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de Vries YA, Roest AM, Burgerhof JGM, de Jonge P. Initial severity and antidepressant efficacy for anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder: An individual patient data meta-analysis. Depress Anxiety 2018; 35:515-522. [PMID: 29659102 PMCID: PMC6667912 DOI: 10.1002/da.22737] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/05/2018] [Accepted: 02/10/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND It has been suggested that antidepressant benefits are smaller for mild than severe depression. Because antidepressants are also used for anxiety disorders, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD), we examined the influence of severity for these disorders. METHODS We used individual patient data of eight trials (3,430 participants) for generalized anxiety disorder (GAD); four trials (1,195 participants) for social anxiety disorder (SAD); four trials (1,132 participants) for OCD; three trials (1,071 participants) for PTSD; and 10 trials (2,151 participants) for panic disorder (PD). Mixed-effects models were used to investigate an interaction between severity and treatment group. RESULTS For GAD and PD, severity moderated antidepressant efficacy. The antidepressant-placebo difference was 1.4 (95% CI: 0.4-2.5; SMD: 0.21) Hamilton Anxiety Rating Scale (HAM-A) points for participants with mild GAD (baseline HAM-A = 10), increasing to 4.0 (3.4-4.6; SMD: 0.45) or greater for severely ill participants (HAM-A ≥ 30). For PD, the difference was 0.4 (0.3-0.6) panic attacks/2 weeks for participants with 10 panic attacks/2 weeks at baseline, increasing to 4.7 (3.0-6.4) for participants with 40. For SAD, OCD, and PTSD, no interaction was found. Across severity levels, the differences were 16.1 (12.9-19.3; SMD: 0.59) Liebowitz Social Anxiety Scale points, 3.4 (2.5-4.4, SMD: 0.39) Yale-Brown Obsessive-Compulsive Scale points, and 10.3 (6.9-13.6; SMD: 0.41) Clinician-Administered PTSD Scale points. CONCLUSIONS Antidepressants are equally effective across severity levels for SAD, OCD, and PTSD. For GAD and PD, however, benefits are small at low severity, and the benefit-risk ratio may be unfavorable for these patients.
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Affiliation(s)
- Ymkje Anna de Vries
- Interdisciplinary Center Psychopathology and Emotion regulation, Department of PsychiatryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands,Developmental Psychology, Department of PsychologyUniversity of GroningenGroningenThe Netherlands
| | - Annelieke M. Roest
- Interdisciplinary Center Psychopathology and Emotion regulation, Department of PsychiatryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands,Developmental Psychology, Department of PsychologyUniversity of GroningenGroningenThe Netherlands
| | - Johannes G. M. Burgerhof
- Department of EpidemiologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Peter de Jonge
- Interdisciplinary Center Psychopathology and Emotion regulation, Department of PsychiatryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands,Developmental Psychology, Department of PsychologyUniversity of GroningenGroningenThe Netherlands
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Abstract
BACKGROUND Pharmacotherapy for generalized anxiety disorder (GAD) may be effective in reducing symptoms in the majority of patients. The study of moderators and predictors of treatment response may help clinicians both to select appropriate interventions to maximize the probability of response and to inform the general prognosis. METHODS A systematic literature search of electronic databases, selected authors, and reference lists was used to identify articles that reported trials of drug monotherapy in GAD. Data on predictors and moderators were extracted. Quality of evidence was determined by the presence of a priori hypotheses, number of variables investigated, adequate quality of the measurement, and use of interaction-effects testing. RESULTS From the 98 articles meeting inclusion criteria, 24 reported a total of 22 factors associated with treatment response. The reported results were heterogeneous, ranging over sociodemographic, clinical, comorbidity, genetic, and functional-imaging studies. Major depressive symptoms were found to moderate treatment outcome in favor of antidepressants versus benzodiazepines. Neuroticism, previous treatment, genetic polymorphisms (including serotonin receptor gene 2A), and functional activation of the anterior cingulate cortex and amygdala were identified as potential predictors of treatment response. CONCLUSIONS Correlates of poor emotion regulation predicted poor treatment response, but subclinical depression was the only variable capable of informing treatment selection in this review. Future research should focus on further exploring the value of depression as a moderator and on a narrower list of potential genetic, brain-imaging, and temperament predictors of response to pharmacotherapy in GAD.
