Hostname: page-component-55f67697df-xq6d9 Total loading time: 0 Render date: 2025-05-12T14:13:32.819Z Has data issue: false hasContentIssue false
  • English
  • Français

WCA Recommendations for the Long-Term Treatment of Generalized Anxiety Disorder

Published online by Cambridge University Press:  07 November 2014

Christer Allgulander ,
Borwin Bandelow ,
Eric Hollander ,
Stuart A. Montgomery ,
David J. Nutt ,
Ahmed Okasha ,
Mark H. Pollack ,
Dan J. Stein  and
Richard P. Swinson
Get access Rights & Permissions [Opens in a new window]

Abstract

What are the current recommendations for the long-term treatment of generalized anxiety disorder (GAD)? GAD is a common disorder with a lifetime prevalence of 4% to 7% in the general population. GAD is characterized by excessive, uncontrollable worry or anxiety about a number of events or activities that the individual experiences on more days than not over a 6-month period. Onset of GAD symptoms usually occurs during an individual's early twenties; however, high rates of GAD have also been seen in children and adolescents. The clinical course of GAD is often chronic, with 40% of patients reporting illness lasting >5 years. GAD is associated with pronounced functional impairment, resulting in decreased vocational function and reduced quality of life. Patients with GAD tend to be high users of outpatient medical care, which contributes significantly to healtcare costs. Currently, benzodiazepines and buspirone are prescribed frequently to treat GAD. Although both show efficacy in acute treatment trials, few long-term studies have been perform Benzodiazepines are not recommended for long-term treatment of GAD, due to associated development of tolerance, psychomotor impairment, cognitive and memory changes, physical dependence, and a withdrawal reaction on discontinuation. The antidepressant venlafaxine extended-release (XR) has received approval for the treatment of GAD in the United States and many other countries. Venlafaxine XR has demonstrated efficacy over placebo in two randomized treatment trials of 6 months' duration as well as in other acute trials. Paroxetine is the first of the selective serotonin reuptake inhibitors (SSRIs) to receive US approval for the treatment of GAD. Paroxetine demonstrated superiority to placebo in short-term trials, and investigations into the use of other SSRIs are ongoing. This suggests that other SSRIs, and serotonin and noradrenaline reuptake inhibitors, are likely to be effective in the treatment of GAD. Of the psychological therapies, cognitive-behavioral therapy (CBT) shows the greatest benefit in treating GAD patients. Treatment gains after a 12-week course of CBT may be maintained for up to 1 year. Currently, no guidelines exist for the long-term treatment of GAD.

Type
Academic Supplement
Information
CNS Spectrums , Volume 8 , supplement S1: Recommendations for the Long-Term Treatment of Anxiety Disorders , August 2003 , pp. 53 - 61
Copyright
Copyright © Cambridge University Press 2003

