An overview of generalized anxiety disorder: disease state--appropriate therapy

Psychomotor and anxiolytic effects of mexazolam in patients with generalised anxiety disorder

OBJECTIVE

The primary aim of this study was to evaluate the psychomotor effects of mexazolam versus placebo in patients with generalised anxiety disorder (GAD).

PATIENTS AND METHODS

This was a multicentre, randomised, double-blind, parallel-group clinical trial in 60 outpatients with GAD (Diagnostic and Statistical Manual of Mental Disorders-4(th) edition [DSM-IV] criteria). After a placebo run-in period, patients were assigned to mexazolam 1mg three times daily (n = 32) or placebo (n = 28) for 21 days. Effects on psychomotor performance were evaluated with the Leeds Psychomotor Test Battery (critical flicker fusion threshold, recognition, motor and total reaction time). The Hamilton Anxiety Rating Scale (HAM-A) and the Clinical Global Impression (CGI) were used to evaluate the patients' clinical status (secondary objective).

RESULTS

At neither assessment were any statistically significant differences detected between mexazolam and placebo for CGI, critical flicker fusion, and the different reaction times. The HAM-A total and the HAM-A somatic scores indicated a statistically significant therapeutic effect for mexazolam vs placebo after 1 week of treatment but not after 3 weeks. The most prominent adverse event with mexazolam was mild drowsiness.

CONCLUSIONS

Mexazolam in a therapeutically effective dosage regimen does not impair psychomotor performance to a clinically relevant extent.

Personality and fatigue perception in a sample of IBD outpatients in remission: a preliminary study

BACKGROUND AND AIMS

Fatigue is considered as a feature of IBD. Nevertheless, medical variables would partly explain this complex phenomenon. Psychological variables would be especially connected to fatigue for patients in remission. Moreover, personality is known to be linked to the fatigue of patients with CFS. This preliminary study aimed to determine if personality dimensions are linked to the perception of fatigue in IBD.

METHODS

81 IBD outpatients in remission completed the MFI (fatigue); ISI, EES (sleep disturbances); TCI-R (personality); HADS (depression and anxiety). Medical data were collected (ferritin, C-reactive protein, number of flare-ups, number of hospitalizations, duration of the disease and surgical sequelae).

RESULTS

With the exception of surgical sequelae, none of the medical variables was linked to fatigue perception. Anxiety and sleep disturbances were the most continuously connected to fatigue perception. Significant relationships were observed between personality categorization on Persistence, Self-Directness and the level of fatigue.

CONCLUSION

In order to improve vitality in IBD patients in remission, identification and treatment of psychological aspects should become a dimension of disease management. Fatigue should not be considered only as a direct feature of IBD.

Synthesis of new serotonin 5-HT7 receptor ligands. Determinants of 5-HT7/5-HT1A receptor selectivity

We report the synthesis of a new set of compounds of general structure I (1-20) with structural modifications in the pharmacophoric elements of the previously reported lead UCM-5600. The new derivatives have been evaluated for binding affinity at 5-HT(7) and 5-HT(1A) receptors. The influence of the different structural features in terms of 5-HT(7)/5-HT(1A) receptor affinity and selectivity was analyzed by computational simulations of the complexes between compounds I and beta(2)-based 3-D models of these receptors. Compound 18 (HYD(1) = 1,3-dihydro-2H-indol-2-one; spacer = -(CH(2))(4)-; HYD(2) + HYD(3) = 3,4-dihydroisoquinolin-2(1H)-yl) exhibits high 5-HT(7)R affinity (K(i) = 7 nM) and selectivity over the 5-HT(1A)R (31-fold), and has been characterized as a partial agonist of the human 5-HT(7)R.

Improvement of psychic and somatic symptoms in adult patients with generalized anxiety disorder: examination from a duloxetine, venlafaxine extended-release and placebo-controlled trial

BACKGROUND

This study examined the efficacy and tolerability of duloxetine and venlafaxine extended-release (XR) treatment for generalized anxiety disorder (GAD), with a secondary focus on psychic and somatic symptoms within GAD.

