Algorithm for GAD

[mistafab]

Wondering of some of the more experienced practitioners here can comment on their general GAD algorithm, or how they conceptualize GAD.

I've essentially boiled it down to a 3 level system as such:

First line, therapy and medicine (SRI - escitalopram or sertraline)
Second line, reiterate they should try therapy. Medication wise class switch to SNRI (duloxetine preferred)
Third line, reiterate that at this point medications are less established to work, and therapy is the most likely option to be effective. I tend to augment at this stage, keeping the above med and adding on either pregabalin, antipsychotic (olanzapine, abilify), atypical (mirtazapine, wellbutrin).

Non-algorithm options I bring up in certain scenarios include propanolol, prn atarax, buspirone. In chronic pain folks, TCA is added on as 3rd line option (nortryptiline).

Any comments on what you tend to lean towards when you're reaching 3rd line treatment options? How do you conceptualize GAD and who gets what treatment?

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[vanfanal]

I’m not that much more experienced. But I’ve picked up that patients on the more adjustment end of the spectrum will just say anxiety or depression. Whereas those who cross the threshold for a disorder are more elaborate with symptoms and have significant impairment. It’s not just about current life stressors, it’s excessive, about too many almost ridiculous things and it’s impairing. I think I have a high threshold for mood disorders compared to most out the community because they don’t see inpt pathology like I do. Really anxiety you feel in the room, same with depression.

Anyways, when I hear more anxious cognitions without significant physical symptoms, impairment, and it’s mainly about current stressors, it’s therapy therapy therapy. Sometimes I recommend the book mind over mood or an online Australian CBT programme called mood gym (costs like $25).

I recommends meds first when the patient gives me an elaborative and spontaneous history consistent with GAD. Then I start with an SSRI and augment with Hydroxyzine or pregabalin…if multiple trials and nothing works, Aripiprazole or quetiapine. I’ll also use clonazepam up to 1mg BID for significant symptoms. All while stressing that meds will numb you out, but therapy is essential to meaningful term recover.

 

[annoyedpsychiatrist]

My own method:

1 SSRI--->if improvement but still significant residual sx, titrate higher until improvement bottoms out. Consider buspirone adjunct if partial responder and improvement bottoms out
2.SSRI second trial-->if no improvement on first SSRI or not tolerated well.
3. SNRI or trintellix--->i often use trintellix as a third line, sometimes ill go with effexor depending on insurance coverage/eligibility for patient assistance program. I have better luck with trintellix than effexor but theres no exact way of knowning obviously
4. SNRI or trintellix-->depending on which I didnt use above
5. If all these agents have failed then im making sure im not missing something at this point and reviewing the diagnosis, personality disorder, significant life stressor, substance use, ADHD, or even bipolar 2, etc
6. If im convinced its still GAD at this point then i look at comorbid sx and try to improve those as much as possible while doing adjunct CBT and trying to get them in with therapist. If thin+insomnia then remeron (but i dont have great luck for anxiety with it, sometimes does ok for depression). Sometimes ill use propanolol in social/performance anxiety situations. Sometimes ill use gabapentin. I consider TCAs at this point as well usually as adjunct therapy to an SSRI, which I may try another SSRI because some people may fail 2 SSRIs and still respond to another.
7. I dont typically use adjunctive seroquel in GAD but i know its done sometimes.


I am pretty against scheduled benzos in GAD. I may give PRN klonopin like 10 tabs for a month but I think the issue with scheduled klonopin is once on it, getting them off is basically impossible. Anxiety is uncomfortable but CBT teaches us that avoidance doesnt help anxiety, and klonopin is really just a form of avoidance. I get 30 mins for f/us so in GAD pts im doing a lot of adjunctive CBT. I am a big believer in CBT for GAD. I preach exercise too- being as active as possible. Aerobic exercise has a definite link to improve in GAD. I hammer the concept of exposure. I present my pts with the analogy of this "If you have a fear of heights, but avoid heights for the rest of your life, does the fear just go away by itself? How do you overcome that fear?"

