Generalized Anxiety Disorder - Treatment

The approach to diagnosing generalized anxiety disorder is not much different from the approaches to diagnosing other anxiety disorders. However, in generalized anxiety disorder, special attention should be paid to recognizing various types of comorbid anxiety and depressive disorders that are often combined with this condition. Patients with generalized anxiety disorder very often have symptoms of major depression, panic disorder, and social phobia. Approaches to pharmacotherapy of 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 cases of generalized anxiety disorder when it is accompanied by symptoms of major depression, social phobia or panic attacks.

The peculiarity of the treatment of isolated generalized anxiety disorder is determined by the fact that in this condition, unlike other anxiety disorders, azapirones (for example, buspirone) have proven to be effective. Their use is also advisable in cases where generalized anxiety disorder is accompanied by alcohol or psychotropic substance abuse, as well as symptoms of major depression. According to some data, azapirones are most effective in patients who have not previously taken psychotropic drugs, while previous use of benzodiazepines causes resistance to their action. However, this opinion remains controversial. The main disadvantage of azapirones (compared to benzodiazepines) is a slower onset of effect: symptoms begin to decrease approximately one week after the start of therapy, and the maximum effect develops in approximately one month. Treatment with buspirone begins with a dose of 5 mg 2 times a day, then it is increased by 5 mg 2-3 times a week. 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 effect in major depression, they are ineffective in panic disorder. Therefore, they are not appropriate for use in cases where 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 provides a choice, since depending on the clinical situation, one or another drug may be preferable. For example, in the elderly, benzodiazepines should be avoided, as they form active metabolites that can accumulate in the body. In this age group, lorazepam or alprazolam are preferable. Treatment with lorazepam is started at a dose of 0.5-1 mg, and with alprazolam - at a dose of 0.25 mg - they are taken from 1 to 3 times a day. The dose of lorazepam can be increased if necessary to 6 mg / day (with 3-4-fold administration), the dose of alprazolam - to 10 mg / day, although in most cases the desired effect is achieved at significantly lower doses. Although quite high doses of benzodiazepines are often prescribed, side effects usually limit the dose to the indicated range. In general, lower doses are used for generalized anxiety disorder than for panic disorder.

In addition to azapirones and benzodiazepines, tricyclic antidepressants are also widely used in generalized anxiety disorder. Their effectiveness has been proven in two randomized clinical trials. Due to the risk of side effects and slow onset of effect, tricyclic antidepressants are not considered the drugs of choice. However, they are advisable to use if azapirones are ineffective and there are contraindications to the use of benzodiazepines. Doses of tricyclic antidepressants for generalized anxiety disorder are the same as for major depression and panic disorder.

Trazodone can also be used for generalized anxiety disorder; its effectiveness has been confirmed in a controlled clinical trial.

Although most patients can improve with first- or second-line drugs, there are resistant cases. Most often, resistance is explained by the presence of comorbid depressive and anxiety disorders. Therefore, if the therapy is ineffective, it is necessary to look for comorbid conditions in the patient that may require changes in the treatment regimen. For example, in a resistant patient with manifestations of social phobia or panic attacks, the choice should be made in favor of MAO inhibitors. If there are signs of bipolar disorder, it is advisable to add anticonvulsants to the treatment regimen.

Generalized anxiety disorder tends to be chronic and usually requires long-term therapy. Therefore, benzodiazepine withdrawal can be a major problem that complicates the treatment of this disorder. Patients usually tolerate a slow dose reduction (approximately 25% per week). The rate of dose reduction should be chosen to avoid increasing anxiety or withdrawal symptoms.

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