© copyright annals of internal medicine, 2013 ann int med. 159 (9): itc5-1. * for best viewing:...
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© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
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© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
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© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
in the clinic
Generalized Anxiety Disorder
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
Which patients are at elevated risk for generalized anxiety disorder?
Women (GAD twice as common in women vs. men)
Comorbid psychiatric disorders
Obesity
History of substance abuse
History of trauma
Family history of GAD
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
Are preventive measures useful for patients at elevated risk?
Adults
No evidence on effectiveness but may benefit
Children
CBT + parent education can prevent GAD
In those with withdrawn behavior / early anxiety signs
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
Should clinicians screen patients for GAD if they are at increased risk? If so, how?
Yes: GAD is underdiagnosed and undertreated
Screening tools
“Are you bothered by nerves?”: 100% sensitive, 59% specific
2-item GAD-2: 86% sensitive, 83% specific
GAD-7 and PRIME-MD: anxiety + symptom severity
4-item PHQ: anxiety + depression
If screen is positive
Assess whether patient meets diagnostic criteria
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
CLINICAL BOTTOM LINE: Screening… Screen adults who are at increased risk
Screening tools have similar sensitivity and specificity
OK to use a tool with as few as 1 or 2 questions
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
What symptoms should prompt clinicians to consider a diagnosis of GAD?
Excess anxiety & worry about everyday issues
Distressed / impaired social, occupational, other functioning
Not attributable to substance or another medical condition
Not better explained by another mental disorder
Plus ≥3 of these symptoms on more days than not (≥6 mos):
Restlessness
Being easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
What physical examination findings indicate possible GAD?
Restlessness, irritability, or fatigue
Medically unexplained symptoms
Chest pain
Rapid heart rate
Exam may uncover underlying / co-occurring medical conditions requiring further evaluation
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
What laboratory tests should clinicians use?
None needed for diagnosis
Routine lab testing has low yield
Consider tests to exclude medical conditions
Thyroid function (thyroid disease)
Hemoglobin measurement (anemia)
Urine drug screen (substance use)
Catecholamine levels (pheochromocytoma)
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
What other diagnoses should clinicians consider?
Cardiopulmonary disorders
Asthma, COPD, CHF
Endocrine disease
Thyroid disorders, diabetes, hypoglycemia
Mood disorders
Major depressive disorder, bipolar disorder
Other anxiety disorders
Simple or social phobia, panic, OCD, PTSD, acute stress
Misuse of substances
Alcohol, benzodiazepines, caffeine, nicotine, stimulants
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
CLINICAL BOTTOM LINE: Diagnosis… A thorough history is the key to diagnosis
Assess each patient for co-morbid mental illness
No lab testing unless underlying medical disorders suspected
Consult mental health specialist if diagnosis is uncertain
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
What nondrug therapies should clinicians recommend for GAD?
Cognitive behavioral therapy
Short-term psychodynamic psychotherapy
Worry exposure or exposure therapy
Relaxation training
Self-help and self-examination therapy
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
How should clinicians choose and dose drug therapy?
Use drug therapy when nondrug therapy is…
Unavailable
Ineffective
Or patient is uninterested in it
First-line: Second-generation antidepressants (SSRIs)
Second-line: azapironesIn, benzodiazepines
Third-line: atypical antipsychotics, antihistimine, anticonvulsant
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
How should clinicians monitor patients?
Until stable: in person or by phone every 2 - 4 weeks
During maintenance therapy: every 3 - 4 months
Use PRIME-MD or GAD-7 to monitor symptom severity
Ask consistently about…
Medication adherence
Treatment side effects
Suicide risk
Continue pharmacotherapy 6 - 12 months after response
20% - 40% relapse in 6 - 12 months after discontinuation
Severe chronic anxiety may require long-term medication
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
When should patients be hospitalized?
When actively suicidal
Assess suicide risk at each follow-up encounter
“Over the last 2 weeks, how often have you been bothered by thoughts that you’d be better off dead or of hurting yourself in some way?”
When symptoms are intractable
For grave disability
To address co-occurring illness
GAD can complicate treatment of co-occurring disorders and adversely affect prognosis
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
When should clinicians consult a psychologist, psychiatrist, or other specialist?
No improvement after 12 - 16 weeks of CBT
No response after 6 weeks to 1st- or 2nd-line drug Rx
Inability to tolerate drug Rx
Suicidal thoughts expressed
Co-morbid substance, mood, anxiety disorders present
Before prescribing 3rd-line drugs
© Copyright Annals of Internal Medicine, 2013Ann Int Med. 159 (9): ITC5-1.
CLINICAL BOTTOM LINE: Treatment… Primary care physicians play an important role in management
CBT is treatment of choice for most adults
If nondrug therapy is unavailable, ineffective, or if patient uninterested in it: try second-generation antidepressants
Assess suicide risk in all GAD patients
Refer complex GAD patients to mental health specialists