Generalized anxiety

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... 

Tollefson GD, Montague-Clouse J, Tollefson SL Treatment of comorbid generalized anxiety in a recently detoxified alcohol population with a selective serotonergic drug (buspirone). J Clin Psychopharmacol 12 19-26, 1992... 

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. 

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. 

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. 

Roy-Byrne PP (1996). Generalized anxiety and mixed anxiety-depression association with disability and health care utilization. J Clin Psychiatry 57 (suppl. 7), 86-91. 

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. 

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... 

TABLE 37-3. Antidepressants Used in the Treatment of Generalized Anxiety Disorder24 29,30... 

Reprinted, with permission, from Kirkwood CK, Melton ST. Anxiety disorders I. Generalized anxiety, panic, and social anxiety disorders. In DiPiro JT, Talbert RL, Yee GC, et al, (eds.) Pharmacotherapy A Pathophysiologic Approach. 6th ed. New York McGraw Hill 2005 1294. 

Allgulander C, Bandelow B, Hollander E, et al. WCA recommendations for the long-term treatment of generalized anxiety disorder. CNS Spectrum 2003 8(8 Suppl 1) 53—61. 

Ballanger JC, Davidson JR, Lecrubier Y, et al. Consensus statement on generalized anxiety disorder from the international consensus group on depression and anxiety. J Clin Psychiatry 2001 62(suppl 11) 53—58. 

Rickels R, Ryan M. Pharmacotherapy of generalized anxiety disorder. J Clin Psychiatry 2002 63(suppl 14) 9—16. 

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