The pharmacologic treatment of patients with generalized anxiety disorder: where are we now and where are we going?

Predicting the naturalistic course in anxiety disorders using clinical and biological markers: a machine learning approach

BACKGROUND

Disease trajectories of patients with anxiety disorders are highly diverse and approximately 60% remain chronically ill. The ability to predict disease course in individual patients would enable personalized management of these patients. This study aimed to predict recovery from anxiety disorders within 2 years applying a machine learning approach.

METHODS

In total, 887 patients with anxiety disorders (panic disorder, generalized anxiety disorder, agoraphobia, or social phobia) were selected from a naturalistic cohort study. A wide array of baseline predictors (N = 569) from five domains (clinical, psychological, sociodemographic, biological, lifestyle) were used to predict recovery from anxiety disorders and recovery from all common mental disorders (CMDs: anxiety disorders, major depressive disorder, dysthymia, or alcohol dependency) at 2-year follow-up using random forest classifiers (RFCs).

RESULTS

At follow-up, 484 patients (54.6%) had recovered from anxiety disorders. RFCs achieved a cross-validated area-under-the-receiving-operator-characteristic-curve (AUC) of 0.67 when using the combination of all predictor domains (sensitivity: 62.0%, specificity 62.8%) for predicting recovery from anxiety disorders. Classification of recovery from CMDs yielded an AUC of 0.70 (sensitivity: 64.6%, specificity: 62.3%) when using all domains. In both cases, the clinical domain alone provided comparable performances. Feature analysis showed that prediction of recovery from anxiety disorders was primarily driven by anxiety features, whereas recovery from CMDs was primarily driven by depression features.

CONCLUSIONS

The current study showed moderate performance in predicting recovery from anxiety disorders over a 2-year follow-up for individual patients and indicates that anxiety features are most indicative for anxiety improvement and depression features for improvement in general.

Regulator of calcineurin 1 modulates expression of innate anxiety and anxiogenic responses to selective serotonin reuptake inhibitor treatment

Regulator of calcineurin 1 (RCAN1) controls the activity of calcium/calmodulin-dependent phosphatase calcineurin (CaN), which has been implicated in human anxiety disorders. Previously, we reported that RCAN1 functioned as an inhibitor of CaN activity in the brain. However, we now find enhanced phosphorylation of a CaN substrate, cAMP response element-binding protein (CREB), in the brains of Rcan1 knock-out (KO) mice. Consistent with enhanced CREB activation, we also observe enhanced expression of a CREB transcriptional target, brain-derived neurotrophic factor (BDNF) in Rcan1 KO mice. We also discovered that RCAN1 deletion or blockade of RCAN1-CaN interaction reduced CaN and protein phosphatase-1 localization to nuclear-enriched protein fractions and promoted CREB activation. Because of the potential links between CREB, BDNF, and anxiety, we examined the role of RCAN1 in the expression of innate anxiety. Rcan1 KO mice displayed reduced anxiety in several tests of unconditioned anxiety. Acute pharmacological inhibition of CaN rescued these deficits while transgenic overexpression of human RCAN1 increased anxiety. Finally, we found that Rcan1 KO mice lacked the early anxiogenic response to the selective serotonin reuptake inhibitor (SSRI) fluoxetine and had improved latency for its therapeutic anxiolytic effects. Together, our study suggests that RCAN1 plays an important role in the expression of anxiety-related and SSRI-related behaviors through CaN-dependent signaling pathways. These results identify RCAN1 as a mediator of innate emotional states and possible therapeutic target for anxiety.

Effects of extended-release quetiapine fumarate on long-term functioning and sleep quality in patients with Generalized Anxiety Disorder (GAD): data from a randomized-withdrawal, placebo-controlled maintenance study

BACKGROUND

This analysis evaluated effects of quetiapine XR maintenance treatment on functioning and sleep in patients with GAD.

METHODS

Analysis of patient-reported data from a randomized-withdrawal, double-blind, placebo-controlled study of quetiapine XR monotherapy in GAD. Following open-label run-in (4-8 weeks) and a 12-18-week stabilization phase (quetiapine XR 50, 150, or 300 mg/day), eligible patients were randomized to continue on quetiapine XR or receive placebo for up to 52 weeks. Primary variable was time to an anxiety event. Secondary variables included the Sheehan Disability Scale (SDS) and Pittsburgh Sleep Quality Index (PSQI).

