Randomized controlled trial of false safety behavior elimination therapy: a unified cognitive behavioral treatment for anxiety psychopathology. Heart rate and heart rate variability in panic, social anxiety, obsessive-compulsive, and generalized anxiety disorders at baseline and in response to relaxation and hyperventilation. Long-term treatment of anxiety disorders with pregabalin: a 1 year open-label study of safety and tolerability An open-label trial of risperidone augmentation for refractory anxiety disorders. Disorder-specific impact of coordinated anxiety learning and management treatment for anxiety disorders in primary care. Long-term effectiveness of cognitive behavioral therapy for youth with anxiety disorders. Guided and unguided Acceptance and Commitment Therapy for social anxiety disorder and/or panic disorder provided via the Internet and a smartphone application: A randomized controlled trial. Child/Adolescent Anxiety Multimodal Study (CAMS): rationale, design, and methods Anxiety Online—A Virtual Clinic: Preliminary Outcomes Following Completion of Five Fully Automated Treatment Programs for Anxiety Disorders and Symptoms Stepped care versus face-to-face cognitive behavior therapy for panic disorder and social anxiety disorder: Predictors and moderators of outcome. One-year follow-up of pharmacotherapy-resistant patients with panic disorder treated with cognitive-behavior therapy: Outcome and predictors of remission. Protocol for a randomised controlled trial investigating the effectiveness of an online e-health application compared to attention placebo or sertraline in the treatment of generalised anxiety disorder Effects of a transdiagnostic unguided Internet intervention ('velibra') for anxiety disorders in primary care: results of a randomized controlled trial. Anxiety Disorders in Primary Care: Prevalence, Impairment, Comorbidity, and Detection Design and baseline data from the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized controlled trial. Sensitivity to 35% carbon dioxide in patients with generalized anxiety disorder. Efficacy and tolerability of escitalopram in 12‐ and 24‐week treatment of social anxiety disorder: Randomised, double‐blind, placebo‐controlled, fixed‐dose study Randomized, placebo-controlled trial of risperidone for acute treatment of bipolar anxiety. Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study. A 15-year follow-up study of patients with panic disorder. Working alliance and competence as predictors of outcome in cognitive behavioral therapy for social anxiety and panic disorder in adults. Oral contraceptive use and psychiatric disorders in a nationally representative sample of women Transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for generalized anxiety disorder and comorbid disorders: A randomized controlled trial. Quality of Life and Treatment Outcome in Panic Disorder: Cognitive Behavior Group Therapy Effects in Patients Refractory to Medication Treatment Fluvoxamine CR in the long-term treatment of social anxiety disorder: the 12- to 24-week extension phase of a multicentre, randomized, placebo-controlled trial. Collaborative stepped care for anxiety disorders in primary care: aims and design of a randomized controlled trial Escitalopram in the treatment of social anxiety disorder: analysis of efficacy for different clinical subgroups and symptom dimensions. Social anxiety disorder above and below the diagnostic threshold: prevalence, comorbidity and impairment in the general population Are benzodiazepines still the medication of choice for patients with panic disorder with or without agoraphobia? Cognitive reappraisal self-efficacy mediates the effects of individual cognitive-behavioral therapy for social anxiety disorder. Anxiety in primary care: is short-term drug treatment appropriate? Effectiveness of Collaborative Stepped Care for Anxiety Disorders in Primary Care: A Pragmatic Cluster Randomised Controlled Trial Associations of fearful spells and panic attacks with incident anxiety, depressive, and substance use disorders: a 10-year prospective-longitudinal community study of adolescents and young adults. Anxiety and Depression in an Outpatient Clinic in Lesotho, Africa Long-term effectiveness and prediction of treatment outcome in cognitive behavioral therapy and sertraline for late-life anxiety disorders. Aripiprazole as augmentation treatment of refractory generalized anxiety disorder and panic disorder.
We tested the efficacy of a unified cognitive-behavioral therapy protocol for anxiety disorders . This group treatment protocol , termed false safety behavior elimination therapy ( F-SET ) , is a cognitive-behavioral approach design ed for use across various anxiety disorders such as panic disorder ( PD ) , social anxiety disorder ( SAD ) , and generalized anxiety disorder ( GAD ) .  F-SET simplifies , as well as broadens , key therapeutic elements of empirically vali date d treatments for anxiety disorders to allow for easier delivery to heterogeneous groups of patients with anxiety psychopathology . Patients with a primary anxiety disorder diagnosis ( N=96 ) were r and omly assigned to F-SET or a wait-list control . Data indicate that F-SET shows good efficacy and durability when delivered to mixed groups of patients with anxieties ( i.e. , PD , SAD , GAD ) by relatively inexperienced clinicians . Findings are discussed in the context of balancing treatment efficacy and clinical utility It remains unclear if diminished high frequency heart rate variability ( HF-HRV ) can be found across anxiety disorders .  HF-HRV and heart rate ( HR ) were examined in panic ( PD ) , generalized anxiety ( GAD ) , social anxiety ( SAD ) , and obsessive-compulsive disorder ( OCD ) relative to healthy controls at baseline and during anxiety stressors . All disorders evidence d diminished baseline HF-HRV relative to controls . Baseline HRV differences were maintained throughout relaxation . For hyperventilation , PD and GAD demonstrated greater HR than controls . Psychotropic medication did not account for HF-HRV differences except in OCD . Age and sex evidence d multiple main effects . Findings suggest that low baseline HF-HRV represents a common index for inhibitory deficits across PD , GAD , and SAD , which is consistent with the notion of autonomic inflexibility in anxiety disorders . Elevated HR responses to hyperventilation , however , are specific to PD and GAD Abstract Objective : Short-term clinical trials have demonstrated the efficacy and safety of pregabalin in the treatment of generalized anxiety disorder ( GAD ) . This study examined long-term safety and tolerability of pregabalin in patients with GAD , social anxiety disorder ( SAD ) , or panic disorder ( PD ) . Research design and methods : Patients ( n = 528 ) completing one of four r and omized , double-blind , placebo-controlled trials of pregabalin for GAD , SAD , or PD were treated , open label , with flexible-dose pregabalin ( 150–600 mg/day ) for 1 year . Clinical trial registration : NCT00150449 . Main outcome measures : The primary outcomes were safety and tolerability . Illness severity was assessed at baseline and Weeks 27/52 using the Clinical Global Impression of Severity ( CGI-S ) scale . Patients were characterized as ‘ responders ’ or ‘ non-responders ’ based on CGI-S scores ≤2 and > 2 , respectively . Analyses were performed on the total anxiety ( GAD , SAD and PD ) and GAD groups . Results : During 1 year of treatment with pregabalin  , dizziness ( 12.5 % ) was the only treatment-related adverse event ( AE ) occurring ≥10 % . Somnolence , weight gain , headache and insomnia occurred at 7.6 % , 5.5 % , 5.3 % and 4.7 % , respectively . Few treatment-related AEs were rated as severe in the total anxiety ( 5.1 % ) or GAD ( 3.6 % ) groups . Discontinuation rates due to AEs were similar ( 9.7 % and 10.6 % , respectively ) . No clinical ly significant laboratory , electrocardiogram , or other treatment-related safety findings were noted , except for treatment-related weight gain , which occurred in both the total ( 24.4 % ) and GAD ( 19.4 % ) groups . Mean CGI-S scores were similar at baseline in the total ( n = 528 ; score , 3.4 ) and GAD groups ( n = 330 ; score , 3.6 ) , and CGI-S responder rates were similar at last-observation-carried-forward endpoint ( 51.3 % and 48.1 % , respectively ) . Conclusions : Pregabalin was generally well tolerated in the long-term treatment of anxiety disorders . Improvement in illness severity was maintained over time . The key limitations of this study were that it was not r and omized and neither placebo- nor active-comparator-controlled BACKGROUND There is a paucity of data to support " next-step " treatments for the many patients with anxiety disorders who remain symptomatic after initial pharmacotherapy . METHOD Thirty patients with a primary diagnosis of an anxiety disorder-panic disorder ( PD ) , social anxiety disorder ( SAD ) , or generalized anxiety disorder (GAD)-refractory to initial pharmacotherapy with an adequate ( or maximally tolerated ) antidepressant and /or benzodiazepine trial of at least 8 weeks ' duration prior to study initiation received open-label augmentation with  flexibly dosed risperidone for 8 weeks . Participants were diagnosed using the Structured Clinical Interview for DSM-IV . RESULTS Risperidone augmentation at a mean + /- SD dose of 1.12 + /- 0.68 mg/day ( range , 0.25 - 3.00 mg/day ) result ed in a significant reduction in anxiety symptoms across disorders as measured by the Clinical Global Impressions-Severity of Illness scale and Hamilton Rating Scale for Anxiety ( HAM-A ) scores and for each disorder-specific primary outcome measure-the Panic Disorder Severity Scale , the Liebowitz Social Anxiety Scale , and HAM-A-in the intent-to-treat sample . Seventy percent ( 21/30 ) of participants completed the 8-week trial , with premature discontinuation due primarily to sedation and weight gain . CONCLUSIONS Although conclusions are limited by the open-label , relatively brief nature of this trial , our data suggest that augmentation with low-dose risperidone may be a useful option for patients with PD , SAD , or GAD refractory to adequate initial intervention with antidepressants and /or benzodiazepines . Longer-term , controlled safety and efficacy data are needed to underst and the place of risperidone augmentation in the algorithm of treatment options for refractory anxiety disorders CONTEXT Anxiety disorders commonly present in primary care , where evidence -based mental health treatments often are unavailable or suboptimally delivered . OBJECTIVE To compare evidence -based treatment for anxiety disorders with usual care ( UC ) in primary care for principal and comorbid generalized anxiety disorder ( GAD ) , panic disorder ( PD ) , social anxiety disorder ( SAD ) , and posttraumatic stress disorder ( PTSD ) . DESIGN A r and omized controlled trial comparing the Coordinated Anxiety Learning and Management ( CALM ) intervention with UC at baseline and at 6- , 12- , and 18-month follow-up assessment s. SETTING Seventeen US primary care clinics . PATIENTS Referred primary care sample , 1004 patients , with principal DSM-IV diagnoses of GAD ( n = 549 ) , PD ( n = 262 ) , SAD ( n = 132 ) , or PTSD ( n = 61 ) ( mean [ SD ] age , 43.7 [ 13.7 ] years ; 70.9 % were female ) . Eighty percent of the participants completed 18-month follow-up . INTERVENTIONS CALM ( cognitive behavior therapy and pharmacotherapy recommendations ) and UC . MAIN OUTCOME MEASURES Generalized Anxiety Disorder Severity Scale , Panic Disorder Severity-Self-report Scale , Social Phobia Inventory , and PTSD Checklist-Civilian Version scores . RESULTS CALM was superior to UC for principal GAD at 6-month ( -1.61 ; 95 % confidence interval [ CI ] , -2.42 to -0.79 ) , 12-month ( -2.34 ; -3.22 to -1.45 ) , and 18-month ( -2.37 ; -3.24 to -1.50 ) , PD at 6-month ( -2.00 ; -3.55 to -0.44 ) and 12-month ( -2.71 ; -4.29 to -1.14 ) , and SAD at 6-month ( -7.05 ; -12.11 to -2.00 ) outcomes . CALM was superior to UC for comorbid SAD at 6-month ( -4.26 ; 95 % CI , -7.96 to -0.56 ) , 12-month ( -8.12 , -11.84 to -4.40 ) , and 18- month ( -6.23 , -9.90 to -2.55 ) outcomes . Effect sizes favored CALM but were not statistically significant for other comorbid disorders . CONCLUSIONS CALM ( cognitive behavior therapy and pharmacotherapy medication recommendations ) is more effective than is UC for principal anxiety disorders and , to a lesser extent , comorbid anxiety disorders that present in primary care Cognitive behavioral therapy ( CBT ) has demonstrated favorable long-term outcomes in youth with anxiety disorders in efficacy trials . However , long-term outcomes of CBT delivered in a community setting are uncertain . This study examined the long-term outcomes of individual ( ICBT ) and group CBT ( GCBT ) in youth with anxiety disorders treated in community mental health clinics . A total of 139 youth ( mean age at assessment 15.5 years , range 11 - 21 years ) with a principal diagnosis of separation anxiety disorder ( SAD ) , social anxiety disorder ( SOP ) , and /or generalized anxiety disorder ( GAD ) were evaluated , on average , 3.9 years post-treatment ( range 2.2 - 5.9 years ) . Outcomes included loss of all inclusion anxiety diagnoses , loss of the principal anxiety diagnosis and changes in youth- and parent-rated youth anxiety symptoms . At long-term follow-up , there was loss of all inclusion anxiety diagnoses in 53 % , loss of the principal anxiety diagnosis in 63 % of participants as well as significant reductions in all anxiety symptom measures . No statistical significant differences in outcome were obtained between ICBT and GCBT . Participants with a principal diagnosis of SOP had lower odds for recovery , compared to those with a principal diagnosis of SAD or GAD . In conclusion , outcomes of CBT for  youth anxiety disorders delivered in community mental health clinics were improved at nearly 4 years post-treatment , and recovery rates at long-term follow-up were similar to efficacy trials Acceptance and Commitment Therapy ( ACT ) can be effective in treating anxiety disorders , yet there has been no study on Internet-delivered ACT for social anxiety disorder ( SAD ) and panic disorder ( PD ) , nor any study investigating whether therapist guidance is superior to unguided self-help when supplemented with a smartphone application . In the current trial , n=152 participants diagnosed with SAD and /or PD were r and omized to  therapist-guided or unguided treatment , or a waiting-list control group . Both treatment groups used an Internet-delivered ACT-based treatment program and a smartphone application . Outcome measures were self-rated general and social anxiety and panic symptoms . Treatment groups saw reduced general ( d=0.39 ) and social anxiety ( d=0.70 ) , but not panic symptoms ( d=0.05 ) compared to the waiting-list group , yet no differences in outcomes were observed between guided and unguided interventions . We conclude that Internet-delivered ACT is appropriate for treating SAD and potentially PD . Smartphone applications may partially compensate for lack of therapist support Objective To present the design , methods , and rationale of the Child/Adolescent Anxiety Multimodal Study ( CAMS ) , a recently completed federally-funded , multi-site , r and omized placebo-controlled trial that examined the relative efficacy of cognitive-behavior therapy ( CBT ) , sertraline ( SRT ) , and their combination ( COMB ) against pill placebo ( PBO ) for the treatment of separation anxiety disorder ( SAD ) , generalized anxiety disorder ( GAD ) and social phobia ( SoP ) in children and adolescents . Methods Following a brief review of the acute outcomes of the CAMS trial , as well as the psychosocial and pharmacologic treatment literature for pediatric anxiety disorders , the design and methods of the CAMS trial are described . Results CAMS was a six-year , six-site , r and omized controlled trial . Four hundred eighty-eight ( N = 488 ) children and adolescents ( ages 7 - 17 years ) with DSM-IV-TR diagnoses of SAD , GAD , or SoP were r and omly assigned to one of four treatment conditions : CBT , SRT , COMB , or PBO . Assessment s of anxiety symptoms , safety , and functional outcomes , as well as putative mediators and moderators of treatment response were completed in a multi-measure , multi-informant fashion . Manual-based therapies , trained clinicians and independent evaluators were used to ensure treatment and assessment fidelity . A multi-layered administrative structure with representation from all sites facilitated cross-site coordination of the entire trial , study protocol s and quality assurance . Conclusions CAMS offers a model for clinical trials methods applicable to psychosocial and psychopharmacological comparative treatment trials by using state-of-the-art methods and rigorous cross-site quality controls . CAMS also provided a large-scale examination of the relative and combined efficacy and safety of the best evidence d-based psychosocial ( CBT ) and pharmacologic ( SSRI ) treatments to date for the most commonly occurring pediatric anxiety disorders . Primary and secondary results of CAMS will hold important implication s for informing practice -relevant decisions regarding the initial treatment of youth with anxiety disorders . Trial registration Clinical Trials.gov NCT00052078 Background The development of e-mental health interventions to treat or prevent mental illness and to enhance wellbeing has risen rapidly over the past decade . This development assists the public in sidestepping some of the obstacles that are often encountered when trying to access traditional face-to-face mental health care services . Objective The objective of our study was to investigate the posttreatment effectiveness of five fully automated self-help cognitive behavior e-therapy programs for generalized anxiety disorder ( GAD ) , panic disorder with or without agoraphobia ( PD/A ) , obsessive – compulsive disorder ( OCD ) , posttraumatic stress disorder ( PTSD ) , and social anxiety disorder ( SAD ) offered to the international public via Anxiety Online , an open-access full-service virtual psychology clinic for anxiety disorders . Methods We used a naturalistic participant choice , quasi-experimental design to evaluate each of the five  Anxiety Online fully automated self-help e-therapy programs .  