5.0. The Results

Generalized Anxiety Disorder undergoes primary care to cure the psychological and Somatic symptoms in efforts to try lower the side effects profile. The recommended Gad treatment can either be conducted by the use of Psychological therapy or application of the antidepressants[1].

5.1. Non-Pharmacological Therapy for GAD

According to the study conducted by the University of Massachusetts, Suffolk University, Boston University and Boston VA Healthcare System International Review Boards, there were no adverse effects reported the entire duration of the study.  A total of 31 participants took part in the study and assigned to (ABT, n=15) Treatment or (n=16) Waitlist[2]. Furthermore, the results from the ACS scale scores illustrated an excellent internal consistency with a total of 0.94. Clients treated with the acceptance-based behavioural therapy reported fewer difficulties in emotion regulation and fear of emotional responses, as well as greater tolerance of uncertainty and perceived control over anxiety than those on the waitlist control condition[3].

Figure 1

 

Figure 2

The Figure 2, above demonstrates the two weeks test-retest reliability(R=0.78) of the internal consistency[4].

Furthermore, study shows that there has been an evolution in the psychological treatment for GAD from the general understanding of the anxiety to the medications to the concepts of pathological worry. However, GAD treatment has empirically supported the use of the more comprehensive anxiety-reduction strategies such as applied relaxation strategy (AR). Research is considerate of the use of the AR as compared to other anxiety –reduction strategies. The data depicts AR as an appropriate treatment for GAD’s worry, severity, depression and general psychology[5].

In demonstrating the data a sample (N=65) involved 43 women and 22 men in the initial Diagnosis of GAD, all the participants were Francophone. In the study, 38.5 years was (SD=12.0) was the participants’ mean age with 15.3 average years of education (SD=3.4).  Moreover, the research included an ethnic composition of the sample with 2% Asian, 2% Hispanic, 5% Middle Eastern and 91% White/European. Besides, 26.6% constituted unemployed sample, student sample was 10.9%, and 62.5 % sample population was employed[6].

 

Figure 3

Another study carried out by Leichsenring et al, indicated that Cognitive Behavioural Therapy is an efficacious treatment for generalized anxiety disorder[7]. The results suggested CBT and short term psychodynamic psychotherapy are beneficial for the patient with GAD. This includes a research that was carried out for a 30 weekly sessions using the primary measure of the Hamilton scale. Furthermore, a research conducted by Evans and the colleagues found that despite CBT’s effectiveness in the treatment of GAD gave a percentage of the patients struggle with residual symptoms. Therefore, it is suggested that Mindfulness-based cognitive therapy be used to help people GAD[8].

Furthermore, there are the secondary conditions included the panic with or without agoraphobia n=27[9].

Figure 4

The study found that there are significant improvements regarding the symptoms of anxiety and depression in both cognitive Behavioural Therapy (CBT) and Short-term Psychodynamic Psychotherapy (STPP)[10].  Following a six month’s follow-up, these effects become stable. However, the treatment of the anxiety and worry was superior with the use of the CBT. The research found that STPP and CBT achieved significant short-term improvements in anxiety and depressions for patients with GAD. This model projected usefulness by reporting the high effects of stress and worry, which become stable and showed improvement within the one year follow-up period.

5.2. Pharmacological Treatment of GAD

5.1.1. SSRIs

5.1.1.1 Citalopram

Citalopram is one of the Selective Serotonin Re-uptake Inhibitors (SSRIs) used to treat anxiety disorders. The study selected 34 participants with more than 60 years of age and with DSM-IV anxiety disorder. They were assigned a Hamilton Anxiety Rating Scale o17 or higher[11]. The responses were determined to the score by use of (1) as (Vey much improved), and (20 indicated (Much improvement). Therefore, the responses along with the side effects got compared to use of the Citalopram and Placebo on a chi-square test and linear modelling[12].

Figure 5

5.1.1.2 Escitalopram

Adults often face the Generalized Anxiety Disorder (GAD). However, there has been insufficient data top facilitate safe treatment.   A study conducted had 177 participants with age exceeding 60 years with a randomised GAD diagnosis. They received either Escitalopram or placebo for two weeks 10-20 MG/D of Escitalopram (n=85) and Placebo (n=92)[13]. This evidence Shows the patient disposition for the14-week study period for all groups. A total of 98 patients (14%) withdrew from the study during the 12-week, double-blind period (Table 2), and withdrawal rate ranged from 10.8% to 18.7%[14]

Figure 6

5.1.1.3 Paroxetine

  The study assessed the efficacy of the fixed doses of Paroxetine to treat generalised anxiety disorder. The Sheehan Disability Scale measured this disorder. In 8 weeks, the reductions in the total score on the Hamilton anxiety scale indicated greater higher levels for paroxetine[15].  Another research indicated that more patients withdrew prematurely due to adverse events from the paroxetine group than the escitalopram group (22.6% vs. 6.6%; p=0.02, Fisher exact test)[16]. No adverse event was reported as a reason for discontinuation from escitalopram treatment by more than one patient; for paroxetine, headache, insomnia, and nausea each led to the discontinuation of two or more patients. The incidence of-treatment emergent adverse events overall was 88.7% for paroxetine and 77.0% for escitalopram[17]. Of note, sexual adverse events (ejaculation disorder, anorgasmia, and decreased libido), constipation, and insomnia were more frequent in paroxetine-treated patients than in escitalopram-treated patients. Conversely, diarrhea and upper respiratory tract infection were more likely to be reported by escitalopram- than paroxetine treated patients[18].

Figure 7

5.1.1.4 Sertraline

The study evaluated Sertraline’s efficacy and tolerability in the treatment of anxiety disorder. The sample population of adult outpatients with DSM-IV and generalised anxiety disorder was performed using Hamilton’s Anxiety Rating scale with a total score of 18 or more. 50-150 mg/day of sertraline got randomly assigned to patients for 12 weeks[19].

