Why do GPs prescribe beta-blockers for anxiety disorders? A qualitative interview study

Problem

The beta-blocker, propranolol, is licensed for the management of anxiety, and prescriptions increased substantially between 2003-2018, particularly in young adults. However, beta-blockers are not recommended by the NICE clinical guidelines for anxiety, which may be due to the inconclusive evidence of their effectiveness in treating anxiety. Further, recent safety reports have highlighted an under-recognised risk of propranolol in patients with mental health difficulties. This study aimed to understand when and why General Practitioners (GPs) are prescribing beta-blockers for anxiety.

Approach

We interviewed 17 GPs from ten practices in Bristol and the surrounding areas. Interviews were digitally-recorded, transcribed verbatim and analysed thematically. A patient and public involvement (PPI) group with lived experience of anxiety provided input into the initial interview topic guide, suggested revisions to the questions during iterative data collection and analysis and informed dissemination.

Findings

Most GPs suggested that beta-blockers were an important ‘tool’ for helping patients with anxiety manage their physical symptoms. For some patients, they could also facilitate a ‘positive feedback loop’, whereby a reduction in physical symptoms could also lead to improved psychological symptoms. Many GPs viewed beta-blockers as a ‘low-risk’ option compared to antidepressants, particularly in young adults where they might have concerns around risk of suicidal ideation. Some GPs thought of beta-blockers as an alternative to benzodiazepines, acting quickly and not leading to dependence. GPs explained that some patients wanted a ‘quick fix’ for their anxiety, and due to substantial waits for talking therapies and delays in antidepressants taking effect, beta-blockers were the quickest option available in primary care. GPs described how some patients seemed to be more willing to try beta-blockers as they were not a ‘mental health drug’ and therefore potentially more acceptable and less stigmatising. Further, GPs viewed beta-blockers as more of a ‘patient-led’ treatment, where patients could manage their own dose and frequency, with less need for GP input.

Consequences

Many GPs suggested that beta-blockers have a role to play in the management of people with anxiety, especially in those with physical symptoms, and they provided justification for their prescribing. There is a need to conduct a definitive trial in this area to determine if beta-blockers are a safe and effective treatment for anxiety.