Generalized anxiety disorder in primary care: emerging issues in management and treatment

Generalized anxiety disorder (GAD) is highly prevalent in primary care patients and is a source of major morbidity. The low rate of recognition and diagnosis of GAD is often the result of insufficient knowledge on the part of primary care physicians, time pressures, and competing demands during patients' visits. Patient attribution of symptoms and the stigma related to mental illness also contribute to underrecognition. Other contributing factors include the natural history of GAD, the bimodal age of presentation, a chronic but waxing and waning course, frequent comorbidity with other anxiety and depressive disorders, and the controversy regarding the best diagnostic criteria. However, proper diagnosis is critical to appropriate management. Primary care management of GAD and associated comorbidities includes education about the nature of GAD as a medical disorder that is amenable to treatment and counseling about treatment alternatives and coping strategies. Most patients with GAD suffer from insomnia, and treating insomnia can be of great benefit to them. While cognitive-behavioral therapy and relaxation therapy are effective in treating GAD, most patients in primary care settings are likely to require pharmacologic treatment. Although commonly used, benzodiazepines and their short-term benefits are overshadowed by their decreased long-term effectiveness, their minimal treatment of psychic symptoms, and their degradation of patient performance. The selective serotonin reuptake inhibitor (SSRI) paroxetine is indicated for the short-term treatment of GAD, although adequate data supporting the use of most SSRIs for GAD are not yet available. The serotonin-norepinephrine reuptake inhibitor venlafaxine provides a treatment option resulting in both short- and long-term improvement of symptoms, attaining not only a response but also remission from GAD and prevention of relapse.