Brazilian Psychiatric Association treatment guidelines for generalized anxiety disorder: perspectives on pharmacological and psychotherapeutic approaches

Generalized anxiety disorder is a highly prevalent mental disorder. Previous data indicate that more than 18 million Brazilians suffer from this condition. Traditionally, generalized anxiety disorder has been considered a mild mental health disorder, despite its links to lower life expectancy, cardiovascular disease, and suicide. The aim of this article is to combine elements of systematic and critical reviews to produce a synthesis of the best evidence about generalized anxiety disorder treatment. Systematic reviews, meta-analyses, and randomized controlled trials were included. The descriptor used in the search was "generalized anxiety disorder," which resulted in 4,860 articles and seven other studies, of which 59 were selected. Antidepressants and benzodiazepines were indicated, as was pregabalin, and atypical antipsychotics, such as quetiapine, have been studied. Individual cognitive behavior therapy (third wave) has proven effective. There is extensive literature on many effective treatments for generalized anxiety disorder. The present review summarizes the therapeutic possibilities, emphasizing those available in Brazil. Further studies are needed to compare other available medications, assess psychotherapies and new treatments in greater depth, as well as to assess the ideal duration of therapy. Registration number: PROSPERO CRD42021288323.

Brazilian Psychiatric Association guidelines for the treatment of generalized anxiety disorder (GAD). Pharmacological and Psychotherapy approach. Perspectives.

OBJECTIVE: To combine elements of a systematic review and critical review to produce best evidence synthesis for the treatament of GAD. METHOD: There was included systematic reviews, metanalysis, and randomized controlled trials. Descriptor used was "generalized anxiety disorder", resulting in 4860 articles and 7 other studies, of which 59 were selected. RESULTS: Antidepressants and benzodiazepines are indicated, as well as pregabalin. From, atypical antipsychotics quetiapine has been studied. Cognitive behavior therapy (third wave of behavioral and cognitive therapies) as well as individual CBT proven to be effective. CONCLUSION: There is extensive literature on many effective treatments for GAD. The present work summarizes the therapeutic possibilities, emphasizing those available in the Brazil. Further studies are still needed to compare other available medications, to assess psychotherapies in more depth, new treatments and specially to assess the ideal time for maintaining therapy.

Benzodiazepine use in Sao Paulo, Brazil.

OBJECTIVES: To report the prevalence and factors associated with the use of benzodiazepines in the general population and those with a mental health condition in the metropolitan area of São Paulo, Brazil. METHODS: 5,037 individuals from the Sao Paulo Megacity Mental Health Survey data were interviewed using the Composite International Diagnostic Interview, designed to generate DSM-IV diagnoses. Additionally, participants were asked if they had taken any medication in the previous 12 months for the treatment of any mental health condition. RESULTS: The prevalence of benzodiazepine use ranged from 3.6% in the general population to 7.8% among subjects with a mental health condition. Benzodiazepine use was more prevalent in subjects that had been diagnosed with a mood disorder as opposed to an anxiety disorder (14.7% vs. 8.1%, respectively). Subjects that had been diagnosed with a panic disorder (33.7%) or bipolar I/II (23.3%) reported the highest use. Individuals aged ≥50 years (11.1%), those with two or more disorders (11.2%), those with moderate or severe disorders (10%), and those that used psychiatric services (29.8%) also reported higher use. CONCLUSION: These findings give an overview of the use of benzodiazepines in the general population, which will be useful in the public health domain. Benzodiazepine use was higher in those with a mental health condition, with people that had a mood disorder being the most vulnerable. Furthermore, females and the elderly had high benzodiazepine use, so careful management in these groups is required.

Efficacy of an acceptance-based group behavioral therapy for generalized anxiety disorder.

