Article

Review: A psychopharmacological treatment algorithm for generalised anxiety disorder (GAD)

Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA.
Journal of Psychopharmacology (Impact Factor: 2.81). 11/2008; 24(1):3-26. DOI: 10.1177/0269881108096505
Source: PubMed

ABSTRACT Generalised anxiety disorder (GAD) is defined as excessive and uncontrollable worry and anxiety about everyday life situations. It is a chronic disorder, and is associated with substantial somatisation, high rates of comorbid depression and other anxiety disorders, and significant disability. The evidence base for pharmacotherapy and psychotherapy has continued to grow, and a wide range of drug choices for GAD now exists. Current guidelines for GAD generally restrict themselves to presentation of the evidence for various treatments, which, as a result, generally do not offer detailed discussion or recommendation of strategies beyond the first level of treatment, or take into account the individual circumstances of the patient. Thus, there is a lack of algorithm-based treatment guidelines for GAD. Our aim is, therefore, to present an algorithm for the psychopharmacologic management of GAD, intended for all clinicians who treat patients with GAD, where issues of pharmacotherapy are under consideration. We also hope that these GAD algorithms and other guidelines can help to identify high-priority areas that need further study. In this algorithm, we provide a sequenced approach to the pharmacotherapy of GAD, taking into account salient symptomatology and comorbidity, levels of evidence and extent of response. Special issues, including comorbidity, insomnia, suicidality, substance abuse, treatment adherence, pregnancy and lactation, cross-cultural issues, use of medication in the elderly, psychosocial treatment and dosing issues are also addressed.

