Beta Blockers May be useful in RX of somatic symptoms such as palpitations, sweating, tremor… 20-60mg of Propranalol/day Not used much except in certain situations

Antihistamines Hydroxizine Little long term data

Quetiapine in acute treatment of GAD randomised double-blind fixed-dose placebo-controlled 8-wk study (LOCF, modified ITT) Mean baseline HAMA scores: placebo 27.3, QUET 50 mg 26.9, QUET 150 mg 26.6, PAR 20 mg 27.1 Bandelow B et al. Int J Psychiatry Clin Pract 2007; 11: 314-315 (abstract)

Gabapentin Tiagabine Riluzole Opipramol Kava Kava St. John’s Wart Valerian Passion flower (Passiflora) Galphimia Glauca (mexican herb)

Psychological Treatments High intensity psychological RX’s delivered by trained supervised competent staff 12-15 weekly hourly sessions Equal efficacy to drug RX CBT, Applied Relaxation.. Need to measure outcomes (audio, video taping sessions for evaluation) Caveat availability/accessibility

Cognitive-behaviour therapy in GAD Study Interventions Findings Butler et al 19911 CBT (4-14 sessions) Behaviour therapy (BT) Waiting list CBT (15/16 measures and BT (4/16) significantly superior to waiting list, CBT superior to BT Barlow et al 19922 Relaxation therapy Cognitive therapy CT plus relaxation Superiority of three interventions over waiting list on observed case analysis Borovec and Costello 19933 Applied relaxation CBT Non-directive intervention At follow-up, relaxation and CBT superior to non-directive intervention (worsened) Durham et al 19944 Anxiety management Analytic psychotherapy CBT superior to analytic therapy at 6 months, but not superior to anxiety management 1. Butler G et al. J Consult Clin Psychol 1991; 59: 167-175 2. Barlow DH et al. Behav Ther 1992; 23: 551-570 3. Borovec TD, Costello E. J Consult Clin Psychol 1993; 61: 611-619 4. Durham R et al. Br J Psychiatry 1994; 165: 315-323

When to refer to secondary care? If you feel diagnosis is uncertain If you feel inexperienced to treat If 1or 2 treatments have failed (adequate doses for adequate length of time) If there is co-morbidity (depression) and risk of suicide If psychological treatments are not available at primary care

Prediction of response to treatment