At this point if all this has failed then there is very often a significant life stressor or personality disorder component.

 

[hippopotamusoath]

Great algorithm, mine is very similar. I think I diverge from many by being more okay with BZD medicines.

My logic is that if the benzodiazepine is scheduled, it is not a safety behavior. It is “turning down the volume” in the same way that chronic SSRI administration seems to turn down the volume. If it is PRN, that is a safety behavior and I think should be avoided.

Yes, getting people off chronic benzodiazepines is a challenge, but often because they work well. In a patient with debilitating symptoms who has improved with a stable, chronic, lower-dose BZD, I fail to see why we shouldn’t keep prescribing?

I certainly get informed consent and we discuss the pitfalls, but at the end of the day, medicines have risks.

I think the benzodiazepines are not first or second line, but they are useful compounds and we shouldn’t shy away from using them in carefully selected patients.

 

[annoyedpsychiatrist]

Great algorithm, mine is very similar. I think I diverge from many by being more okay with BZD medicines.

My logic is that if the benzodiazepine is scheduled, it is not a safety behavior. It is “turning down the volume” in the same way that chronic SSRI administration seems to turn down the volume. If it is PRN, that is a safety behavior and I think should be avoided.

Yes, getting people off chronic benzodiazepines is a challenge, but often because they work well. In a patient with debilitating symptoms who has improved with a stable, chronic, lower-dose BZD, I fail to see why we shouldn’t keep prescribing?

I certainly get informed consent and we discuss the pitfalls, but at the end of the day, medicines have risks.

I think the benzodiazepines are not first or second line, but they are useful compounds and we shouldn’t shy away from using them in carefully selected patients.

My main concern is that as people get older, they often tolerate these less and less. So it may work ok in your 30s, and 40s. But then you eventually up in late 60s, 70s, 80s and people can have issues tolerating them, and once youve been on them for years, coming off is no picnic. To me they're just like devices that obliterate anxiety which is counterintuitive because by completely avoiding anxiety/panic how does one get better? Often, people get anxiety specifically related to obtaining the next benzo dose, creating a psychological dependence. With PRN use, it forces the patient to expose themselves to uncomfortable situations and process these emotions. But they at least know, if they're a situation where having a panic attack isnt adviseable (job interview, work dinner, etc) then it gives them some power over their situation. Often their anxiety is relieved knowning they're not SOL if they start having a panic attack during a crucial moment. Also if you have a patient getting chronic benzos, what do you do for breakthrough anxiety? Do you titrate the benzo? Add another PRN? What PRN could you go to? Ive also found that when someone uses a benzo, nothing else "works" so to speak cause itll never be the same effect.

Just my personal opinion of course, i just personally dont like them and try to avoid when I can, or at least do it in a PRN manner

 

[Merovinge]

My own method:

1 SSRI--->if improvement but still significant residual sx, titrate higher until improvement bottoms out. Consider buspirone adjunct if partial responder and improvement bottoms out
2.SSRI second trial-->if no improvement on first SSRI or not tolerated well.
3. SNRI or trintellix--->i often use trintellix as a third line, sometimes ill go with effexor depending on insurance coverage/eligibility for patient assistance program. I have better luck with trintellix than effexor but theres no exact way of knowning obviously
4. SNRI or trintellix-->depending on which I didnt use above
5. If all these agents have failed then im making sure im not missing something at this point and reviewing the diagnosis, personality disorder, significant life stressor, substance use, ADHD, or even bipolar 2, etc
6. If im convinced its still GAD at this point then i look at comorbid sx and try to improve those as much as possible while doing adjunct CBT and trying to get them in with therapist. If thin+insomnia then remeron (but i dont have great luck for anxiety with it, sometimes does ok for depression). Sometimes ill use propanolol in social/performance anxiety situations. Sometimes ill use gabapentin. I consider TCAs at this point as well usually as adjunct therapy to an SSRI, which I may try another SSRI because some people may fail 2 SSRIs and still respond to another.
7. I dont typically use adjunctive seroquel in GAD but i know its done sometimes.


