Treatment Approaches for GAD

The main treatment approaches for GAD comprise psychotherapy, pharmacotherapy 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.  Your patients may require a sequential trial of treatments or possibly the use of combination therapy. Given the chronic nature of GAD, long-term treatment of at least 12 months is usually recommended.

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.

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