Magazine article Clinical Psychiatry News

GAD Patients Often Require Combined Therapy

Magazine article Clinical Psychiatry News

GAD Patients Often Require Combined Therapy

Article excerpt

It may lack the compulsive behaviors and dramatic attacks of kindred syndromes, but generalized anxiety disorder is by no means simple to treat.

Primary care physicians see more than half of patients with anxiety disorders, the highest proportion of whom have generalized anxiety disorder (GAD), so those who come to psychiatrists' attention largely represent the more complex and problematic cases, said Dr. Linda Carpenter of Brown University and Butler Hospital in Providence, R.I.

"Remission is still the goal, but we recognize the chronicity of the disorder more than in the past. We're more attuned to the idea that we need to think of treatment with an eye to benefits and tolerability over the long term," she said.

First-line pharmacotherapy is generally an antidepressant. Two selective serotonin reuptake inhibitors (SSRIs)--paroxetine (Paxil) and escitalopram (Lexapro)--and venlafaxine (Effexor), which also affects norepinephrine, have been approved for treating GAD. Many clinicians consider the other SSRIs to be of equal efficacy, however.

"If I hear that a family member has had successful treatment with a particular SSRI, I'll be inclined to choose that one" on the rationale that genetics may work in its favor, Dr. Carpenter said. On the other hand, she tries to respect a patient's misgivings, even if they are based on hearsay. "Placebo effects are large, and I don't want to give a drug that he or she is negative about," she noted.

Because the activation that often accompanies antidepressant initiation can be particularly distressing, Dr. Carpenter starts patients at a lower dosage (5 mg of escitalopram or paroxetine) than she would for depression, and titrates slowly. "I don't want to blow them away with side effects," she said.

Education is particularly important for patients with GAD, given the tendency to worry and the sensitivity to physical sensations that characterize the disorder.

Dr. Moira Rynn, medical director of the mood and anxiety disorders program at the University of Pennsylvania, Philadelphia, takes pains to alert patients about what to expect and strives to establish a collaborative approach.

"I tell patients that the medication I'm giving them may actually increase the symptoms that make them uncomfortable, and that they may hate me for it. I tell them to call me about anything that distresses them, but I make it clear that I'm going to beg them to stay on the drug, and that if they can push through the first weeks, it will be worth it," she said.

Initiating a benzodiazepine at the outset of antidepressant treatment is a common strategy, both to buffer activation and to relieve symptoms while the SSRI takes effect.

Dr. Mary Elizabeth Salcedo, medical director of the Ross Center for Anxiety and Related Disorders, Washington, tends to use this approach for patients who are acutely distressed, but avoids it for those who are particularly sensitive to or worried about medication. She prefers clonazepam (Klonopin) and alprazolam extended-release (Xanax XR), because their longer half-life minimizes the chance of interdose withdrawal.

For a partial response to the SSRI--a common scenario--Dr. Rynn would push the dose aggressively and switch to another member of the same class if that didn't work. Dr. Carpenter would go to venlafaxine, on the theory that "two neurotransmitters are better than one. …

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