I am pretty against scheduled benzos in GAD. I may give PRN klonopin like 10 tabs for a month but I think the issue with scheduled klonopin is once on it, getting them off is basically impossible. Anxiety is uncomfortable but CBT teaches us that avoidance doesnt help anxiety, and klonopin is really just a form of avoidance. I get 30 mins for f/us so in GAD pts im doing a lot of adjunctive CBT. I am a big believer in CBT for GAD. I preach exercise too- being as active as possible. Aerobic exercise has a definite link to improve in GAD. I hammer the concept of exposure. I present my pts with the analogy of this "If you have a fear of heights, but avoid heights for the rest of your life, does the fear just go away by itself? How do you overcome that fear?"

At this point if all this has failed then there is very often a significant life stressor or personality disorder component.

I heard such bad press about Buspar (that it's basically a placebo) in med school and rarely saw it used in residency/fellowship, but have found a significant minority of patients to have real benefit from it. I like it both with SSRIs or for patients on the bipolar spectrum with significant anxiety who should not be on SSRIs. I almost feel like BID/TID dosage has people feel like it's more effective as they take it more frequently and the safety profile is great.

 

[annoyedpsychiatrist]

I heard such bad press about Buspar (that it's basically a placebo) in med school and rarely saw it used in residency/fellowship, but have found a significant minority of patients to have real benefit from it. I like it both with SSRIs or for patients on the bipolar spectrum with significant anxiety who should not be on SSRIs. I almost feel like BID/TID dosage has people feel like it's more effective as they take it more frequently and the safety profile is great.

yes this x1000000. I heard all the time "its just basically water" but i have this subset of patients who really respond to it. And absosutely, i see anxiety a lot with bipolar and im hesistant to throw on SSRis, but ive done the same thing with giving buspirone to these people with some positive outcomes.

 

[clozareal]

Where does pregabalin fit into all of your lists for GAD?

 

[Psych19]

Where does pregabalin fit into all of your lists for GAD?

It's approved in Europe for GAD.
I'd be curious to hear others' experiences getting insurance to pay for it.

 

[zenmedic]

Do any of you find natural supplements useful in your algorithm? Like magnesium, ashwagandha, saffron, etc?

 

[splik]

The problem with GAD is that it is not an anxiety disorder. In DSM-III (and ICD-10) GAD is an anxiety disorder, with fear based criteria. From DSM-IV onwards, GAD was transformed into a "worry based" diagnosis. Other anxiety disorders are particularly noteworthy for their physiologic symptoms and psychic anxiety is fear based. This includes panic disorder, social anxiety, specific phobias, OCD, illness anxiety disorder, and PTSD. GAD is the odd one out and clusters more with depression rather than the other anxiety disorders. This is one reason why it is not as easy to treat. Panic disorder, social anxiety disorder, specific phobias, and PTSD for example are all potentially curable. GAD less so. GAD is also much more likely to respond to treatment with SSRIs than the aforementioned disorders.

These GAD patients often can be classified into two groups (not dissimilar from MDD surprise, surprise). The first group respond marvellously to decent doses of SSRIs or SNRIs and psychotherapy. Many will have had the onset of symptoms begin following a life event in adult life. The second group run a chronic course with variable response to treatment with onset in childhood or adolescence. histories of bedwetting, school refusal, separation anxiety, truancy, selective mutism, and somatization are common in such patients.

Many patients with persistent worry are best conceptualized as having personality disorders, or developmental trauma related disorders. These patients may end up on multiple medications (SSRIs, benzos, buspirone, mirtazapine, hydroxyzine, gabapentin/pregabalin, atypical antipsychotics, and even barbiturates) often with little evidence of improvement in their symptoms. You can play the "algorithm" game, but each additional medication tends to have little response, often not tolerated or with many side effects reported. These patients often have frank borderline, narcissistic, dependent, avoidant and/or obsessive-compulsive personality traits/disorder. Their histories reveal patterns of dysfunctional interpersonal relationships that activate their attachment anxiety.

