Treatment Of Generalized Anxiety Disorder

Abstract

Generalized anxiety disorder (GAD) is a relatively common presentation in primary care and a significant vulnerability factor for future morbidity, particularly depression and alcohol abuse. Despite this it is frequently overlooked and undertreated in both primary and secondary care when comorbid disorders are present. Recent clinical guidelines emphasize a stepped approach to care with individual therapy (cognitive–behaviour therapy (CBT)), pharmacological therapy (SSRIs) or self-help (along CBT lines) offered as first-line treatments in primary care, with the choice depending on patient preference, clinical need and availability of suitably trained therapists. A poor response to at least two of these interventions should lead to a more intensive assessment and intervention in specialist mental health services. There is a growing evidence base for the efficacy of both CBT and pharmacotherapy (escitalopram, sertraline and paroxetine) and they appear to be broadly equivalent in outcome in the medium term, with about 50% of patients achieving recovery over 3–6 months. CBT may have the edge in the maintenance of treatment gains over the long term. There are, however, very few direct comparisons between psychological and pharmacological interventions and there is no reliable evidence base at present for knowing whether or not the combination of antidepressant medication and CBT is more efficacious than either alone. GAD tends to be a chronic condition and a significant minority of patients respond poorly to current treatments and require long-term clinical management. Better outcomes require earlier intervention through improved recognition and treatment strategies that target more precisely those vulnerabilities that maintain the disorder.

• Clinical guidelines concerning effective treatment for GAD for adults in primary, secondary and community care have been published by the National Institute for Health and Clinical Excellence

• These guidelines emphasize the importance of a stepped-care model of service delivery with shared decision-making and information provision, and systematic monitoring of treatment outcomes

• Psychological therapy (CBT ), pharmacological therapy (SSRIs) and self-help (along CBT lines) should be offered as first-line treatments following discussion and taking account of patient preference

• Detailed clinical guidelines for pharmacological treatment of anxiety disorders, including GAD, have been published by the British Association for Psychopharmacology

A Common Disorder Infrequently Diagnosed

Generalized anxiety disorder (GAD) is a common and often chronic disorder, with an estimated lifetime prevalence rate of 5.7% in the general population, but it is often overlooked and undertreated. ¹ Why should this be so?

Comorbid Disorders Motivate Help-seeking

The core symptoms of GAD are chronic worry and tension. The patient will often experience these throughout the course of his/her lifetime, although symptom severity will vary in response to social and environmental stressors. These symptoms may be viewed by the patient as a personality trait rather than evidence of a disorder requiring treatment, therefore motivation to seek help may arise only when other comorbid disorders, such as depression, are experienced. These comorbid disorders become the main focus of medical and psychiatric attention and the presence of GAD can go unrecognized. Approximately 80% of GAD cases referred to secondary care comprise various combinations of GAD and other personality and clinical disorders.

A Significant Public Health Problem

Chronic generalized anxiety is associated with increased risk for medical illness and may be a risk factor in the aetiology of a range of psychiatric disorders, particularly depression and alcohol abuse. GAD is estimated to cause a similar level of psychosocial disability to chronic somatic disease and depression, and the overall evidence supports the view that GAD is a significant public health problem. Failure to detect and treat the disorder is therefore a matter of considerable concern. ¹