121 - Pregabalin

Pregabalin

448 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 3 overdose toxicity of opiates.38 Pregabalin should not be stopped abruptly as it may precipitate a severe withdrawal syndrome that includes seizures.39 Psychological approaches There is good evidence to support the efficacy of psychological interventions in anxiety spectrum disorders.11,40 Examples include exposure therapy in OCD and social phobia. Initial drug therapy may be required to help the patient become more receptive to psychological input, although evidence to support this assumption is slim. Some studies suggest that optimal outcome is achieved by combining psychological and drug therapies,6,41 but negative studies also exist.42,43 A discussion of the evidence base for psychological interventions is outside the scope of this text. It is recognised that for many patients psychological therapies are the appropriate first-­line treatment, and this is supported by NICE.6 Summary of NICE guidelines for the treatment of GAD, panic disorder and OCD ■ ■A ‘stepped care’ approach is recommended to help in choosing the most effective intervention for GAD,6 panic disorder6 and OCD.30 ■ ■A comprehensive assessment is recommended, which considers the degree of distress and functional impairment, the effect of any comorbid mental illness, substance misuse or medical condition, and past response to treatment. ■ ■Treat the primary disorder first. ■ ■Psychological therapy is more effective than pharmacological therapy and should be used as first-­line therapy where possible. Details of the types of therapy recommended and their duration can be found in the NICE guidelines. ■ ■Pharmacological therapy is also effective. Most evidence supports the use of the SSRIs (sertraline as first line). ■ ■Provide information on the probable benefits and disadvantages of each mode of treatment. ■ ■Consider combination therapy for complex anxiety disorders that are refractory to treatment. Panic disorder ■ ■Benzodiazepines should not be used except in a crisis. ■ ■An SSRI should be used as first-­line therapy. If SSRIs are contraindicated or there is no response, imipramine or clomipramine can be used. ■ ■Self-­help (based on CBT principles) should be encouraged, as should formal CBT. GAD ■ ■Benzodiazepines should not be used except for crises. ■ ■An SSRI should be used as first-­line treatment. ■ ■SNRIs and pregabalin are second and third choices, respectively. ■ ■High-­intensity psychological intervention and self-­help (based on CBT principles) should be encouraged. ■ ■Antipsychotics should not be offered (presumably this includes quetiapine).