Generalized anxiety disorder: how to treat, and for how long?

Generalized anxiety disorder (GAD) is a common, chronic and disabling anxiety disorder with considerable comorbidity with depression as well as with other anxiety disorders. Although tricyclic antidepressants and benzodiazepines have been found to be efficacious in patients with GAD, tolerability problems and other risks limit their use in clinical practice. In placebo-controlled, acute (<8 weeks) trials, several medications, including the selective serotonin reuptake inhibitors ([SSRIs] escitalopram, paroxetine, and sertraline) and others (venlafaxine, buspirone, pregabalin), have demonstrated efficacy in patients with GAD. Indeed, current guidelines for the treatment of GAD recommend SSRIs as first-line pharmacological therapy because of their efficacy and tolerability profiles. Although GAD is a chronic condition that is usually present for years, with symptoms typically fluctuating in intensity over time, there have been few randomized, controlled trials of pharmacotherapy beyond the acute phase of treatment. However, data from recent relapse-prevention studies and longer-term maintenance studies with paroxetine, venlafaxine and escitalopram strongly support the value of continued treatment for at least a further 6 months. This article focuses on pharmacological treatment, and reviews recently available data from acute, long-term and relapse-prevention trials in patients with GAD. In addition, issues relating to the natural course of GAD are highlighted as important considerations to guide selection of pharmacotherapy.