BACKGROUND: Generalized anxiety disorder (GAD) shows the weakest treatment response among anxiety disorders. This study aimed at examining whether an acceptance-based group behavioral therapy (ABBT) for patients in a Brazilian anxiety disorders program, combining mindfulness and exposure strategies, can improve clinical outcome when compared with a standard nondirective supportive group therapy (NDST). METHODS: Ninety-two individuals diagnosed with GAD were randomized to receive 10 sessions of either ABBT or NDST. Assessments at pretreatment, midtreatment, posttreatment, and 3-month follow-up comprised the following outcome measures: Hamilton Anxiety Rating Scale (HAM-A), Penn State Worry Questionnaire (PSWQ), Depression Anxiety and Stress Scale (DASS), and the Clinical Global Impressions (CGI). The World Health Organization Quality of Life (WHOQOL) was administered at pretreatment and posttreatment. RESULTS: The mixed-effects regression models for DASS-stress, Hamilton Anxiety Interview, and CGI showed a significant effect for Time and the Time × Treatment effect, but not for the Treatment main effect. Similarly, there was a significant Time × Treatment effect for the PSWQ, but not main effects of Time or Treatment. Altogether, these data indicate that symptoms decreased in both conditions across treatment and follow-up, and that the rate of change was more rapid for those participants in the ABBT condition. We found no differences between groups from pretreatment to posttreatment in DASS-anxiety or any secondary outcome measure, but for the physical health domain of WHOQOL, which was faster in ABBT. CONCLUSIONS: Both groups showed good clinical outcomes, but in general, participants of the ABBT group improved faster than those in the NDST group.

Benzodiazepine use in Sao Paulo, Brazil

OBJECTIVES: To report the prevalence and factors associated with the use of benzodiazepines in the general population and those with a mental health condition in the metropolitan area of São Paulo, Brazil. METHODS: 5,037 individuals from the Sao Paulo Megacity Mental Health Survey data were interviewed using the Composite International Diagnostic Interview, designed to generate DSM-IV diagnoses. Additionally, participants were asked if they had taken any medication in the previous 12 months for the treatment of any mental health condition. RESULTS: The prevalence of benzodiazepine use ranged from 3.6% in the general population to 7.8% among subjects with a mental health condition. Benzodiazepine use was more prevalent in subjects that had been diagnosed with a mood disorder as opposed to an anxiety disorder (14.7% vs. 8.1%, respectively). Subjects that had been diagnosed with a panic disorder (33.7%) or bipolar I/II (23.3%) reported the highest use. Individuals aged ≥50 years (11.1%), those with two or more disorders (11.2%), those with moderate or severe disorders (10%), and those that used psychiatric services (29.8%) also reported higher use. CONCLUSION: These findings give an overview of the use of benzodiazepines in the general population, which will be useful in the public health domain. Benzodiazepine use was higher in those with a mental health condition, with people that had a mood disorder being the most vulnerable. Furthermore, females and the elderly had high benzodiazepine use, so careful management in these groups is required.

Misinterpretation of the Borg's Rating of Perceived Exertion Scale by patients with panic disorder during ergospirometry challenge.

INTRODUCTION: The most widely used instrument to measure perceived exertion or exercise intensity is the Borg's Rating of Perceived Exertion (RPE) Scale. Panic attacks are aversive experiences that may be triggered by bodily sensations such as palpitations, breathlessness or dizziness due to increasing autonomic distress, prior sensitisation to panic and fear conditioning. The consequence is catastrophic interpretation of bodily sensations of arousal in general, which can lead to misinterpretation of exertion or exercise intensity. PURPOSE: To verify the effectiveness of the Borg's RPE Scale as a measure of perceived effort in panic disorder subjects. METHODS: The study enrolled 72 subjects: the control group (C, healthy sedentary subjects, n=30) and patients with panic disorder (PD, n=42). All subjects were submitted to an ergospirometry challenge. Perceived exertion RPE scores and heart rate at 90% VO2max were compared between groups. RESULTS: Patients with PD showed lower levels of maximal oxygen consumption, when compared with C group [VO2max (mL/kg/min): PD=29.42±6.50xC=34.51±5.35; Student's t-test=-3.51; p <0.05]. Furthermore, among PD subjects, the maximum heart rate during ergospirometry challenge was lower than expected [predict max HR (bpm)=200.85±6.33xheart rate test (bpm)=178.86±7.28; Z=-5.64; p<0.05]. Perceived exertion, as measured by RPE, was also overestimated in relation to heart rate at 90% of maximum oxygen consumption compared with controls (RPE90%VO2max: PD=18.93±0.55xC=16.67±0.60; U=8.00; Z=7.42; p<0.05). CONCLUSIONS: The present study findings suggest that the Borg's RPE Scale may not be an appropriate measure of subjective exertion among subjects with panic disorder performing a cardiopulmonary exercise test.