METHOD

The design was a 10-week, multi-center, double-blind placebo-controlled study of duloxetine (20 mg or 60-120 mg once daily) and venlafaxine XR (75-225 mg once daily) treatment. Efficacy was measured using the Hamilton Anxiety Rating Scale (HAMA), which includes psychic and somatic factor scores. Tolerability was measured by occurrence of treatment-emergent adverse events (TEAEs) and discontinuation rates.

RESULTS

Adult out-patients (mean age 42.8 years; 57.1% women) with DSM-IV-defined GAD were randomly assigned to placebo (n=170), duloxetine 20 mg (n=84), duloxetine 60-120 mg (n=158) or venlafaxine XR 75-225 mg (n=169) treatment. Each of the three active treatment groups had significantly greater improvements on HAMA total score from baseline to endpoint compared with placebo (p=0.01-0.001). For the HAMA psychic factor score, both duloxetine treatment arms and venlafaxine XR demonstrated significantly greater improvement compared with placebo (p=0.01-0.001). For the HAMA somatic factor score, the mean improvement in the duloxetine 60-120 mg and venlafaxine XR groups was significantly greater than placebo (p0.05 and p0.01 respectively), whose mean improvement did not differ from the duloxetine 20 mg group (p=0.07). Groups did not differ in study discontinuation rate due to adverse events.

CONCLUSIONS

Duloxetine and venlafaxine treatment were each efficacious for improvement of core psychic anxiety symptoms and associated somatic symptoms for adults with GAD.

Efficacy of duloxetine in the treatment of generalized anxiety disorder in patients with clinically significant pain symptoms

Anxiety disorders often are accompanied by painful physical symptoms. This report assessed the effectiveness of duloxetine in improving anxiety symptoms, pain severity, and patient functioning in adults diagnosed with generalized anxiety disorder (GAD), who presented with clinically significant pain symptoms. Data were pooled from two multicenter, randomized, double-blind, placebo-controlled clinical studies evaluating the efficacy of duloxetine 60-120 mg once daily compared with placebo in the treatment of GAD. The primary patient population for these analyses was patients with baseline Visual Analog Scale (VAS) overall pain severity score > or =30. Of the 798 randomized patients that had baseline VAS scores, approximately 44.4% of GAD patients were identified as having baseline VAS overall pain severity score > or =30 (duloxetine N=208, placebo N=146). Duloxetine-treated patients had significantly greater improvement compared with placebo-treated patients on anxiety symptoms (measured by Hamilton Anxiety Scale total score), on patient functioning (measured by the Sheehan Disability Scale Global Functional Impairment Score and across all Sheehan Disability Scale domains), and on all VAS pain items. Patients achieving remission at endpoint, and patients with lower scores on the Clinical Global Impression of Improvement and Patient Global Impression of Improvement scales had greater improvement in VAS pain severity scores. These results suggest that in patients with GAD who present with clinically significant pain symptoms, duloxetine is effective in reducing anxiety symptoms, pain severity, and in improving patient functioning.

The relationship of treatment preferences and experiences to outcome in generalized anxiety disorder (GAD)

OBJECTIVES

The relationship of treatment preferences and experiences to outcome was explored in patients with generalized anxiety disorder (GAD).

DESIGN

Patients were randomly allocated to either affect-focused body psychotherapy (ABP) (N=26) or standard psychiatric out-patient treatment (N=17).

METHOD

Initial preferences and subsequent experiences of treatment interventions were measured using a questionnaire focusing on support, inward reflection, concrete and directive problem solving, and affective expression. Outcome was assessed after 1 and 2 years in relation to symptom change.

RESULTS

ABP patients reported being helped by supportive and reflective treatment interventions to a greater extent than controls. ABP patients also had more positive experiences of supportive and emotionally expressive interventions than they had expected at initial assessment. When patients were divided into two groups on the basis of patterns of preferences and experiences using cluster analysis, it was found that differences in outcome were considerably more marked for clusters than treatment groups.

CONCLUSIONS

It is concluded that treatment preferences may have considerable interpersonal potential in therapy; how therapists utilize this potential may be important for improving outcome.