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

REFERENCES

1.Allgulander, C. Generalized anxiety disorder. Clinical characteristics and treatment. South African Rev Psychiatry. 2001;1:6–12.Google Scholar
2.Wittchen, HU, Zhao, S, Kessler, RC, Eaton, WW. DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:355–364.CrossRefGoogle ScholarPubMed
3.Rickels, K, Schweizer, E. The clinical course and long-term management of generalized anxiety disorder. J Clin Psychopharmacol. 1990;10:101S–110S.CrossRefGoogle ScholarPubMed
4.Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980.Google Scholar
5.Kessler, RC, Keller, MB, Wittchen, HU. The epidemiology of generalized anxiety disorder. Psychiatr Clin North Am. 2001;24:19–39.CrossRefGoogle ScholarPubMed
6.Diagnostic and. Statistical Manual of Mental Disorders. 3rd ed. [revised]. Washington, DC: American Psychiatric Association; 1987.Google Scholar
7.Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.Google Scholar
8.International Classification of Diseases. 10th revision. Geneva, Switzerland: World Health Organization; 1992.Google Scholar
9.Lader, MH. The nature and duration of treatment for GAD. Acta Psychiatr Scand. 1998;393(suppl):109–117.CrossRefGoogle ScholarPubMed
10.Blazer, DG, Hughes, D, George, LK. Generalized anxiety disorder. In: Robins, LN, Regier, DA, eds. Psychiatric Disorders in America: The Epidemtologic Catchment Area Study. New York, NY: The Free Press; 1991;180–203.Google Scholar
11.Carter, RM, Wittchen, HU, Pfister, H, Kessler, RC. One-year prevalence of subthreshold and threshold DSM-IV generalized anxiety disorder in a nationally representative sample. Depress Anxiety. 2001; 13:78–88.CrossRefGoogle Scholar
12.Wittchen, HU, Carter, RM, Pfister, H, Montgomery, SA, Kessler, RC. Disabilities and quality of life in pure and comorbid generalized anxiety disorder and major depression in a national survey. Int Clin Psychopharmacol. 2000;15:319–328.CrossRefGoogle ScholarPubMed
13.Kessler, RC, McGonagle, KA, Zhao, S, et al.Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:8–19.CrossRefGoogle ScholarPubMed
14.Katon, W, Von Korff, M, Lin, E, et al.Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry. 1990;12:355–362.CrossRefGoogle ScholarPubMed
15.Souêtre, E, Lozet, H, Cimarosti, I, et al.Cost of anxiety disorders: impact of comorbidity. J Psychosom Res. 1994;38(suppl 1):151–160.CrossRefGoogle ScholarPubMed
16.Lecrubier, Y, Weiller, E. GAD: current treatment and costs. Eur Neuropsychopharmacol. 2000;10(suppl 3):170–171.CrossRefGoogle Scholar
17.Schweizer, E. Generalized anxiety disorder. Longitudinal course and pharmacologic treatment. Psychiatr Clin North Am. 1995;18:843–857.CrossRefGoogle ScholarPubMed
18.Papp, LA, Gorman, JM. Generalized anxiety disorder. In: Comprehensive Textbook of Psychiatry. 6th ed. Baltimore, Md: Williams and Wilkins; 1995;1236–1249.Google Scholar
19. Environmental factors in the etiology of anxiety. Available at: http://www.acnp.org/g4/GN401000127/Default.htm. Accessed: May 2003.Google Scholar
20.Tiihonen, J, Kuikka, J, Rasanen, P, et al.Cerebral benzodiazepine receptor binding and distribution in generalized anxiety disorder: a fractal analysis. Mol Psychiatry. 1997;2:463–471.CrossRefGoogle ScholarPubMed
21.Wu, JC, Buchsbaum, MS, Hershey, TG, Hazlett, E, Sicotte, N, Johnson, JC. PET in generalized anxiety disorder. Biol Psychiatry. 1991;29:1181–1199.CrossRefGoogle ScholarPubMed
22.Ninan, PT. The functional anatomy, neurochemistry, and pharmacology of anxiety. J Clin Psychiatry. 1999;60(suppl 22):12–17.Google ScholarPubMed
23.Nutt, DJ. Neurobiological mechanisms in generalized anxiety disorder. J Clin Psychiatry. 2001;62(suppl 11):22–27.Google ScholarPubMed
24.Hamilton, M. The assessment of anxiety by rating. Br J Med Psychol. 1959;32:50–55.CrossRefGoogle ScholarPubMed
