Anxiety disorders, which include generalized anxiety disorder, panic disorder/agoraphobia and social anxiety disorder, are the most common psychiatric disorder diagnosed (Bandelow et al., 2017). Anxiety disorders are also considered to have a “high burden of illness” and are undertreated as well as underrecognized in the doctor office setting (Bandelow et al., para. 2, 2017). Generalized anxiety disorder (GAD) is a chronic psychiatric illness that typically begins in adolescence or when someone is a young adult and continues throughout their entire life (Bandelow et al., 2017). Left untreated, GAD can lead to other psychiatric conditions, such as major depressive disorder (Bandelow et al., 2017).
The treatment of GAD involves both pharmacotherapy as well as psychotherapy in order to be successful (Bandelow et al., 2017). The first line treatment of GAD from a medication standpoint is SSRIs, SNRIs and buspirone (Bandelow et al., 2017). The second line treatment of GAD includes the class of medication known as benzodiazepines (Rosenthal & Burchum, 2021). It is important to understand that relief of anxiety when using a benzodiazepine has a very quick onset of relief, but this category of drugs is only recommended for short-term as it is highly addictive (Rosenthal & Burchum, 2021). Common benzodiazepines used for GAD include alprazolam, chlordiazepoxide, diazepam, lorazepam, and clonazepam (Rosenthal & Burchum, 2021); common SSRIs used to treat GAD are escitalopram and paroxetine (Rosenthal & Burchum, 2021); common SNRIs/other medications used to treat GAD include buspirone, duloxetine and venlafaxine (Rosenthal & Burchum, 2021). “Venlafaxine, an SNRI, was the first antidepressant approved for GAD” (Rosenthal & Burchum, pg. 244, 2021). The only type of SSRIs currently approved for treatment of GAD are escitalopram and paroxetine (Rosenthal & Burchum, 2021); however, these medications are not as well-tolerated as the class of benzodiazepines (Rosenthal & Burchum, 2021). Treatment for long-term management of GAD should be managed with antidepressants and buspirone (Rosenthal & Burchum, 2021). “Compared with benzodiazepines, the antidepressants do a better job of decreasing cognitive and psychic symptoms of anxiety but are not as good at decreasing somatic symptoms” (Rosenthal & Burchum, pg. 243, 2021).
It is important to realize that pharmacological treatment of GAD should go along with nondrug therapy to have success in treating the patient’s anxiety (Rosenthal & Burchum, 2021). Patients with mild GAD can have success in nondrug treatment alone, such as cognitive behavioral therapy, relaxation training and supportive therapy (Rosenthal & Burchum, 2021). “Because GAD is a chronic disorder, initial drug therapy should be prolonged, lasting at least 12 months and possibly longer” (Rosenthal & Burchum, pg. 243, 2021).
A patient’s individual pharmacokinetic and pharmacodynamics play into how pharmacological treatment works or doesn’t work. Age, gender, mental health history and genetics all can affect the anxiolytic medications used to treat GAD (Hoffman, 2021). As GAD occurs throughout the lifetime and is a chronic disease, aging affects the pharmacokinetics and pharmacodynamics of each individual (Hoffman, 2021). As we age, our body changes and these changes can affect the way medications are absorbed and metabolized (U.S. Food and Drug Administration, 2019). Anxiety is common in the elderly population and this population tends to be on multiple medications for different medical conditions, which allows for multiple potential drug-interactions (Crocco et al., 2017).
Another interesting fact I found when researching GAD was the discovery of CYP450, which is a pharmacokinetic gene related to generalized anxiety disorder (Hoffman, 2021). “The selection of a specific SSRI can be customized to an individual patient based on the drug’s side effect profile and drug-to-drug interactions but should be equally evaluated for potential pharmacokinetic gene-drug interactions” (Hoffman, para. 4, 2021). This research has found that there are many variants in the CYP450 genes that can help providers make informed decisions when prescribing medications for GAD based on that individual’s drug metabolism profile (Hoffman, 2021).
Patients with GAD, such as those with other psychiatric conditions, require a personalized care plan that is individualized to their specific needs and pharmacodynamics (Strawn et al., 2018). Personalized care plans are used to individualize treatment, specific to the patient’s lifestyle, genetics, other medical conditions and gender to name a few; personalized care plans have the best success rate for the patient and encourage medication compliance (Strawn et al., 2018).
I personally have dealt with Generalized Anxiety Disorder (GAD). I was diagnosed 6 years ago. I’m currently taking Celexa which is a Selective Serotonin Reuptake Inhibitor (SSRI) and have found this medication helpful, but I feel at my best when I do other non-pharmacological interventions along with taking medication. According to Sheffler 2021 SSRIs block reuptake and enhance and prolong serotonergic neurotransmission causing an increase in serotonin within the brain. Serotonin is a chemical neurotransmitter within the brain that carries signals to the neurons. Slowing the re-absorption of serotonin helps to lower anxiety and regulate mood (Sheffler, 2021). 2 APA refrences
The recommended first line of treatment for GAD is the medication Effexor which is considered a Serotonin norepinephrine reuptake inhibitor (SNRI) (Rosenthal & Burchum, 2021). Not only does Effexor increase serotonin, but it also increases norepinephrine, and dopamine by blocking their transport and blocking the reuptake of these neurotransmitters, increasing the stimulation of postsynaptic receptors (Singh, 2021).
It is also recommended that combined pharmacological therapy and non-pharmacological interventions together create the best outcomes for patients with GAD (Rosenthal & Burchum, 2021). I personally have been trying to incorporate mindfulness, which my therapist recommended. It has been found that the practice of mindfulness is an effective tool to lower and treat anxiety (Hoge et al., 2017). 2APA refrences
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