with Luana Marques, PhD, and Sanjay J. Mathew, MD

Clinicians often struggle to differentiate between anxiety disorders, sometimes leading to misdiagnosis. In a session on generalized anxiety disorder (GAD) from the perspective of a psychologist and psychiatrist at the interactive Psych Congress 2020, Luana Marques, PhD, and Sanjay J. Mathew, MD, provided their take on the disorder’s clinical features, differential diagnoses, and evidence-based treatments.

Psychotherapy Approaches to Generalized Anxiety Disorder

Dr. Marques, an associate professor of psychiatry at Harvard Medical School and president of the Anxiety and Depression Association of America, shared evidence-based psychotherapy approaches for managing GAD. To illustrate how a specific situation can trigger thoughts and behaviors leading to GAD, she offered a case study of Mary, who had received a negative performance evaluation from her boss.

After her evaluation, Mary was overcome with worries and “What ifs,” such as “What if I get fired? What if everyone knows? What if I cry?” These thoughts resulted in troublesome behaviors including going out of her way to avoid interacting with her boss and seeking ongoing reassurance from others. In addition, she felt physically nauseous, jumpy, restless, and tense.

Dr. Marques went on to describe GAD as having a median age of onset of 30 years and being more prominent in women than men. According to the DSM-5,1 GAD is anxiety not caused by drugs or other mental health conditions and is characterized by:

  • excessive worry for at least 6 months
  • difficulties controlling the worries
  • three of more of the following symptoms – restlessness, fatigue, irritability, difficulty concentrating, sleep disturbance
  • impairment or distress

Available screening tests include the GAD-7, which has a sensitivity of 89% and a specificity of 82%,2 and the shorter version, GAD-2, which has a sensitivity of 86% and a specificity of 83% for GAD.3 “The GAD-2 should be followed by a more structured interview,” advised Dr. Marques.

Due to the COVID-19 pandemic, 36% of the US population currently has anxiety symptoms that may be related to an anxiety disorder, compared to 9% in the first half of 2019.4

When addressing GAD in patients, Dr. Marques recommends CBT to help those who feel stuck when a situation triggers certain thoughts, emotions, and  behaviors. By moving through the stages of treatment, patients learn to deal with current, specific anxieties and hopefully, generalize their skills to other situations. Here’s a snapshot of her CBT approach:

  • An introduction to CBT includes identifying and separating thoughts, emotions, and behavior and encouraging patients to consider alternatives.
  • Mid-treatment focuses on cognitive restructuring. This involves challenging patients’ thoughts so they can see the world in a different way and become more flexible in their thinking. This stage also includes activities such as designating “worry time” each day and increasing exposure to a feared behavior trigger.
  • Later on, patients learn to generalize treatment and apply it to different domains of their lives.

Is CBT efficacious? It depends on the patient.

Dr. Marques described a meta-analysis of 28 studies that showed a significant beneficial effect of CBT and psychotherapy in general.5 Yet, she said, there is a need for treatment innovation, as 50% of patients do not experience symptom reduction after their initial treatment. Moreover, patients who experience only partial recovery are more vulnerable to relapse. CBT can be thought of as a skill, and not a therapy. We need to consider different forms of evidence-based psychotherapy, she noted, such as acceptance and commitment therapy, mindfulness, and relaxation approaches, as the pooled effect size of psychotherapy is large.

Pharmacologic Treatment Considerations for Generalized Anxiety Disorder

Sanjay Mathew, MD, professor of psychiatry and behavioral sciences at Baylor College of Medicine in Houston, spoke about the pharmacology of treating GAD – including clinical challenges in, such as the overuse of benzodiazepines (sometimes in combination with opioids) and the low remission rates associated with SSRIs/SNRIs.

Only four medications are currently FDA approved for GAD:

  • duloxetine (an SNRI)
  • escitalopram (an SSRI)
  • paroxetine (an SSRI)
  • venlafaxine XR (an SNRI)

Buspirone was approved in 1986 for general anxiety disorders before they were further categorized by the DSM, and pregabalin is approved in Europe but not in the United States.

There have been no new FDA approvals in 13 years despite anxiety being the most common mental health illness in the US.6

Benzodiazepines are commonly prescribed for GAD symptoms in primary care settings. Dr. Mathew noted the alarming increase in prescribing these medications in combination with an opioid or another CNS depressant, which contributes to poor outcomes.

Dr. Mathew said the current thinking on the use of benzodiazepines for GAD is that, “It is not recommended for new starts. “For inherited patients, you can have a discussion, and work on a long-term taper,” he said, noting that hydroxyzine can be a reasonable option for someone who wants to avoid benzodiazepines.

Many different treatment guidelines and algorithms exist for GAD. Dr. Matthew presented an algorithm for the pharmacotherapy of GAD that was developed at the Harvard South Shore Program.7 In this algorithm, SSRIs are the basic first-line medication, with duloxetine, buspirone, hydroxyzine, pregabalin, or bupropion included as early alternatives. A different SSRI may be recommended if the response is inadequate. If the response is still unsatisfactory, an SNRI may be recommended. Other alternatives for treatment-resistant or treatment-intolerant patients include tricyclic antidepressants (TCAs), second-generation antipsychotics, and the anticonvulsant valproate.7

Dr. Matthew also shared a published review of treatments which indicated that SSRIs and SNRIs represent the first-line psychopharmacologic treatment while second-line pharmacotherapies include buspirone, benzodiazepines, second-generation antipsychotics, and pregabalin.8

The British Association of Psychopharmacology Guidelines recommends continuing drug treatment for a longer period of up to 18 months and using CBT over other psychotherapeutic treatments. When stopping treatment, the association calls for a slow and gradual taper of at least 3 months to avoid rebound symptoms.9

Patient Counseling and Psychoeducation

When medication is chosen as a treatment course, Dr. Mathew said that psychoeducation for medication adherence is especially important for long-term management. Clinicians should acknowledge to patients that there are challenges in adherence, particularly when also taking medication for other conditions, and not hesitate to question patients directly about barriers such as cost, side effects such as weight gain or sexual dysfunction; fear of being found out/stigmatized; and frequency of dosing – can it be reduced?

Dr. Mathew summarized his primary takeaways for clinicians:

  • GAD is a chronic, relapsing condition that can be very debilitating
  • There have been no new FDA-approved medications for GAD in more than a decade.
  • SSRIs or SNRIs are a rational first-choice option for most patients
  • Clinicians should pay close attention to the dosing for buspirone and pregabalin; patients may require higher doses
  • There is a need to address medical comorbidities.

Psych Congress 2020 Highlights

Additional virtual meeting summaries

SUDs in ElderlyCOVID & Mental HealthSuicide & Schizophrenia
References
Last Updated: Nov 30, 2020