25.Guy, W. Clinical Global Impressions. ECDEU Assessment Manual for Psychopharmacobgy. Rockville, MD: US National Institute of Health, Psychopharmacology Research Branch; 1976;217–222.Google Scholar
26.Uhlenhuth, EH, Baiter, MB, Ban, TA, Yang, K. International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: VI. Trends in recommendations for the pharmacotherapy of anxiety disorders, 1992–1997. Depress Anxiety. 1999;9:107–116.3.0.CO;2-T>CrossRefGoogle Scholar
27.Uhlenhuth, EH, Baiter, MB, Ban, TA, Yang, K. International study of expert judgement on therapeutic use of benzodiazepines and other psychotherapeutic medications: II. Pharmacotherapy of anxiety disorders. J Affect Disord. 1995;35:153–162.CrossRefGoogle Scholar
28.Brawman-Mintzer, O. Pharmacologic treatment of generalized anxiety disorder. Psychiatr Clin North Am. 2001;24:119–137.CrossRefGoogle ScholarPubMed
29.Nutt, DJ, Malizia, AL. New insights into the role of the GABA(A)-benzodiazepine receptor in psychiatric disorder. Br J Psychiatry. 2001;179:390–396.CrossRefGoogle ScholarPubMed
30.Mahe, V, Balogh, A. Long-term pharmacological treatment of generalized anxiety disorder. Int Clin Psychopharmacol. 2000;15:99–105.CrossRefGoogle ScholarPubMed
31.Gorman, JM, Papp, LA. Chronic anxiety: deciding the length of treatment. J Clin Psychiatry. 1990;51(suppl):11–15.Google ScholarPubMed
32.Rickels, K, Schweizer, E, Csanalosi, I, et al.Long-term treatment of anxiety and risk of withdrawal. Prospective comparison of clorazepate and buspirone. Arch Gen Psychiatry. 1988;45:444–450.CrossRefGoogle ScholarPubMed
33.Lydiard, RB. An overview of generalized anxiety disorder: disease state—appropriate therapy. Clin Ther. 2000;22(suppl A):A3–19.CrossRefGoogle ScholarPubMed
34.Lydiard, RB, Brawman-Mintzer, O, Ballenger, JC. Recent developments in the psychopharmacology of anxiety disorders. J Consult Clin Psychol. 1996;64:660–668.CrossRefGoogle ScholarPubMed
35.Apter, JT, Allen, LA. Buspirone: future directions. J Clin Psychopharmacol. 1999;19:86–93.CrossRefGoogle ScholarPubMed
36.Sramek, JJ, Tansman, M, Suri, A, et al.Efficacy of buspirone in generalized anxiety disorder with coexisting mild depressive symptoms. J Clin Psychiatry. 1996;57:287–291.Google ScholarPubMed
37.DeMartinis, N, Rynn, M, Rickels, K, Mandos, L. Prior benzodiazepine use and buspirone response in the treatment of generalized anxiety disorder. J Clin Psychiatry. 2000;61:91–94.CrossRefGoogle ScholarPubMed
38.Rickels, K, Downing, R, Schweizer, E, et al.Antidepressants for the treatment of generalized anxiety disorder. A placebo-controlled comparison of imipramine, trazodone, and diazepam. Arch Gen Psychiatry. 1993;50:884–895.CrossRefGoogle ScholarPubMed
39.Hoehn-Saric, R, McLeod, DR, Zimmerli, WD. Differential effects of alprazolam and imipramine in generalized anxiety disorder: somatic versus psychic symptoms. J Clin Psychiatry. 1988;49:293–301.Google ScholarPubMed
40.Hackett, D. Venlafaxine XR in the treatment of anxiety. Acta Psychiatr Scand. 2000;102(suppl 46):30–35.CrossRefGoogle Scholar
41.Kelsey, JE. Efficacy, safety, and tolerability of venlafaxine XR in generalized anxiety disorder. Depress Anxiety. 2000;12(suppl 1):81–84.3.0.CO;2-F>CrossRefGoogle ScholarPubMed
42.Davidson, JR, Dupont, RL, Hedges, D, Haskins, JT. Efficacy, safety, and tolerability of venlafaxine extended release and buspirone in outpatients with generalized anxiety disorder. J Clin Psychiatry. 1999;60:528–535.CrossRefGoogle ScholarPubMed
43.Sheehan, DV. Venlafaxine extended release (XR) in the treatment of generalized anxiety disorder. J Clin Psychiatry. 1999;60(suppl 22):23–28.Google ScholarPubMed
44.Rickels, K, Pollack, MH, Sheehan, DV, Haskins, JT. Efficacy of extended-release venlafaxine in nondepressed outpatients with generalized anxiety disorder. Am J Psychiatry. 2000;157:968–974.CrossRefGoogle ScholarPubMed
