Generalized anxiety disorder: diagnosis and treatment

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7500 (Published 27 November 2012)
Cite this as: BMJ 2012;345:e7500

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Any discussion of the causes of GAD, however brief, may benefit from a mention of the historical trend of anxiety symptoms, in recent decades.

Twenge reviewed more than 250 studies, involving 52,000 people, which measured anxiety levels in the USA between 1952 and 1993. (1) They showed a continuous upward trend. By the late 1980s, the average North American child was more anxious than child psychiatric patients in the 1950s.

Wilkinson and Pickett have described interesting cultural changes, possibly associated with these trends. (2)

In their account of management options, Hoge and colleagues give equal space to the role of psychological and pharmacological approaches. (3)

Thirty and more years ago, doctors were encouraged to prescribe “safe” benzodiazepines to their anxious patients. They had none of the problems associated with barbiturates, we were assured.

It was recently reported that 1 million people in the UK are dependent on benzodiazepines. (4)

The NHS faces financial restrictions that have decimated psychological services, the prescribing of SSRIs increases annually, and politicians talk, occasionally, of the need for a measurement of national happiness to replace GNP as the arbiter of last resort.

Might there be a lesson here ?

Primary care practices who encourage their doctors and other staff to use and teach meditative and mindfullness techniques might find that the wellbeing of staff improves along with patients’ coping mechanisms, to the benefit of all, not forgetting the size of the NHS drug bill.

1 J.M.Twenge, ‘The age of anxiety ? Birth cohort change in anxiety and neuroticism,1952-1993, ‘ Journal of Personality and Social Psychology (2007) 79 (6):1007-21.

2 Wilkinson and Pickett, ‘The Spirit Level’ Allen Lane, (2009)

3 Hoge et al BMJ 2012;345:e7500

4 The Times, 1.10.2012

Competing interests: None declared

Noel Thomas, retd GP

n/a, Bronygarn Maesteg, CF34 9AL

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Generalised Anxiety Disorder: Choosing the right medication

The authors of this review highlight the use of SSRI or SNRI as the first choice medications in the management of Generalised Anxiety Disorder.

Benzodiazepines have the disadvantage of tolerability and dependence. In my article on good clinical care, we discuss this important issue and advice on the management of inappropriate prescribing of benzodiazepines and Z drugs in clinical practice.

However, in an interesting article, benzodiazepines for anxiety disorders: maximising the benefits and minimising the risks, Starcevic, recommends that benzodiazepines definitely has a place. He endorses benzodiazepine use, long term, in a highly selective group of patients, patients who have absence of current or past substance misuse and patients who have disabling side-effects from antidepressants resulting in premature cessation of medication. He also recommends considering antidepressants in patients who have a co-occurring depressive disorder and who have predominance of cognitive aspects of pathological anxiety and patients who have current or past substance misuse/dependence.

Selecting the right medication for the right patient may improve outcomes in generalised anxiety disorder.

References:

1. Yadav DS, Davies RH. Good Clinical Care, Benzodiazepines and Z drugs: Managing inappropriate hypnotic prescribing in clinical practice. Foundation Years Journal 2012; 6 (6): 6-9

2. Starcevic V. Benzodiazepines for anxiety disorders: maximising the benefits and minimising the risks. Advances in Psychiatric Treatment 2012; 18: 250-258.

Competing interests: None declared

Devender Singh Yadav, Specialty Doctor in Psychiatry

ABM University LHB, Princess of Wales Hospital, Bridgend. CF31 1RQ

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