Human and economic burden of generalized anxiety disorder

The goal of the current work is to provide a comprehensive review and interpretation of the literature on the human and economic burden of generalized anxiety disorder (GAD) and how it compares with that of other mental disorders. The term "human burden" is used to describe quantified impairments in role functioning and quality of life (QOL). "Economic burden" describes costs related to health care resource utilization and lost work. A review of 34 studies reporting original quantitative data on associations between GAD and role functioning, QOL, and/or economic costs was undertaken. GAD was defined by DMS-III-R, DSM-IV, or ICD-10 DCR. Persons with GAD (both with and without a comorbid mental disorder) described significant impairments due to both physical and emotional problems. Studies typically showed that role and QOL impairments of GAD were at least comparable in magnitude to those of other anxiety disorders, somatoform disorders, and physical conditions, and greater than those of substance use disorders. Large representative studies showed that role impairments of pure GAD were similar in magnitude to those of pure MDD. Studies of DSM-IV disorders showed that QOL impairments of GAD were at least comparable in magnitude to those of MDD; studies of DSM-III-R disorders showed the opposite pattern. GAD was associated with considerable economic costs owing to lost work productivity and high medical resource use. Quality of care initiatives that have been implemented to increase recognition and improve treatment outcomes for persons with MDD should be extended to the effective management of GAD.

Pharmacotherapy of anxiety

The pharmacological treatment of anxiety has a long and chequered history, and recent years have seen a rich development in the options available to prescribers. Most of the currently used anxiolytic agents act via monoaminergic (chiefly serotonin) or amino acid (GABA or glutamate) neurotransmitters, and this chapter describes the pharmacology of the major drug groups. Clinical applications are discussed with respect to the five major anxiety disorders, as well as simple phobia and depression with concomitant anxiety. Prospective future developments in the field are considered.

The behavioral profile of the potent and selective mGlu5 receptor antagonist 3-[(2-methyl-1,3-thiazol-4-yl)ethynyl]pyridine (MTEP) in rodent models of anxiety

Previous reports have demonstrated the anxiolytic effect of the potent and systemically active metabotropic glutamate subtype 5 (mGlu5) receptor antagonist 2-methyl-6-(phenylethynyl)pyridine (MPEP) in rodents. Here, we present evidence for the anxiolytic activity of a novel mGlu5 receptor antagonist, 3-[(2-methyl-1,3-thiazol-4-yl)ethynyl]pyridine (MTEP), in rats and compare its profile to the benzodiazepine receptor agonist diazepam. MTEP occupied mGlu5 receptors in a dose-dependent manner with essentially full receptor occupancy at the highest dose tested (10 mg/kg, i.p.). At doses appropriate for mGlu5 receptor-mediated effects, MTEP significantly reduced fear-potentiated startle and increased punished responding in a modified Geller-Seifter conflict model consistent with an anxiolytic-like profile. In both models, the magnitude of the anxiolytic-like response was similar to that seen with diazepam. In contrast, MTEP decreased unpunished responding to a lesser extent than diazepam and had no effect on rotarod performance when administered either alone or in combination with ethanol. Repeated dosing with MTEP in this model eliminated the increase in punished responding observed with acute dosing. The present results suggest that mGlu5 receptor antagonists lack the side effects seen with benzodiazepines, such as sedation and ethanol interaction, and provide insight into a possible role for mGlu5 receptor antagonists in the modulation of mood disorders.

Venlafaxine: A 2003 update

BACKGROUND

venlafaxine has been available for use as an antidepressant in the United States for a decade.

OBJECTIVE

Comprehensive reviews of venlafaxine have been published elsewhere; thus, this update focuses on newer issues of treatment remission in depression, treatment-resistant depression, and extended-release venlafaxine for generalized anxiety disorder (GAD).

METHODS

Relevant clinical literature from 1993 through 2003 was identified from database searches of MEDLINE and International Pharmaceutical Abstracts, and from manual searches of reference lists of the identified papers. Search terms included venlafaxine extended-release, venlafaxine XR, treatment-resistant depression, depressive disorders, anxiety disorders, generalized anxiety disorder, and antidepressive agents second generation.

