Generalized anxiety disorder

Social anxiety disorder/generalized anxiety disorder (GAD) Paroxet ne (immediate-and controlled-release except Pexei/a), sertraline, escitalopram. 

Social anxiety disorder, generalized anxiety disorder PO (Extended-Release) Initially,... 

Davidson JR. Use of benzodiazepines in social anxiety disorder, generalized anxiety disorder, and posttrau-matic stress disorder. J Clin Psychiatry. 2004 65(suppl 5) 29-33. 

The following anxiety disorders generally are not treated with psychotropic medications a referral should be made only if the patient s symptoms are severe or fail to respond to psychological treatments ... 

Anxiety disorders (generalized anxiety disorder, obsessive-compulsive disorder, or panic disorder) Substance abuse (alcohol or sedative-hypnotic withdrawal) Pharmacologically induced Anticonvulsants Central adrenergic blockers Diuretics... 

Anxiety disorders and insomnia represent relatively common medical problems within the general population. These problems typically recur over a person s lifetime (3,4). Epidemiological studies in the United States indicate that the lifetime prevalence for significant anxiety disorders is about 15%. Anxiety disorders are serious medical problems affecting not only quaUty of life, but additionally may indirecdy result in considerable morbidity owing to association with depression, cardiovascular disease, suicidal behavior, and substance-related disorders. 

Antidepressants are small heterocyclic molecules entering the circulation after oral administration and passing the blood-brain barrier to bind at numerous specific sites in the brain. They are used for treatment of depression, panic disorders, generalized anxiety disorder, social phobia, obsessive compulsive disorder, and other psychiatric disorders and nonpsychiatric states. 

OCD, panic disorder, general anxiety disorder, social anxiety disorder, post-traumatic stress syndrome Depression, OCD, panic disorders, post-traumatic stress disorder... 

Iwata N, Cowley DS, Radel M, et al Relationship between a GABA alpha g Pro385Ser substitution and benzodiazepine sensitivity. Am] Psychiatry 156 1447—1449,1999 Jacobson AF, Dominguez RA, Goldstein B, et al Comparison of buspirone and diazepam in generalized anxiety disorder. Pharmacotherapy 5 290—296, 1985 Jaffe JH, Ciraulo DA, Nies A, et al Abuse potential of halazepam and diazepam in patients recently treated for acute alcohol withdrawal. Clin Pharmacol Ther 34 623-630, 1983... 

Rates of smoking among patients with bipolar disorders and anxiety disorders (e.g., posttraumatic stress disorder, panic disorder) are also higher than those in the general population (Lasser et al. 2000), but there has been htde smdy of the factors associated with motivation to quit smoking or of smoking cessation interventions in these patient groups. 

The anxiety disorders are a case in point. They comprise a range of conditions contiguous with the affective disorders and the stress responses (Table 4.1). Much overlap and comorbidity exist. Furthermore, definitions and diagnostic criteria have changed substantially over the years. For example, generalized anxiety disorder is a rare condition in its pure form, but a common condition if comorbid phobic and depressive disorders are accepted. 

A further factor concerns the milieu in which the anxiety disorders are encountered. These are essentially detected, diagnosed and treated by primary-care practitioners. In the UK, for instance, less than 10% of such cases are referred to specialists, although the figure tends to be higher in the USA and continental Europe. General practitioners often make syndromal or even symptomatic assessments rather than diagnosing disorders, so it may be difficult to extrapolate across countries. 

In this chapter pharmacoeconomic considerations of the anxiety disorders in general are outlined, followed by accounts of some studies in each major disorder. 

Out-patient treatment is substantially cheaper than in-patient management and is generally as effective (Lowman, 1991). A French study on patients with generalized anxiety disorder estimated costs per patient over 3 months to he US 423 for hospitalization, 335 for out-patient services and 43 for medications (Souetre et al, 1994). Comorbid conditions (mostly alcoholism and depression) doubled these direct health-care costs. Over three-quarters of all patients were taking anxiolytic medication. 

The usually accepted prevalences for generalized anxiety disorder (GAD) are around 1.6% for current, 3.1% for 1 year and 5.1% lifetime (Roy-Byrne, 1996). The condition is twice as common in women as in men (Pigott, 1999). A small minority (10%) have GAD alone, and about the same proportion suffer from mixed anxiety and depression. Morbidity is high. About a half of those with uncomplicated GAD seek professional help, but two-thirds of those with comorbid GAD do so. Up to a half take medication at some point. The condition may coexist with other anxiety disorders such as phobias, with affective disorders, or with medical conditions such as unexplained chest pain and irritable bowel syndrome. 

Generalized anxiety disorder has been relatively neglected from the point of view of both health economics and pharmacoeconomics. The changing diagnostic criteria have made it difficult to compare data over time, leading researchers to focus on the more clearly defined disorders such as panic and obsessions. Drug treatment has been dominated by the benzodiazepines, usually available genetically and cheaply. However, as the final section of this chapter will show, all this is in flux. 

Unlike most anxiety disorders, panic disorder leads to a high utilization of general medical services, reflecting the frequency, severity and alarming nature of physical symptoms such as palpitations, gastrointestinal distress, respiratory problems and headaches (Zaubler and Katon, 1998). This can result in extensive investigations and sometimes inappropriate but expensive medications. 

The anxiety disorders are common and surprisingly disabling conditions. Studies on the health economics of generalized anxiety disorder, panic disorder, social anxiety disorders and obsessive compulsive disorder document the cost to the individual and to society. Attention has focused on the major psychiatric disorders such as depression, schizophrenia and the dementias. Studies suggest that many anxiety disorders are of early onset and too often chronic they are quite common and impose a heavy burden on society. More studies will be needed to discern the fine grain in the survey material and to identify more precisely the location and type of societal costs. These factors will vary from country to country, from district to district, between men and women and between various age groups. 

Generalized Anxiety Disorder, Panic Disorder, and Social Anxiety Disorder... 

Describe pathophysiologic findings in generalized anxiety, panic, and social anxiety disorder patients. 

O The goals of therapy for generalized anxiety disorder are to acutely reduce the severity and duration of anxiety symptoms and restore overall functioning. The long-term goal in generalized anxiety disorder is to achieve and maintain remission. 

Antidepressants are considered first-line agents in the management of chronic generalized anxiety disorder. 

Benzodiazepines are recommended for acute treatment of generalized anxiety disorder when short-term relief is needed, as an adjunct during initiation of antidepressant therapy, or to improve sleep. 

The dose of benzodiazepine required for improvement in panic disorder generally is higher than that used in other anxiety disorders. 

With a lifetime prevalence of 28.8%, anxiety disorders collectively represent the most prevalent Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR)2 class of disorders, with specific phobia (12.5%) and social anxiety disorder (12.1%) being the most common.3 Recent reports from the National Comorbidity Survey Revised (NCS-R) estimate the lifetime and 1-year prevalence of generalized anxiety disorder (GAD) for those 18 years of age and older to be 5.7% and 3.1%, respectively.3,4 Rates for panic disorder (PD) are slightly lower, with an estimated 12-month prevalence of 2.7% and lifetime prevalence of 4.7%. 

CHAPTER 37 / GENERALIZED ANXIETY DISORDER, PANIC DISORDER, AND SOCIAL ANXIETY DISORDER 607... 

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