PsychoTropicalResearch, serotonin and serotonin syndrome research.
Generalised anxiety disorder - Treatment
Generalised anxiety disorder - Treatment
Date Created: 04/09/1999 Last Modified: 19/01/2002 Last Checked: 07/01/2003
Although it is usually stated and agreed that medication is not the indicated first line treatment for 'Generalised anxiety disorder' such patients are frequently treated with medication. Also, some patients either fail to get a satisfactory result with non-drug therapies, or these options are unavailable, either practically or economically. Thus, in some places and circumstances, patients and doctors may wish to consider the benefits of drug treatment.
There is are large overlap between depression and generalised anxiety disorder (see other notes especially 'diagnostic criteria'). So it is not surprising that drug trials appear to demonstrate efficacy of both TCAs and SSRIs in anxiety disorder. However, their apparent effect in anxiety disorder cannot be entirely put down to improvement in unrecognised depression, even though that is probably common.
The definition of 'Generalised anxiety disorder' has changed quite significantly between 'DSM-3, DSM 3R, and DSM -4; the definition in the WHO system 'ICD-10' is again significantly at variance with DSM. It is not surprising that this has not facilitated longitudinal studies and this is a major weakness in the data. The shaky status of Generalised anxiety disorder may be best attested to by the finding that up to 90% of these patients may attract a concurrent diagnosis of another psychiatric disorder and up to 40% (in some studies) a diagnosis of depression; as suggested above this gives an insight into the possible reason for the apparent efficacy of anti-depressants.
All antidepressants demonstrate efficacy in generalised anxiety disorder. This includes TCAs, SSRIs, the old MAOIs. Perhaps the most remarkable exception is the apparent failure of moclobemide to show efficacy in anxiety.
So far there is no reason to suppose any particular SSRI is any better. Selection of a treatment of proven low toxicity and benign side effects profile is even more relevant for what will often be milder illnesses, (see other notes especially 'SSRIs').
The benzodiazepines will become less fashionable for anxiety now; the most prominent disadvantages are:-- possible habituation / withdrawal effects, impairment of driving etc, memory impairment. There is a greater tendency for them to interact with other commonly used drugs, especially anti-histamines and alcohol, and also commonly used anti-biotics, compared to alternatives such as selected SSRIs.
Recently the old anti-histamine compound Hydroxyzine has attracted attention. It is a pharmacologically dirty old 'tri-cyclic' drug with multiple effects on various receptors. Click 'view references' to go to the references screen where you can also see the associated notes / abstract summary).
Another similar choice is doxepin which is a weak noradrenalin reuptake inhibitor (and probably not a good antidepressant). It is however the most potent H1 blocker on the world market and thus very sedative. Besides this it is a potent 5-HT2A blocker. That property (like the new drugs nefazodone and mirtazapine) may give it efficacy as a sleep enhancer. It can be helpful in doses of only 10-20 mg at night. If given in maximum quantities of 50 of the 10 mg tablets its high toxicity in over-dose is not likely to be a problem.
Click 'view references' to go to the references screen where you can also see the associated notes / abstract summary.
All text ©Dr Ken Gillman MRC Psych - PsychoTropical Research®
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