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Generalized anxiety disorder (GAD ) (Click here for help)
Generalized anxiety disorder (GAD) occurs more frequently in middle-aged, widowed, or divorced females, with the ratio of females to males being 2:1 (Wilson & Stein, 2019). Genetics has been shown to play a role in the expression of GAD, influencing approximately 31% of emergence, as shown in twin studies. The overall prevalence in the United States is 4.1%, with symptoms being chronic and remission rates of only about 20%. The treatment goal is to improve the symptoms and improve function (AHC Media, 2021). (Click here for help)
The first-line medications used to treat GAD in the U.S. are selective serotonin reuptake inhibitors (SSRIs) followed by serotonin-norepinephrine reuptake inhibitors (SNRIs). The SSRIs are Escitalopram (Lexapro) and Paroxetine (Paxil), the SNRIs are Duloxetine (Cymbalta) and Venlafaxine (Effexor), and the Azapirone Buspirone (BuSpar) (Wilson& Stein, 2019). There is an increased risk of suicidal ideations and other adverse effects such as insomnia and restlessness in children and adolescents treated with SSRIs, but this is not the case with SNRIs (Abubakar et al., 2021). In the elderly, altered pharmacokinetics such as delayed absorption and decreased excretion must be considered when initiating therapy and drug-drug interactions reviewed. Buspirone is frequently used in addition to SSRIs/SNRIs instead of a benzodiazepine due to it having no potential for abuse but is not generally used as first-line therapy (AHC Media, 2021). Females tend to have higher CYP2D6 and CYP3A4 activity, increasing the clearance of SSRIs/SNRIs but have a lower glomerular filtration rate which slows the elimination of some metabolites. Females are also more prone than males to QT interval elongation, so QT must be monitored with some SSRIs/SNRIs (Wilson & Stein, 2019).
Benzodiazepines are considered second-line drugs in the treatment of GAD. They are highly effective at reducing the symptoms of GAD but have a high rate of abuse, dependence, and withdrawal and should only be used in severe or acute episodes of GAD (AHC, 2021). This class of medication is also contraindicated when the patient takes other psychoactive substances or drinks alcohol (Abubaker et al., 2021).