RESULTS

With its dual action of serotonin and noradrenergic reuptake inhibition, venlafaxine has been shown to be superior in efficacy to selective serotonin reuptake inhibitors for severe major depressive disorder, treatment-resistant depression, and depressive symptom remission. Its demonstrated efficacy for both short- and long-term treatment of GAD has led to its use for obsessive-compulsive disorder and chronic pain syndromes, although inadequate clinical literature currently exists to support these latter 2 uses. In the past decade, no new or unexpected adverse events have been identified with venlafaxine therapy, except a possibly greater risk of fatal overdose compared with other serotonergic drugs, suggesting the need for caution in patients with suicidal ideation. Because venlafaxine is a potent serotonin agonist, caution must also be exercised to prevent the possibility of serotonin syndrome when used with other serotonin agonists, and its dose should be tapered very gradually to minimize the risk of a serotonin withdrawal reaction.

CONCLUSION

Venlafaxine has emerged as a successful post-SSRI-era antidepressant with an expanded range of uses since it was first marketed.

WCA recommendations for the long-term treatment of generalized anxiety disorder

What are the current recommendations for the long-term treatment of generalized anxiety disorder (GAD)? GAD is a common disorder with a lifetime prevalence of 4% to 7% in the general population. GAD is characterized by excessive, uncontrollable worry or anxiety about a number of events or activities that the individual experiences on more days than not over a 6-month period. Onset of GAD symptoms usually occurs during an individual's early twenties; however, high rates of GAD have also been seen in children and adolescents. The clinical course of GAD is often chronic, with 40% of patients reporting illness lasting >5 years. GAD is associated with pronounced functional impairment, resulting in decreased vocational function and reduced quality of life. Patients with GAD tend to be high users of outpatient medical care, which contributes significantly to healthcare costs. Currently, benzodiazepines and buspirone are prescribed frequently to treat GAD. Although both show efficacy in acute treatment trials, few long-term studies have been performed. Benzodiazepines are not recommended for long-term treatment of GAD, due to associated development of tolerance, psychomotor impairment, cognitive and memory changes, physical dependence, and a withdrawal reaction on discontinuation. The antidepressant venlafaxine extended-release (XR) has received approval for the treatment of GAD in the United States and many other countries. Venlafaxine XR has demonstrated efficacy over placebo in two randomized treatment trials of 6 months' duration as well as in other acute trials. Paroxetine is the first of the selective serotonin reuptake inhibitors (SSRIs) to receive US approval for the treatment of GAD. Paroxetine demonstrated superiority to placebo in short-term trials, and investigations into the use of other SSRIs are ongoing. This suggests that other SSRIs, and serotonin and noradrenaline reuptake inhibitors, are likely to be effective in the treatment of GAD. Of the psychological therapies, cognitive-behavioral therapy (CBT) shows the greatest benefit in treating GAD patients. Treatment gains after a 12-week course of CBT may be maintained for up to 1 year. Currently, no guidelines exist for the long-term treatment of GAD.

Predicting panic disorder among patients with chest pain: an analysis of the literature

As many as 25% of patients with chest pain who come to hospital emergency departments have panic disorder. Rates of panic disorder are even higher among those who present for outpatient evaluation of their chest pain. Unfortunately, panic disorder remains largely undiagnosed and untreated in these settings. The authors reviewed studies published between 1970 and 2001 that addressed the prevalence of panic disorder among persons who seek treatment for chest pain in an emergency department or outpatient cardiology clinic. A meta-analysis of the findings revealed five variables that appear to correlate with higher rates of panic disorder among persons who present with chest pain: 1). absence of coronary artery disease, 2). atypical quality of chest pain, 3). female sex, 4). younger age, and 5). a high level of self-reported anxiety. Further studies of these and other variables associated with panic disorder should aid in the detection of this disabling but treatable cause of chest pain.

