Long-term Management of Generalized Anxiety Disorder
As mentioned, GAD is a chronic, continuous condition in the ma-jority of patients. Frequently beginning in adolescence or early adulthood, the course of GAD can persist for decades, with rela-tively low remission rates. The HARP data indicate that among the 164 GAD patients followed, only 15% had a full remission for 2 months or longer at any time during the first follow-up year, 25% had a full remission during the 2-year follow-up, and only 35% had a full remission after 5 years (Yonkers et al., 1996). In a 5-year follow-up study of 64 GAD patients, only 18% of GAD subjects achieved a full remission compared with 45% of panic disorder subjects (Woodman et al., 1999).
Despite these findings, less research has been conducted to assess the efficacy of chronic long-term anxiolytic therapy. To our knowledge, only three double-blind, controlled studies eval-uating the long-term pharmacological treatment of GAD have been conducted. The first, a 1-year follow-up of patients who par-ticipated in a 6-month diazepam maintenance study, found that two-thirds of all patients relapsed within a 1-year period after di-azepam discontinuation. In the second study, GAD patients were treated for 6 months with buspirone or clorazepate, and reevalu-ated them after discontinuation at 6 and 40 months. The authors found that the improvement achieved in both treatment groups was sustained during the 6-month maintenance phase, with no need for an increase in medication intake, and no evidence of tolerance or abuse. At follow-up, approximately 60% of patients treated initially with clorazepate compared with 30% of patients treated initially with buspirone were experiencing at least mod-erate anxiety symptoms. Finally, in a recent study, Stocchi and colleagues (2001) found that many patients with GAD are not able to remain symptom-free for long periods without treatment. Therefore, a long-term therapy may be needed in many patients. Generally, the current recommendation for GAD treatment sug-gests a treatment period of approximately 1 year after response has been established prior to considering treatment discontinua-tion. Stress management and problem-solving techniques, along with specific psychotherapeutic approaches such as cognitive– behavioral therapy, should be attempted in addition to medica-tion treatment.