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Short-term efficacy and tolerability of venlafaxine extended release in adults with generalized anxiety disorder without depression: A meta-analysis. PLoS One 2017; 12:e0185865. [PMID: 28982121 PMCID: PMC5628888 DOI: 10.1371/journal.pone.0185865] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/20/2017] [Indexed: 12/20/2022] Open
Abstract
Background Although efficacy of venlafaxine extended release (XR) for generalized anxiety disorder (GAD) has been reported in previous analyses in 2002 and 2004, the sample size was rather small and estimate of safety or tolerability was not clear. The present analysis had the advantage of large sample size and provided evidence for tolerability. Methods Literature databases were searched, including Pubmed, Embase, Cochrane Central Register of Controlled Trials, Web of science and clinical trials. 10 eligible articles were finally selected and data was extracted and logged into the Review Manager 5.3 by two independent authors. The risk of bias was evaluated by the Cochrane Collaboration’s Risk of Bias Tool and the stability of the results was assessed by sensitivity analysis. The publication bias was assessed by funnel plot and Egger’s/Begg’s test using Stata Version 12.0 software. Results In the current meta-analysis, 10 articles (14 studies) satisfying the inclusion criteria were analyzed. As efficacy outcomes, our findings indicated venlafaxine XR was significantly more effective than placebo according to mean change of the Hamilton Rating Scale for Anxiety total scores [mean difference = 3.31, 95% confidence interval(CI) 1.44–5.18, P = 0.0005], response [odds ratio(OR) = 1.83, 95%CI 1.58–2.12, P<0.00001], and remission (OR = 2.55, 95%CI 1.36–4.78, P = 0.003). In terms of tolerability, the most frequently reported treatment-emergent adverse events were nausea, dry mouth, dizziness, insomnia, somnolence, and headache. In addition, discontinuation due to all-cause (OR = 1.17, 95%CI 0.92–1.49, P = 0.19) was not significantly different between the two groups, whereas discontinuation due to adverse events was statistically higher in the venlafaxine XR group compared with the placebo treatment (OR = 2.80, 95%CI 2.21–3.54, P<0.00001) and discontinuation due to inefficacy was lower in venlafaxine than placebo treatment (OR = 0.26, 95%CI 0.17–0.40, P<0.00001). There was no significant publication bias and sensitivity analysis showed that our analysis exhibited high stability. Conclusion We concluded that venlafaxine XR (75–225 mg/day) is an effective and well-tolerated pharmacological treatment option for adult patients with GAD.
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de Vries YA, de Jonge P, van den Heuvel E, Turner EH, Roest AM. Influence of baseline severity on antidepressant efficacy for anxiety disorders: meta-analysis and meta-regression. Br J Psychiatry 2016; 208:515-21. [PMID: 26989093 DOI: 10.1192/bjp.bp.115.173450] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 09/21/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Antidepressants are established first-line treatments for anxiety disorders, but it is not clear whether they are equally effective across the severity range. AIMS To examine the influence of baseline severity of anxiety on antidepressant efficacy for generalised anxiety disorder (GAD), social anxiety disorder (SAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and panic disorder. METHOD Fifty-six trials of second-generation antidepressants for the short-term treatment of an anxiety disorder were included. Baseline and change scores were extracted for placebo and treatment groups in each trial. Mixed effects meta-regression was used to investigate the effects of treatment group, baseline severity and their interaction. RESULTS Increased baseline severity did not predict greater improvement in drug groups compared with placebo groups. Standardised regression coefficients of the interaction term between baseline severity and treatment group were 0.04 (95% CI -0.13 to 0.20, P = 0.65) for GAD, -0.06 (95% CI -0.20 to 0.09, P = 0.43) for SAD, 0.04 (95% CI -0.07 to 0.16, P = 0.46) for OCD, 0.16 (95% CI -0.22 to 0.53, P = 0.37) for PTSD and 0.002 (95% CI -0.10 to 0.10, P = 0.96) for panic disorder. For OCD, baseline severity did predict improvement in both placebo and drug groups equally (β = 0.11, 95% CI 0.05 to 0.17, P = 0.001). CONCLUSIONS No relationship between baseline severity and drug-placebo difference was found for anxiety disorders. These results suggest that if the efficacy of antidepressants is considered clinically relevant, they may be prescribed to patients with anxiety regardless of symptom severity.