 

[reca]

yes this x1000000. I heard all the time "its just basically water" but i have this subset of patients who really respond to it. And absosutely, i see anxiety a lot with bipolar and im hesistant to throw on SSRis, but ive done the same thing with giving buspirone to these people with some positive outcomes.

I’ve found it surprisingly effective for SSRI induced sexual dysfunction. Significantly better results than bupropion.

 

[annoyedpsychiatrist]

Many patients with persistent worry are best conceptualized as having personality disorders, or developmental trauma related disorders. These patients may end up on multiple medications (SSRIs, benzos, buspirone, mirtazapine, hydroxyzine, gabapentin/pregabalin, atypical antipsychotics, and even barbiturates) often with little evidence of improvement in their symptoms. You can play the "algorithm" game, but each additional medication tends to have little response, often not tolerated or with many side effects reported. These patients often have frank borderline, narcissistic, dependent, avoidant and/or obsessive-compulsive personality traits/disorder. Their histories reveal patterns of dysfunctional interpersonal relationships that activate their attachment anxiety.

i would strongly agree with this that it is often a result of low emotional resilence, poor coping skills, limited insight, developemental stuff often manifesting into like you said a personality disorder, for the chronic non responders. I usually take off stuff before I keep adding. The people that "need" to stay on chronic benzos for anxiety I would wager most of them it just acts as a nice numbing agent and then their anxiety becomes "what if my benzo is taken away" and actually gets worse.

 

[mistafab]

I had a geriatric patient where activation from SSRI/SNRI was too distressing, and was already taking the gaba agents for chronic pain. I found in his case buspirone was highly effective in his treatment at a moderate dose (45 mg TDD). It was night and day for this guy. He was a prototypical "worrier" without a fear, or fear of fear component to his GAD.

 

[allantois]

I really hope no one would be putting me on an SGA for anxiety or insomnia as a patient should I become old and demented

 

[Merovinge]

The problem with GAD is that it is not an anxiety disorder. In DSM-III (and ICD-10) GAD is an anxiety disorder, with fear based criteria. From DSM-IV onwards, GAD was transformed into a "worry based" diagnosis. Other anxiety disorders are particularly noteworthy for their physiologic symptoms and psychic anxiety is fear based. This includes panic disorder, social anxiety, specific phobias, OCD, illness anxiety disorder, and PTSD. GAD is the odd one out and clusters more with depression rather than the other anxiety disorders. This is one reason why it is not as easy to treat. Panic disorder, social anxiety disorder, specific phobias, and PTSD for example are all potentially curable. GAD less so. GAD is also much more likely to respond to treatment with SSRIs than the aforementioned disorders.\

Don't social anxiety d/o and OCD have pretty strong SSRI response data? There is very good social anxiety d/o SSRI data in the adolescent population and fairly good data for OCD as well.

GAD specifically has the muscle tension, fatigue, and restlessness physiologic criteria as well (so 3/6 criteria).

These GAD patients often can be classified into two groups (not dissimilar from MDD surprise, surprise). The first group respond marvellously to decent doses of SSRIs or SNRIs and psychotherapy. Many will have had the onset of symptoms begin following a life event in adult life. The second group run a chronic course with variable response to treatment with onset in childhood or adolescence. histories of bedwetting, school refusal, separation anxiety, truancy, selective mutism, and somatization are common in such patients.

Many patients with persistent worry are best conceptualized as having personality disorders, or developmental trauma related disorders. These patients may end up on multiple medications (SSRIs, benzos, buspirone, mirtazapine, hydroxyzine, gabapentin/pregabalin, atypical antipsychotics, and even barbiturates) often with little evidence of improvement in their symptoms. You can play the "algorithm" game, but each additional medication tends to have little response, often not tolerated or with many side effects reported. These patients often have frank borderline, narcissistic, dependent, avoidant and/or obsessive-compulsive personality traits/disorder. Their histories reveal patterns of dysfunctional interpersonal relationships that activate their attachment anxiety.