Participants were required to have at least sub clinical levels of one of the anxiety disorders to be offered the associated disorder-specific fully automated self-help e-therapy program . These programs are offered free of charge via Anxiety Online . Results A total of 225 people self-selected one of the five e-therapy programs ( GAD , n = 88 ; SAD , n = 50 ; PD/A , n = 40 ; PTSD , n = 30 ; OCD , n = 17 ) and completed their 12-week posttreatment assessment . Significant improvements were found on 21/25 measures across the five fully automated self-help programs . At post assessment we observed significant reductions on all five anxiety disorder clinical disorder severity ratings ( Cohen d range 0.72–1.22 ) , increased confidence in managing one ’s own mental health care ( Cohen d range 0.70–1.17 ) , and decreases in the total number of clinical diagnoses ( except for the PD/A program , where a positive trend was found ) ( Cohen d range 0.45–1.08 ) . In addition , we found significant improvements in quality of life for the GAD , OCD , PTSD , and SAD e-therapy programs ( Cohen d range 0.11–0.96 ) and significant reductions relating to general psychological distress levels for the GAD , PD/A , and PTSD e-therapy programs ( Cohen d range 0.23–1.16 ) . Overall , treatment satisfaction was good across all five e-therapy programs , and posttreatment assessment completers reported using their e-therapy program an average of 395.60 ( SD 272.2 ) minutes over the 12-week treatment period . Conclusions Overall , all five fully automated self-help e-therapy programs appear to be delivering promising high- quality outcomes ; however , the results require replication . Trial Registration Australian and New Zeal and Clinical Trials Registry ACTRN121611000704998 ; http://www.anzctr.org.au/trial_view.aspx?ID=336143 ( Archived by WebCite at http://www.webcitation.org/618r3wvOG OBJECTIVE To investigate predictors and moderators of treatment outcome by comparing immediate face-to-face cognitive behavioral therapy ( FtF-CBT ) to a Stepped Care treatment model comprising three steps : Psychoeducation , Internet-delivered CBT , and FtF-CBT for panic disorder ( PD ) and social anxiety disorder ( SAD ) . METHOD Patients ( N = 173 ) were recruited from nine public mental health out-patient clinics and r and omized to immediate FtF-CBT or Stepped Care treatment .  Characteristics related to social functioning , impairment from the anxiety disorder , and comorbidity was investigated as predictors and moderators by treatment format and diagnosis in multiple regression analyses . RESULTS Lower social functioning , higher impairment from the anxiety disorder , and a comorbid cluster C personality disorder were associated with significantly less improvement , particularly among patients with PD . Furthermore , having a comorbid anxiety disorder was associated with a better treatment outcome among patients with PD but not patients with SAD . Patients with a comorbid depression had similar outcomes from the different treatments , but patients without comorbid depression had better outcomes from immediate FtF-CBT compared to guided self-help . CONCLUSIONS In general , the same patient characteristics appear to be associated with the treatment outcome for CBT provided in low- and high-intensity formats when treated in public mental health care clinics . The findings suggest that patients with lower social functioning and higher impairment from their anxiety disorder benefit less from these treatments and may require more adapted and extensive treatment . CLINICAL TRIALS.GOV : Identifier : NCT00619138 Non-response to pharmacotherapy for panic disorder ( PD ) is a well-documented problem . However , little information exists to guide next-step strategies for these non-responders . In addition to pharmacologic augmentation strategies , several studies support the efficacy of cognitive-behavior therapy ( CBT ) for these patients , although data on long-term outcomes has been lacking . In this study , we provide one-year outcomes on a sample of 63 patients who completed group CBT for PD after failing to respond adequately to previous pharmacotherapy . Sustained significant benefit was found for all dimensional outcome scores , and nearly two-thirds of the sample met remission criteria . This occurred with reductions in medication use over the follow-up period . Negative predictors of remission status included comorbid dysthymia , social phobia , and generalized anxiety disorder . These results provide additional evidence for the efficacy of CBT for medication non-responders with PD Background Generalised anxiety disorder ( GAD ) is a high prevalence , chronic psychiatric disorder which commonly presents early in the lifespan . Internet e-health applications have been found to be successful in reducing symptoms of anxiety and stress for post traumatic stress disorder ( PTSD ) , panic disorder , social phobia and depression . However , to date , there is little evidence for the effectiveness of e-health applications in adult GAD . There are no studies which have directly compared e-health applications with recognised evidence -based medication . This study aims to determine the effectiveness of a  web-based program for treating GAD relative to sertraline and attention placebo . Methods / Design 120 community-dwelling participants , aged 18 - 30 years with a clinical diagnosis of GAD will be recruited from the Australian Electoral Roll . They will be r and omly allocated to one of three conditions : ( i ) an online treatment program for GAD , E-couch ( ii ) pharmacological treatment with a selective serotonin re-uptake inhibitor ( SSRI ) , sertraline ( a fixed-flexible dose of 25 - 100 mg/day ) or ( iii ) an attention control placebo , HealthWatch . The treatment program will be completed over a 10 week period with a 12 month follow-up . Discussion As of February 2010 , there were no registered trials evaluating the effectiveness of an e-health application for GAD for young adults . Similarly to date , this will be the first trial to compare an e-health intervention with a pharmacological treatment . Trial Registration Current Controlled Trials IS RCT BACKGROUND Internet-based cognitive-behavioural treatment ( ICBT ) for anxiety disorders has shown some promise , but no study has yet examined unguided ICBT in primary care . This r and omized controlled trial ( RCT ) investigated whether a transdiagnostic , unguided ICBT programme for anxiety disorders is effective in primary care setting s , after a face-to-face consultation with a physician ( MD ) . We hypothesized that care as usual ( CAU ) plus unguided ICBT would be superior to CAU in reducing anxiety and related symptoms among patients with social anxiety disorder ( SAD ) , panic disorder with or without agoraphobia ( PDA ) and /or generalized anxiety disorder ( GAD ) . METHOD Adults ( n = 139 ) with at least one of these anxiety disorders , as reported by their MD and confirmed by a structured diagnostic interview , were r and omized .  Unguided ICBT was provided by a novel transdiagnostic ICBT programme ( ' velibra ' ) . Primary outcomes were generic measures , such as anxiety and depression symptom severity , and diagnostic status at post-treatment ( 9 weeks ) . Secondary outcomes included anxiety disorder-specific measures , quality of life , treatment adherence , satisfaction , and general psychiatric symptomatology at follow-up ( 6 months after r and omization ) . RESULTS CAU plus unguided ICBT was more effective than CAU at post-treatment , with small to medium between-group effect sizes on primary ( Cohen 's d = 0.41 - 0.47 ) and secondary ( Cohen 's d = 0.16 - 0.61 ) outcomes . Treatment gains were maintained at follow-up . In the treatment group , 28.2 % of those with a SAD diagnosis , 38.3 % with a PDA diagnosis , and 44.8 % with a GAD diagnosis at pretreatment no longer fulfilled diagnostic criteria at post-treatment . CONCLUSIONS The unguided ICBT intervention examined is effective for anxiety disorders when delivered in primary care Context Anxiety and depression are both common in primary care patients , but much less attention has been paid to anxiety . Contribution The authors administered a 7-item anxiety scale ( Generalized Anxiety Disorder [GAD]-7 ) to 965 primary care patients , who also had a structured interview , to detect an anxiety disorder . Of these patients , 19.5 % had at least 1 anxiety disorder . Patients with anxiety had worse functional status , more disability days , and more physician visits , but 41 % were not being treated for any anxiety disorder . The GAD-7 had high sensitivity and good specificity for detecting a generalized anxiety disorder , panic disorder , social anxiety disorder , and posttraumatic stress disorder . Implication s Anxiety disorders are common , underrecognized , and undertreated , but they are easy to detect with a brief question naire . The Editors Anxiety and depression are the 2 most common mental health problems seen in the general medical setting ( 15 ) . Although increasing attention has been paid to anxiety , it still lags far behind depression in terms of research as well as clinical and public health efforts in screening , diagnosis , and treating affected individuals . This is unfortunate given the prevalence of anxiety and its substantial impact on patient functioning , work productivity , and health care costs ( 614 ) . More than 30 million Americans have a lifetime history of anxiety ( 15 ) , and anxiety disorders cost an estimated $ 42 billion dollars per year in the United States alone , counting direct and indirect costs ( 16 ) . The 4 most common anxiety disorders ( excluding simple phobias that seldom present clinical ly ) are generalized anxiety disorder , panic disorder , social anxiety disorder , and posttraumatic stress disorder ( PTSD ) ( 1723 ) . However , despite the substantial disability associated with each anxiety disorder and the availability of effective treatments , only a minority of patients ( 15 % to 36 % ) with anxiety are recognized in primary care ( 24 , 25 ) . In our paper , we analyze results from a large primary carebased anxiety study ( 26 ) to answer several questions . First , what is the prevalence of these 4 anxiety disorders , both individually and concurrent with one another ? Second , how do these disorders compare in functional impairment , health care use , and comorbid depressive and somatic symptom burden ? Third , how effective is a brief anxiety measure in screening for each disorder ? Compared with previous research , our study is particularly well-positioned to ascertain commonalities among anxiety diagnoses that are traditionally considered to be discrete and to determine whether a single measure can be used as a first step , common metric . This is especially salient for the busy , complex primary care setting , in which simplifying initial recognition of mental disorders may in fact make wider efforts at recognition more feasible . Methods Patient Sample The Patient Health Question naire ( PHQ ) anxiety study ( 26 ) was conducted to develop a short measure to assess generalized anxiety disorder .  Patients were enrolled from a research network of 15 primary care sites ( 13 family practice and 2 internal medicine sites ) located in 12 states and administered central ly by Clinvest , Inc. , Springfield , Missouri , from November 2004 to June 2005 . The Generalized Anxiety Disorder (GAD)-7 scale was developed and vali date d in 2149 patients . In the original study , 2982 persons were invited to participate ; of these , 2740 ( 92 % ) completed the 4-page question naire and had no or minimal missing data ( 26 ) . To minimize sampling bias , consecutive patients were approached at each site in clinic sessions until the target quota for that week was achieved . Of the 2740 participants , the first 2149 were used for development and validation of the GAD-7 scale , whereas the last 591 were used to determine the testretest reliability of the scale . Of the 2149 patients in the validation group , 1654 agreed to a telephone interview , of whom 965 were r and omly selected to undergo this interview within 1 week of their clinic visit by 1 of 2 mental health professionals : a clinical psychologist ( with a PhD ) or a senior psychiatric social worker . Contact information was sent by fax to each interviewer , who shuffled the fax sheets received each day and then drew from the stack several participants to interview that day . The 965 interviewed patients comprise the study population for this paper , and compared with the 1184 participants who did not undergo a mental health professional interview , these were more often women ( 69 % vs. 63 % ; P= 0.003 ) and had slightly higher GAD-7 anxiety scores ( 5.7 vs. 5.1 ; P= 0.010 ) but were similar in age , race , and education . Of note , we only used data from the 1184 participants not undergoing a mental health professional interview to derive the GAD-7 ( 26 ) . The study was approved by the Sterling Institutional Review Board . Study Question naire Before seeing their physicians , patients completed a 4-page question naire that included the GAD-7 ( Appendix Figure ) . This scale was shown to have good internal and testretest reliability , as well as convergent , construct , criterion , procedural , and factorial validity for the diagnosis of generalized anxiety disorder ( 26 ) . Scores on the GAD-7 range from 0 to 21 ; scores of 5 , 10 , and 15 represent mild , moderate , and severe anxiety symptoms , respectively . The first 2 items of the GAD-7 represent core anxiety symptoms , and scores on this GAD-2 subscale range from 0 to 6 . Appendix Figure . The Generalized Anxiety Disorder (GAD)-7 scale . The first 2 items constitute the GAD-2 subscale . GAD-7 2006 Pfizer Inc. All rights reserved . Used with permission . The study question naire also included questions about age , sex , education , race or ethnicity , and marital status ; the Medical Outcomes Study Short Form-20 ( SF-20 ) , which measures functional status in 6 domains ( 27 ) ; the 10-item anxiety subscale from the Hopkins Symptom Checklist ( 28 ) ; the PHQ-8 depression scale ( 29 ) ; a 3-item version  of the Social Phobia Inventory ( Mini-SPIN ) ( 30 ) ; the 5-item PHQ panic module ( 25 ) ; and the PHQ-15 somatic symptom scale ( 31 ) . Also , single-item global assessment s of anxiety , depression , and pain based on a scale of 0 ( none ) to 10 ( as bad as you can imagine ) were included . Finally , patients reported the number of physician visits and disability days during the previous 3 months . Structured Psychiatric Interview The 2 mental health professionals , while blinded to the results of the self-report research question naire , conducted structured psychiatric interviews by telephone to establish independent criteria -based diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders , fourth edition ( DSM-IV ) ( 32 ) . The interview consisted of the generalized anxiety disorder , social anxiety disorder , and PTSD sections of the Structured Clinical Interview for DSM-IV ( SCID ) ( 33 ) . Reinterview by telephone was used because of its feasibility in our multisite study and its demonstrated comparability with face-to-face research interviews ( 3436 ) . The 2 mental health professionals based diagnoses of generalized anxiety disorder and PTSD on the SCID interview . For generalized anxiety disorder , some questions were slightly modified to better assess each DSM-IV criterion . They based a diagnosis of social anxiety disorder on whether the patient met SCID diagnostic criteria and had a Mini-SPIN score of 8 or greater , because this improves the accuracy of social anxiety disorder diagnoses ( 37 ) . They based a diagnosis of panic disorder on answering yes to all 5 questions on the PHQ panic module , a threshold that reflects DSM-IV criteria and has been vali date d in both clinical ( 25 ) and population -based ( 38 ) sample s. Statistical Analysis We estimated sample size with respect to sensitivity of the  GAD-7 scale for diagnosing the target disease ( generalized anxiety disorder ) . We needed 60 participants with generalized anxiety disorder to ensure that the total width of the 95 % CI around a sensitivity proportion of 0.80 was no greater than 0.20 . Given that the estimated prevalence of generalized anxiety disorder in the primary care population was 6 % ( 18 ) , we needed a total of 1000 unselected primary care patients to have approximately 60 patients with generalized anxiety disorder . We determined the prevalence of each of the 4 anxiety disorders and compared them in patient demographic characteristics , functional status , psychiatric comorbidity , disability days , and physician visits . Consistent with previous work ( 1 , 26 , 29 , 39 ) , we replaced missing values in a scale with the mean value of the remaining items if 25 % or fewer items were missing . If more than 25 % of items were missing , the sum score was not computed and was counted as missing . The amount of missing data for any individual variable or scale score was very low ( < 1 % ) . The 15 sites did not differ in missing data . In addition to descriptive statistics , we used analysis of covariance to examine associations among each anxiety disorder and the 6 SF-20 functional status scales , self-reported disability days , and physician visitscontrolling for demographic variables ( sex , age , race , and educational level ) and study site . We ran similar models to examine the effect of the number of anxiety disorders . In all models , patients with no anxiety disorder were the reference group . We adjusted pairwise statistical comparisons by using the Bonferroni correction . Because some dependent variables displayed a skewed ( but unimodal ) distribution , we also reran the models using the rank transformation of the dependent variables . We examined the operating characteristics ( sensitivity , specificity , and positive likelihood ratio ) for a range of cutoff scores of the GAD-7 and GAD-2 for each anxiety disorder . We conducted receiver-operating characteristic curve analyses to determine the area under the curve ( AUC ) for each anxiety disorder . We calculated AUCs and performed statistical comparisons ( GAD-7 vs. BACKGROUND Depression and anxiety in cardiac patients are independently associated with adverse cardiovascular outcomes , including mortality .  