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Affiliation(s)
- Ymkje Anna de Vries
- Ymkje Anna de Vries, MSc, Peter de Jonge, PhD, Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands; Edwin van den Heuvel, PhD, Department of Mathematics and Computer Science, Technical University Eindhoven, Eindhoven, The Netherlands; Erick H. Turner, MD, Behavioral Health and Neurosciences Division, Portland Veterans Affairs Medical Center, and Department of Psychiatry, Oregon Health and Science University, Portland, Oregon, USA; Annelieke M. Roest, PhD, Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Peter de Jonge
- Ymkje Anna de Vries, MSc, Peter de Jonge, PhD, Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands; Edwin van den Heuvel, PhD, Department of Mathematics and Computer Science, Technical University Eindhoven, Eindhoven, The Netherlands; Erick H. Turner, MD, Behavioral Health and Neurosciences Division, Portland Veterans Affairs Medical Center, and Department of Psychiatry, Oregon Health and Science University, Portland, Oregon, USA; Annelieke M. Roest, PhD, Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Edwin van den Heuvel
- Ymkje Anna de Vries, MSc, Peter de Jonge, PhD, Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands; Edwin van den Heuvel, PhD, Department of Mathematics and Computer Science, Technical University Eindhoven, Eindhoven, The Netherlands; Erick H. Turner, MD, Behavioral Health and Neurosciences Division, Portland Veterans Affairs Medical Center, and Department of Psychiatry, Oregon Health and Science University, Portland, Oregon, USA; Annelieke M. Roest, PhD, Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Erick H Turner
- Ymkje Anna de Vries, MSc, Peter de Jonge, PhD, Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands; Edwin van den Heuvel, PhD, Department of Mathematics and Computer Science, Technical University Eindhoven, Eindhoven, The Netherlands; Erick H. Turner, MD, Behavioral Health and Neurosciences Division, Portland Veterans Affairs Medical Center, and Department of Psychiatry, Oregon Health and Science University, Portland, Oregon, USA; Annelieke M. Roest, PhD, Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Annelieke M Roest
- Ymkje Anna de Vries, MSc, Peter de Jonge, PhD, Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands; Edwin van den Heuvel, PhD, Department of Mathematics and Computer Science, Technical University Eindhoven, Eindhoven, The Netherlands; Erick H. Turner, MD, Behavioral Health and Neurosciences Division, Portland Veterans Affairs Medical Center, and Department of Psychiatry, Oregon Health and Science University, Portland, Oregon, USA; Annelieke M. Roest, PhD, Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands
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Khan A, Durgam S, Tang X, Ruth A, Mathews M, Gommoll CP. Post Hoc Analyses of Anxiety Measures in Adult Patients With Generalized Anxiety Disorder Treated With Vilazodone. Prim Care Companion CNS Disord 2016; 18:15m01904. [PMID: 27486544 PMCID: PMC4956429 DOI: 10.4088/pcc.15m01904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 02/04/2016] [Indexed: 11/04/2022] Open
Abstract
Objective To investigate vilazodone, currently approved for major depressive disorder in adults, for generalized anxiety disorder (GAD). Method Three randomized, double-blind, placebo-controlled studies showing positive results for vilazodone (2,040 mg/d) in adult patients with GAD (DSM-IV-TR) were pooled for analyses; data were collected from June 2012 to March 2014. Post hoc outcomes in the pooled intent-to-treat population (n = 1,462) included mean change from baseline to week 8 in Hamilton Anxiety Rating Scale (HARS) total score, psychic and somatic anxiety subscale scores, and individual item scores; HARS response (≥ 50% total score improvement) and remission (total score ≤ 7) at week 8; and category shifts, defined as HARS item score ≥ 2 at baseline (moderate to very severe symptoms) and score of 0 at week 8 (no symptoms). Results The least squares mean difference was statistically significant for vilazodone versus placebo in change from baseline to week 8 in HARS total score (−1.83, P < .0001) and in psychic anxiety (−1.21, P < .0001) and somatic anxiety (−0.63, P < .01) subscale scores; differences from placebo were significant on 11 of 14 HARS items (P < .05). Response rates were higher with vilazodone than placebo (48% vs 39%, P < .001), as were remission rates (27% vs 21%, P < .01). The percentage of patients who shifted to no symptoms was significant for vilazodone on several items: anxious mood, tension, intellectual, depressed mood, somatic-muscular, somatic-sensory, cardiovascular, respiratory, and autonomic symptoms (P < .05). Conclusions Treatment with vilazodone versus placebo was effective in adult GAD patients, with significant differences between treatment groups found on both psychic and somatic HARS items. Trial Registration ClinicalTrials.gov identifiers: NCT01629966, NCT01766401, NCT01844115.