Figure 8

5.2. SNRIs

5.2.1 Duloxetine

A flexible-dose study was conducted to evaluate the efficacy and safety of Duloxetine 30-120mg once in daily in the treatment of GAD in older patients. The study was a double-blind survey conducted to patients with at least 65 years of age. The procedure performed was either for duloxetine (N=151) or Placebo (N=140)[20].  In an internet study conducted by Two-part piecewise growth models were fitted for the treatment group only and included follow-up data at 6 months. On PSWQ there was a significant negative slope during the follow-up phase, b ¼ _0.1, 95% CI [_0.17, _0.03], indicating that participants continued to improve during the follow up phase[21].

 

Figure 9

5.1.3. Vortioxetine

Table 1: Vortioxetine safety measures (Bidzan, L., et, al., 2012)

Term
Placebo

(n=150)

 
Vortioxetine 5mg

 

( n=150)

 

 
Events
Subjects %
 

Events

Subjects

Gastrointestinal disorders
106
 

55(36.7)

137
 

74 (49.3)

Nervous system disorders
10
 

9(6.0)

19
18(12.0)

Headache
14
4(2.7)
10
9(6.0)

 

5.1.4. Pregabalin

The GAD diagnosis by use of Pregabalin in patients was evaluated. Patients were placed to eight weeks of flexible –dose treatment with PGB (300=600mg/day), Placebo or (VXR) 72-255 mg/day)[22].

Figure 10

PGB was a safe and effective treatment of GAD, with a significantly earlier onset of anxiolytic activity than VXR [23].On the other hand, Non-pharmaceutical methods demonstrated advanced levels in coping strategies due to heightened emotional intensity and adverse reactions to emotions[24].

6.0 Discussion

In the analysis, all the randomised, placebo-controlled and double-blind trials indicated that SSRIs and SSNRIs in patients with GA demonstrated efficacy for all individual agents put on trial[25].  Evidence indicated that drug treatment reported an increased level of treatment over the non-drug therapies.

6.1 Non-pharmaceutical

Specifically, the research illustrated that patients that underwent BBT showed reduced difficulties in emotional responses and regulation. At the same time, they depicted an increase in tolerance of uncertainty and perceived control over anxiety[26]. Most of the non-pharmaceutical theoretical models also suggested a certain level of reliability for the treatment of the GAD components. However, the finds illustrated the importance of therapy based on a specific model to give a clear picture of the categorical impacts of a particular treatment model. Cognitive Behavioural Therapies focus on heightening the emphasis on individual’s tolerance and uncertainty.  The non-drug GAD treatment includes Relaxation, hypnotherapy, Rogerian nondirective and supportive therapy[27]. Furthermore, non-drug therapies Cognitive Behaviour Therapy, and relaxation methods serve as the primary methods used in the treatment anxiety disorders during the randomised controlled trials. The research study proves that CBT is shown useful in the treatment of all DSM-IV categories of Anxiety disorders in all the Randomized Control Trials and other types of meta-analyses.

6.1.2 Cognitive Behavioural Therapy (CBT) for GAD

Nondrug therapies are used in the assessment for various cases of phobias and obsessions. Cognitive behavioural therapy aims at enhancing emotional responses and at the same time obtains extinction to emotional[28]. Furthermore, the emphasis on the acceptance-based and mindfulness procedures, the participants indicated a greater control on a variety of anxiety –related emotion and events following treatments[29]. The findings are in support with the fact that a declined distress level goes along with the mindfulness and acceptance based interventions. There is a bigger role played by mindfulness in influencing an experience. BBT is therefore likely to alter the patient’s expectations about their abilities to take control of certain situations in their lives[30]. Such as situation is likely to influence the perceived control measurement, therapists engage with the clients abut are less likely to have an overall influence over each other’s live. In this phase, clients are only encouraged to take part in actions that are more likely to fall under their control.

The interaction for the subscale scores focuses at Depression, anger, anxiety and Positive Affect. Patients in the treatment conditions face great decrease in the amount of fear of emotions as well as difficulties in emotional controls. Furthermore, additional variance occurs in CBT that proves effectiveness over AR method. The results indicated similarities in the 12 and 24 months follow-ups. Moreover, CBT once more proved superiority over WL in providing change to depressive and general anxiety symptoms[31]. Furthermore, AR method also proved superiority over the WL on at least one outcome of overall severity in the assessment for ADIS-iv patients. However, the long outcomes of CBT and AR conditions indicated little differences in the groups used in the sample. This is to show that when the data from the two groups were compared, the results proved that participants had achieved significant progress in the follow-up phase. Therefore, the tests appeared that the CBT formula used to tests the patients had a substantial impact on the patient’s treatment by decreasing their worry after the procedure was terminated. A significant factor is that the CBT process helps the patients to begin changing their beliefs and behaviours and the change process is likely to progress even at in the post-treatment phase[32]. Clients can take control of their own actions.  On the hand, the AR was less likely to continue with positive outcomes in two years after the treatment process is conducted.

The non-drug GAD therapy for CBT is a more considerable change by making the clinical improvement from the pre-treatment to post-treatment[33]. The comparisons between CBT and AR adequately meets the needs of the individuals with GAD and promote the use of the behavioural approach to solve issues of anxiety disorders.

Shortcomings in the articles

Significantly, the articles on non-medical approaches to treat GAD disorders are not limited to flaws, for instance, there is the likelihood that CBT was favoured in its treatment of patients compared to other non-drug treatments. However, the treatment methodology vastly depends on the specific therapist’s ability to carry out the treatment process. The study relatively failed to assess the therapist’s competencies, therefore, posing as an alternative limitation to the study as their integrities often reflect their abilities to work[34]. Finally, the study’s weakness revealed in the way it used the self-recruited samples.