RESULTS

In total, 432 patients were randomized (quetiapine XR, N=216; placebo, N=216). The risk of an anxiety event was significantly reduced for quetiapine XR vs. placebo (HR 0.19; 95% CI 0.12, 0.31; p<0.001). Quetiapine XR was more effective than placebo at maintaining SDS total scores (LSM change: -0.19 vs. 1.01; p=0.017) and non-work-related SDS domain score 'family life/home responsibilities' (-0.13 vs. 0.32; p=0.011), but not 'social life' (0.05 vs. 0.34; p=0.114). Quetiapine XR was more effective than placebo at maintaining the work-related SDS domain score 'days lost' (-0.05 vs. 0.11; p=0.027), but not 'work/school' (-0.10 vs. 0.29; p=0.051) or 'days underproductive' (0.06 vs. 0.13; p=0.619). PSQI global scores were reduced from randomization with quetiapine XR vs. placebo (0.39 vs. 1.60; p<0.001).

LIMITATIONS

Lack of active-comparator arm, exclusion of patients with comorbid depression.

CONCLUSIONS

In patients with GAD, long-term treatment with quetiapine XR (50-300 mg/day) monotherapy was effective at maintaining improvements in functioning and sleep quality.

Early pain reduction can predict treatment response: results of integrated efficacy analyses of a once-daily gastroretentive formulation of gabapentin in patients with postherpetic neuralgia

OBJECTIVE

The objectives of this study were to identify and determine the validity of early decision criteria following once-daily gastroretentive gabapentin (G-GR) treatment in patients with postherpetic neuralgia (PHN).

DESIGN

In two placebo-controlled studies, 279 patients were randomized to 1,800 mg G-GR and 270 to placebo with the evening meal; patients underwent a 2-week dose titration, followed by 8 weeks of stable dosing, and 1 week of dose tapering. Patients.  Adults with PHN for ≥6 months and an average baseline Numerical Pain Rating Scale (NPRS) score of ≥4 were included in the study.

OUTCOME MEASURES

Percent change from baseline to week 10 in NPRS scores and the percentage of responders (defined as ≥30% reduction in NPRS scores from baseline to week 10) were determined.

METHODS

Patients randomized to G-GR were categorized at each week based on their percent pain reduction up to that week, and for each category, the percentage of week 10 responders was computed. For several early-improvement criteria, the percentage of week 10 responders, odds ratios for achieving week 10 treatment response, sensitivity, and specificity were calculated.

RESULTS

There was a significant positive association between early pain reduction and week 10 treatment response. Pain reduction of <10% at week 5 of G-GR treatment was the best early predictor of lack of endpoint response, with only 8% of these patients moving on to become week 10 treatment responders.

CONCLUSIONS

Early response was a reliable predictor of final response. This approach holds promise for aiding clinicians in decision making regarding the need for alternative or supplemental treatment during G-GR therapy for PHN.

An open, non-randomised comparison of escitalopram and duloxetine for the treatment of subjects with Generalized Anxiety Disorder

OBJECTIVES

This study compares the effectiveness of a 6-months treatment with escitalopram (ESC), a selective serotonin reuptake inhibitor, or duloxetine (DUL), a balanced serotonin and nor-adrenaline reuptake inhibitor, in 43 subjects with Generalized Anxiety Disorder (GAD).

METHODS

Assessment was made with the Hamilton Anxiety and Depression scales (HAM-A; HAM-D), with the CGI, and with the GAF at T0 (intake), T1, T3, T6 (1, 3, and 6 months later). The comparison among the two treatment groups (ESC=20; DUL=23) at the four endpoints was made through a GLM-ANOVA for repeated measures. Rates of remission (HAM-A<7), response (HAM-A reduction of 50% or above) and dropout were evaluated.

RESULTS

At 1, 3, and 6 months after treatment inception both treatment groups showed a significant improvement in the scores of CGI, HAMA, HAM-D, and GAF, and an equivalent rate of dropout. The DUL group registered a greater amount of remission and response rates at T1 against the ESC group in all the scales except in the HAM-D scale. Duloxetine was more effective than escitalopram after the first month of treatment only in the somatic subscale of HAM-A. The presence of a cluster C personality disorder was associated in both groups to greater difficulties in attaining remission and to dropout.

CONCLUSIONS

Implications for clinical practice are discussed.