45.Rocca, P, Fonzo, V, Scotta, M, Zanalda, E, Ravizza, L. Paroxetine efficacy in the treatment of generalized anxiety disorder. Acta Psychiatr Scand. 1997;95:444–450.CrossRefGoogle ScholarPubMed
46.Davidson, JR. Pharmacotherapy of generalized anxiety disorder. J Clin Psychiatry. 2001;62(suppl 11):46–50.Google ScholarPubMed
47.Pollack, MH, Zaninelli, R, Goddard, A, et al.Paroxetine in the treatment of generalized anxiety disorder: results of a placebo-controlled, flexible-dosage trial. J Clin Psychiatry. 2001;62:350–357.CrossRefGoogle ScholarPubMed
48.Bellew, KM, McCafferty, JP, Iyengar, M, Zaninelli, RM. Paroxetine treatment of GAD: a double-blind placebo-controlled trial. Poster presented at: Annual Meeting of the American Psychiatric Association; May 13–18, 2000; Chicago, Ill.Google Scholar
49.Gelenberg, AJ, Lydiard, RB, Rudolph, RL, Aguiar, L, Haskins, JT, Salinas, E. Efficacy of venlafaxine extended-release capsules in nondepressed outpatients with generalized anxiety disorder: A 6-month randomized controlled trial. JAMA. 2000;283:3082–3088.CrossRefGoogle ScholarPubMed
50.Allgulander, C, Hackett, D, Salinas, E. Venlafaxine extended release (ER) in the treatment of generalised anxiety disorder: twenty-four-week placebo-controlled dose-ranging study. Br J Psychiatry. 2001;179:15–22.CrossRefGoogle Scholar
51.Stocchi, F, Nordera, G, Jokinen, R, Lepola, U. Efficacy and tolerability of paroxetine for the long-term treatment of generalised anxiety disorder (GAD). Poster presented at: Annual Meeting of the American Psychiatric Association; May 5–10, 2001; New Orleans, La.CrossRefGoogle Scholar
52.Hackett, D, Desmet, A, Salinas, EO. Dose-response efficacy of venlafaxine XR in GAD. Poster presented at: 11th World Congress of Psychiatry; August 6–11, 1999; Hamburg, Germany.Google Scholar
53.Durham, RC, Allan, T. Psychological treatment of generalized anxiety disorder. A review of the clinical significance of results in outcome studies since 1980. Br J Psychiatry. 1993;163:19–26.CrossRefGoogle Scholar
54.Borkovec, TD, Whisman, MA. Psychosocial treatment for generalized anxiety disorder. In: Mavissakalian, M, Prien, R, eds. Long-term Treatment for the Anxiety Disorders. Washington, DC: American Psychiatric Press; 1996;171–199.Google Scholar
55.Fisher, PL, Durham, RC. Recovery rates in generalized anxiety disorder following psychological therapy: an analysis of clinically significant change in the STAI-T across outcome studies since 1990. Psychol Med. 1999;29:1425–1434.CrossRefGoogle ScholarPubMed
56.Borkovec, TD, Ruscio, AM. Psychotherapy for generalized anxiety disorder. J Clin Psychiatry 2001;62 (suppl 11):37–42.Google ScholarPubMed
57.Gould, RA, Otto, MW, Pollack, MH, et al.Cognitive behavioral and pharmacological treatment of generalized anxiety disorder: a preliminary meta-analysis. Bekav Ther. 1997;28:285–305.Google Scholar
58.Brown, TA, O'Leary, TA, Barlow, DH. Generalized anxiety disorder. In: Barlow, DH, ed. Clinical Handbook of Psychological Disorders. 2nd ed. New York, NY: Guildford; 1993;137–188.Google Scholar
59.Borkovec, TD, Costello, E. Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder. J Consult Clin Psychol. 1993;61:611–619.CrossRefGoogle ScholarPubMed
60.Lader, MH, Bond, AJ. Interaction of pharmacological and psychological treatments of anxiety. Br J Psychiatry. 1998;(suppl 34):42–48.CrossRefGoogle ScholarPubMed
61.Shapiro, AK, Struening, EL, Shapiro, E. Diazepam: how much better than placebo? J Psychiatr Res. 1983;17:51–73.CrossRefGoogle Scholar
62.Power, KG, Simpson, RJ, Swanson, V, Wallace, LA. Controlled comparison of pharmacological and psychological treatment of generalized anxiety disorder in primary care. Br J Gen Pract. 1990;40:289–294.Google ScholarPubMed
63.Schweizer, E, Rickels, K. Strategies for treatment of generalized anxiety in the primary care setting. J Clin Psychiatry. 1997;58(suppl 3):27–31.Google ScholarPubMed