Placebo effect after prefrontal magnetic stimulation in the treatment of resistant obsessive-compulsive disorder: a randomized controlled trial.

Many patients with obsessive-compulsive disorder (OCD) do not achieve satisfactory symptom improvement with conventional treatments. Here, we evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) applied over the right dorsolateral prefrontal cortex (rDLPFC) in patients with treatment-resistant OCD. This was a double-blind randomized trial involving 30 treatment-resistant OCD outpatients, allocated to have either sham or active high-frequency rTMS (over the rDLPFC) added to their treatment regimens for 6 wk, with 6 wk of follow-up. Active rTMS consisted of 30 applications (figure-of-eight coil; 10 Hz at 110% of motor threshold; 1 session/d; 40 trains/session; 5 s/train; 25-s intertrain interval). At weeks 0, 2, 6, 8, and 12, we applied the Yale-Brown Obsessive-Compulsive Scale (YBOCS), Clinical Global Impression (CGI) scale, 14-item Hamilton Anxiety Rating Scale (HAMA-14), 17-item Hamilton Depression Rating Scale (HAMD-17), and 36-item Short-form Health Survey. The primary outcome measure was a positive response (≥ 30% improvement in YBOCS score, together with a 'much improved' or 'very much improved' CGI - Improvement scale rating). One patient in each group showed a positive response (p=1.00). For YBOCS score, there was significant effect of time (F=7.33, p=0.002) but no significant group effect or group×time interaction. In treatment-resistant OCD, active rTMS over the rDLPFC does not appear to be superior to sham rTMS in relieving obsessive-compulsive symptoms, reducing clinical severity, or improving treatment response, although there is evidence of a placebo effect.

[Psychiatric comorbidities decrease quality of life in chronic migraine patients]. / Comorbidade psiquiátrica diminui a qualidade de vida de pacientes com enxaqueca crônica.

INTRODUCTION: Chronic migraine is a common, debilitating condition affecting quality of life and social functioning with significant impact. Migraine is highly comorbid with anxiety and mood disorders, but little is known about psychiatric comorbidities impact in the migraine patient quality of life. METHOD: Fifty patients with chronic migraine diagnosed according to the International Headache Society (2004) were interviewed and met diagnostic criteria for mental disorders, according to the structured interview SCID-I/P and were evaluated by the SF-36 Health Survey questionnaire. Patients were divided in the following groups: chronic migraine with both mood and anxiety disorders, with only anxiety disorders, with generalized anxiety disorder, with only a mood disorder, and without psychopathology. The scores in the group without psychopathology were compared with the other groups. All eight domains of the SF-36 scale were compared in those groups. RESULTS: Significantly lower (p<0.05) quality of life was found on all eight SF-36 domains for CM psychiatric comorbidity patients compared to no-co morbidity patients. On the SF-36 General Health domain alone, quality of life was not significantly lower for all four CM psychiatric comorbidity groups. On the SF-36 Physical Aspects domain alone, quality of life was not significantly lower only for the Anxiety Disorders group. CONCLUSION: Chronic migraine comorbidity with mental disorder is a significant factor affecting patients' quality of life.

