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: 3.59). 11/2008; 24(1):3-26. DOI: 10.1177/0269881108096505
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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[Show abstract] [Hide abstract] 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.
- "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). "
[Show abstract] [Hide abstract] ABSTRACT: Prescription and use of antidepressants and benzodiazepines are common in the general population. Prescription of psychotropic drugs is a complex process: patient, physician and healthcare characteristics mediate, interact and influence it. The current study aimed to establish the prevalence and factors associated with the use of antidepressants (ADs) and benzodiazepines (BZDs) in Singapore. The Singapore Mental Health Study (SMHS) was a nationally representative survey of Singapore Residents aged 18 years and above. Face-to-face interviews were conducted from December 2009 to December 2010. The diagnoses of mental disorders were established using the Composite International Diagnostic Interview version 3.0 (CIDI-3.0). The pharmacoepidemiology section was used to collect information on medication use. The overall prevalence estimates for ADs and BZDs use during the 12 months prior to the interview were 1.1% and 1.2% respectively. In all, 2.0% had used ADs and/or BZDs. 'Help seeking for emotional or mental health problems' was the most important predictor for the use of ADs and BZDs---help seekers were much more likely to use ADs (adjusted OR: 31.62, 95% CI: 13.36--74.83) and more likely to use BZDs than non-help seekers in the previous 12 months (adjusted OR: 34.38, 95% CI: 12.97--91.16). Only 27.6% of those with 12-month major depressive disorder (MDD) had sought formal medical help for their problems and ADs were being used by just over a quarter of this 'help-seeking group' (26.3%). We found that the use of ADs and BZDs in our population was relatively low, and 'help-seeking' was the most important predictor of the use of ADs and BZDs. In concordance with research from other Western countries, use of ADs was low among those with 12-month MDD.
- "Most recent international treatment guidelines [35,36] further, recommend limiting the use of BDZs only in patients with primary major depression to those with pronounced anxiety or persistent insomnia that are not adequately relieved by ADs. International guidelines for anxiety disorders [35,37] currently recommend selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs) as the drugs of first choice, with BZDs as second-line option. "
[Show abstract] [Hide abstract] 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).
- "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. "