Anxiety disorders are prevalent and impairing. A recent article in JAMA summarizes the research so far and lays out the current accepted treatment plan for most anxiety disorders.
Everyone worries from time to time, especially when life takes particularly stressful and unexpected turns. But short-term states and long-term traits of anxiety can manifest much more seriously than merely nervousness and concern. Anxiety disorders are both common and debilitating. According to an opinion article by Dr. Murray B. Stein, MD, MPH, and Dr. Michelle G. Craske, PhD, published in The Journal of the American Medical Association, physicians encounter patients most often suffering from generalized anxiety disorder, panic disorder, social anxiety disorder, and post-traumatic stress disorder.
Characteristics of anxiety disorders frequently include the presence of anxiety (often accompanied by physical symptoms such as abnormally rapid heart rate, difficult or labored breathing, or gastrointestinal upset), worry, or avoidance in excess or disproportional to the situation, as well as persistent impairments in social and occupational functioning. While many people function well despite periods of stress, if lingering or repeatedly recurring anxiety may require medical intervention.
Depending on the severity of the anxiety disorder, physicians may first recommend patient treatments that are the most accessible and safe, and the least expensive. These include physical activity and mindfulness-based stress reduction approaches that are available to patients via mobile apps and internet-based programs.
Although many patients report major improvements after trying these strategies, most will require more intensive treatment, such as antidepressants (like selective serotonin reuptake inhibitors [SSRIs] or serotonin and norepinephrine reuptake inhibitors [SNRIs]) and cognitive behavioural therapies (CBTs). Each of these therapies may benefit over 50% of patients with anxiety and are often incorporated into collaborative care programs or in clinical settings.
The most commonly prescribed SSRIs and SNRIs, such as duloxetine, escitalopram, fluoxetine, sertraline, and Venlafaxine, are introduced at the lowest available doses and then gradually increased every few weeks to balance therapeutic response with the risk of adverse effects (e.g. hypertension, nausea, agitation or sedation, decreased libido and delayed orgasm, etc).
Cognitive behavioural therapy, on the other hand, is a goal-oriented program that focuses on the following targets: reducing excessively negative interpretations of situations, substituting avoidant behaviours with coping behaviours, and diminishing levels of tension and autonomic arousal. Patients may be able to access cognitive behavioural therapy online, as well as in person.
In the event that treatment with antidepressants and cognitive behavioural therapy has been deemed unsuccessful, a class of psychoactive drugs called benzodiazepines may be an option. Similar to the treatment of opioids for pain, benzodiazepines are highly effective at treating anxiety in the short term but should be avoided by patients who have histories of alcohol or drug abuse.
While yoga, meditation, and massage may prove to be somewhat beneficial to patients and are unlikely to present harm, experimental treatments like 3,4-methylenedioxymethamphetamine (MDMA, or “ecstasy”) or ketamine are not currently recommended, as further controlled research to determine efficacy and safety is required. There is currently little scientific evidence to support the use of cannabis products in the treatment of anxiety, and it is not recommended.
Measuring treatment progress is key. Severity and treatment response can be tracked by clinicians by administering assessments – such as the Generalized Anxiety Disorder 7-Item Scale – at little or no cost.
As the leading cause of disability-adjusted life-years around the world, it may be disquieting and frustrating to learn that there have been no new anxiolytics (anti-panic and anti-anxiety medications)approved by the US Food and Drug Administration (FDA) since 2007. While existing pharmacological and psychosocial treatments can be of benefit to patients, a critical need for new therapies undoubtedly exists.Novel therapeutics are expected to be developed in the relatively-near future; there is hope for those living with anxiety. In the meantime, research demonstrates that the lives of patients with anxiety disorders can indeed be improved using tools and resources currently available.
Written by Jordyn Posluns, B.Sc. (Hons)
Reference: Stein MB and Craske MG. Treating Anxiety in 2017 Optimizing Care to Improve Outcomes. JAMA. 2017 August 4.