Collaborative care ( CC ) programs , which use care managers to assess patients , coordinate care , and perform therapeutic interventions , have proven effective in managing depression in this population . However , no prior CC intervention has simultaneously managed depression and anxiety disorders , and there has been minimal study of CC in high-risk cardiac in patients . MATERIAL S AND METHODS The Management of Sadness and Anxiety in Cardiology ( MOSAIC ) study was a prospect i ve r and omized trial of a low-intensity CC intervention , compared to enhanced usual care , for patients hospitalized for acute coronary syndrome , heart failure , or arrhythmia , and diagnosed with depression , generalized anxiety disorder ( GAD ) , or panic disorder ( PD ) . The primary outcome measure for MOSAIC was mental health-related quality of life ( HRQoL ) , measured using the Medical Outcomes Study Short Form-12 . Additional outcomes included psychological , functional , and medical outcomes , including rehospitalizations . RESULTS A total of 183 eligible participants were enrolled ( 92 collaborative care , 91 enhanced usual care ) ; 94 % of depressed patients reported being depressed for > 1month , and 53 % of those with GAD reported clinical ly significant anxiety for > 1year . One hundred thirty-three patients had depression , 118 had GAD , and 19 had PD ; 74 participants ( 40 % ) had two or more of the disorders . CONCLUSION The MOSAIC trial will provide data regarding whether an intervention that concurrently manages these common psychiatric disorders results in meaningful improvements in HRQoL , psychiatric symptoms , and medical outcomes in cardiac patients at high risk for adverse outcomes BACKGROUND Panic disorder and generalized anxiety disorder ( GAD ) are both characterized by severe anxiety , but there is evidence that indicates a qualitative difference between these 2 anxiety disorders . To investigate the specificity of the association between carbon dioxide ( CO2 ) hypersensitivity and panic disorder and the possible relationships between panic disorder and GAD , the responses to inhalation of a gas mixture of 35 % CO2 and 65 % oxygen ( O2 ) were assessed . METHOD Fifteen patients with panic disorder , 13 patients with GAD , and 10 patients with comorbid GAD and panic disorder according to a consensus diagnosis using Diagnostic Interview Schedule Version III-R ( DIS-R ) and DSM-IV criteria , and 12 healthy controls inhaled 2 vital capacities : 1 of 35 % CO2 and 1 of compressed air . A double-blind , r and omized , crossover design was used . RESULTS GAD patients showed reactions to 35 % CO2  that were similar to those of healthy controls and significantly weaker than that of panic disorder patients . Patients with comorbid panic disorder and GAD had anxiogenic reactions similar to those of subjects with panic disorder . CONCLUSION The results of the present study support the idea that panic disorder and GAD are separate disorders that have at least some differences in pathogenetic mechanisms and suggest that the 35 % CO2 test might be a valid tool for discriminating between these 2 disorders Selective serotonin reuptake inhibitors are the pharmacological treatment of choice for the treatment of  social anxiety disorder ( SAD ) . The efficacy and tolerability of fixed doses of escitalopram were compared to those of placebo in the long‐term treatment of generalised SAD , using paroxetine as an active reference . Patients with a DSM‐IV diagnosis of SAD between 18–65 years of age were r and omised to 24 weeks of double‐blind treatment with placebo ( n = 166 ) , 5 mg escitalopram ( n = 167 ) , 10 mg escitalopram ( n = 167 ) , 20 mg escitalopram ( n = 170 ) , or 20 mg paroxetine ( n = 169 ) . Based on the primary efficacy parameter , Liebowitz Social Anxiety Scale ( LSAS ) total score at Week 12 ( LOCF ) , a significantly superior therapeutic effect compared to placebo was seen for 5 and 20 mg escitalopram and for all doses for the OC analyses . Further improvement in LSAS scores was seen at Week 24 ( OC and LOCF ) , with significant superiority over placebo for all doses of escitalopram , and 20 mg escitalopram was significantly superior to 20 mg paroxetine . Response to treatment ( assessed by a Clinical Global Impression‐Improvement score ≤2 ) was significantly higher for all active treatments than for placebo at Week 12 . Clinical relevance was supported by a significant decrease in all the Sheehan disability scores , and the good tolerability  of escitalopram treatment . It is concluded that doses of 5–20 mg escitalopram are effective and well tolerated in the short‐ and long‐term treatment of generalised SAD . Depression and Anxiety 00:000–000 , 2004 . © 2004 Wiley‐Liss , BACKGROUND The treatment of bipolar disorder is often complicated by the presence of a co-occuring anxiety disorder . Although second generation antipsychotics are being used with increasing frequency in bipolar patients , their anxiolytic effects have not been well studied in this population . METHODS The anxiolytic effect of risperidone 0.5 - 4 mg/day was tested in an 8-week , double-blind , placebo-controlled , r and omized clinical trial in 111 patients with bipolar disorder and a co-occuring panic disorder or generalized anxiety disorder ( GAD ) . The primary outcome measure was the Clinician Global Improvement-21 Anxiety scale ( CGI-21 Anxiety ) . Secondary measures included the Hamilton Anxiety Scale ( HAM-A ) and the Sheehan Panic Disorder Scale . RESULTS On the last-observation-carried forward analysis of repeated measures analysis of variance ( ANOVA ) , risperidone was not more effective than placebo for the CGI-21 Anxiety score or the other anxiety outcome measures .  Risperidone was well tolerated , with only two patients withdrawing because of adverse events . LIMITATIONS The  risperidone treated group had more patients with mixed states and lifetime panic disorder at r and omization than the placebo group . The study was limited to 8 weeks and to individuals with bipolar and comorbid panic disorder or GAD . The results may not be applicable to risperidone as an add-on treatment to mood stabilizers , or to bipolar disorder comorbid with anxiety disorders other than panic disorder or GAD . CONCLUSIONS Risperidone monotherapy was not an effective anxiolytic for bipolar patients with comorbid panic disorder or GAD in doses of 0.5 - 4 mg/day over 8 weeks of treatment . The efficacy of other second generation antipsychotics and mood stabilizers on anxiety in patients with bipolar disorder and a co-occuring anxiety disorder should be investigated in double-blind , placebo-controlled studies OBJECTIVE The authors sought to observe the long-term clinical course of anxiety disorders over 12 years and to examine the influence of comorbid psychiatric disorders on recovery from or recurrence of panic disorder , generalized anxiety disorder , and social phobia . METHOD Data were drawn from the Harvard/Brown Anxiety Disorders Research Program , a prospect i ve , naturalistic , longitudinal , multicenter study of adults with a current or past history of anxiety disorders . Probabilities of recovery and recurrence were calculated by using st and ard survival analysis methods . Proportional hazards regression analyses with time-varying covariates were conducted to determine risk ratios for possible comorbid psychiatric predictors of recovery and recurrence . RESULTS Survival analyses revealed an overall chronic course for the majority of the anxiety disorders . Social phobia had the smallest probability of recovery after 12 years of follow-up . Moreover , patients who had prospect ively observed recovery from their intake anxiety disorder had a high probability of recurrence over the follow-up period . The overall clinical course was worsened by several comorbid psychiatric conditions , including major depression and alcohol and other substance use disorders , and by comorbidity of generalized anxiety disorder and panic disorder with agoraphobia . CONCLUSIONS These data depict the anxiety disorders as insidious , with a chronic clinical course , low rates of recovery , and relatively high probabilities of recurrence . The presence of particular comorbid psychiatric disorders significantly lowered the likelihood of recovery from anxiety disorders and increased the likelihood of their recurrence . The findings add to the underst and ing of the nosology and