6.3 Drug Treatment for GAD

6.3.1 Citalopram

Citalopram is one of the best treatments applied in the early stages of patient treatment following GAD symptoms. The data in figure 5 shows that Citalopram is efficacious in the management of the acute anxiety disorders in the older aged people. Over the 8 weeks’ observation, the participants reflected an advanced level of improvement. In the current study, there was significant toleration of Citalopram as compared to the side effects posed by Placebo[35]. The UKU side Effects rating scale found that citalopram reduced the overall number of side effects. Similarly, the drug has achieved the treatment to the late-life depression under the comorbid anxiety.

Furthermore, the study related with some limitations. First, the study featured a small sample; the results are likely to later with an increase in the number of participants. Besides, the effectiveness of the drug may differ in accordance to the gender, for example, GAD treatment cannot be generalised for both men and women groups unless the sample considers the selection of the same sample size. Finally, the study shows that Citalopram is only sufficient to the elderly patients as opposed to the young[36].

6.3.2 Escitalopram
The study shows that Escitalopram was tolerated and was safe to use. Patients placed on the Escitalopram had higher improvement rates compared to placebo in all the defined efficacy aspects. Escitalopram has benefits on both the psychological and somatic symptoms of GAD. The drug led to the overall improvement of the patient’s condition and that it the reason it is globally recognised. The comparison between the Escitalopram and Placebo indicated that those put on the Escitalopram dosage had higher ratings in the quality of their life. During the treatment period, there was a considerable reduction in the GAD symptoms and became consistent with the efficacy of 10 mg/day dosage[37]. During the trials, the 10mg/day dosage of escitalopram in the depression trials addressed the comorbid GAD. On the other hand, Escitalopram was well tolerated by the GAD patients more than the placebo[38]. It is because the drug has continuously reflected progress in various depression trial studies. Escitalopram’s tolerability is significantly higher than other GAD treatments since it serves appropriately in it evaluated with warranted safety and efficacy. The Escitalopram’s dosage was relatively superior to the Placebo on a 10 and 20 mg.  Escitalopram dosage was efficacious in the mid-term treatment of the generalised anxiety disorder. Moreover, the drug has a few safety risks as compared to other therapeutic procedures and antidepressants.

6.3.3Paroxetine

The study provided proof that paroxetine doses were significantly useful in the treatment of GAD. The process follows an eight-week placebo-controlled survey under the fixed dosage of 20 and 40gm/day. Previous research has also demonstrated increased effectiveness in the drug’s ability to alleviate the GAD symptoms in patients and similarly regarded with superiority over the placebo dosage. With the use of the Hamilton scale, clear signs described a higher level of improvement in the paroxetine sample during the early period of study such as the fourth week. According to the results, the drug indicated as much as 50% of the reduction in the severity rates of GAD symptoms[39]. As a result, the cut is clinically significant since the critical symptoms in the early stages of treatment declined during the onset of the 8th week. Furthermore, the paroxetine patients that completed the study were indistinguishable from the healthy population as the response rates had escalated to 80%. The drug was validated by measurements that scored it as user-friendly across the treatment groups to indicate that the patients demonstrated a heightened level of improvement.

In a review of the results, Paroxetine was well tolerated and also had a lower dropout rate of 11% for the treatment groups. It is a sign to show that higher dosage of the paroxetine would be more useful in individual cases. The drug has thus established as an appropriate treatment for depression along with other anxiety disorders frequently associated with the generalised anxiety. The drugs’ versatile nature allows it to manage any drug that would, in any case, come along with the ability to manage chronic suffering and impairments that usually pose a medical challenge.

6.3.4 Sertraline

In the study, Sertraline indicated a symptom reduction following a short-term treatment procedure. It resulted in the improvement of both improvements in the quality of work productivity as well as life[40]. It regards the generalised anxiety disorder with an impairment which received similar treatment for the social anxiety and panic. Furthermore, treatments with sertraline reported good toleration by the patients. Also, Sertraline demonstrated a greater level of efficacy in comparison to the Placebo on the psychic and somatic anxiety issues.  Figure 8 demonstrated the patient’s response to the drug diagnosis whereby the treatment with Sertraline became tolerated with the symptoms similar adverse and severe events. The study properly demonstrates well effective responses to elderly patients. However, the study was limited to the use of the small sample sizes insufficient to demonstrate the entire population in the nation.

6.4 SNRIs

6.4.1 Duloxetine

This study used the randomised, multicenter, double-blind and placebo-controlled to evaluate the tolerability and efficacy in older GAD patients. The results illustrated that the patient’s use of the duloxetine 30-120 mg reduced anxiety symptoms faster than the sample placed on the placebo. Furthermore, the patients put on Duloxetine were more likely to give superior patient improvements as compared to placebo-treated. The patients got improvement during their experiences in the acute therapies[41]. The success of the study is that Duloxetine treatment was likely to initiate higher completion rate and lower discontinuation rates. Up to 60.3% of duloxetine-treated patients demonstrated more improvement in the cognition and depressive symptoms as compared to Placebo[42]. Placebo had more levels of nausea, diarrhoea, dry mouth and constipation as it corresponds to the placebo.

Another major significance in this study demonstrated high efficacious in the improvement of the diseases severity, functioning and enjoyment of life for adult patients with GAD. The safety and tolerability of duloxetine treatment were consistent with the treatment of the GAD. Patients that received duloxetine experienced a higher improvement in their anxiety symptoms as compared to placebo[43]. It is because there were no serious adverse events that occurred in the duloxetine groups. Duloxetine experienced a 31.1% of discontinuation as compared to 16.2% of placebo-treated patients[44]. Other signs experienced included dizziness, but also experienced improvement in the overall symptom of severity than those who received placebo. Duloxetine-treated patients faced a reduction in the symptom level with anxious mood, tension, muscular pain, respiratory symptoms and anxiety behaviours compared with placebo-treated patients. 87% of the patients with GAD improve following their complaints on depression, sleep disturbances, physical illnesses and pain[45].   Moreover, the finding indicated that duloxetine helped attain a reduction in the somatic symptoms associated with GAD since it significantly assisted to break the cycle between worry and physical complaints. The Sheem Disability Scale illustrated that duloxetine-treated patients had more significant improvements when compared to placebo-treated patients.  Duloxetine 60 mg and 120mg were well tolerated hence the low discontinuation rates tom adverse events which did not give a significant variation between the two groups[46]. However, the treatment exceeding two weeks indicated an increase in the duloxetine adverse events as compared to the placebo-treated patients.