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Affiliation(s)
- Arif Khan
- Northwest Clinical Research Center, Bellevue, Washington; Duke University School of Medicine, Department of Psychiatry, Durham, North Carolina
| | - Suresh Durgam
- Forest Research Institute, an Allergan affiliate, Jersey City, New Jersey
| | - Xiongwen Tang
- Forest Research Institute, an Allergan affiliate, Jersey City, New Jersey
| | - Adam Ruth
- Prescott Medical Communications Group, Chicago, Illinois
| | - Maju Mathews
- Forest Research Institute, an Allergan affiliate, Jersey City, New Jersey
| | - Carl P Gommoll
- Forest Research Institute, an Allergan affiliate, Jersey City, New Jersey
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Gabrieli JDE, Ghosh SS, Whitfield-Gabrieli S. Prediction as a humanitarian and pragmatic contribution from human cognitive neuroscience. Neuron 2015; 85:11-26. [PMID: 25569345 DOI: 10.1016/j.neuron.2014.10.047] [Citation(s) in RCA: 336] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Neuroimaging has greatly enhanced the cognitive neuroscience understanding of the human brain and its variation across individuals (neurodiversity) in both health and disease. Such progress has not yet, however, propelled changes in educational or medical practices that improve people's lives. We review neuroimaging findings in which initial brain measures (neuromarkers) are correlated with or predict future education, learning, and performance in children and adults; criminality; health-related behaviors; and responses to pharmacological or behavioral treatments. Neuromarkers often provide better predictions (neuroprognosis), alone or in combination with other measures, than traditional behavioral measures. With further advances in study designs and analyses, neuromarkers may offer opportunities to personalize educational and clinical practices that lead to better outcomes for people.
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Affiliation(s)
- John D E Gabrieli
- Poitras Center for Affective Disorders Research at the McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.
| | - Satrajit S Ghosh
- Poitras Center for Affective Disorders Research at the McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Otology and Laryngology, Harvard Medical School, Boston, MA 02115, USA
| | - Susan Whitfield-Gabrieli
- Poitras Center for Affective Disorders Research at the McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
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Predictors of treatment response in Canadian combat and peacekeeping veterans with military-related posttraumatic stress disorder. J Nerv Ment Dis 2011; 199:639-45. [PMID: 21878776 DOI: 10.1097/nmd.0b013e318229ce7b] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Military-related posttraumatic stress disorder (PTSD) is a significant psychiatric condition associated with severe psychosocial dysfunction. This study examined the predictors of treatment outcome in a group of veterans with military-related PTSD. Participants were 102 Canadian combat and peacekeeping veterans who received treatment at a specialized outpatient clinic for veterans with psychiatric disorders resulting from military operation. Analysis demonstrated a significant decrease in PTSD severity during the 1-year period (Yuan-Bentler χ [86, N = 99] = 282.45, p < 0.001). We did not find chronicity, alcohol use, and anxiety or depression severity as significant predictors for PTSD symptom decline. However, initial depression significantly predicted anxiety symptom decline, and initial anxiety predicted depression symptom decline. This study demonstrated that, despite considerable comorbidity, significant treatment gains, including remission of PTSD, can be achieved in an outpatient setting in veterans with chronic military-related PTSD.