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    • "Considering that patients frequently stop benzodiazepine treatments before the full anxiolytic effects emerged (Martin et al., 2007), current guidelines do not recommend benzodiazepines for GAD treatment except for short-term interventions up to 4 weeks (compare, for example, Davidson et al., 2010). We would like to point out that one randomized controlled treatment showed the efficacy of a cognitive behavioral treatment of GAD with medication tapering for benzodiazepine discontinuation (Gosselin, Ladouceur, Morin, Dugas, & Baillargeon, 2006). "
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    ABSTRACT: Five types of intervention may be of special relevance and in consequence have been included in treatments targeting generalized anxiety disorder (GAD) symptomology: metacognitive therapy targeting both negative and positive metacognitions concerning worrying; fear imagery exposure, based on the avoidance theory of worrying; interventions developed to increase tolerance of uncertainty; relaxation exercises; and finally, treatment modules focusing on negative problem orientation. This chapter first describes the diagnostic procedures most helpful for the preparation of treatment and then the treatment modules. All these modules have been included in manualized treatments, which have been evaluated with regard to their efficacy in a number of RCTs. The chapter presents an overview of the evidence for the efficacy of variations of this cognitive-behavioral treatment (CBT). Applied relaxation is one of the most regularly used components within standard CBTs for GAD. Besides cognitive-behavioral therapy and psychodynamic psychotherapy, pharmacotherapy offers another evidence-based treatment option for GAD.
    The Wiley Handbook of Anxiety Disorders, 04/2014: pages 1003-1037; , ISBN: 9781118775356
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    • "Nevertheless , the scarce literature reporting agomelatine's properties in reducing anxiety in OCD, generalized SAD, and PD patients cannot be overlooked. Although the lifetime prevalence of GAD is estimated to be in the range of 2.8% to6.6% among adults, and the evidence base for pharmacotherapy is growing, current guidelines do not offer detailed strategies or recommendations beyond the first level of treatment, which could include the use of an SSRI or SNRI (serotonin and noradrenaline reuptake inhibitor) (Davidson et al., 2010). Moreover, some drugs suggested as second-line treatments have shown little evidence of benefit in the treatment of GAD patients in clinical studies. "
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    ABSTRACT: Agomelatine is an antidepressant with a novel mechanism of being a selective melatonergic MT1/MT2 receptor agonist with serotonin 5-HT2c receptor antagonist activities. Although the vast majority of the clinical data concerning the effectiveness of agomelatine concern its antidepressant properties, there is also preliminary evidence of anxiolytic effects. The purpose of the study was to perform a review of studies that investigated the efficacy of agomelatine in the treatment of anxiety disorders (ADs) and a discussion of the clinical utility of agomelatine in this clinical population. Previous clinical data indicated that agomelatine was more efficacious than both placebo and comparator drugs in reducing anxiety symptoms in depressed patients. Moreover, agomelatine effectiveness in the treatment of AD patients was observed in 2 double-blind, randomized trials, in a case series and in 3 case reports. Greater clinical evidence was observed with generalized AD patients. Agomelatine was efficacious both in reducing anxiety symptoms and in preventing relapses after a 6-month follow-up. However, concerning other ADs, evidence of agomelatine's effects on anxiety was found only in isolated case descriptions. Nevertheless, those case reports emphasized the drug's favorable side effect profile (in comparison to serotonin reuptake inhibitors) and its effectiveness in treatment-refractory patients. Considering the high incidence of poor efficacy and tolerability of the first-line agents in the treatment of ADs, agomelatine seems to be a promising option in cases of treatment failure, and it could be used as a second or third option, as monotherapy or as augmentation treatment. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
    Experimental and Clinical Psychopharmacology 10/2012; 20(6). DOI:10.1037/a0030263 · 2.63 Impact Factor
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    • "It is therefore important that alternative, effective therapeutic options exist for patients failing treatment with SSRIs/SNRIs. One treatment algorithm discussed the use of augmentation strategies (e.g. with atypical antipsychotics ) for partial response or switching strategies for partial or nonresponse in patients with general symptom persistence [16]. However, the authors acknowledged that long-term controlled trials are currently lacking and there is little evidence-based guidance on the best management strategy for these patients. "
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    ABSTRACT: PURPOSE: To investigate medication use, direct healthcare costs and comorbidities in patients with generalised anxiety disorder (GAD) within specialised care in Sweden 2006-2007. METHODS: A retrospective study was conducted using data from the National Patient Register and the Swedish Prescribed Drug Register. All patients with a primary GAD (ICD-10) diagnosis in 2006 were followed for 12months to study medication use and health care consumption. Resource use was evaluated from the number of hospitalisation episodes, number of visits to outpatient care and medication dispensed. Costs were calculated by multiplying the number of visits and hospitalisation episodes with the corresponding unit costs. Descriptive statistics were used for all analyses. RESULTS: Three thousand seven hundred and one patients with a primary GAD diagnosis were included in the study. Thirty-four percent of the patients (n=1246) had at least one secondary comorbid diagnosis. SSRIs/SNRIs were the most commonly dispensed medications, followed by benzodiazepine-anxiolytics, hypnotics and antihistamines. The mean number of treatment days for all medications prescribed and dispensed was highest (1144days) for elderly women aged 65years or more (treatment days per patient could exceed 365days due to multiple concomitant medication use). Elderly patients were frequently prescribed benzodiazepine-anxiolytics (n=92/117 men [79%]; n=238/284 women [84%]) and hypnotics (n=70 men [60%]; n=178 women [63%]) compared to the overall study population (n=612/1303 men [47%] and n=935/2398 women [39%], respectively). GAD-related direct costs accounted for 96% of all direct costs. Mean number of hospitalisation days and corresponding costs were high (19days; SEK 92,156; n=358 [9.7%]) in relation to medication (SEK 5520; n=3352 [91%]) and outpatient costs (SEK 7698; n=3461 [94%]). CONCLUSIONS: The high rate of polypharmacy, significant psychiatric comorbidity and widespread use of benzodiazepine-anxiolytics and medications not indicated for GAD suggest that the disease burden is high. Total direct costs associated with the disease were high but still likely to be underestimated.
    European Psychiatry 04/2012; DOI:10.1016/j.eurpsy.2012.02.003 · 3.21 Impact Factor
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