Notably, nausea was the only adverse effect that contributed to the particular rates of study discontinuation.  However, most of the patients that experienced nausea could tolerate it leading only to 2.7% of the interruption. After discontinuation, the most recognised symptom was dizziness[47].

To sum up, the finding of the study should be considerate of the limitations such as short-term treatment of 9 weeks was used to generalise the results of the study. Also, efficacy, safety and tolerability of the drug could not be executed through a direct comparison one type of medication.

4.4.2Vortioxetine

Vortioxetine improves the patients’ outcomes in the total score.  Besides, Vortioxetine is considerably important over the placebo when used in an eight weeks anxiety sub-score.  All patients with severe GAD have a more substantial benefit from the treatment with vortioxetine than placebo. The trial failed to illustrate a failure in the experiments as the inverse probability of the patients to respond. For instance, there was a significant difference indicated in the mean change for the baseline scores of the Vortioxetine vs placebo.  Primary analysis stated the benefits of Vortioxetine against Placebo

4.4.3 Pregabalin

The investigation was conducted to study the treatment duration to demonstrate the tremendous significance for pregabalin efficiency as compared to placebo.  Some of the side effects of the drug include tiredness, dry mouth, vomiting, bloating, headache and dizziness.

4.4.4 To evaluate the efficacy and tolerability of non-drug therapy versus drug therapy in the treatment of Generalised anxiety disorder (GAD)

The Generalized anxiety disorder (GAD) a standard therapy in the clinical setting. For purposes of an appropriate remedy for the diseases, the study utilised various approaches to come up with pharmacological treatment for GAD.  The specific factors use included the response rates to acute therapy, prediction of response and treatment tolerability. On the basis of the recent study, the pharmacological treatment recommended for the treatment of the generalised anxiety disorder.

The GAD disorder is based on various categories of somatic and psychic anxiety symptoms that include the irritability, fatigue, restlessness, and disturbed sleep[48]. The findings of the randomised placebo-controlled trials indicate that less than 60% of the patients responded to placebo and 75% to SSRI[49]. The tolerability structure meant that medication is an essential consideration in the long-term treatment. The only adverse effects SSRIs and SNRIs included a headache, nausea and nervousness.  Alternatively, some of the problems as SSRIs and SNRIs in the long-term treatment include sexual dysfunction, discontinuation, and persistent disturbance sleep.

The most disturbing part to use the pharmacological treatment is that one cannot predict the patients that will respond well or have a limited response to treatment[50]. GAD is a chronic disorder that requires naturalistic recovery. It calls for the longitudinal fluidity of the diagnosis especially the use of the antidepressants that help to reduce the risk of recurring symptoms. The value of the long-term involvement of the antidepressants based on the factor that there is the possibility of these symptoms to reoccur. The study has recommended six consecutive months for the treatment. Most of the double-blind treatment for placebo goes up to 18 months after the first response.

The sampling account between the drug and non-drug treatment yields the specific estimation of the increased use of the antidepressants among the youths and the older adults.  In this case, age plays a vital role in ensuring that the observed disorders display a high rate of observable symptoms. Active treatment by use of the antidepressants is importantly associated with high levels of somatic symptoms during and after the severity symptoms appear[51]. Despite the differences in the antidepressants used to treat patients, they are considered bests in the analysis of the anxiety disorders. Findings determine the relationship in the studies with continuous outcomes with

Discontinuation symptoms

  The discontinuation symptoms involve stopping treatment with many psychotropic drugs such as the SSRIs and SNRIs. Discontinuation symptoms occur on antidepressant withdrawal during the period when more patients. The influence of more extended treatment compounds results in a more prolonged duration of dosage as well as higher treatment that influence dropout by severity. For instance, the study proves that after an eight weeks study 20mg/d paroxetine or placebo, there were reports of anxiety, nausea, or dizziness[52].

The recommended guidelines for SSRI pharmacological treatment of GAD to give a balance on the efficacy and tolerability, an alternative medication intervention to withdraw from these drugs include switching drugs and combining medication with psychological treatment. Sometimes, mental intervention becomes essential for some patients especially the young ones. Cognitive behavioural therapy repeatedly became identified as the most critical psychological treatment due to its superior control of the patient’s management. Cognitive behaviour therapy is an effective treatment of GAD problem[53]. The study has found that CBT takes more time that of medication. However, no single treatment is based suited for every patient.

Conclusion

Primary and secondary caregivers often encounter generalised Anxiety disorder (GAD). The patients face recurrent and abrupt panic attacks. Such conditions can have an impact on the patient’s quality of life and in the process disrupt their day to day activities[54].  These conditions require essential considerations. Typically, there are physical symptoms associated with GAD such as chronic headaches, restlessness, sleep disturbance, irritability and muscle tension.  Various scales are used to establish a diagnosis of the severity of the disease.

Efficacy side effects and lengths of drug and non-drug treatment

Drugs vary in the psychotherapies and psychotropic for the treatment of the patient with GAD.  Randomized double-blind in placebo-controlled trials provide the correct evidence for the efficacy of some SSRIs, SNRIs, and other drugs. There are the long-term and short-term treatments which have the adverse effects when given to patients for long periods exceeding 12 months. The exact type of treatment is determined by factors such as the patient’s preference for the approach as well as the presence of the comorbid depression or the history of the same. Doctors guide patients to understand that the healing process is not immediate, sometimes, these symptoms are seen to worsen in the first stages of treatment and gets better with time. GAD patients have a definite room for improvement with the use of the more efficacious and acceptable pharmacological approaches to manage the disorder.