treatment of these disorders BACKGROUND Panic disorder ( PD ) is generally regarded as a chronic condition with considerable variation in severity of symptoms . AIMS To describe the long-term outcome of naturalistically treated PD . METHODS Fifty-five out patients with PD , who participated in a placebo-controlled drug trial of the efficacy of alprazolam and imipramine 15 years ago were reassessed with the same instruments used in the original study . RESULTS Complete recovery ( no panic attacks and no longer on medication during the last 10 years ) was seen in 18 % of patients , and an additional 13 % recovered but were still on medication . Fifty-one percent experienced recurrent anxiety attacks whereas 18 % still met diagnostic criteria for PD . The incidence of agoraphobia decreased from 69 % to 20 % . Patients with agoraphobia at admission tended to have a poorer long-term outcome according to daily functioning compared with patients without agoraphobia at admission , although both groups reported improved daily functioning at follow-up . Maintenance medication was common . No benzodiazepine abuse was reported . CONCLUSION PD has a favourable outcome in a substantial proportion of patients . However , the illness is chronic and needs treatment . The short-term treatment given in the drug trial had no influence on the long-term outcome OBJECTIVE The research on the association between the working alliance and therapist competence/adherence and outcome from cognitive behavioral therapy ( CBT ) is limited and characterized by inconclusive findings . This study investigates the working alliance and competence/adherence as predictors of outcome of CBT for social anxiety disorder ( SAD ) and panic disorder ( PD ) . METHOD Eighty-two clinical ly referred patients ( 58.5 % female ; age : M = 33.6 years , SD = 10.3 ) with PD ( n = 31 ) or SAD ( n = 51 ) were treated with 12 sessions of manualized CBT by 22 clinicians with limited CBT experience in a r and omized controlled effectiveness trial . Independent assessors rated the CBT competence/adherence of the therapists using a revised version of the  Cognitive Therapy Adherence and Competence Scale  , and the patients rated the  quality of the working alliance  using the  Working Alliance Inventory-short form in therapy sessions 3 and 8 . The outcome was assessed by independent assessors as well as by patients self-report . A total of 20.7 % of the patients ( 27.5 % SAD , 9.7 % PD ) dropped out during treatment . The association between the alliance , competence/adherence , outcome and dropout was investigated using multiple regression analyses . RESULTS Higher therapist ' competence/adherence early in the therapy was associated with a better outcome among PD patients , lower competence/adherence was associated with dropout among SAD patients . Higher rating of the alliance late in the therapy was associated with a better outcome , whereas lower alliance rating late in the therapy was associated with dropout . CONCLUSION The findings indicate that the therapist competence/adherence and the working alliance have independent contributions to the outcome from CBT for anxiety disorders , but in different phases of the treatment The purpose of this study is to examine the association between  oral contraceptive use  ( any current use , duration , and type ) and major depressive disorder ( MDD ) , generalized anxiety disorder ( GAD ) , and panic disorder ( PD ) in a nationally representative sample of women in the USA . Data were drawn from 1,105 women aged 20–39 in the National Health and Nutrition Examination Surveys from 1999 to 2004 . The associations between self-reported use of oral contraceptives in the past year and DSM-IV diagnosed and subthreshold MDD , GAD , and PD in the past year were assessed comparing oral contraceptive users to all non-users , former users , and former long-term users . Women using oral contraceptives had a lower past-year prevalence of all disorders assessed , other than subthreshold MDD . When adjusted for confounders , women using oral contraceptives in the past year had significantly lower odds of subthreshold PD , compared to former users ( odds ratio ( OR ) = 0.34 , 95 % CI 0.14–0.84 ) . Effects estimates were strongest for monophasic ( versus multiphasic ) oral contraceptive users . Hormonal contraceptive use was associated with reduced risk of subthreshold PD . A potential mental health benefit of hormonal contraceptives has substantial public health implication s ; prospect i ve longitudinal studies are needed to confirm whether hormonal contraceptive use improves mental health Generalized anxiety disorder ( GAD ) can be treated effectively with either disorder-specific cognitive behavior therapy ( DS-CBT ) or transdiagnostic CBT ( TD-CBT ) . The relative benefits of DS-CBT and TD-CBT for GAD and the relative benefits of delivering treatment in clinician guided ( CG-CBT ) and self-guided ( SG-CBT ) formats have not been examined . Participants with GAD ( n=338 ) were r and omly allocated to receive an internet-delivered TD-CBT or DS-CBT intervention delivered in either CG-CBT or SG-CBT formats . Large reductions in symptoms of GAD ( Cohen 's d ≥ 1.48 ; avg . reduction ≥ 50 % ) and comorbid major depressive disorder ( Cohen 's d ≥ 1.64 ; avg . reduction ≥ 45 % ) , social anxiety disorder ( Cohen 's d ≥ 0.80 ; avg . reduction ≥ 29 % ) and panic disorder ( Cohen 's d ≥ 0.55 ; avg . reduction ≥ 33 % ) were found across the conditions . No substantive differences were observed between DS-CBT and TD-CBT or CG-CBT and SG-CBT , highlighting the public health potential of carefully developed TD-CBT and SG-CBT Background : Improvements in quality of life ( QoL ) as well as symptomatic relief are important outcomes for the treatment of panic disorder ( PD ) . The aim of this study is to assess the impact of brief cognitive behavior group therapy ( CBGT ) for panic disorder on QoL and to identify the clinical features associated with these changes . Methods : Thirty-six patients with PD refractory to pharmacological treatment took part in a treatment protocol consisting of 12 sessions of CBGT . To evaluate the changes in QoL , the WHOQOL-bref was administered before and after treatment . Results : Thirty-two patients completed the treatment . Significant improvement in all domains of QoL was observed ( p < 0.001 ) , which was associated with reductions in general and anticipatory anxiety ( p = 0.018 ) and agoraphobic avoidance ( p = 0.046 ) . Consistent with previous findings , associations between QoL and panic-free status did not reach significance in this small study ( p = 0.094 ) . Conclusions : CBGT was efficacious in the treatment of PD ; the symptoms of anticipatory anxiety and avoidance appear to be more important than episodic panic episodes in affecting Fluvoxamine CR has been reported effective in the short-term ( 12-wk ) treatment of  generalized social anxiety disorder ( social phobia ) . Social anxiety disorder ( SAD ) is , however , a chronic disorder thought to require maintenance treatment . We report on data from the extension phase of a short-term study , in order to explore the efficacy and safety profile of fluvoxamine CR ( 100 - 300 mg/d ) in the longer-term treatment of this disorder . Adult out patients with generalized social anxiety disorder ( GSAD ) at 35 centres in Europe , South Africa , and USA were included in an acute phase study ( 12 wk ) . Subjects who demonstrated at least minimal improvement by endpoint ( n=112 ) , were offered participation in an extension phase , in which medication was continued for a further 12 wk under double-blind conditions . Efficacy was assessed using the Liebowitz Social Anxiety Disorder Scale ( LSAS ) , the Clinical Global Impression Global Improvement score ( CGI-I ) , the Clinical Global Impressions Severity of Illness score ( CGI-S ) , and the Sheehan Disability Scale ( SDS ) . Safety and tolerability assessment s were also performed at regular intervals . Subjects treated with fluvoxamine CR had a numerically greater decrease in LSAS total scores than subjects treated with placebo at endpoint . Analysis of data from baseline ( day 1 ) to endpoint ( last observation carried forward ) demonstrated that this difference tended towards significance , while severity of illness on the CGI-S and disability on the SDS were significantly lower in the fluvoxamine CR group than in the placebo group . The same trends were observed when only data from weeks 12 - 24 were included in the analysis ; although the magnitude of changes was smaller in the extension phase than in the acute phase , fluvoxamine CR-treated subjects continued to show improvement compared to placebo-treated subjects . Most treatment-emergent signs and symptoms ( TESS ) were mild to moderate in severity . No unexpected abnormalities were reported on vital signs , electrocardiagrams , or laboratory investigations . These data support the long-term efficacy , safety , and tolerability of fluvoxamine CR in the treatment of GSAD . Given the prevalence , persistence , and disability associated with GSAD , and the relative paucity of long-term treatment studies of SAD , the current data set provides empirical support for the current clinical consensus that pharmacotherapy of this disorder should be continued beyond the acute phase Background Panic disorder ( PD ) and generalized anxiety disorder ( GAD ) are two of the most disabling and costly anxiety disorders seen in primary care . However , treatment quality of these disorders in primary care generally falls beneath the st and ard of international guidelines . Collaborative stepped care is recommended for improving treatment of anxiety disorders , but cost-effectiveness of such an intervention has not yet been assessed in primary care . This article describes the aims and design of a study that is currently underway . The aim of this study is to evaluate effects and costs of a collaborative stepped care approach in the primary care setting for patients with PD and GAD compared with care as usual . Methods / design The study is a two armed , cluster r and omized controlled trial . Care managers and their primary care practice s will be r and omized to deliver either collaborative stepped care ( CSC ) or care as usual ( CAU ) . In the CSC group a general practitioner , care manager and psychiatrist work together in a collaborative care framework . Stepped care is provided in three steps : 1 ) guided self-help , 2 ) cognitive behavioral therapy and 3 ) antidepressant medication .  Primary care patients with a DSM-IV diagnosis of PD and /or GAD will be included . 134 completers are needed to attain sufficient power to show a clinical ly significant effect of 1/2 SD on the primary outcome measure , the Beck Anxiety Inventory ( BAI ) . Data on anxiety symptoms , mental and physical health , quality of life , health re source use and productivity will be collected at baseline and after three , six , nine and twelve months . Discussion It is hypothesized that the collaborative stepped care intervention will be more cost-effective than care as usual . The pragmatic design of this study will enable the research ers to evaluate what is possible in real clinical practice , rather than under ideal circumstances . Many requirements for a high quality trial are being met . Results of this study will contribute to treatment options for GAD and PD in the primary care setting . Results will become available in 2011.Trial registration Escitalopram has demonstrated efficacy for the acute treatment of social anxiety disorder ( SAD ) in two placebo-controlled trials and for long-term treatment in a relapse-prevention study . Social anxiety disorder is a heterogeneous disorder . This study questions whether this new selective serotonin reuptake inhibitor is effective across different subgroups of patients . Data from two r and omised , placebo-controlled , 12-week escitalopram SAD trials were pooled . General linear models were used to determine the efficacy of escitalopram in different patient subgroups . Furthermore , a factor analysis of the primary efficacy scale , the Liebowitz Social Anxiety Scale ( LSAS ) , was undertaken , and a determination made of whether treatment effects were similar for the different symptom dimensions . Escitalopram was effective in both younger and older patients , in male and female patients , and in patients with more and less severe social anxiety symptoms .  The LSAS factor analysis showed six factors , which were differentially associated with different areas of disability .  Escitalopram was significantly superior to placebo for all six symptom dimensions . The treatment effects of escitalopram were independent of gender , symptom severity and chronicity , and comorbid depressive symptoms . A six-factor model of social anxiety symptoms is supported by the distinctive association between these symptom dimensions and different areas of disability , but did not predict differential response to escitalopram Background There is a lack of data systematic ally describing subthreshold expressions of social anxiety disorder ( SAD ) with regard to prevalence , comorbidity , and impairment . Methods This analysis was based on data from the German Health Survey ( GHS ) and its Mental Health Supplement ( GHS-MHS ) . Social anxiety disorder and its syndromes as well as other mental disorders were assessed with a st and ardized diagnostic interview ( M-CIDI ) in 4,174 adults . Results The 12-month prevalence rate for threshold SAD was 2.0 % , subthreshold and symptomatic social anxiety ( one DSM-IV criterion missing/two or more criteria missing ) was found in 3.0 and 7.5 % of the participants , respectively . As expected , threshold SAD was characterized by an elevated risk for comorbid disorders and associated with impairment in diverse areas of life . However , this was also true for the two subthreshold expressions of social anxiety , which were also significantly associated with higher comorbidity and greater impairment compared to the control group . Conclusions Our results suggest that social anxiety below the diagnostic threshold is clearly associated with adverse outcomes . Prospect i ve design s should examine the exact temporal and possible causal pathways of this burden in order to inform prevention and early intervention programs OBJECTIVE Recently , pharmacological treatment guidelines for panic disorder have changed as newer treatment options have become available . The authors examined how the use of psychotropic drugs has shifted over the course of 10 years to determine if prescribing patterns have changed to reflect these revised treatment guidelines . METHOD A total of 443 patients with panic disorder were enrolled in the Harvard/Brown Anxiety Research Project , a prospect i ve longitudinal study of anxiety disorders . These patients were interviewed over the course of 10 years to examine their use of psychotropic medications . RESULTS Despite efforts aim ed at increasing the use of selective serotonin reuptake inhibitors ( SSRIs ) in patients with panic disorder ( e.g. , APA 's practice guideline for panic disorder , Food and Drug Administration approval of particular SSRIs for the treatment of panic disorder ) , only a modest increase in their use was found . Treatment patterns for psychotropic drugs  appear to have remained stable over the past decade , with benzodiazepines being the most commonly used medication for panic disorder . In comparison , SSRI use throughout the follow-up period has remained low . Patients using an SSRI did not have a more favorable clinical course than those using a benzodiazepine , nor were there significantly better rates of remission in patients using SSRIs and benzodiazepines concomitantly . CONCLUSIONS These results highlight a gap between pharmacological treatment guidelines and actual delivery of care in that recommendations to use SSRIs to treat panic disorder are not being followed . Factors potentially associated with promoting and ignoring treatment recommendations are discussed OBJECTIVE To examine whether changes in cognitive re appraisal self-efficacy ( CR-SE ) mediate the effects of individually administered cognitive-behavioral therapy ( I-CBT ) for social anxiety disorder ( SAD ) on severity of social anxiety symptoms . METHOD A r and omized controlled trial in which 75 adult patients ( 21 - 55 years of age ; 53 % male ; 57 % Caucasian ) with a principal diagnosis of generalized SAD were r and omly assigned to 16 sessions of I-CBT ( n = 38 ) or a wait-list control ( WL ) group ( n = 37 ) . All patients completed self-report inventories  measuring CR-SE and social anxiety symptoms at baseline and post-I-CBT/post-WL , and I-CBT completers were also assessed at 1-year posttreatment . RESULTS Compared with WL , I-CBT result ed in greater increases in CR-SE and greater decreases in social anxiety . Increases in CR-SE during I-CBT mediated the effect of I-CBT on social anxiety . Gains achieved by patients receiving I-CBT were maintained 1-year posttreatment , and I-CBT-related increases in CR-SE were also associated with reduction in social anxiety at the 1-year follow-up . CONCLUSIONS Increasing CR-SE may be an important mechanism by which I-CBT for SAD produces both immediate and long-term reductions in social anxiety Thirty-six patients with generalised anxiety disorder , panic disorder or agoraphobia with panic attacks , diagnosed by DSM-III criteria , were treated with a new non-benzodiazepine anti-anxiety drug , buspirone , and with diazepam and placebo , in a cross-over design . Each patient took buspirone , diazepam and placebo for one week each in flexible dosage and balanced order . Ratings of symptomatology using the Comprehensive Psychopathological Rating Scale were made after each week 's treatment and a sub-scale used for measuring anxiety change alone was used separately . There was no overall difference in efficacy between the drugs , but when the scores for individual symptoms were analysed , diazepam was significantly superior to the other treatments for the symptom of muscle tension only . The results suggest that the common practice of giving short-term therapy with tranquilising drugs for anxiety in primary care is pharmacologically suspect Background : Collaborative stepped care ( CSC ) may be an appropriate model to provide evidence -based treatment for  anxiety disorders in primary care . Methods : In a cluster r and omised controlled trial , the effectiveness of CSC compared to care as usual ( CAU ) for adults with panic disorder ( PD ) or generalised anxiety disorder ( GAD ) in primary care was evaluated . Thirty-one psychiatric nurses who provided their services to 43 primary care practice s in the Netherl and s were r and omised to deliver  CSC  ( 16 psychiatric nurses , 23 practice s ) or CAU ( 15 psychiatric nurses , 20 practice s ) . CSC was provided by the psychiatric nurses ( care managers ) in collaboration with the general practitioner and a consultant psychiatrist . The intervention consisted of 3 steps , namely guided self-help , cognitive behavioural therapy and antidepressants .  