One of the largest subset of GAD in adolescents I see is the teenagers who feel the weight of "needing" to get into a top college to get a good job to be able to afford a life even similar to their parents (currently work in an affluent suburb). Some will watch a significant amount of social media about future concerns (e.g. global warming, wealth inequility, etc.). This leads to a profound amount of catastrophizing and significant impairment in life. It is certainly associated with a higher rate of MDE than the rest of the local population but do not present with PD traits (other than possibly OCPD), SM/SA, school refusal, bedwetting etc. I don't have any data on this but a number of CAP I speak to see quite a bit of this in their practices.

 

[Orgone]

I had a geriatric patient where activation from SSRI/SNRI was too distressing, and was already taking the gaba agents for chronic pain. I found in his case buspirone was highly effective in his treatment at a moderate dose (45 mg TDD). It was night and day for this guy. He was a prototypical "worrier" without a fear, or fear of fear component to his GAD.

I know a geriatric internist, undoubtedly treats more psychiatric patients than we do although not by choice, who talks about having fantastic results with buspirone.

 

[forchinet121]

I know a geriatric internist, undoubtedly treats more psychiatric patients than we do although not by choice, who talks about having fantastic results with buspirone.

I don’t think an internist treats more psychiatric patients than a psychiatrist..

 

[calvnandhobbs68]

I heard such bad press about Buspar (that it's basically a placebo) in med school and rarely saw it used in residency/fellowship, but have found a significant minority of patients to have real benefit from it. I like it both with SSRIs or for patients on the bipolar spectrum with significant anxiety who should not be on SSRIs. I almost feel like BID/TID dosage has people feel like it's more effective as they take it more frequently and the safety profile is great.

yes this x1000000. I heard all the time "its just basically water" but i have this subset of patients who really respond to it. And absosutely, i see anxiety a lot with bipolar and im hesistant to throw on SSRis, but ive done the same thing with giving buspirone to these people with some positive outcomes.

Probably because people do things like start 5mg BID and then go "ugh never works, it's just like water".

I also think there are these myths that get perpetuated in residency/fellowship based on the culture of the institution which then impact your prior expectations going forward about certain meds. Like strattera, the number of times I hear or heard people call it "crapterra" and insist it doesn't work in training (and even currently) is just ridiculous, when meta-analysis show that even in 12 week studies it has a decent effect size for kids and an almost equivalent effect size to methylphenidate in adults.

 

[clozareal]

It's approved in Europe for GAD.
I'd be curious to hear others' experiences getting insurance to pay for it.

It's generic in the US.

 

[clausewitz2]

Don't social anxiety d/o and OCD have pretty strong SSRI response data? There is very good social anxiety d/o SSRI data in the adolescent population and fairly good data for OCD as well.

OCD has generally quite low response rate to placebo, so the effects in trials of SSRIs end up being bigger. GAD response rates to placebo seem to be in line with MDD in my read of the literature, thus, a smaller effect size. I've never seen a great argument for why GAD should not be classified as a personality disorder.

But, like @splik said, social phobia and OCD are mostly disorders of actual fear that are usually very treatable. The folks under the OCD umbrella who tend to do less well are a) the contamination folks who are driven more by disgust than fear and b) the ones whose lack of insight verges on the delusional. People who are afraid for what they perceive as stupid reasons want to stop being afraid. People who think something is gross beyond words or who think they are afraid for really very good reasons are going to have a harder time with voluntarily approaching the relevant situations/stimuli.

 

[Merovinge]

Probably because people do things like start 5mg BID and then go "ugh never works, it's just like water".

I also think there are these myths that get perpetuated in residency/fellowship based on the culture of the institution which then impact your prior expectations going forward about certain meds. Like strattera, the number of times I hear or heard people call it "crapterra" and insist it doesn't work in training (and even currently) is just ridiculous, when meta-analysis show that even in 12 week studies it has a decent effect size for kids and an almost equivalent effect size to methylphenidate in adults.

Oh man, completely agree about underdosing Buspar, I don't even start at 5 these days for my fully grown adolescents, very rarely get complaints about 10mg BID. Absolutely nothing wrong with increasing as tolerated.