Basically, study shows that medication and psychotherapies are effective in the treatment of the suspected anxiety disorder[55].  The non-drug therapy is an important foundation in treating the Anxiety disorder. Sometimes, patient education is a relevant step to manage the patient’s behaviour. Most of the non-drug symptoms are recommended to lower the anxiety related symptoms. Usually, specialists advise their patients to avoid using things that trigger the symptoms. Although non-drug treatment is considered tolerable and efficacious, the symptoms are more likely to recur in future hence the need to come up with treatment. There is an identified dose-response relations linked to tolerance and side effects. These are the adverse effects evaluated in the use of drug prescribed interventions.

More often psychotherapy and relaxation Therapies have various approaches like CBT. CBT applied to such methods like relaxation, exposure, breathing, and cognitive restructuring[56].   For effectiveness, GAD patients undergo weekly therapies with at least eight weeks.  Cognitive Behaviour Therapies are useful in the GAD treatment. It helps to assists the cognitive patterns primarily by the introduction of thinking strategies that enable patients to relax. The patient’s particular anxieties got connected to his or her needs. These therapeutically approaches have minimal adverse effects; however, they are still linked to the mild increase in the anxiety[57].

Besides, mindfulness is another psychotherapy process that helps to support the CBT as well as other therapies[58]. These processes are necessary in the stress reduction and also reduce the anxiety symptoms. Despite the effectiveness in the care, there are rebound symptoms that occur with psychotherapy more than it does in the medications

The data based on the UK treatments. The table 1 above describes the procedures using placebo for responses along with Vortioxetine[59]. Furthermore, all comparisons made along with placebo in the long run, depicted active treatments by specific drugs. Furthermore, all the results show that alternative drugs became favoured over the Placebo. The mixed treatments meta-analysis encouraged the use of the drug treatment for the generalized anxiety disorder in UK. The analysis placed duloxetine, pregnable, escitalopram with the quickest responses, remissions and withdrawals following adverse events[60]. Evidence shows that low rate of GAD treatment is uncalled for, this because the various non pharmacological and drug have proved efficacy. The drugs have a well-designed ability to intervene the clinical issue especially the use of SSRI’s and SNRI’s[61]. The development of the drugs is generally a preferable methodology that will help suppress the number of young and aged patients.  Drug and dosage have to be specified to each patient and help meet their health needs.  The well-being therapy along other proven methods can turn into improved medical treatment desirable for each specific medical GAD issue.

Moreover, the efficacy and tolerability of medications for GAD and other psychiatric disorder have been continuously instrumental to provide evidence that support the clinical decision making. The short-term and long-term studies have proved efficacy is revealed in various drug interventions for up to 26 weeks. More scales have proved   measurement dimensions aggregated to reduce the symptoms. The multiple drugs used in the clinical trials maintained a lower withdrawal rate that helped to pose a balance between efficacy and tolerability[62]. These interventions are worthy have added little adverse effects. It was consistent with the various trials that have been carried out in the previous studies. In some cases some factors influenced the outcome of the investigation; such factors include the sample size, dosages and design. The Clinical bottom line should be structured in a manner that all the patients suspected of the mental disorders are assessed to serve the first goals of therapy which involves the identification of the primary patterns that seem irrational and replace them with the rational ones. Most clinicians have not been able to choose whether to use the drug dosage or not. In such a scenario, it is advisable that CBT or any other non-drug therapy is utilized. This is because the strategy is free form dependency risks and impairment .However, a study conducted on the patients with an age higher than 60 years illustrated that they required the use of the sertraline. The patient’s ability to use and cope with the side effects should sometimes serve as the basis to guide decisions on drug therapy.

Preliminary, research has found that the use of drugs will moderate the psychological disorders[63]. Besides, there is the need to consolidate the psychotherapy with the help of memory experiences which leverage the patient’s ability to disrupt the inconsistencies in the memories. Continuous outcomes standardised the possible pair of treatments with the probability to shows a relative intervention without uncertainty. The pharmacological management proved the drugs by the improvement[64]. The study shows that a given number of patients showed the possibilities to worry about their dependency levels on medication. As a result, there has been pharmacological effectiveness with satisfactory.

 

 

 

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Lenze J, Rollman B, Shear K, Dew M, Pollock B, Ciliberti C, Constantino, Snyder S, Shi P, Spitznagel and Butters M. Escitalopram for Older Adults with Generalized Anxiety Disorder A Randomized Controlled Trial. American Medical Association, 2009; 3001(3).
Dahlin M, Anderson G, Magnusson K, Johansson T, Sjogren J, Hakansson A, Pettersson M, Kadowaki A, Cuijpers P, and Carlbrign P. Internet-delivered acceptance-based behaviour therapy for generalized anxiety disorder: A randomized controlled. Behaviour Research and Therapy, 2016; 77; 86-95.
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Brenes G, Danhauer S, Lyles MHogan P, Miller M. Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults with Generalized Anxiety Disorder A Randomized Clinical Trial. JAMA Psychiatry, October 2015, 72(10).
Mewton L, Wong N, and Andrews G. The effectiveness of internet cognitive behavioural therapy for generalized anxiety disorder in clinical practice. Depression and Anxiety; 2012; 29:843–849.
Rothschild A, Mahableshwarkar A, Jacobsen P, Yan Minhjin and Sheehan D. Vortioxetine (Lu AA21004) 5 mg in generalized anxiety disorder: Results of an 8-week randomized, double-blind, placebo-controlled clinical trial in the United States. European Neuropsycho-pharmacology; 2012; 22, 858–866.
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End Notes

[1] Cvjetkovic-Bosnjak M, Soldatovic-Stajic B, Babovic S, Boskovic1 K, and Jovicevic M. Pregabalin versus sertraline in generalized anxiety disorder. An open label study, European Review for medical and pharmacological Science, 19:2120-2124, 2015.

