essential elements in modern medicine. These units reflect the highest levels of scientific and technological advance in medicine. Within these units, however, lie significant psychiatric challenges for patients and staff. This article examines the identification and treatment of the most frequent psychiatric problems facing patients entering critical care units, including delirium, depression and anxiety. These conditions are important to address in order to decrease patient suffering and improve morbidity and mortality. The article also addresses some of the most common staff stressors encountered in working in these units. Managing these stressors makes the critical care unit a place where staff can flourish instead of burning out. Specific techniques may help the staff deal with the complex medical, psychological, and ethical issues found in these units in an empathic, compassionate, and well-balanced manner that allows ongoing work satisfaction.

Are psychosocial factors associated with the pathogenesis and consequences of cardiovascular disease in the elderly?

It is well known that older individuals are at higher risk of developing cardiovascular disease (CVD). In addition, evidence exists for the relationship between psychosocial factors and the pathogenesis and cognitive consequences of CVD. However, less is known about the effect of psychosocial factors on the development and consequences of CVD in older individuals. Using a biopsychosocial framework, this article examines the influence of psychosocial factors, specifically depression, anxiety, and social isolation on older persons with CVD as well as the influence of CVD on psychosocial factors. The effectiveness of interventions for modifying adverse psychosocial factors is also discussed.

How safe are serotonin reuptake inhibitors for depression in patients with coronary heart disease?

Depression occurs frequently in patients with coronary heart disease (CHD), and confers significant risk for additional morbidity and mortality. The cardiac effects of the tricyclic antidepressants (TCAs) have been well characterized. In contrast, the cardiac effects of the selective serotonin reuptake inhibitors (SSRIs) have been less thoroughly investigated. The Medline database from 1986 to 1996 was searched for all reports of cardiac effects of SSRIs, and this literature is summarized. In addition, potential drug interactions, reports of side effects, and efficacy studies in the elderly are reviewed. Finally, recommendations are made considering the risk/benefit ratio.

Psychiatric management of acute myocardial infarction in the coronary care unit

Failure to recognize and treat the psychiatric complications of myocardial infarction (MI) may aggravate the underlying cardiac condition and interfere with its treatment. The timing and manifestations of several distinct psychiatric conditions that commonly accompany the acute phase of MI (anxiety, depression, delirium, and behavioral abnormalities secondary to a person's premorbid character style) will be reviewed. In addition, the importance of psychological risk factors for the development of coronary artery disease (e.g., life stress and the Type A behavior pattern) and the impact of denial on the cardiac patient's condition will be discussed. Management strategies that include nonpharmacologic (i.e., support, reassurance, brief psychotherapy and cardiac rehabilitation) and psychopharmacologic interventions (e.g., the rational use of benzodiazepines, antidepressants and neuroleptic agents) for psychiatric conditions in the MI patient will be provided. Postdischarge issues that occur in both the patient and his or her family are outlined, and the enrollment in cardiac rehabilitation programs is encouraged.

Cardiac symptoms and anxiety disorders: contributing factors and pharmacologic treatment

Anxiety may have deleterious effects on the cardiovascular system in persons who have, or are predisposed to have, cardiovascular disease. Contributing factors consist of the type of anxiety, constitutional characteristics and personality traits. The treatment of anxiety thus has a beneficial effect on patients with cardiovascular disease. However, anxiety reduction through medication, even if it includes subjective improvement in somatic symptoms, should not necessarily be equated with beneficial effects on the cardiovascular system. Three groups of medication used in the treatment of anxiety have different effects. Antidepressants lower psychic anxiety but may have the opposite effect on the cardiovascular system, whereas beta-adrenergic blockers lower sympathetic tone without affecting psychic anxiety. Only benzodiazepines fulfill both functions. Since subjective reports of somatic, including cardiovascular, changes correlate poorly with physiologic changes, assessment of new medications should not rely on self-reported improvement in cardiac symptoms but should include objective measures as well.