Exercício aeróbio como terapia de exposição a estímulos interoceptivos no tratamento do transtorno de pânico: [revisão] / Aerobic exercise as exposure therapy to interoceptive cues in panic disorder: [review]

Os ataques de pânico são representados por um período distinto no qual há o início súbito de intensa apreensão, temor ou terror, freqüentemente associados com sentimentos de catástrofe iminente, diagnosticado em aproximadamente 10 por cento da população. O Transtorno de Pânico é um transtorno de ansiedade que se caracteriza pela recorrência de ataques de pânico: crises súbitas de mal-estar e sensação de perigo ou morte iminente, acompanhadas de diversos sintomas físicos e cognitivos. Os indivíduos com Transtorno de Pânico apresentam, caracteristicamente, preocupações acerca das implicações ou conseqüências dos ataques de pânico. É uma condição clínica complexa que envolve diferentes modalidades ou conglomerados de sintomas. Assim, o foco nas sensações físicas erroneamente interpretadas no transtorno de pânico e na hipocondria centraliza-se basicamente nas manifestações autonômicas, como taquicardia e dispnéia. Há poucos estudos sobre atividade física e transtorno de pânico. O principal objetivo do estudo visa identificar com diferentes descrições se há uma população "nuclear" com sintomas predominantemente respiratórios apresentando esquiva de atividade física e a influência do exercício nesta população.

Panic attacks are represented by distinct periods in which there is a sudden beginning of internal apprehension, fear or terror, frequently associated with feelings of imminent catastrophe, diagnosed in approximately 10 percent of the population. The panic disorder is an anxiety crisis that is characterized by the recurrence of panic attacks: sudden crises of uneasiness and sensation of danger or imminent death, followed by diverse physical and cognitive symptoms. Individuals with panic disorder are characteristically concerned about panic attacks implications or consequences. It is a complex clinical condition that involves different modalities or myriad of symptoms. Thus, the focus on the physical sensations misinterpreted in panic disorder and hypochondria, is basically centered in autonomic manifestations, such as tachycardia and dyspnea. There are scarce studies on physical activity and panic disorder. The main purpose of the study is to identify with different descriptions whether there is a 'main' population with symptoms predominantly respiratory presenting avoidance of physical activity and exercise influence on this population.

Comorbidade psiquiátrica diminui a qualidade de vida de pacientes com enxaqueca crônica / Psychiatric comorbidities decrease quality of life in chronic migraine patients

INTRODUÇÃO: A enxaqueca apresenta elevada comorbidade com os transtornos de humor e de ansiedade e extremo impacto no grau de incapacidade e qualidade de vida do indivíduo afetado, mas pouco se sabe sobre a qualidade de vida dos pacientes com enxaqueca crônica e o impacto das comorbidades psiquiátricas. MÉTODO: Cinquenta pacientes com diagnóstico de enxaqueca crônica (Sociedade Internacional de Cefaléias, 2004) foram diagnosticados quanto à presença de transtornos mentais, através da entrevista estruturada SCID-I/P e do questionário de qualidade de vida SF-36. Pacientes foram divididos nos seguintes grupos: enxaqueca crônica com transtornos de ansiedade, transtorno de ansiedade generalizada, transtornos de ansiedade com pelo menos um episódio depressivo maior, com episódio depressivo maior, comparados a pacientes sem comorbidade psiquiátrica. RESULTADOS: Constatou-se qualidade de vida significativamente inferior nos oito domínios da SF-36, nos pacientes com enxaqueca crônica associada a comorbidade psiquiátrica tais como transtornos de ansiedade, transtorno de ansiedade generalizada, transtornos de ansiedade com pelo menos um episódio depressivo maior, assim como nos pacientes apenas com episódio depressivo maior, comparados a pacientes com enxaqueca crônica sem comorbidade psiquiátrica (p<0,05). Somente no domínio Estado Geral de Saúde do SF-36, a qualidade de vida não foi significativamente inferior em todos os grupos de pacientes com enxaqueca crônica associada a comorbidade psiquiátrica. Nos domínios do SF-36 relacionados aos aspectos físicos, a qualidade de vida não foi significativamente inferior somente nos transtornos de ansiedade. CONCLUSÃO: A comorbidade da enxaqueca crônica e transtornos mentais é fator associado à piora da qualidade de vida dos pacientes e deve ser ativamente pesquisada nesta população.

