1. 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

2. 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

3. SLEEP

4. DIAGNOSTIC CRITERIA FOR GAD

5. 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

6. 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

7. 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

8. STEP 3 OTHER OPTIONS  B uspirone (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

9. 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

10. 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.

11. STEP 6 If no response, consider Comorbidity? Compliance? Comorbid substance use? Personality disorder? Underlying Medical Disorder? Pharmacokinetic issues? Psychosocial issues?

12. 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)