대한불안의학회지 (Anxiety and mood)

  • 제20권2호
  • /
  • Pages.72-81
  • /
  • 2024
  • /
  • 2586-0151(pISSN)
  • /
  • 2586-0046(eISSN)
대한불안의학회 (Korean Academy of Anxiety Disorders)
권호 표지
DOI QR코드

DOI QR Code

2024 한국형 범불안장애 치료지침 III: 치료 반응이 불충분한 경우 및 공존질환이 존재하는 경우 치료 전략

Korean Guidelines for the Treatment of Generalized Anxiety Disorder 2024 Part III: Strategies for Insufficient Treatment Response and Comorbidities

  • 서준호 (연세대학교 원주의과대학 정신건강의학교실) ;
  • 박천일 (연세대학교 의과대학 정신과학교실) ;
  • 김민경 (차의과학대학교 정신건강의학교실) ;
  • 문은수 (부산대학교 의과대학 정신건강의학교실) ;
  • 안명희 (서울아산병원 건강의학과) ;
  • 이현아 (순천향대학교 의과대학 정신건강의학교실) ;
  • 장윤영 (인제대학교 의과대학 정신건강의학교실) ;
  • 김원 (인제대학교 의과대학 정신건강의학교실) ;
  • 이경욱 (가톨릭대학교 의과대학 정신건강의학교실) ;
  • 서호석 (서호석연세정신건강의학과)
  • June-ho Seo (Department of Psychiatry, Yonsei University Wonju College of Medicine) ;
  • Chun Il Park (Department of Psychiatry, Yonsei University College of Medicine) ;
  • Min-Kyoung Kim (Department of Psychiatry, CHA Ilsan Medical Center, CHA University) ;
  • Eunsoo Moon (Department of Psychiatry, Pusan National University School of Medicine) ;
  • Myung Hee Ahn (Division of Psychiatry, Health Screening and Promotion Center, Asan Medical Center) ;
  • Hyeon-Ah Lee (Department of Psychiatry, College of Medicine, Soonchunhyang University Cheonan Hospital) ;
  • Yoon Young Chang (Department of Psychiatry, Sanggye Paik Hospital, Inje University College of Medicine) ;
  • Won Kim (Department of Psychiatry, Sanggye Paik Hospital, Inje University College of Medicine) ;
  • Kyoung-Uk Lee (Department of Psychiatry, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, College of Medicine) ;
  • Ho-Suk Suh (Suh Hosuk Yonsei Psychiatry Clinic for Healthy Mind)
  • 투고 : 2024.10.03
  • 심사 : 2024.10.23
  • 발행 : 2024.10.30
PDF 다운로드
⟨ 이전 논문 다음 논문 ⟩

초록

Objective : This study aimed to establish expert consensus on treatment strategies for generalized anxiety disorder (GAD) when treatment response is insufficient and when comorbid conditions are present as part of developing the 2024 Korean guidelines for the treatment of GAD. Methods : The executive committee developed a questionnaire based on existing international and Korean treatment guidelines and academic literature. Sixty-five experts participated in a survey. Responses were analyzed using chi-squared test and 95% confidence intervals to determine the level of consensus. Treatment strategies were categorized into first-line, second-line, and third-line choices. Results : For patients with an insufficient treatment response, combining pharmacotherapy and psychotherapy was the most preferred first-line strategy. Experts recommended switching to or augmenting with a different class of antidepressants, adding benzodiazepines or azapirones, and augmenting with atypical antipsychotics as first-line pharmacotherapy adjustments. Suitable psychotherapies included cognitive behavioral therapy (CBT), mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), and applied relaxation. For patients with comorbid conditions such as depression, other anxiety disorders, or alcohol and substance use disorders, a combination of pharmacotherapy and psychotherapy was also the most preferred first-line treatment. In these cases, the use of antidepressants alone or in combination with benzodiazepines, azapirones, or atypical antipsychotics was recommended. Conclusion : This expert consensus reflects current clinical practices and experiences in Korea, providing valuable insights for clinicians treating GAD patients who have insufficient treatment responses or comorbidities. Findings of this study emphasize the importance of a multimodal treatment approach, including both pharmacotherapy and psychotherapy. They also offer specific recommendations for adjusting treatment strategies in these complex cases.