INTRODUCTION: Chronic migraine is a common, debilitating condition affecting quality of life and social functioning with significant impact. Migraine is highly comorbid with anxiety and mood disorders, but little is known about psychiatric comorbidities impact in the migraine patient quality of life. METHOD: Fifty patients with chronic migraine diagnosed according to the International Headache Society (2004) were interviewed and met diagnostic criteria for mental disorders, according to the structured interview SCID-I/P and were evaluated by the SF-36 Health Survey questionnaire. Patients were divided in the following groups: chronic migraine with both mood and anxiety disorders, with only anxiety disorders, with generalized anxiety disorder, with only a mood disorder, and without psychopathology. The scores in the group without psychopathology were compared with the other groups. All eight domains of the SF-36 scale were compared in those groups. RESULTS: Significantly lower (p<0.05) quality of life was found on all eight SF-36 domains for CM psychiatric comorbidity patients compared to no-co morbidity patients. On the SF-36 General Health domain alone, quality of life was not significantly lower for all four CM psychiatric comorbidity groups. On the SF-36 Physical Aspects domain alone, quality of life was not significantly lower only for the Anxiety Disorders group. CONCLUSION: Chronic migraine comorbidity with mental disorder is a significant factor affecting patients' quality of life.

Depression in chronic migraine: severity and clinical features.

INTRODUCTION: Chronic migraine (CM) is a common medical condition affecting 2.4% of the general population. Depression is one of the most frequent comorbid disorders in CM. METHOD: Seventy patients diagnosed with chronic migraine were studied. All patients evaluated filled out the Beck Depression Inventory (BDI). Depression severity was divided into none or minimal depression, mild, moderate, and severe. RESULTS: BDI ranged from 4 to 55, mean 21 +/- 10.7. Moderate or severe depression, were present in 58.7% of the patients. Some degree of depression appeared in 85.8% of patients. The BDI scores correlated with pain intensity (p = 0.02). Severe depression was more frequent in patients with comorbid fibromyalgia and in patients reporting fatigue. CONCLUSION: The BDI is an easy tool to access depression in CM patients. Suicide risk assessment is needed in CM patients. Patients with fibromyalgia and fatigue are at even higher risk for severe depression.

Depression in chronic migraine: severity and clinical features

INTRODUÇÃO: A migrânea crônica (MC) é uma doença comum, que afeta 2,4% da população geral. A depressão é uma das comorbidades mais frequentes em enxaqueca. MÉTODO: Setenta pacientes diagnosticados com migrânea crônica foram estudados. Todos os pacientes preencheram o Inventário de Depressão Beck.(BDI). A gravidade da depressão foi dividida em nenhuma ou leve, mínima, moderada, e grave. RESULTADOS: O BDI variou de 4 a 55, média 21 ± 10,7. A depressão moderada ou grave esteve presente em 58,7% dos pacientes. Algum grau de depressão foi observado em 85,8% dos pacientes. Os escores de depressão correlacionaram-se com a intensidade da dor. A depressão grave foi mais freqüente em paciente com comorbidade com fibromialgia e fadiga. CONCLUSÃO: O BDI é um instrumento de fácil avaliação da depressão em MC. A identificação do risco de suicídio é necessária nestes pacientes. Fibromialgia e fadiga são fatores de risco para depressão grave.