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Bodkin JA, Allgulander C, Llorca PM, Spann ME, Walker DJ, Russell JM, Ball SG. Predictors of relapse in a study of duloxetine treatment for patients with generalized anxiety disorder. Hum Psychopharmacol 2011; 26:258-66. [PMID: 21678494 DOI: 10.1002/hup.1211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Data from a relapse prevention study of duloxetine treatment for adults with generalized anxiety disorder (GAD) were examined to identify predictors of relapse. METHODS Patients responding to 6 months of open-label duloxetine treatment were randomized to continuation with duloxetine or withdrawal to placebo for a 6-month double-blind continuation phase (duloxetine, N= 216; placebo, N= 213). Post hoc analyses compared time to GAD relapse during continuation phase by using predictor variables that included patient demographics, symptom severity measures (Hamilton Anxiety Scale Scores [HAMA], Hospital Anxiety and Depression Scale), functional outcomes, and visual analogue scale (VAS) pain measures. Univariate and multivariate analyses were performed using predictor variables from time of randomization into the continuation, withdrawal phase. RESULTS Severity of anxiety symptoms, degree of functional impairment, and severity of pain at time of randomization were significantly predictive of likelihood of relapse during the continuation phase. Multivariate backwards elimination analysis of significant univariate predictors identified HAMA item one (anxious mood) ≥ 1 and severity of pain while awake (≥ 30 on VAS) as the strongest predictors of GAD relapse. CONCLUSIONS For patients with GAD responding to open-label treatment with duloxetine, residual symptoms related to anxious mood, pain severity, and psychosocial function were associated with increased relapse risk, although the greatest risk was associated with anxious mood and increased severity of pain while awake.
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Affiliation(s)
- J Alexander Bodkin
- Clinical Psychopharmacology Research Program, McLean Hospital, Belmont, Massachusetts 02478, USA.
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Garner M, Möhler H, Stein DJ, Mueggler T, Baldwin DS. Research in anxiety disorders: from the bench to the bedside. Eur Neuropsychopharmacol 2009; 19:381-90. [PMID: 19327970 DOI: 10.1016/j.euroneuro.2009.01.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Accepted: 01/30/2009] [Indexed: 01/22/2023]
Abstract
The development of ethologically based behavioural animal models has clarified the anxiolytic properties of a range of neurotransmitter and neuropeptide receptor agonists and antagonists, with several models predicting efficacy in human clinical samples. Neuro-cognitive models of human anxiety and findings from fMRI suggest dysfunction in amygdala-prefrontal circuitry underlies biases in emotion activation and regulation. Cognitive and neural mechanisms involved in emotion processing can be manipulated pharmacologically, and research continues to identify genetic polymorphisms and interactions with environmental risk factors that co-vary with anxiety-related behaviour and neuro-cognitive endophenotypes. This paper describes findings from a range of research strategies in anxiety, discussed at the recent ECNP Targeted Expert Meeting on anxiety disorders and anxiolytic drugs. The efficacy of existing pharmacological treatments for anxiety disorders is discussed, with particular reference to drugs modulating serotonergic, noradrenergic and gabaergic mechanisms, and novel targets including glutamate, CCK, NPY, adenosine and AVP. Clinical and neurobiological predictors of active treatment and placebo response are considered.
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Affiliation(s)
- Matthew Garner
- School of Psychology and Division of Clinical Neurosciences, School of Medicine, University of Southampton, UK.
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The pharmacologic treatment of patients with generalized anxiety disorder: where are we now and where are we going? CNS Spectr 2009; 14:5-12. [PMID: 19238125 DOI: 10.1017/s1092852900027243] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Evidence-based guidelines for the pharmacologic management of patients with generalized anxiety disorder (GAD) recommend initial treatment with either a selective serotonin reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI). However, response rates to initial treatment with an SSRI or SNRI can be disappointing, and it remains impossible to predict reliably which patients will respond positively or negatively to treatment. Due to the dearth of longitudinal studies of outcome in GAD and the relatively small number of placebo-controlled relapse prevention studies, the optimal duration of treatment after a satisfactory response to acute treatment is still uncertain. Furthermore, there have been few studies on the management of patients who do not respond to initial treatment. Also, there is a clear need for further randomized controlled trials of augmentation treatment in patients who do not respond to SSRI, SNRI, or other initial pharmacologic approaches. Future guidelines will be influenced by emerging data with both established and novel drug treatments, and through better identification of patient groups that are likely to respond preferentially to particular interventions.
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Calleo J, Stanley MA, Greisinger A, Wehmanen O, Johnson M, Novy D, Wilson N, Kunik M. Generalized anxiety disorder in older medical patients: diagnostic recognition, mental health management and service utilization. J Clin Psychol Med Settings 2009; 16:178-85. [PMID: 19152056 DOI: 10.1007/s10880-008-9144-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Accepted: 12/30/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary care physicians often treat older adults with Generalized Anxiety Disorder. Objective To estimate physician diagnosis and recognition of anxiety and compare health service use among older adults with GAD with two comparison samples with and without other DSM diagnoses. METHODS Participants were 60+ patients of a multi-specialty medical organization. Administrative database and medical records were reviewed for a year. Differences in frequency of health service use were analyzed with logistic regression and between-subjects analysis of covariance. RESULTS Physician diagnosis of GAD was 1.5% and any anxiety was 9%, and recognition of anxiety symptoms was 34% in older adults with GAD. After controlling for medical comorbidity, radiology appointments were increased in the GAD group relative to those with and without other psychiatric diagnoses, chi(2) (2, N = 225) = 4.75, p < .05. CONCLUSIONS Most patients with anxiety do not have anxiety or symptoms documented in their medical records.
