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GENERALIZED ANXIETY
DISORDER IN PRIMARY CARE
Curley Bonds, MD
Medical Director
Didi Hirsch Mental Health Services
Professor & Chair
Charles R. Drew University of Medicine & Science
Department of Psychiatry & Human Behavior
OVERVIEW
I. Criteria for diagnosing Generalized Anxiety Disorder
II. Algorithm for Pharmacotherapy of GAD
III. Conditions and Factors Complicating Treatment of GAD
IV. Assessing Response to Treatment
SLEEP
DIAGNOSTIC CRITERIA FOR GAD
GAD IN PC
Generally GAD can be conceptualized as a
“tension disorder”.
Psychic symptoms (worries, feeling keyed up, irritable)
Physical symptoms (muscle tension, restlessness,
insomnia)
Patients generally describe themselves as ‘worriers’
Worry may be avoidant behavior– to reduce tension
STEP 2
COMPLICATED?
I.
Non-REM: aka slow wave sleep or S sleep
 GeriatricPatients – often have co-morbid depression.
Sensitive to adverse drug effects (falls, accidents, fractures).
Avoid benzos and long acting drugs. Use lower doses.
 Alcohol/Substance Abuse - Generally require a period of
abstinence before symptoms can be adequately assessed.
 Other Co-morbid Disorders – high rates among patients
with other anxiety disorders and mood disorders. Oftehn
they will respond to antidepressants as first line agents.
 Pregnancy/Lactation - avoid meds. Use Fluoxetine with
caution.
 Co-morbid Medical Disorders and Meds – drug interactions
STEP 3
TCAS/VENLAFAXINE/SSRIS
 TCAs – too many side effects to be truly useful (except possibly in those
with co-morbid chronic pain)
 Venlafaxine (also Duloxetine if on Formulary) – effective in both short and
long term trials. (Starting dose of Venlafaxine SR 75mg, Duloxetine 20mg)
 SSRIs – associated with fewer side effects. No addiction risk.
 Fluoxetine 10mg – 80mg
 Paroxetine 20mg -40mg
 Citalopram 10mg-20mg
 Escitalopram 10-40mg
 Sertraline 25-150mg
STEP 3
OTHER OPTIONS
 Buspirone (5 HT 1a antagonist) takes 2-4 weeks to start working,
not helpful in patient who have taken benzodiazipines (5 -30mg
TID0
 Beta Blockers* – evidence is limited (propranolol for stage fright)
 Kava Extract – shows some promise
 Antipsychotics – use caution because of EPS and TD
 Anticonvulsants* – Gabapentin, Pregabalin (50-100mg TID)
 Antihistamines – Diphenhydramine, Hydroxyzine
*off label indications
STEP 4
Determine med Response
Evaluate change in symptoms initially targeted
Excessive worry, somatic complaints, functional
impairment
Intolerant patients can be switched to different med
Optimize dose and duration
May have to ‘push’ the dose with SSRIs
 If Benzodiazipines are used – long acting agents are
preferred over short acting ones:
Clonazepam
Alprazolam
STEP 5
At the end of a trial of optimal dose and duration,
reassess patient
May need to continue the medication
Average duration of treatment should be 6 months to 1
year
50% relapse even after this period
If history includes past episodes, then treatment should
be longer term
Augmentation and switching strategies not well
established or studied.
STEP 6
If no response, consider
Comorbidity?
Compliance?
Comorbid substance use?
Personality disorder?
Underlying Medical Disorder?
Pharmacokinetic issues?
Psychosocial issues?
STEP 7
If medication trial is adequate, consider a thorough
reassessment
May need to try a different medication
Research about what to use as second line is scant
Different class (antidepressants)
Those with cognitive symptoms may respond better to
antidepressants
Somatic symptoms may respond better to benzos (minority)