Aplicação da estimulação magnética transcraniana de repetição no tratamento do transtorno obsessivo-compulsivo e outros transtornos de ansiedade / Repetitive transcranial magnetic stimulation as a treatment for obsessive-compulsive disorder and other anxiety disorders

A estimulação magnética transcraniana de repetição (EMTr) vem sendo amplamente investigada como ferramenta terapêutica em transtornos psiquiátricos, especialmente a depressão. Neste trabalho, compilamos as informações provenientes de estudos que investigaram as aplicações da EMTr no tratamento dos transtornos de ansiedade: transtorno do pânico (TP), transtorno de estresse pós-taumático (TEPT), transtorno de ansiedade generalizada (TAG) e especialmente o transtorno obsessivo compulsivo (TOC). Três estudos foram publicados abordando o tratamento do TOC, sendo que utilizaram metodologias e parâmetros de aplicação extremamente diversos, dificultando a obtenção de informações conclusivas sobre a efetividade deste tratamento. Quatro estudos publicados sobre TEPT e EMTr também apresentam dados conflitantes e pouco comparáveis, mas destaca-se publicação recente com desenho duplo-cego e resultados positivos. Quanto ao TP e o TAG, apenas pequenas investigações iniciais foram realizadas. Conclusão: Apesar dos estudos citados, não há dados conclusivos sobre a eficácia terapêutica da EMTr nos transtornos de ansiedade. Isto se dá especialmente devido aos estudos com amostras pequenas e desenho aberto. Portanto, devem ser realizados estudos mais aprofundados para que possamos obter estas respostas.

Transtorno de panico / Panic disorder

A ideia de publicar esta edicao especial da Revista de Psiquiatria Clinica surgiu apos o evento "Transtorno de Panico na Pratica Medica" realizado em 1998 pelo Ambulatorio de Ansiedade do Instituto de Psiquiatria do HCFMUSP...

Relevancia medico-social do transtorno de panico / Medical and social impact of panic disorder

O aumento do interesse nos aspectos epidemiologicos, sociais e economicos dos transtornos mentais associa-se a preocupacao com os custos crescentes dos servicos medicos...

Estudo comparativo entre o citalopram e a imipramina no tratamento do transtorno de panico / Comparative study of citalopram and imipramine in the treatment of panic disorder

Neste estudo, um total de 39 pacientes (media mais ou menos DP idade igual 32,2 mais ou menos 10,1 ; 24 mulheres e 15 homens) com transtorno do panico sem sindromes depressivas associadas (RDC)foi randomizado e tratado com doses flexiveis de imipramina...

Fobia social: editorial / Social phobia: editorial

No final de 1998 foi realizado o evento "Fobia Social, interface entre a biologia e o comportamento", que contou com a participacao de profissionais de diversas instituicoes universitarias do Brasil. Varios desses palestrantes concordaram em ser colaboradores desta edicao especial que conseguiu, assim, abranger as areas da biologia e tratamento medico dos transtornos fobico-ansiosos e aquelas, por muitos, vistas como...

Tratamento farmacologico da fobia social / The pharmacological treatment of social phobia

A fobia social e um transtorno cronico que leva a um prejuizo importante do funcionamento dos pacientes. Na ultima decada, maior enfase tem sido dada a farmacoterapia da ansiedade social. Os betabloqueadores sao uteis na fobia social circunscrita, enquanto os antidepressivos, especialmente os inibidores seletivos de recaptacao de serotonina, sao a primeira escolha nos quadros de fobia social generalizada. Este artigo revisa as possibilidades farmacologicas existentes e discute a sua aplicacao na pratica clinica.

Dificuldades na utilizacao de escalas de avaliacao de sintomas ansiosos em psicofarmacologia clinica e experimental / Difficulties on the use of rating scales of anxiety symptoms in clinical and experimental psychopharmacology

Escalas de avaliacao de sintomatologia psiquiatrica ainda sao o principal instrumento de mensuracao em pesquisa psiquiatrica. As reformulacoes conceituais e nosograficas encontradas na area dos transtornos neuroticos (ansiosos), bem como disputas ideologicas, levam a proliferacao de instrumentos e consequentemente a problemas de validade, alem de dificultar a comparacao de resultados de diferentes centros. Outros problemas comuns sao erros: sistematicos (vies) ou aleatorios. Fontes de erro incluem a formulacao de itens da escala, variaveis do ambiente onde esta e utilizada e problemas relacionados ao avaliador (hetero ou auto-avaliacao). O papel do treinamento adequado para avaliadores e enfatizado