Abbreviations: *CBT = cognitive-behavioral therapy, *SSRI = selective serotonin reuptake inhibitor  *SNRI = serotonin-norepinephrine reuptake inhibitor.  Medications listed are suggestions.

Selection and dosing should be based upon symptoms, co-morbid conditions and medication tolerance.  SmartCare is available to provide consultation and assistance in helping to decide the best options for the patient.

Concomitant psychiatric or medical disorders can be present in patients who are being assessed for GAD and may complicate accurate diagnosis and treatment. Initially, the patient should have a full psychiatric and medical history with appropriate consideration or referral for laboratory and physical examination. After a failed trial of treatment, the clinician should look for common coexisting conditions, such as depression, alcohol problems, bipolar disorder, and undiagnosed medical illness, e.g. endocrine (thyroid), pulmonary or cardiac disease.

Psychological therapies are an important first-line option in the management of GAD. “Psychoeducation,” including information to patients about the causes and treatment of their condition, has been recommended for all patients. This  includes paying attention to alcohol, caffeine, and tobacco consumption; regulating sleep; and the control of external stimuli for improving sleep. Simple coping techniques can be taught in the primary care setting for the control of worry, such as setting aside time to rationalize concerns, organizing these into minor and major worries, and identifying priorities and next steps toward addressing them.  Handouts may be helpful for patients to read and reference.

Antidepressants: The following antidepressants have demonstrated efficacy in GAD: SSRIs, SNRIs, tricyclic antidepressants, and trazodone. Of these, SSRIs and SNRIs are generally preferred as first-line therapy. They are usually better tolerated than the other classes of antidepressants.

Although the SSRIs are generally well tolerated, these agents are nonetheless associated with a range of adverse effects, including GI symptoms, somnolence, disrupted sleep, and agitation. Weight gain and sexual side effects can occur and can persist during the treatment period.

The SNRIs venlafaxine and duloxetine may also be effective. Adverse effects include those associated with the SSRIs, as well as orthostatic hypotension, increased blood pressure, sweating, and urinary hesitancy. Patients taking venlafaxine or duloxetine should be monitored for increases in blood pressure.

Benzodiazepines:  Historically, benzodiazepines have been widely used in the management of anxiety disorders. They have a rapid onset of action and are effective in GAD. While benzodiazepines improve core symptom, they are not recommended as monotherapy for depression, dysthymia, obsessive-compulsive disorder, and posttraumatic stress disorder, which co-commonly occur with GAD. However, benzodiazepines can be effective for panic and social anxiety disorders, as well as for insomnia, a common symptom. In severe cases, benzodiazepines are often prescribed as adjunctive therapy to help patients in acute crisis or while waiting for a SSRI orSNRI to take effect.

Benzodiazepine use can be problematic, particularly in older people, due to side effects such as falls, memory impairment, incoordination, drowsiness, and confusion.  Benzodiazepines can disrupt sleep architecture, and rebound insomnia may occur after stopping treatment.

Benzodiazepines have modest abuse potential and should not generally be administered to patients with a history of misuse of these drugs within the primary care setting. They are generally recommended only for short-term use and are not recommended for first-line long-term treatment of GAD, but they may have a role in the management of acute anxiety and in some cases in which somatic symptoms are more prominent than psychic symptoms

Buspirone: Buspirone, an azapirone that acts as a partial agonist at the 5HT1a receptor, is effective for the treatment of GAD though may be less effective than the benzodiazepines. Common side effects of buspirone included drowsiness, dizziness, and nausea.

Antihistamines: Hydroxyzine is an H1 antagonist that has been reported to be effective in the treatment of GAD symptoms in well-controlled studies.  It is typically used as a prn medication for breakthrough anxiety.

Atypical antipsychotics: Recent studies have suggested that atypical antipsychotics may also have a role in GAD. In patients who do not respond adequately to initial pharmacologic treatment, the addition of an atypical antipsychotic agent may provide additional benefit.

GAD is usually chronic with a waxing and waning course, and continued support and education is often required. Patients should be given clear information on how long treatment will take to become effective and how to cope with their symptoms in the meantime.

The use of appropriate screening tools and providing information to patients with GAD on their condition and its treatment are an important starting point toward increasing recognition and appropriate treatment of GAD.

Generalized anxiety disorder (GAD) is characterized by excessive, uncontrollable and often irrational worry, that is, apprehensive expectation about events or activities. This excessive worry often interferes with daily functioning, as individuals with GAD typically anticipate disaster, and are overly concerned about everyday matters such as health issues, money, death, family problems, friendship problems, interpersonal relationship problems, or work difficulties

The main diagnostic criteria of GAD are excessive anxiety and worry that is difficult to control, along with at least 3 from a list of 6 symptoms: restlessness, irritability, difficulty concentrating, muscle tension, sleep disturbances, and being easily fatigued and duration of the disorder for at least 6 months.  Symptoms must be distressing or impairing and not adequately explained by another related disorder.

Screening for GAD can potentially be helpful in improving detection rates in primary care, which can lead to more appropriate treatment and improved patient outcomes. GAD-7 was developed to facilitate the diagnosis. The scale has been shown to be an efficient tool that can screen for likely cases of GAD and can assess symptom severity and assist with the clinical assessment and treatment of GAD.  A link to the assessment tool is included.

The main treatment approaches for GAD include pharmacotherapy or psychotherapy or a combination of both. The often chronic and disabling nature of GAD means that some individuals may fail to respond fully to first-line treatment. Patients may therefore require a sequential trial of treatments.  Psychological therapies are an important first-line option in the management of GAD.

The treatment plan for GAD should account for (1) predominant symptoms, (2) severity of the condition, (3) presence of concomitant medical illness, (4) complications such as substance abuse or the risk of suicide, (5) outcomes of any previous treatments, (6) cost issues, (7) availability of treatment in a given area, and (8) patient preferences.

There are various options for medication management of GAD. Next week’s newsletter will focus on this topic.

GAD is frequently associated with other psychiatric conditions such as other mood or anxiety disorders, somatoform/pain disorders, medically unexplained symptoms, and substance use disorders.  It has also been linked with medical disorders such as heart disease, GI and chronic pain disorders.

Effective management of GAD has the potential to improve quality of life for patients and their families, as well as improve patient productivity and reduce the impact of the condition on health care resources.  The use of appropriate screening tools and providing information to patients with GAD on their condition and its treatment are an important starting point toward increasing recognition and appropriate treatment of GAD.

References:

http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911006/