Pharmacotherapy of generalized anxiety disorder

Generalized anxiety disorder (GAD) is chiefly characterized by a cognitive focus on threats and risks towards the individual and/or the immediate family. It is accompanied by a sense of tension, worry, muscle pain, disturbed sleep and irritability. The condition impairs work capacity, relations, and leisure activities, and aggravates concurrent somatic diseases. Due to its chronic course, GAD increases costs for the individual, the family, and health care services, and reduces work and educational performance. In cardiovascular or cerebrovascular disease, pulmonary disease, diabetes and neurological diseases, GAD is a risk factor for somatic complications and for lowered adherence to somatic treatments. There is evidence that GAD can be treated with cognitive behavioural therapy (CBT), and/or with medications. First-line pharmacotherapies are selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs) and pregabalin. If such therapies fail, one may reconsider the diagnosis, question adherence with the prescribed schedule, and determine the adverse influence of comorbidity (such as depression, substance use, and physical ill-health) as well as the influence of social stressors. Second-line pharmacotherapies are largely not supported by controlled trials, and so leave much to clinical judgment and careful monitoring. One may attempt treatments with benzodiazepine anxiolytics, with quetiapine, or with pregabalin as an adjunct therapy in patients with partial response to SSRI or SNRI treatment. CBT is a valid alternative to pharmacotherapy, depending on patient preference.