 

[2] Trenor, M, Erisman, S, Salters-Pedneault, K, Roemer, L and Orsillo, S. An acceptance-based behavioral therapy for GAD: Effects on outcomes from three theoretical models. Depression Anxiety, 28(2): 127–136; 2011.

[3] Rickels K, Zaninelli R, McCafferty J, Bellew, K Iyengar M, and Sheehan D. Paroxetine Treatment of Generalized Anxiety Disorder: A Double-Blind, Placebo-Controlled Study. Journal Psychiatry, 2003; 160:749–75.

 

[4] Trenor, M, Erisman, S, Salters-Pedneault, K, Roemer, L and Orsillo, S. An acceptance-based behavioral therapy for GAD: Effects on outcomes from three theoretical models. Depression Anxiety, 28(2): 127–136; 2011.

[5] Dugas J, Brillon P, Savard P, Turcotte J, Gaudet A, Ladouceur R, Leblanc R, and Gervais N. Concordia UniversityA Randomized Clinical Trial of Cognitive-Behavioral Therapy and Applied Relaxation for Adults with Generalized Anxiety Disorder. Behavioral Therapy, 41(1): 46–58; 2010.

[6] Dugas J, Brillon P, Savard P, Turcotte J, Gaudet A, Ladouceur R, Leblanc R, and Gervais N. Concordia UniversityA Randomized Clinical Trial of Cognitive-Behavioral Therapy and Applied Relaxation for Adults with Generalized Anxiety Disorder. Behavioral Therapy, 41(1): 46–58; 2010

[7] Leichsenring F, Salzer S, Jaege U, Kächele H, Kreische R, Leweke F, Rüger U, Winkelbach C, and Leibing E. Short-Term Psychodynamic Psychotherapy and Cognitive-Behavioral Therapy in Generalized Anxiety Disorder: A Randomized, Controlled Trial. Am J Psychiatry, 2009; 166:875–881.

[8] Evans S, Fernando, Findler M, Stowell C, Smart C, and Haglin, D. Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorder, 2008; 716-721.

 

[9] Rickels K, Zaninelli R, McCafferty J, Bellew, K Iyengar M, and Sheehan D. Paroxetine Treatment of Generalized Anxiety Disorder: A Double-Blind, Placebo-Controlled Study. Journal Psychiatry, 2003; 160:749–75.

[10] Leichsenring F, Salzer S, Jaege U, Kächele H, Kreische R, Leweke F, Rüger U, Winkelbach C, and Leibing E. Short-Term Psychodynamic Psychotherapy and Cognitive-Behavioral Therapy in Generalized Anxiety Disorder: A Randomized, Controlled Trial. Am J Psychiatry; 166:875–881, 2009.

[11] Lenze E, Mulsant B,  and Shear K. Dew M, Miller M, Pollock, B, Houck P, Tracey B,  and Reynolds C. Efficacy and Tolerability of Citalopram in the Treatment of Late-Life Anxiety Disorders: Results From an 8-Week Randomized, Placebo-Controlled Trial. Am J Psychiatry 162:146–150; 2005.

[12] Lenze E, Mulsant B,  and Shear K. Dew M, Miller M, Pollock, B, Houck P, Tracey B,  and Reynolds C. Efficacy and Tolerability of Citalopram in the Treatment of Late-Life Anxiety Disorders: Results From an 8-Week Randomized, Placebo-Controlled Trial. Am J Psychiatry 162:146–150; 2005

[13] Lenze E, Mulsant B,  and Shear K. Dew M, Miller M, Pollock, B, Houck P, Tracey B,  and Reynolds C. Efficacy and Tolerability of Citalopram in the Treatment of Late-Life Anxiety Disorders: Results From an 8-Week Randomized, Placebo-Controlled Trial. Am J Psychiatry 162:146–150; 2005.

[14] Baldwin D, Karina A, Huusom T, and Melham E. Escitalopram and paroxetine in the treatment of generalized anxiety disorder Randomized, placebo-controlled, double-blind study. British Journal of psychiatry, 2005, 189; 264-272.

 

[15] Rickels K, Zaninelli R, McCafferty J, Bellew, K Iyengar M, and Sheehan D. Paroxetine Treatment of Generalized Anxiety Disorder: A Double-Blind, Placebo-Controlled Study. Journal Psychiatry, 2003; 160:749–75.

[16]Bielski R, Bose A, and Chang C. A Double-Blind Comparison of Escitalopram and Paroxetine in the Long-Term Treatment of Generalized Anxiety Disorder. Annals of Clinical Psychiatry, 2005; 17(2):65–69.

 

[17] Bielski R, Bose A, and Chang C. A Double-Blind Comparison of Escitalopram and Paroxetine in the Long-Term Treatment of Generalized Anxiety Disorder. Annals of Clinical Psychiatry, 2005; 17(2):65–69.

 

[18] Bielski R, Bose A, and Chang C. A Double-Blind Comparison of Escitalopram and Paroxetine in the Long-Term Treatment of Generalized Anxiety Disorder. Annals of Clinical Psychiatry, 2005; 17(2):65–69.

 

[19] Cvjetkovic-Bosnjak M, Soldatovic-Stajic B, Babovic S, Boskovic1 K, and Jovicevic M. Pregabalin versus sertraline in generalized anxiety disorder. An open label study, European Review for medical and pharmacological Science, 2015; 19:2120-2124.

[20] Alaka K, Montejo A, Noble W, and Lily, E. Efficacy and safety of duloxetine in the treatment of older adult patients with generalized anxiety disorder: A randomized… International Journal of Geriatric Psychiatry, 2014; 29: 978–986.