키워드

참고문헌

  1. McEvoy PM, Grove R, Slade T. Epidemiology of anxiety disorders in the Australian general population: findings of the 2007 Australian National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry 2011;45:957-967. 
  2. Bandelow B, Allgulander C, Baldwin DS, Costa D, Denys D, Dilbaz N, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders-version 3. Part I: Anxiety disorders. World J Biol Psychiatry 2023;24:79-117. 
  3. Tyrer P, Tyrer H, Johnson T, Yang M. Thirty-year outcome of anxiety and depressive disorders and personality status: comprehensive evaluation of mixed symptoms and the general neurotic syndrome in the follow-up of a randomised controlled trial. Psychol Med 2021;12:1-10. 
  4. Wittchen HU. Generalized anxiety disorder: prevalence, burden, and cost to society. Depress Anxiety 2002;16:162-171. 
  5. Wittchen HU, Zhao S, Kessler RC, Eaton WW. DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:355-364. 
  6. Kessler RC, Gruber M, Hettema JM, Hwang I, Sampson N, Yonkers KA. Co-morbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up. Psychol Med 2008;38:365-374. 
  7. Andrews G, Slade T, Issakidis C. Deconstructing current comorbidity: data from the Australian National Survey of Mental Health and WellBeing. Br J Psychiatry 2002;181:306-314. 
  8. Moffitt TE, Harrington H, Caspi A, Kim-Cohen J, Goldberg D, Gregory AM, et al. Depression and generalized anxiety disorder: cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Arch Gen Psychiatry 2007;64:651-660. 
  9. Zhu B, Zhao Z, Ye W, Marciniak MD, Swindle R. The cost of comorbid depression and pain for individuals diagnosed with generalized anxiety disorder. J Nerv Ment Dis 2009;197:136-139. 
  10. De Salas-Cansado M, Olivares JM, Alvarez E, Carrasco JL, Barrueta A, Rejas J. Pregabalin versus SSRIs and SNRIs in benzodiazepine-refractory outpatients with generalized anxiety disorder: a post hoc cost-effectiveness analysis in usual medical practice in Spain. Clinicoecon Outcomes Res 2012;4:157-168. 
  11. Hoge EA, Worthington JJ, 3rd, Kaufman RE, Delong HR, Pollack MH, Simon NM. Aripiprazole as augmentation treatment of refractory generalized anxiety disorder and panic disorder. CNS Spectr 2008;13:522-527. 
  12. Lee JY, Kim MS, Lee SH, Yang JC, Kim CH, Yoo BH, et al. Korean Medication Algorithm Project for Generalized Anxiety Disorder 2009 (II): medication algorithm & long-term medication treatment strategy. J Korean Neuropsychiatr Assoc 2010;49:553-563. 
  13. Crits-Christoph P, Newman MG, Rickels K, Gallop R, Gibbons MB, Hamilton JL, et al. Combined medication and cognitive therapy for generalized anxiety disorder. J Anxiety Disord 2011;25:1087-1094. 
  14. National Institute for Health and Care Excellence: Guidelines. Generalised anxiety disorder and panic disorder in adults: management. London: National Institute for Health and Care Excellence (NICE) vCopyright © NICE 2020;2019. 
  15. Sagliano L, Atripaldi D, De Vita D, D'Olimpio F, Trojano L. Non-invasive brain stimulation in generalized anxiety disorder: a systematic review. Prog Neuropsychopharmacol Biol Psychiatry 2019;93:31-38. 
  16. Andrews G, Bell C, Boyce P, Gale C, Lampe L, Marwat O, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Australian & New Zealand Journal of Psychiatry 2018;52:1109-1172. 
  17. Katzman MA, Bleau P, Blier P, Chokka P, Kjernisted K, Van Ameringen M, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry 2014;14 Suppl 1:S1. 
  18. Bandelow B, Chouinard G, Bobes J, Ahokas A, Eggens I, Liu S, et al. Extended-release quetiapine fumarate (quetiapine XR): a once-daily monotherapy effective in generalized anxiety disorder. Data from a randomized, double-blind, placebo- and active-controlled study. Int J Neuropsychopharmacol 2010;13:305-320. 
  19. Khan A, Joyce M, Atkinson S, Eggens I, Baldytcheva I, Eriksson H. A randomized, double-blind study of once-daily extended release quetiapine fumarate (quetiapine XR) monotherapy in patients with generalized anxiety disorder. J Clin Psychopharmacol 2011;31:418-428. 
  20. Stein DJ, Bandelow B, Merideth C, Olausson B, Szamosi J, Eriksson H. Efficacy and tolerability of extended release quetiapine fumarate (quetiapine XR) monotherapy in patients with generalised anxiety disorder: an analysis of pooled data from three 8-week placebo-controlled studies. Hum Psychopharmacol 2011;26:614-628. 
  21. Pollack MH, Simon NM, Zalta AK, Worthington JJ, Hoge EA, Mick E, et al. Olanzapine augmentation of fluoxetine for refractory generalized anxiety disorder: a placebo controlled study. Biol Psychiatry 2006;59:211-215. 
  22. Brawman-Mintzer O, Knapp RG, Nietert PJ. Adjunctive risperidone in generalized anxiety disorder: a double-blind, placebo-controlled study. J Clin Psychiatry 2005;66:1321-1325. 
