What is the appropriate management for a 25-year-old male with severe anxiety, as evidenced by a Generalized Anxiety Disorder (GAD) score of 16, indicating moderate to severe anxiety?

From the Guidelines

For a 25-year-old male with severe anxiety and a GAD score of 16, I recommend starting with cognitive behavioral therapy (CBT) or other individual or group therapy options, such as behavioral activation (BA), structured physical activity and exercise, or psychosocial interventions with empirically supported components, as these have been shown to be effective in managing moderate to severe anxiety symptoms. This approach is supported by the most recent and highest quality study, which suggests that individual or group therapy with any one of the following treatment options: CBT, BA, structured physical activity and exercise, or psychosocial interventions with empirically supported components, should be offered to patients with moderate symptoms of anxiety 1. While medication may also be considered, the current evidence suggests that therapy should be the first line of treatment, with medications such as SSRIs or SNRIs considered if therapy is not effective or if symptoms are severe 1. Some key points to consider when implementing this treatment plan include:

• Regular therapy sessions, ideally weekly, for 12-16 weeks
• Lifestyle modifications, such as regular exercise, mindfulness meditation, limiting caffeine and alcohol, and maintaining consistent sleep patterns, to enhance treatment effectiveness
• Regular follow-up appointments to monitor progress and adjust treatment as needed It's also important to note that the treatment plan should be tailored to the individual patient's needs and preferences, and that a multidisciplinary approach, including both therapy and medication, may be necessary to achieve optimal outcomes.

From the FDA Drug Label

Generalized Anxiety Disorder (DSM-IV) is characterized by excessive anxiety and worry (apprehensive expectation) that is persistent for at least 6 months and which the person finds difficult to control It must be associated with at least 3 of the following 6 symptoms: Restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance The efficacy of PAXIL in the treatment of GAD was established in two 8-week placebo-controlled trials in adults with GAD A third study, also flexible-dose comparing paroxetine (20 mg to 50 mg daily), did not demonstrate statistically significant superiority of PAXIL over placebo on the Hamilton Rating Scale for Anxiety (HAM-A) total score, the primary outcome. In a longer-term trial, 566 patients meeting DSM-IV criteria for Generalized Anxiety Disorder, who had responded during a single-blind, 8-week acute treatment phase with 20 to 50 mg/day of PAXIL, were randomized to continuation of PAXIL at their same dose, or to placebo, for up to 24 weeks of observation for relapse

The appropriate management for a 25-year-old male with severe anxiety, as evidenced by a Generalized Anxiety Disorder (GAD) score of 16, indicating moderate to severe anxiety, is treatment with paroxetine (PAXIL). The recommended dose is 20-50 mg/day. The patient should be monitored for relapse and the dose adjusted as needed. It is essential to note that the patient's response to treatment should be evaluated after an 8-week acute treatment phase, and continuation of treatment should be based on the patient's response 2 2.

• Key considerations:
  • The patient's GAD symptoms should be monitored regularly.
  • The dose of paroxetine may need to be adjusted based on the patient's response to treatment.
  • The patient should be informed about the potential benefits and risks of treatment with paroxetine.

From the Research

Management of Generalized Anxiety Disorder (GAD)

The management of GAD involves a combination of pharmacological and psychological interventions. For a 25-year-old male with severe anxiety, as evidenced by a GAD score of 16, the following management options are recommended:

• First-line pharmacotherapies:
  • Selective serotonin reuptake inhibitors (SSRIs) 3, 4, 5, 6
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs) 3, 6
  • Pregabalin 3, 4
• Psychological interventions:
  • Cognitive behavioural therapy (CBT) 3, 4, 7
• Combination therapy:
  • Pharmacotherapy and CBT can be used in combination for optimal results 4, 7
• Considerations:
  • Patient preference should be taken into account when choosing between pharmacotherapy and CBT 3, 7
  • Comorbidities, such as depression and substance use, should be considered when selecting a treatment option 3
  • Treatment should be continued for at least 12 months to achieve optimal results 6

Treatment Outcomes

Studies have shown that:

• Pregabalin has a rapid onset of action and is effective in treating GAD symptoms 4
• Sertraline, an SSRI, is also effective in treating GAD symptoms, but may have a slower onset of action compared to pregabalin 4
• CBT is a valid alternative to pharmacotherapy and can be used in combination with medication for optimal results 3, 7