Generalized anxiety disorder: prevalence, burden, and cost to society

Generalized anxiety disorder (GAD) is a prevalent and disabling disorder characterized by persistent worrying, anxiety symptoms, and tension. It is the most frequent anxiety disorder in primary care, being present in 22% of primary care patients who complain of anxiety problems. The high prevalence rate of GAD in primary care (8%) compared to that reported in the general population (12-month prevalence 1.9-5.1%) suggests that GAD patients are high users of primary care resources. GAD affects women more frequently than men and prevalence rates are high in midlife (prevalence in females over age 35: 10%) and older subjects but relatively low in adolescents. The natural course of GAD can be characterized as chronic with few complete remissions, a waxing and waning course of GAD symptoms, and the occurrence of substantial comorbidity particularly with depression. Patients with GAD demonstrate a considerable degree of impairment and disability, even in its pure form, uncomplicated by depression or other mental disorders. The degree of impairment is similar to that of cases with major depression. GAD comorbid with depression usually reveals considerably higher numbers of disability days in the past month than either condition in its pure form. As a result, GAD is associated with a significant economic burden owing to decreased work productivity and increased use of health care services, particularly primary health care. The appropriate use of psychological treatments and antidepressants may improve both anxiety and depression symptoms and may also play a role in preventing comorbid major depression in GAD thus reducing the burden on both the individual and society.

Single use of sumatriptan: a patient interview study

OBJECTIVE

To investigate the possible reasons associated with the use of a single prescription of sumatriptan.

BACKGROUND

A few population-based studies concerning the usage patterns of sumatriptan have revealed a relatively high incidence (approximately 40%) of sumatriptan users who utilize only a single prescription of the drug.

DESIGN AND METHODS

Using automated prescription data from 11 community pharmacies, we identified single and multiple sumatriptan prescription recipients. The data were collected from May 1, 1998, to April 30, 2000. Several patient- and medication-related variables possibly associated with single recipiency of sumatriptan were analyzed. In addition, single recipients of sumatriptan were invited for an interview and asked a number of questions related to their clinical status and their experience with the medication.

RESULTS

Four hundred ninety-five, first-time users of sumatriptan were identified during the patient selection period, of whom 38% were single recipients of sumatriptan. Of the latter, 102 patients were considered eligible for interview. Reasons for terminating treatment after only 1 prescription included: inefficacy and/or occurrence of side effects, 78% (n=79); uncertain diagnosis of migraine, 39.2% (n=40); and reduction in headache frequency, 33.3% (n=34). Almost half of the population had terminated treatment without having consulted their physician. More than half relied upon the use of over-the-counter (OTC) analgesics after having tried sumatriptan. Compared to multiple users of sumatriptan, single recipients were far less likely to have used another form of migraine treatment prior to (odds ratio, 0.35; [95% confidence interval, 019 to 0.67]) and after (odds ratio, 0.34 [95% confidence interval, 0.19 to 0.63]) initiating sumatriptan. Furthermore, single recipients had demonstrated an increased tendency towards benzodiazepine use prior to receiving sumatriptan (odds ratio, 1.80 [95% confidence interval, 1.00 to 3.28]).

CONCLUSIONS

Single use of a sumatriptan prescription reveals some issues that may impact negatively the provision of effective migraine management. These include: rapidly developing dissatisfaction with the treatment provided and a lower tendency to seek out medical care. Our results also suggest that the drug may be used (inappropriately) as a diagnostic tool.

Test-retest reliability of self-reported age at onset of selected psychiatric diagnoses in general health care

OBJECTIVE

To investigate reliability of self-reported age at onset of frequent mental disorders and its association with patient and disorder characteristics.

METHOD

A total of 1031 primary care patients with at least one lifetime psychiatric diagnosis were asked to report age at onset of their disorders at baseline and after 1 year. Intraclass correlation coefficients (ICC) for age at onset information were calculated for individual disorders.

RESULTS

ICC were high and lay between 0.6790 (generalized anxiety disorder) and 0.7977 (dysthymia). Factors associated with reliability are different for different disorders: gender for depressive episodes, gross national product per year per inhabitant for dysthymia, age for pain disorder, years of formal education for dysthymia, generalized anxiety disorder, and agoraphobia, and number of lifetime diagnoses for depression and agoraphobia.

CONCLUSION

Self-reported age at onset is reliable. Further research on factors associated with reliability should focus on interview conditions and subject parameters during interview.