1. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide

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3. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. in the clinic Generalized Anxiety Disorder

4. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. Which patients are at elevated risk for generalized anxiety disorder?  Women (GAD twice as common in women vs. men)  Comorbid psychiatric disorders  Obesity  History of substance abuse  History of trauma  Family history of GAD

5. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. Are preventive measures useful for patients at elevated risk?  Adults  No evidence on effectiveness but may benefit  Children  CBT + parent education can prevent GAD  In those with withdrawn behavior / early anxiety signs

6. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. Should clinicians screen patients for GAD if they are at increased risk? If so, how?  Yes: GAD is underdiagnosed and undertreated  Screening tools  “Are you bothered by nerves?”: 100% sensitive, 59% specific  2-item GAD-2: 86% sensitive, 83% specific  GAD-7 and PRIME-MD: anxiety + symptom severity  4-item PHQ: anxiety + depression  If screen is positive  Assess whether patient meets diagnostic criteria

7. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. CLINICAL BOTTOM LINE: Screening…  Screen adults who are at increased risk  Screening tools have similar sensitivity and specificity  OK to use a tool with as few as 1 or 2 questions

8. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. What symptoms should prompt clinicians to consider a diagnosis of GAD?  Excess anxiety & worry about everyday issues  Distressed / impaired social, occupational, other functioning  Not attributable to substance or another medical condition  Not better explained by another mental disorder  Plus ≥3 of these symptoms on more days than not (≥6 mos):  Restlessness  Being easily fatigued  Difficulty concentrating  Irritability  Muscle tension  Sleep disturbance

9. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. What physical examination findings indicate possible GAD?  Restlessness, irritability, or fatigue  Medically unexplained symptoms  Chest pain  Rapid heart rate  Exam may uncover underlying / co-occurring medical conditions requiring further evaluation

10. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. What laboratory tests should clinicians use?  None needed for diagnosis  Routine lab testing has low yield  Consider tests to exclude medical conditions  Thyroid function (thyroid disease)  Hemoglobin measurement (anemia)  Urine drug screen (substance use)  Catecholamine levels (pheochromocytoma)

11. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. What other diagnoses should clinicians consider?  Cardiopulmonary disorders  Asthma, COPD, CHF  Endocrine disease  Thyroid disorders, diabetes, hypoglycemia  Mood disorders  Major depressive disorder, bipolar disorder  Other anxiety disorders  Simple or social phobia, panic, OCD, PTSD, acute stress  Misuse of substances  Alcohol, benzodiazepines, caffeine, nicotine, stimulants

12. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. CLINICAL BOTTOM LINE: Diagnosis…  A thorough history is the key to diagnosis  Assess each patient for co-morbid mental illness  No lab testing unless underlying medical disorders suspected  Consult mental health specialist if diagnosis is uncertain

13. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. What nondrug therapies should clinicians recommend for GAD?  Cognitive behavioral therapy  Short-term psychodynamic psychotherapy  Worry exposure or exposure therapy  Relaxation training  Self-help and self-examination therapy

14. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. How should clinicians choose and dose drug therapy?  Use drug therapy when nondrug therapy is…  Unavailable  Ineffective  Or patient is uninterested in it  First-line: Second-generation antidepressants (SSRIs)  Second-line: azapironesIn, benzodiazepines  Third-line: atypical antipsychotics, antihistimine, anticonvulsant

15. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. How should clinicians monitor patients?  Until stable: in person or by phone every 2 - 4 weeks  During maintenance therapy: every 3 - 4 months  Use PRIME-MD or GAD-7 to monitor symptom severity  Ask consistently about…  Medication adherence  Treatment side effects  Suicide risk  Continue pharmacotherapy 6 - 12 months after response  20% - 40% relapse in 6 - 12 months after discontinuation  Severe chronic anxiety may require long-term medication

16. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. When should patients be hospitalized?  When actively suicidal  Assess suicide risk at each follow-up encounter  “Over the last 2 weeks, how often have you been bothered by thoughts that you’d be better off dead or of hurting yourself in some way?”  When symptoms are intractable  For grave disability  To address co-occurring illness  GAD can complicate treatment of co-occurring disorders and adversely affect prognosis

17. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. When should clinicians consult a psychologist, psychiatrist, or other specialist?  No improvement after 12 - 16 weeks of CBT  No response after 6 weeks to 1 st - or 2 nd -line drug Rx  Inability to tolerate drug Rx  Suicidal thoughts expressed  Co-morbid substance, mood, anxiety disorders present  Before prescribing 3 rd -line drugs

18. © Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. CLINICAL BOTTOM LINE: Treatment…  Primary care physicians play an important role in management  CBT is treatment of choice for most adults  If nondrug therapy is unavailable, ineffective, or if patient uninterested in it: try second-generation antidepressants  Assess suicide risk in all GAD patients  Refer complex GAD patients to mental health specialists