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Affiliation(s)
- Jessica Calleo
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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Stein DJ, Baldwin DS, Baldinetti F, Mandel F. Efficacy of pregabalin in depressive symptoms associated with generalized anxiety disorder: a pooled analysis of 6 studies. Eur Neuropsychopharmacol 2008; 18:422-30. [PMID: 18359203 DOI: 10.1016/j.euroneuro.2008.01.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Revised: 01/09/2008] [Accepted: 01/22/2008] [Indexed: 10/22/2022]
Abstract
Epidemiological evidence supports comorbidity of generalized anxiety disorder (GAD) and major depressive disorder (MDD) or dysthymia, and its association with significant disability. As pregabalin, a new alpha(2)-delta anxiolytic treatment for GAD, unlike most other licensed treatments for GAD has not undergone investigation in patients with MDD, we examined its efficacy in depressive symptoms associated with GAD, through a post-hoc analysis of the existing clinical trial database. The results provide consistent evidence that in patients with GAD pregabalin reduced associated symptoms of depression. This was seen in the 150 mg/day, 300-450 mg/day and 600 mg/day dosing groups. Even in subjects with more prominent depressive symptoms, pregabalin remained effective for both sub-syndromal depression and GAD symptoms, with pregabalin 300-450 mg/day demonstrating the most beneficial response. In conclusion, pregabalin, an alternative treatment option for GAD with a novel mechanism of action, also demonstrated efficacy in treating depressive symptoms typically encountered in GAD patients.
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Affiliation(s)
- Dan J Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
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Duration of untreated illness as a predictor of treatment response and clinical course in generalized anxiety disorder. CNS Spectr 2008; 13:415-22. [PMID: 18496479 DOI: 10.1017/s1092852900016588] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The aim of the present study was to investigate the impact of the duration of untreated illness (DUI)-defined as the time elapsing between the onset of generalized anxiety disorder (GAD) and the first adequate pharmacologic treatment-on treatment response and clinical course in a sample of subjects with GAD. METHODS One hundred patients with GAD, diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision criteria, were enrolled and their main demographic and clinical features collected. Patients were then treated with selective serotonin reuptake inhibitors or venlafaxine for 8 weeks in open-label conditions. Treatment response and other clinical variables were analyzed after dividing the sample into two groups according to DUI (DUI <or=12 months and DUI >12 months). RESULTS When the DUI was computed with respect to the first antidepressant treatment (DUI-AD), a higher improvement (Clinical Global Impressions-Severity of Illness scale) after the pharmacologic treatment was found in the group with a shorter DUI (analysis of variance with repeated measures: time effect F=654.975, P<.001; group effect: F=4.369, P=.039). When computed with respect to the first treatment with benzodiazepines (DUI-BDZ), the two groups did not show any significant difference in treatment response (time effect: F=652.183, P<.001; group effect: F=0.009, P=.924). In addition, patients with a longer DUI (DUI-BDZ or DUI-AD) showed an earlier age at onset, a longer duration of illness and a higher rate of comorbid psychiatric disorders with onset later than GAD. CONCLUSION Results from this preliminary study seem to suggest that a shorter DUI-AD may determine a better response to pharmacologic treatment in patients with GAD, and that a longer DUI (DUI-BDZ and DUI-AD) may be associated to a worse clinical course. Further investigation on the relationship between DUI and GAD is needed.
