Generalized Anxiety Disorder in Primary Care: Emerging Issues in Management and Treatment

Generalized anxiety disorder (GAD) is highly prevalent in primary care patients and is a source ofmajor morbidity. The low rate of recognition and diagnosis of GAD is often the result of insufficientknowledge on the part of primary care physicians, time pressures, and competing demands duringpatients’ visits. Patient attribution of symptoms and the stigma related to mental illness also contributeto underrecognition. Other contributing factors include the natural history of GAD, the bimodal age ofpresentation, a chronic but waxing and waning course, frequent comorbidity with other anxiety anddepressive disorders, and the controversy regarding the best diagnostic criteria. However, properdiagnosis is critical to appropriate management. Primary care management of GAD and associatedcomorbidities includes education about the nature of GAD as a medical disorder that is amenableto treatment and counseling about treatment alternatives and coping strategies. Most patients withGAD suffer from insomnia, and treating insomnia can be of great benefit to them. While cognitive-behavioraltherapy and relaxation therapy are effective in treating GAD, most patients in primary caresettings are likely to require pharmacologic treatment. Although commonly used, benzodiazepinesand their short-term benefits are overshadowed by their decreased long-term effectiveness, their minimaltreatment of psychic symptoms, and their degradation of patient performance. The selectiveserotonin reuptake inhibitor (SSRI) paroxetine is indicated for the short-term treatment of GAD, althoughadequate data supporting the use of most SSRIs for GAD are not yet available. The serotoninnorepinephrinereuptake inhibitor venlafaxine provides a treatment option resulting in both short- andlong-term improvement of symptoms, attaining not only a response but also remission from GAD andprevention of relapse.