[21]Dahlin M, Anderson  G, Magnusson  K, Johansson T, Sjogren J, Hakansson A, Pettersson M, Kadowaki A, Cuijpers P,  and  Carlbrign P.  Internet-delivered acceptance-based behaviour therapy for generalized anxiety disorder: A randomized controlled. Behaviour Research and Therapy, 2016; 77; 86-95.

[22] Kaspera S, Giancarl H,  Michael N, Ameringen V, Petraliad A, Mandelb F,  Baldinettie, F and Borwin B,. Efficacy of pregabalin and venlafaxine-XR in generalized anxiety disorder: resu Alaka K, Montejo A, Noble W, and Lily, E. Efficacy and safety of duloxetine in the treatment of older adult patients with generalized anxiety disorder: A randomized… International Journal of Geriatric Psychiatry, 29: 978–986; 2014. lts of a double-blind placebo-controlled 8-week trial

[23] Petralia A, Mandel F, Baldinetti F, and Bandelow B. Efficacy of pregabalin and venlafaxine-XR in generalized anxiety disorder: results of a double-blind, placebo-controlled 8-week trial. Int Clin Psychopharmacol, 2009, 24:87–96.

[24] Montgomery S, Zornberg G, Kasper S, and Pande AC. Efficacy and safety of pregabalin in the treatment of generalized anxiety disorder: a 6week, multicenter, randomized, doubleblind, placebo-controlled comparison of pregabalin and venlafaxine. Journal of Clinic Psychiatry.67(5):77182, 2006.

[25] Alaka K, Montejo A, Noble W, and Lily, E. Efficacy and safety of duloxetine in the treatment of older adult patients with generalised anxiety disorder: A randomised… International Journal of Geriatric Psychiatry, 2014; 29: 978–986.

[26] Trenor, M, Erisman, S, Salters-Pedneault, K, Roemer, L and Orsillo, S. An acceptance-based behavioral therapy for GAD: Effects on outcomes from three theoretical models. Depression Anxiety, 2011; 28(2): 127–136.

[27] Leichsenring F, Salzer S, Jaege U, Kächele H, Kreische R, Leweke F, Rüger U, Winkelbach C, and Leibing E. Short-Term Psychodynamic Psychotherapy and Cognitive-Behavioral Therapy in Generalized Anxiety Disorder: A Randomized, Controlled Trial. Am J Psychiatry, 2009; 166:875–881.

[28] Leichsenring F, Salzer S, Jaege U, Kächele H, Kreische R, Leweke F, Rüger U, Winkelbach C, and Leibing E. Short-Term Psychodynamic Psychotherapy and Cognitive-Behavioral Therapy in Generalized Anxiety Disorder: A Randomized, Controlled Trial. Am J Psychiatry, 2009; 166:875–881.

[29] Evans S, Fernando, Findler M, Stowell C, Smart C, and Haglin, D. Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorder, 2008; 716-721.

 

[30] Dugas J, Brillon P, Savard P, Turcotte J, Gaudet A, Ladouceur R, Leblanc  R, and  Gervais N.  A Randomized Clinical Trial of Cognitive-Behavioral Therapy and Applied Relaxation for Adults with Generalized Anxiety Disorder. Behavioural Therapy, 2010; 41(1): 46–58.

[31] Evans S, Fernando, Findler M, Stowell C, Smart C, and Haglin, D. Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorder, 2008; 716-721.

[32] Roemer E, Orsillo S, and Salters-Pedneault. Efficacy of an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder: Evaluation in a Randomized Controlled Therapy. Consult Clin Psychol, 2008; 76(6): 1083–1089

[34]Dugas J, Brillon P, Savard P, Turcotte J, Gaudet A, Ladouceur R, Leblanc R, and Gervais N. Concordia UniversityA Randomized Clinical Trial of Cognitive-Behavioral Therapy and Applied Relaxation for Adults with Generalized Anxiety Disorder. Behavioral Therapy, 2010; 41(1): 46–58.

[35] Lenze E, Mulsant B,  and Shear K. Dew M, Miller M, Pollock, B, Houck P, Tracey B,  and Reynolds C. Efficacy and Tolerability of Citalopram in the Treatment of Late-Life Anxiety Disorders: Results From an 8-Week Randomized, Placebo-Controlled Trial. Am J Psychiatry 2005; 162:146–150.

[36] Lenze E, Mulsant B,  and Shear K. Dew M, Miller M, Pollock, B, Houck P, Tracey B,  and Reynolds C. Efficacy and Tolerability of Citalopram in the Treatment of Late-Life Anxiety Disorders: Results From an 8-Week Randomized, Placebo-Controlled Trial. Am J Psychiatry 2005; 162:146–150.

[37] Bielski R, Bose A, and Chang C. A Double-Blind Comparison of Escitalopram and Paroxetine in the Long-Term Treatment of Generalized Anxiety Disorder. Annals of Clinical Psychiatry, 2005; 17(2):65–69.

[38] Lenze J, Rollman B, Shear K, Dew M, Pollock B, Ciliberti C, Constantino, Snyder S, Shi P, Spitznagel and Butters M. Escitalopram for Older Adults With Generalized Anxiety Disorder A Randomized Controlled Trial. American Medical Association, 2009; 3001(3).

[40] Cvjetkovic-Bosnjak M, Soldatovic-Stajic B, Babovic S, Boskovic1 K, and Jovicevic M. Pregabalin versus sertraline in generalized anxiety disorder. An open label study, European Review for medical and pharmacological Science, 2015; 19:2120-2124.

[41] Koponen H, Allgulander C, Erickson J, Dunayevich E, Pritchett Y, Detke M, Ball S, and Russel M. Efficacy of Duloxetine for the treatment of Generalized anxiety disorder: implications for primary care physicians, 2007 Pdf.

[42] Alaka K, Montejo A, Noble W, and Lily, E. Efficacy and safety of duloxetine in the treatment of older adult patients with generalized anxiety disorder: A randomized… International Journal of Geriatric Psychiatry, 2014; 29: 978–986.

