Generalized+Anxiety+Disorder

** General: **
o In any given year 18% of people will suffer from an anxiety disorder. The four most common anxiety disorders in primary care are: panic, generalized anxiety disorder, social anxiety disorders and PTSD. Of these Generalized Anxiety Disorder (GAD) is the most common.

Epidemiology/risk factors:
o Lifetime prevalence rate is 4.1%. Twice as many women as men have GAD. Accounted for 12.3 million office visits (1997-1998). Majority of patients have comorbid psychiatric disorder including: major depression/panic disorder/social phobia/specific phobia/OCD/PTSD and substance abuse.

o Risk Factors: Family History/ stressful life events/ history of childhood physical or emotional abuse

Symptoms/Diagnosis:
o Symptoms: excessive anxiety and worry about a number of events or activities, occurring more days than not for at least 6 months, that are out of proportion to the likelihood or impact of feared events. Somatic symptoms may include fatigue, muscle tension,memory loss and insomia. (DSM IV: [])

o Diagnostic Tool: The GAD-7 Anxiety Scal (printable PDF) A score of 10 or more on the GAD-7 represents a reasonable cut point for identifying cases of GAD. The sensitivity at this level was 89%, and the specificity was 82%. Cut points of 5, 10, and 15 may be interpreted as representing mild, moderate, and severe levels of anxiety on the GAD-7.


 * Over the last 2 weeks, how often have you been bothered by the following problems? || Not at all sure || Several days || Over half the days || Nearly every day ||
 * Feeling nervous, anxious, or on edge || 0 || 1 || 2 || 3 ||
 * Not being able to stop or control worrying || 0 || 1 || 2 || 3 ||
 * Worrying too much about different things || 0 || 1 || 2 || 3 ||
 * Trouble relaxing || 0 || 1 || 2 || 3 ||
 * Being so restless that it's hard to sit still || 0 || 1 || 2 || 3 ||
 * Becoming easily annoyed or irritable || 0 || 1 || 2 || 3 ||
 * Feeling afraid as if something awful might happen || 0 || 1 || 2 || 3 ||
 * Add the score for each column ||  ||   ||   ||   ||
 * Total Score (add your column scores) ||  ||   ||   ||   ||

Treatment and follow-up:
Step 1: SSRI Step 2: Non-response after adequate SSRI trial can be followed by a different SSRI, SNRI, TCA. Partial response can be followed with buspirone or hydroxyzine. Step 3: Non-response after adequate trials of second-line antidepressants can be followed with trials of other less well studied antidepressants. Partial response can be addressed by augmentation.

MEDICATIONS:
SSRI approved for GAD:
 * Escitalopram**(lexapro) no CYP450 interactions (not covered consider Citalopram(Celexa))
 * Paroxetine**(Paxil) shorter half life so higher risk of breakthrough anxiety and CYP450 effects (2D6 inhibitor so interacts with Metoprolol)

SNRI approved for GAD:
 * Venlafaxine** (effexor) no CYP450 effects shorter half life

Other SSRI commonly used for GAD:
 * Fluoxetine**(Prozac) most stimulating but longer half life so less breakthrough
 * Sertraline** (Zoloft) intermediate half life minimal CYP450 effects but has diarrhea

Buspar(buspirone) Bupropion (Wellbutrin) Citalopram (Celexa) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Venlafaxine (Effexor)
 * CCHP Covers:**

Monitor improvement with OASIS tool (appendix 2 of reference 2) http://www.chammp.org/Training/Resources/Assessment-Tools/Anxiety.aspx

Articles/References:
1. Roy-Byrne P et al. Brief intervention for anxiety in primary care patients. J AM Board Fam Med 2009; 22:175-86 ( [] )

2. Fricchione G. Generalized anxiety disorder. NEJM 2004; 351(7):675-82

3. UpToDate