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Whalen PJ, Johnstone T, Somerville LH, Nitschke JB, Polis S, Alexander AL, Davidson RJ, Kalin NH. A functional magnetic resonance imaging predictor of treatment response to venlafaxine in generalized anxiety disorder. Biol Psychiatry 2008; 63:858-63. [PMID: 17964548 PMCID: PMC2654286 DOI: 10.1016/j.biopsych.2007.08.019] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Revised: 08/02/2007] [Accepted: 08/31/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Functional magnetic resonance imaging (fMRI) holds promise as a noninvasive means of identifying neural responses that can be used to predict treatment response before beginning a drug trial. Imaging paradigms employing facial expressions as presented stimuli have been shown to activate the amygdala and anterior cingulate cortex (ACC). Here, we sought to determine whether pretreatment amygdala and rostral ACC (rACC) reactivity to facial expressions could predict treatment outcomes in patients with generalized anxiety disorder (GAD). METHODS Fifteen subjects (12 female subjects) with GAD participated in an open-label venlafaxine treatment trial. Functional magnetic resonance imaging responses to facial expressions of emotion collected before subjects began treatment were compared with changes in anxiety following 8 weeks of venlafaxine administration. In addition, the magnitude of fMRI responses of subjects with GAD were compared with that of 15 control subjects (12 female subjects) who did not have GAD and did not receive venlafaxine treatment. RESULTS The magnitude of treatment response was predicted by greater pretreatment reactivity to fearful faces in rACC and lesser reactivity in the amygdala. These individual differences in pretreatment rACC and amygdala reactivity within the GAD group were observed despite the fact that 1) the overall magnitude of pretreatment rACC and amygdala reactivity did not differ between subjects with GAD and control subjects and 2) there was no main effect of treatment on rACC-amygdala reactivity in the GAD group. CONCLUSIONS These findings show that this pattern of rACC-amygdala responsivity could prove useful as a predictor of venlafaxine treatment response in patients with GAD.
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Affiliation(s)
- Paul J Whalen
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire 03755, USA.
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15
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Menezes GBD, Fontenelle LF, Mululo S, Versiani M. Resistência ao tratamento nos transtornos de ansiedade: fobia social, transtorno de ansiedade generalizada e transtorno do pânico. BRAZILIAN JOURNAL OF PSYCHIATRY 2007; 29 Suppl 2:S55-60. [DOI: 10.1590/s1516-44462007000600004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJETIVOS: Os transtornos de ansiedade são condições psiquiátricas prevalentes que determinam importante prejuízo funcional, piora na qualidade de vida do indivíduo e um enorme custo social. Embora diversas medicações eficazes para os transtornos de ansiedade encontrem-se disponíveis, um número significativo de pacientes não responde adequadamente ao tratamento e muitos permanecem com sintomas residuais clinicamente significativos. O objetivo deste estudo é rever aspectos relacionados à resistência ao tratamento e estratégias farmacológicas no manejo dos transtornos de ansiedade resistentes ao tratamento. MÉTODO: Revisão narrativa. RESULTADOS: São discutidos os diversos aspectos conceituais relacionados à resistência ao tratamento, os possíveis preditores de resistência e, finalmente, algumas estratégias a serem utilizadas no manejo dos transtornos de ansiedade (incluindo transtorno de ansiedade social, transtorno de ansiedade generalizada e transtorno do pânico) que não respondem às abordagens terapêuticas convencionais. CONCLUSÃO: A resistência ao tratamento ainda é um desafio para a prática clínica que começa em conceitos não operacionalizados de resposta e resistência e termina na escassez de estudos controlados sobre estratégias de tratamento nesse último cenário clínico.
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Affiliation(s)
| | | | - Sara Mululo
- Universidade Federal do Rio de Janeiro, Brasil
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16
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Stahl SM, Ahmed S, Haudiquet V. Analysis of the rate of improvement of specific psychic and somatic symptoms of general anxiety disorder during long-term treatment with venlafaxine ER. CNS Spectr 2007; 12:703-11. [PMID: 17805217 DOI: 10.1017/s1092852900021544] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Generalized anxiety disorder (GAD) is a chronic illness with psychic and somatic symptoms that do not respond uniformly in the first weeks of treatment. METHODS A post-hoc analysis of pooled data from five placebo-controlled, double-blind, randomized studies in non-depressed GAD patients treated with venlafaxine extended release (ER) or placebo was performed to determine the temporal response of psychic and somatic symptoms to treatment over 8 weeks. Two of the studies included extension phases of up to 6 months, the results of which were also analyzed here. RESULTS The earliest symptoms to respond included both psychic symptoms (anxious mood, tension, behavior at interview) and somatic muscular, cardiovascular, and respiratory symptoms. The last symptoms to respond included the psychic symptoms of insomnia and fear and the somatic sensory, gastrointestinal and autonomic symptoms, perhaps in part because of drug-related side effects. Continuing treatment beyond 8 weeks in venlafaxine ER responders for up to 6 months of total treatment results not only in additional improvement in early-responding symptoms, but also in the improvement of late-responding symptoms, perhaps due in part to the development of tolerance to antidepressant side effects. CONCLUSION Serious consideration should be given to maintaining partial responders to venlafaxine ER treatment on the same treatment for > or = 3-6 months.
