Generalized Anxiety Disorder: Treatment

The approach to the diagnosis of generalized anxiety disorder differs little from the approaches to the diagnosis of other anxiety disorders. Nevertheless, with a generalized anxiety disorder, special attention should be paid to the recognition of various kinds of comorbid anxiety and depressive disorders, which are often combined with this condition. In patients with generalized anxiety disorder, the symptoms of major depression, panic disorder, social phobia are very often revealed. Approaches to pharmacotherapy of an isolated generalized anxiety disorder and a similar disorder, but accompanied by panic attacks, symptoms of depression or social phobia, may differ. SSRIs are the drugs of choice in those cases of generalized anxiety disorder, when it is accompanied by symptoms of major depression, social phobia or panic attacks.

The peculiarity of treatment of an isolated generalized anxiety disorder is determined by the fact that in this condition, unlike other anxiety disorders, azapirones (for example, buspirone) have proved to be effective. Their use is also useful when generalized anxiety disorder is accompanied by alcohol abuse or psychotropic substances, as well as symptoms of major depression. According to some reports, azapirones are most effective in patients who have not taken psychotropic drugs before, whereas the previous use of benzodiazepines causes resistance to their action. However, this opinion remains controversial. The main disadvantage of azapirones (in comparison with benzodiazepines) is a slower onset of the effect: the symptoms begin to decrease about a week after the start of therapy, and the maximum effect develops in about a month. Buspirone treatment starts with a dose of 5 mg 2 times a day, then 2-3 times a week it is increased by 5 mg. The effective dose of buspirone is usually 30-40 mg / day, but in some cases it is increased to 60 mg / day. The daily dose is divided into two doses. Although azapirones have some positive effects with major depression, they are ineffective in panic disorder. Therefore, it is not appropriate to appoint them in those cases when generalized anxiety disorder is combined with panic attacks or panic disorder.

A whole group of benzodiazepines has been tested for the treatment of generalized anxiety disorder. This makes it possible to choose, because depending on the clinical situation, the use of a particular drug may be preferable. For example, the elderly should avoid benzodiazepines, which form active metabolites, which can accumulate in the body. In this age group, it is preferable to use lorazepam or alprazolam. Treatment with lorazepam begin with a dose of 0.5-1 mg, and alprazolam - with doses of 0.25 mg - they are taken 1 to 3 times a day. The dose of lorazepam, if necessary, can be increased to 6 mg / day (with a 3-4-fold intake), the dose of alprazolam is up to 10 mg / day, although in most cases the required effect is brought substantially lower doses. Although often given high enough doses of benzodiazepines, side effects usually limit the dose to the specified limits. In general, with a generalized anxiety disorder, lower doses are used than with panic disorder.

In addition to azapirones and benzodiazepines in generalized anxiety disorder, tricyclic antidepressants are widely used. Their effectiveness has been demonstrated in two randomized clinical trials. Because of the risk of side effects and the slow development of the effect, tricyclic antidepressants are not considered drugs of choice. However, it is advisable to use them in the inefficiency of azapirones and the presence of contraindications to the use of benzodiazepines. Doses of tricyclic antidepressants in generalized anxiety disorder are the same as those with major depression and panic disorder.

In generalized anxiety disorder, trazodone can also be used, its effectiveness is confirmed in a controlled clinical trial.

Although the majority of patients can achieve improvement with drugs of the first or second line, there are also resistant cases. Most often, the resistance is due to the presence of comorbid depressive and anxiety disorders. Therefore, if the effectiveness of therapy is low, it is necessary to look for comorbid conditions in the patient, which may require changes in the treatment regimen. For example, in a resistant patient who has manifestations of social phobia or panic attacks, the choice should be made in favor of MAO inhibitors. If there are signs of bipolar disorder, anticonvulsants should be added to the treatment regimen.

A generalized anxiety disorder tends to be chronic and usually requires prolonged therapy. In this regard, the abolition of benzodiazepines may present a serious problem complicating the treatment of this disease. Patients usually tolerate a slow reduction in dose (approximately 25% per week). It is necessary to select such a rate of dose reduction in order to avoid an increase in anxiety or abstinence symptoms.

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