  23. Pandina GJ, Canuso CM, Turkoz I, Kujawa M, Mahmoud RA. Adjunctive risperidone in the treatment of generalized anxiety disorder: a double-blind, prospective, placebo-controlled, randomized trial. Psychopharmacol Bull 2007;40:41-57. 
  24. Simon NM, Connor KM, LeBeau RT, Hoge EA, Worthington JJ, 3rd, Zhang W, et al. Quetiapine augmentation of paroxetine CR for the treatment of refractory generalized anxiety disorder: preliminary findings. Psychopharmacology (Berl) 2008;197:675-681. 
  25. Katzman MA, Vermani M, Jacobs L, Marcus M, Kong B, Lessard S, et al. Quetiapine as an adjunctive pharmacotherapy for the treatment of non-remitting generalized anxiety disorder: a flexible-dose, openlabel pilot trial. J Anxiety Disord 2008;22:1480-1486. 
  26. Altamura AC, Serati M, Buoli M, Dell"Osso B. Augmentative quetiapine in partial/nonresponders with generalized anxiety disorder: a randomized, placebo-controlled study. Int Clin Psychopharmacol 2011;26:201-205. 
  27. Menza MA, Dobkin RD, Marin H. An open-label trial of aripiprazole augmentation for treatment-resistant generalized anxiety disorder. J Clin Psychopharmacol 2007;27:207-210. 
  28. Lohoff FW, Etemad B, Mandos LA, Gallop R, Rickels K. Ziprasidone treatment of refractory generalized anxiety disorder: a placebo-controlled, double-blind study. J Clin Psychopharmacol 2010;30:185-189. 
  29. Snyderman SH, Rynn MA, Rickels K. Open-label pilot study of ziprasidone for refractory generalized anxiety disorder. J Clin Psychopharmacol 2005;25:497-499. 
  30. Chen TR, Huang HC, Hsu JH, Ouyang WC, Lin KC. Pharmacological and psychological interventions for generalized anxiety disorder in adults: a network meta-analysis. J Psychiatr Res 2019;118:73-83. 
  31. Stein DJ, Ahokas AA, de Bodinat C. Efficacy of agomelatine in generalized anxiety disorder: a randomized, double-blind, placebo-controlled study. J Clin Psychopharmacol 2008;28:561-566. 
  32. Stein DJ, Khoo JP, Ahokas A, Jarema M, Van Ameringen M, Vavrusova L, et al. 12-week double-blind randomized multicenter study of efficacy and safety of agomelatine (25-50 mg/day) versus escitalopram (10-20 mg/day) in out-patients with severe generalized anxiety disorder. Eur Neuropsychopharmacol 2018;28:970-979. 
  33. Bidzan L, Mahableshwarkar AR, Jacobsen P, Yan M, Sheehan DV. Vortioxetine (Lu AA21004) in generalized anxiety disorder: results of an 8-week, multinational, randomized, double-blind, placebo-controlled clinical trial. Eur Neuropsychopharmacol 2012;22:847-857. 
  34. Baldwin DS, Loft H, Florea I. Lu AA21004, a multimodal psychotropic agent, in the prevention of relapse in adult patients with generalized anxiety disorder. Int Clin Psychopharmacol 2012;27:197-207. 
  35. Mahableshwarkar AR, Jacobsen PL, Chen Y, Simon JS. A randomised, double-blind, placebo-controlled, duloxetine-referenced study of the efficacy and tolerability of vortioxetine in the acute treatment of adults with generalised anxiety disorder. Int J Clin Pract 2014;68:49-59. 
  36. Mahableshwarkar AR, Jacobsen PL, Serenko M, Chen Y. A randomized, double-blind, fixed-dose study comparing the efficacy and tolerability of vortioxetine 2.5 and 10mg in acute treatment of adults with generalized anxiety disorder. Hum Psychopharmacol 2014;29:64-72. 
  37. Rothschild AJ, Mahableshwarkar AR, Jacobsen P, Yan M, Sheehan DV. Vortioxetine (Lu AA21004) 5 mg in generalized anxiety disorder: results of an 8-week randomized, double-blind, placebo-controlled clinical trial in the United States. Eur Neuropsychopharmacol 2012;22:858-866. 
  38. Rickels K, Shiovitz TM, Ramey TS, Weaver JJ, Knapp LE, Miceli JJ. Adjunctive therapy with pregabalin in generalized anxiety disorder patients with partial response to SSRI or SNRI treatment. Int Clin Psychopharmacol 2012;27:142-150. 
  39. Baldwin DS, Anderson IM, Nutt DJ, Allgulander C, Bandelow B, den Boer JA, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol 2014;28:403-439. 
  40. Meibach RC, Dunner D, Wilson LG, Ishiki D, Dager SR. Comparative efficacy of propranolol, chlordiazepoxide, and placebo in the treatment of anxiety: a double-blind trial. J Clin Psychiatry 1987;48:355-358. 
  41. Hettema JM. The nosologic relationship between generalized anxiety disorder and major depression. Depress Anxiety 2008;25:300-316. 
  42. Preti A, Vrublevska J, Veroniki AA, Huedo-Medina TB, Fountoulakis KN. Prevalence, impact and treatment of generalised anxiety disorder in bipolar disorder: a systematic review and meta-analysis. Evid Based Ment Health 2016;19:73-81. 
  43. Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RM, Petukhova M, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry 2007;64:543-552.