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Affiliation(s)
- Stephen M Stahl
- Department of Psychiatry, University of California-San Diego, La Jolla, CA, USA.
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17
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Martin JLR, Sainz-Pardo M, Furukawa TA, Martín-Sánchez E, Seoane T, Galán C. Benzodiazepines in generalized anxiety disorder: heterogeneity of outcomes based on a systematic review and meta-analysis of clinical trials. J Psychopharmacol 2007; 21:774-82. [PMID: 17881433 DOI: 10.1177/0269881107077355] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
No systematic review or meta-analysis using a hard outcome has been conducted on the role of benzodiazepines for generalized anxiety disorder (GAD). The objective of this study was to assess the effectiveness and efficacy of benzodiazepines in the treatment of GAD based on trial drop-out rates. We used a systematic review of randomized controlled trials that compared any of the three best established benzodiazepines (diazepam, Lorazepam and aLprazolam) against placebo. Our primary outcome for effectiveness was withdrawal for any reason. Our secondary outcome tapping efficacy was withdrawal due to lack of efficacy, and that tapping side effects was withdrawals due to adverse events. We included 23 trials. Pooled analysis indicated less risk of treatment discontinuation due to lack of efficacy for benzodiazepines, compared to placebo, relative risk (RR) 0.29 (95% CI 0.18-0.45; p < 0.00001). Nevertheless, pooled analysis showed no conclusive results for risk of all-cause patient discontinuation, RR 0.78 (95% CI 0.62-1.00; p = 0.05). Meta-regression model showed that 74% of the variation in logRR across the studies was explained by year of publication (p <0.001). This systematic review did not find convincing evidence of the short-term effectiveness of the benzodiazepines in the treatment of GAD. On the other hand, for the outcome of efficacy, this review found robust evidence in favour of benzodiazepines. Due to the heterogeneity induced by year of publication, three hypotheses are plausibLe when it comes to being able to account for the differences between efficacy and effectiveness observed in the outcomes (publication bias, quality of the trial literature and a non-differential response to the placebo effect).
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Affiliation(s)
- Jose Luis R Martin
- Department of Clinical Research, Castile-La Mancha Health Research Foundation (FISCAM), Toledo, Spain.
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18
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Bekker MH, van Mens-Verhulst J. Anxiety Disorders: Sex Differences in Prevalence, Degree, and Background, But Gender-Neutral Treatment. ACTA ACUST UNITED AC 2007; 4 Suppl B:S178-93. [DOI: 10.1016/s1550-8579(07)80057-x] [Citation(s) in RCA: 222] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2007] [Indexed: 11/26/2022]
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Abstract
Response and remission rates are commonly used to evaluate the efficacy of treatments for anxiety disorders and other psychiatric illnesses. Response is generally regarded as a clinically meaningful improvement in symptoms, while remission, the goal of treatment, is generally thought of as the absence or near absence of symptoms following illness, accompanied by a return to premorbid levels of functioning. Response and remission are often defined using psychiatric rating scales, based on score cutoffs or the magnitude of score changes from baseline. While no universally accepted criteria exist, a commonly used threshold for response is a >50% improvement in the total score, while for remission, various cutoff points have been used. Comparison of cutoffs or change scores for disease-specific scales with Clinical Global Impressions ratings is a useful way of evaluating response and remission criteria across disorders. To illustrate the use of disease-specific and global measures, this article summarizes data from randomized, placebo-controlled studies of adult patients with generalized anxiety disorder, social anxiety disorder, or panic disorder treated with the serotonin norepinephrine reuptake inhibitor venlafaxine extended release, for which acute-phase data are available (a total of 13 trials).
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Affiliation(s)
- Borwin Bandelow
- Department of Psychiatry and Psychotherapy, University of Gottingen, Gottingen, Germany
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