[43] Rynn M, Russel J, Erickson J, Detke M, Ball S, Dinkel J, Rickels K, and Raskin J. Efficacy and Safety of Duloxetine in the Treatment of Generalized Anxiety Disorder: A Flexible-dose, Progressive titration, Placebo-controlled Trial, PDF

[44] Alaka K, Montejo A, Noble W, and Lily, E. Efficacy and safety of duloxetine in the treatment of older adult patients with generalized anxiety disorder: A randomized… International Journal of Geriatric Psychiatry, 2014; 29: 978–986.

[45] Evans S, Fernando, Findler M, Stowell C, Smart C, and Haglin, D. Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorder, 2008; 716-721.

[46] Crits- Christoph P, Newman M, Rickels K, Gallop R, Gibbons M, Hamilton J, Ring-Kurtz S and Pastva A. Combined medication and cognitive therapy for generalized anxiety disorder. Journal of anxiety disorders, 2004 25; 1087-1094

[47] Pande A, Crockatt J, Feltner D, Janney C, Smith W , Weisler R, Londborg,  P, Bielski R, Zimbroff D, Davidson J, and Liu-Dumaw M. Pregabalin in Generalized Anxiety Disorder: A Placebo-Controlled Trial. Am J Psychiatry, 2003; 160:533–540.

[48] . Rothschild A, Mahableshwarkar A, Jacobsen P, Yan Minhjin and Sheehan D. Vortioxetine (Lu AA21004) 5 mg in generalized anxiety disorder: Results of an 8-week randomized, double-blind, placebo-controlled clinical trial in the United States. European Neuropsycho-pharmacology; 2012; 22, 858–866.

[49] Alaka K, Montejo A, Noble W, and Lily, E. Efficacy and safety of duloxetine in the treatment of older adult patients with generalized anxiety disorder: A randomized… International Journal of Geriatric Psychiatry, 2014; 29: 978–986.

[50] . Rothschild A, Mahableshwarkar A, Jacobsen P, Yan Minhjin and Sheehan D. Vortioxetine (Lu AA21004) 5 mg in generalized anxiety disorder: Results of an 8-week randomized, double-blind, placebo-controlled clinical trial in the United States. European Neuropsycho-pharmacology; 2012; 22, 858–866.

[51] Rynn M, Russel J, Erickson J, Detke M, Ball S, Dinkel J, Rickels K, and Raskin J. Efficacy and Safety of Duloxetine in the Treatment of Generalized Anxiety Disorder: A Flexible-dose, Progressive titration, Placebo-controlled Trial, PDF.

[52] Davidson J, Bose A, Korotzer A, and Zheng H. Double-blind, placebo controlled, flexible-dose study. Depression and Anxiety 19:234-240, 2004.

[53] Dahlin M, Anderson G, Magnusson K, Johansson T, Sjogren J, Hakansson A, Pettersson M, Kadowaki A, Cuijpers P, and Carlbrign P.  Internet-delivered acceptance-based behaviour therapy for generalized anxiety disorder: A randomized controlled. Behaviour Research and Therapy, 2016; 77; 86-95.

[54] Bielski R, Bose A, and Chang C. A Double-Blind Comparison of Escitalopram and Paroxetine in the Long-Term Treatment of Generalized Anxiety Disorder. Annals of Clinical Psychiatry, 2005; 17(2):65–69.

[55] Leichsenring F, Salzer S, Jaege U, Kächele H, Kreische R, Leweke F, Rüger U, Winkelbach C, and Leibing E. Short-Term Psychodynamic Psychotherapy and Cognitive-Behavioral Therapy in Generalized Anxiety Disorder: A Randomized, Controlled Trial. Am J Psychiatry, 2009;166:875–881.

[56] Evans, S. Ferrando S, Marianne F, Stowell C, Smart C, and Haglin D. Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 2008; 716-721.

[57] Mewton L, Wong N, and Andrews G. The effectiveness of internet cognitive behavioural therapy for generalized anxiety disorder in clinical practice. Depression and Anxiety; 2012; 29:843–849.

[58] Brenes G, Danhauer S,  Lyles MHogan P,Miller M. Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy For Rural Older Adults with Generalized Anxiety Disorder A Randomized Clinical Trial. JAMA Psychiatry, October 2015, 72(10).

[59] Rothschild A, Mahableshwarkar A, Jacobsen P, Yan Minhjin and Sheehan D. Vortioxetine (Lu AA21004) 5 mg in generalized anxiety disorder: Results of an 8-week randomized, double-blind, placebo-controlled clinical trial in the United States. European Neuropsycho-pharmacology; 2012; 22, 858–866.

[60] Davidson J, Bose A, Korotzer A, and Zheng H. Double-blind, placebo controlled, flexible-dose study. Depression and Anxiety 19:234-240, 2004.

[61] Lenze E, Mulsant B,  and Shear K. Dew M, Miller M, Pollock, B, Houck P, Tracey B,  and Reynolds C. Efficacy and Tolerability of Citalopram in the Treatment of Late-Life Anxiety Disorders: Results From an 8-Week Randomized, Placebo-Controlled Trial. Am J Psychiatr, 2005;162:146–150.

[62] Davidson J, Bose A, Korotzer A, and Zheng H. Double-blind, placebo controlled, flexible-dose study. Depression and Anxiety 19:234-240, 2004.

[63] Brenes G, Danhauer S, Lyles MHogan P, Miller M. Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults with Generalized Anxiety Disorder A Randomized Clinical Trial. JAMA Psychiatry, October 2015, 72(10).

s[64] Lenze J, Rollman B, Shear K, Dew M, Pollock B, Ciliberti C, Constantino, Snyder S, Shi P, Spitznagel and Butters M. Escitalopram for Older Adults With Generalized Anxiety Disorder A Randomized Controlled Trial. American Medical Association, 2009; 3001(3).