Anxiety symptoms were measured with the Beck Anxiety Inventory ( BAI ) at baseline and after 3 , 6 , 9 and 12 months . Results : We recruited 180 patients with a DSM-IV diagnosis of PD or GAD , of whom 114 received CSC and 66 received usual primary care .  On the BAI , CSC was superior to CAU [ difference in gain scores from baseline to 3 months : -5.11 , 95 % confidence interval ( CI ) -8.28 to -1.94 ; 6 months : -4.65 , 95 % CI -7.93 to -1.38 ; 9 months : -5.67 , 95 % CI -8.97 to -2.36 ; 12 months : -6.84 , 95 % CI -10.13 to -3.55 ] . Conclusions : CSC , with guided self-help as a first step , was more effective than CAU for primary care patients with PD or GAD OBJECTIVE The concept of fearful spells ( FS ) denotes distressing spells of anxiety that might or might not qualify for criteria of panic attacks ( PA ) . Few studies examined prospect ive-longitudinal associations of FS not meeting criteria for PA with the subsequent onset of mental disorders to clarify the role of FS as risk markers of psychopathology . METHOD A representative community sample of adolescents and young adults ( N = 3021 , age 14 - 24 at baseline ) was prospect ively followed up in up to 3 assessment waves over up to 10 years .  FS , PA , anxiety , depressive , and substance use disorders were assessed using the DSM-IV/M-CIDI . Odds Ratios ( OR ) from logistic regressions were used to examine the predictive value of  FS-only ( no PA ) and PA at baseline for incident disorders at follow-up . RESULTS In logistic regressions adjusted for sex and age , FS-only predicted the onset of any subsequent disorder , any anxiety disorder , panic disorder , agoraphobia , GAD , social phobia , any depressive disorder , major depression , and dysthymia ( ORs 1.54 - 4.36 ) ; PA predicted the onset of any anxiety disorder , panic disorder , GAD , social phobia , any depressive disorder , major depression , dysthymia , any substance use disorder , alcohol abuse/dependence , and nicotine dependence ( ORs 2.08 - 8.75 ; reference group : No FS-only and no PA ) . Associations with psychopathology were slightly smaller for FS-only than for PA , however , differences in associations ( PA compared to FS-only ) only reached significance for any anxiety disorder ( OR = 3.26 ) and alcohol abuse/dependence ( OR = 2.26 ) . CONCLUSIONS Findings suggest that compared to PA , FS-only have similar predictive properties regarding subsequent psychopathology and might be useful for an early identification of high-risk individuals Objective : Past studies of psychiatric disorders in primary care in developing countries have utilized measures to determine conspicuous psychiatric morbidity ( CPM ) rather than diagnoses . Our goal was to determine the prevalence of DSM-III major depression ( DEP ) , panic disorder ( PD ) , and generalized anxiety disorder ( GAD ) in an outpatient clinic in Lesotho , Africa . Methods : As part of a larger community study , we utilized a translated version of the N.I.M.H. Diagnostic Interview Schedule to determine the prevalence of DEP , PD , and GAD in 126 r and omly selected out patients ( response rate = 77 % ) attending a general hospital clinic . We compared these data to information about demographics and symptom presentation . Results : We found twenty-nine ( 23 % ) patients with DEP , thirty ( 24 % ) with PD , and thirty-six ( 29 % ) with GAD . Forty-six ( 36 % ) had either DEP or PD , with thirteen ( 45 % ) having concurrent illness . Patients with DEP and /or PD presented with a significantly higher number of physical symptoms , and a higher percentage of symptoms that were pain or autonomic nervous system related than patients with no disorder ever . Conclusion : There is significant psychiatric morbidity of common diagnoses in outpatient clinic in Lesotho , and patients present primarily with somatic symptoms , as in developed countries . There is a need for better elucidation of cross-cultural phenomenology , medical co-morbidity as a con-founder , and help-seeking and treatment patterns in the developing world BACKGROUND Although anxiety disorders are prevalent in older adults , r and omized controlled trials of treatment effectiveness for late-life anxiety are scarce and have focused primarily on the effectiveness of psychotherapeutic interventions . However , recent findings suggest that in some cases , pharmacological treatment may be more beneficial for late-life anxiety disorders . As yet , there have been no systematic studies investigating prognostic factors for the outcome of cognitive behavioral therapy ( CBT ) and pharmacotherapy for late-life anxiety . The objective of the present study was to study long-term treatment outcomes and to explore differential predictors for both short-term and long-term treatment outcomes of sertraline and CBT for late-life anxiety disorders . METHODS Participants of a r and omized controlled trial ( RCT ) comparing sertraline and CBT for the treatment of late-life anxiety were contacted one year after completing their treatment , so that predictors for both short-term and long-term treatment outcome could be established . RESULTS Sertraline showed a greater reduction of symptoms than CBT on anxiety ( Hamilton Anxiety Rating Scale ; HARS ) and worry ( Worry Domain Question naire ) ratings at one-year follow-up . The strongest predictor for short-term CBT outcome was poor perceived health , explaining 40 % of the variance in post-treatment residual gain scores on the HARS . The strongest predictor for long-term CBT outcome was neuroticism , explaining 20 % of the variance in residual gain scores at one-year follow-up . Analyses revealed no significant predictors for treatment outcome in sertraline participants . CONCLUSIONS Our study suggests that long-term use of sertraline might be more beneficial for late-life anxiety than a 15-week CBT program . Poor perceived health and neuroticism are predictive of less improvement after CBT in anxious older adults . Implication s of these findings are discussed INTRODUCTION Individuals with anxiety disorders often remain symptomatic despite treatment with a first-line pharmacologic agent . More research examining pharmacotherapy augmentation strategies to improve outcomes is needed . METHODS In an 8-week , open-label , prospect i ve augmentation study , we examined the efficacy and tolerability of the novel antipsychotic agent aripiprazole for adult out patients with generalized anxiety disorder ( n=13 ) or panic disorder ( n=10 ) who remained symptomatic despite treatment for at least 8 weeks with an adequate ( or maximally tolerated ) dose of typical pharmacotherapy . RESULTS Aripiprazole augmentation was associated with a significant reduction in Clinical Global Impressions-Severity scores ( paired t=4.41 , df=22 , P<.001 ) in the intent-to-treat sample of 23 individuals . Three subjects ( 13 % ) discontinued due to sedation , chest discomfort , and restlessness , respectively . CONCLUSION These data provide preliminary evidence that aripiprazole may be a useful augmentation strategy for individuals with generalized anxiety disorder or panic disorder who show a limited response to initial pharmacotherapy
Our review confirms the usefulness of long-term pharmacological treatments for PD and GAD and suggests that they can provide further improvement over that obtained during short-term therapy .
Paroxetine , escitalopram , and clonazepam can be effective for long-term treatment of PD .
Pregabalin and quetiapine can be effective for long-term treatment of GAD , while preliminary suggestions emerged for agomelatine and vortioxetine .
We did not find any evidence for determining the optimal length and /or dosage of medications to minimize the relapse risk .
Many aspects of long-term pharmacological treatments for  anxiety disorders ( AnxDs ) are still debated .
We undertook an up date d systematic review of long-term pharmacological studies on panic disorder ( PD ) , generalized anxiety disorder ( GAD ) , and social anxiety disorder ( SAD ) .