Also completely agree about Strattera with a very solid effect size (as well as no diversion risks, way less appetite suppression, risk of exacerbating psychosis etc). Ironically, some folks I know that don't like Strattera are all about starting Qelbree. I guess if nothing else it being released as name brand is good to give some kids extra access to that class of meds when stimulants are not a good fit.

 

[FlowRate]

I’ve found it surprisingly effective for SSRI induced sexual dysfunction. Significantly better results than bupropion.

Interesting, I've had a bunch of patients try it and never had anyone report positive results for sexual ADR. I've had more luck using it as adjunt or monotherapy for anxiety than for sexual ADR. Bupropion, OTOH, works for roughly 75% of my patients.

This might now be a self-perpetuating pattern as I've started recommending bupropion for sexual ADR first more often and people who respond to bupropion don't end up needing to try something else--they may well have also responded to buspirone if that had been tried first.

I guess that's the issue with relatively small clinical experience sample sizes.

 

[Stagg737]

Agree with a lot of what's been said in regards to actually conceptualizing anxiety. I think it's necessary to develop a real formulation for anxiety more so than any other set of disorders we treat, partially because of the range of symptoms we consider anxiety and partially because patients oftentimes don't understand anxiety themselves. My first question about anxiety is always to ask them to describe their anxiety as if I'd never heard of anxiety before. "What does anxiety mean to you?" Without an understanding of this I don't think one can really make a decent algorithm for anxiety, as "anxiety" as described by DSM isn't really a singular mechanism.

I also do research (currently on hold) regarding dimensional models like HiTOP or the AMPD and I think use of traits will be more useful than the categorical model we currently use as I think it helps delineate forms of "anxiety" better than the DSM does. Imo, the "algorithm" for how you conceptualize and define the patient's "anxiety" is more important than the treatment algorithm.

 

[allantois]

My favorite is when they tell me that they don't know if they are anxious and that's why they are here so I can figure it out.. lol

 

[ObsequiousAplomb]

My favorite is when they tell me that they don't know if they are anxious and that's why they are here so I can figure it out.. lol

Honestly those are really fun. Especially because they generally don't have an anxiety disorder requiring medication treatment, but might have some other disorder and really never learned / aren't certain regarding the vocabulary to describe internal states. That way they don't adamantly repeat that they are anxious despite clearly describing having a movement disorder, ADHD, MDD, or even psychosis without comorbid GAD.

 

[MedMusic]

Anybody have thoughts on using Silexan for anxiety? I've been doing some reading on this and am curious if anybody actually uses it.

Efficacy and safety of lavender essential oil (Silexan) capsules among patients suffering from anxiety disorders: A network meta-analysis - Scientific Reports

A systematic review and network-meta analysis (NMA) were performed to estimate significance of the anxiolytic effect of lavender essential oil taken as silexan capsules versus other comparators (i.e., placebo/paroxetine/lorazepam). The outcome of interest was Hamilton Anxiety Scale (HAMA)...

www.nature.com

 

[calvnandhobbs68]

Anybody have thoughts on using Silexan for anxiety? I've been doing some reading on this and am curious if anybody actually uses it.

Efficacy and safety of lavender essential oil (Silexan) capsules among patients suffering from anxiety disorders: A network meta-analysis - Scientific Reports

A systematic review and network-meta analysis (NMA) were performed to estimate significance of the anxiolytic effect of lavender essential oil taken as silexan capsules versus other comparators (i.e., placebo/paroxetine/lorazepam). The outcome of interest was Hamilton Anxiety Scale (HAMA)...

www.nature.com

I have, not awesome results so far but that doesn't mean it doesn't work, just haven't tried it with a ton of people. I think maybe one person out of a handful felt it helped on its own. Worth trying for people who want more "natural" stuff instead of SSRIs for anxiety disorders...when I'm asked about that I usually talk to them about lifestyle change stuff of course, Silexan and Magnesium in terms of actual supplements I'm somewhat familiar with.