The Cochrane Abstract below is a su...

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by dint of an interpretation that will help clinicians bring forward evidence into practice. Cheryl A. Flynn MD M and YC Christine Chen, MPH at hand a clinical scenario and question based upon the Cochrane Abstract, along with the evidence-based answer and a replete critique of the abstract.

This clinical contentment conforms to AAFP criteria for evidence-based continuing medical education (EB CME) EB CME is clinical satisfy presented with practice recommendations supported by the agency of evidence that has been systematically reviewed from an AAFP-approved source. The practice recommendations in this activity are available at http://www.cochrane.org/cochrane/revabstr/AB003592.htm

Clinical Scenario

A 40-year-old man is in counseling for generalized anxiety disorder (GAD). He asks about pharmacotherapeutic treatment options, expressing a desire to avoid addictive medications.

Clinical Question

Are antidepressants an effective and acceptable treatment for GAD?

Evidence-Based Answer

As a cluster antidepressants are an effective short-term treatment for GAD. Compared with placebo, about five to six patients must be treated to acquire one additional patient who replys to therapy. Side effects meet the eye more frequently with antidepressants than with placebo, unless they are not severe enough to require discontinuation of treatment.

Practice Pointers

Psychotherapy and anxiolytics have been the mainstay of therapy for GAD. Antidepressants also are considered a possible treatment because of the answer occurring in patients with comorbid depression. The Cochrane Collaboration has planned a series of reviews onward GAD to include antidepressants, 5HT-1 agonists, benzodiazepines, and psychotherapy.

This Cochrane review, the first of the series, finds symptomatic benefit in short-term studies of antidepressants in patients with GAD unless without concurrent depressive disorders (relative risk, 070; 95 percent confidence interval, 060 to 082 for nonresponse). Compared with placebo, approximately six patients ne to be treated for the same additional patient to have a clinical replication (NNT = 5.5). Antidepressants were more likely than placebo to cause side drifts (e.g., drowsiness, dry mouth, dizziness, constipation, nausea, somnolence, sexual dysfunction), if it be not that dropout rates were similar between the form into groupss The majority of primary care patients with GAD will have about comorbid depressive symptoms; these data would be awaited to generalize. Nevertheless, the long-term benefit is unknown.

The small number of studies for any single medication and the limited number of direct comparisons of antidepressants furnish little data to guide physicians in choosing an antidepressant. Tricyclic antidepressants and newer selective serotonin reuptake inhibitors were similar in efficacy: the NNT for imipramine was 40 compared with 50 for venlafaxine and 67 for paroxetine. No differences were noted between imipramine and paroxetine in the single application of mind that compared them. Sertraline was shown in the same study to be effective in children and adolescents.

remedy interactions, costs, and physician and patient prioritys may guide the choice of antidepressant used to treat GAD. Imipramine dosages generally ranged from 50 to 150 mg by day (cost, $10 to $30 by month); paroxetine was given in a dosage of 20 mg by day (cost, $85 per month); and venlafaxine dosages ranged from 75 to 225 mg daily (cost $50 to $150 by month), with no identifiable differences in reply rates by dosage. (Average wholesale take away froms based on Red book. Montvale, NJ: Medical Economics Data, 2003)

This patient likely would benefit from a trial of antidepressant therapy. Because he is young and has no comorbidities, imipramine at a dosage of 50 mg daily would be a reasonable first choice of medication. The dosage should be titrated upward until reply is noted, as was done in greatest in quantity of the trials.

REFERENCE

1 Kapczinski F Lima M Souza J Schmitt R Antidepressants for generalized anxiety disorder. Cochrane Database Syst Rev 2003: CD003592 Accessed October 2003 at: http://www.cochrane. org/cochrane/revabstr/AB003592.htm.

RELATED ARTICLE: Cochrane abstract.

Background. Pharmacologic treatments have been used luckily to treat GAD. In past decades, the mainstay of treatment has been the benzodiazepine and nonbenzodiazepine anxiolytics. Data emerging athwart the past two decades have shown that antidepressants may be equally effective as anxiolytics for treating GAD. The use of antidepressants may be advantageous, because GAD has a high comorbidity ratio with major depressive disorder (62 percent) and dysthymia (37 percent)

Objectives. To assess the efficacy and acceptability of antidepressants for treating GAD.

Search strategy. The authors (1) searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controll Trials Register (through May 2002) Anxiety Neurosis (through May 2002) and Cochrane Controll Trials Register (through May 2002) MEDLINE (1966 to May 2002) and LILACS (1982 to May 2002) They also searched hints personal communications, conference abstracts, and main division chapters on the treatment of GAD.