Treatments for generalized anxiety disorder

Efficacy of Brahmi vati in generalised anxiety disorder - Randomized double blind comparative clinical trial

Background

Generalized Anxiety Disorder (GAD) is the most common anxiety disorder. GAD has high comorbidities and it can affect social, professional and personal life. Ayurvedic medicine, Brahmi vati is explored for the possible role in management of GAD and is compared to Manasmitra vataka.

Aim

To evaluate the efficacy of B. vati on Generalized Anxiety Disorder.

Methods

A randomized double blind controlled trial, with total 56 patients meeting the DSM V criteria of GAD between 20–60 years of age and either sex participated in the study. Participants were randomly divided into two groups, Brahmi group received capsule B. vati 500 mg and Manasmitra group received capsule M. vataka 500 mg thrice a day with water for 45 days. Assessments were conducted through various clinical parameters such as Hamilton Anxiety Rating Scale (HARS), GAD 7 scale (GAD 7), Beck Depression Inventory scale (BDI), Epworth sleepiness scale (ESS), Pittsburgh Sleep Quality Index (PSQI), WHO Quality of Life- BREF (WHOQOL-BREF), Clinical Global Improvement scale (CGI). Blood variables including Haemoglobin, Erythrocyte Sedimentation Rate (ESR), Liver Function Test (LFT) and serum creatinine were assessed before and after the study. Assessments during intervention were conducted on every 15th day.

Results

Study results indicate that both B. vati and M. vataka were comparable and each produced significant improvement (p < 0.001) in HARS, GAD-7, BDI, ESS, PSQI, WHOQOL-BREF and CGI. Brahmi vati also produced significant decrease in systolic (p = 0.002) and diastolic (p < 0.001) blood pressure. Both groups showed good safety profile evaluated through the assessment of serum creatinine levels and LFT.

Conclusion

B. vati and M. vataka were effective, safe and comparable in the management of GAD. Warrants further studies.

Influence of Mindfulness and Relaxation on Treatment of Essential Hypertension: Meta-Analysis

Background

Some studies published previously have shown a strong correlation between hypertension and psychological nature including impulsion emotion or mindfulness and relaxation temperament, among which mindfulness and relaxation temperament might have a benign influence on blood pressure, ameliorating the hypertension. However, the conclusion was not confirmed.

Objective

The meta-analysis was performed to investigate the influence of mindfulness and relaxation on essential hypertension interventions and confirm the effects.

Methods

Systematic searches were conducted in common English and Chinese electronic databases (i.e., PubMed/MEDLINE, EMBASE, Web of Science, CINAHL, PsycINFO, Cochrane Library, and Chinese Biomedical Literature Database) from 1980 to 2020. A meta-analysis including 5 studies was performed using Rev Man 5.4.1 software to estimate the influence of mindfulness and relaxation on blood pressure, ameliorating the hypertension. Publication bias and heterogeneity of samples were tested using a funnel plot. Studies were analyzed using either a random-effect model or a fixed-effect model.

Results

All the 5 studies investigated the influence of mindfulness and relaxation on diastolic and systolic blood pressure, with total 205 participants in the control group and 204 in the intervention group. The random-effects model (REM) was used to calculate the pooled effect for mindfulness and relaxation on diastolic blood pressure (I 2 = 0%, t 2 = 0.000, P=0.41). The random pooled effect size (MD) was 0.30 (95% CI = -0.81-1.42, P=0.59). REM was used to calculate the pooled effect for mindfulness and relaxation on systolic blood pressure (I 2 = 49%, t 2 = 3.05, P=0.10). The random pooled effect size (MD) was -1.05 (95% CI = -3.29-1.18, P=0.36). The results of this meta-analysis were influenced by publication bias to some degree.

Conclusion

All the results showed less influence of mindfulness and relaxation might act on diastolic or systolic blood pressure, when mindfulness and relaxation are used to intervene in treating CVD and hypertension.

The Impact of Yoga Nidra and Seated Meditation on the Mental Health of College Professors

BACKGROUND

World statistics for the prevalence of anxiety and mood disorders shows that a great number of individuals will experience some type of anxiety or mood disorder at some point in their lifetime. Mind-body interventions such as Hatha Yoga and seated meditation have been used as a form of self-help therapy and it is especially useful for challenging occupations such as teachers and professors.

AIMS

In this investigation, we aimed at observing the impact of Yoga Nidra and seated meditation on the anxiety and depression levels of college professors.

MATERIALS AND METHODS

Sixty college professors, men and women, aged between 30 and 55 years were randomly allocated in one of the three experimental groups: Yoga Nidra, seated meditation, and control group. Professors were evaluated two times throughout the 3-month study period. Psychological variables included anxiety, stress, and depression.

RESULTS

Data analysis showed that the relaxation group presented better intragroup results in the anxiety levels. Meditation group presented better intragroup results only in the anxiety variable (physical component). Intergroup analysis showed that, except for the depression levels, both intervention groups presented better results than the control group in all other variables.

CONCLUSIONS

Prepost results indicate that both interventions represent an effective therapeutic approach in reducing anxiety and stress levels. However, there was a tendency toward a greater effectiveness of the Yoga Nidra intervention regarding anxiety, which might represent an effective tool in reducing both cognitive and physiological symptoms of anxiety.

NASCIDOS PARA CORRER: A IMPORTÂNCIA DO EXERCÍCIO PARA A SAÚDE DO CÉREBRO

RESUMO A hipótese evolutiva da corrida de resistência afirma que o movimento teve um papel crucial no aparecimento de características anatômicas tipicamente humanas, assim como na modelação da estrutura e forma do cérebro humano. A íntima ligação entre exercício e evolução humana é evidenciada pelo fato de a inatividade nos tornar doentes. Efetivamente, o corpo humano, incluindo o cérebro, evoluiu para suportar períodos prolongados de estresse cardiovascular. O movimento é de tal modo essencial para o cérebro, que a atividade física regular é imprescindível para que funcione de modo adequado. Estudos vêm demonstrando que o exercício aeróbico aumenta a proliferação de neurônios, a síntese de fatores neurotróficos, gliogênese, sinaptogênese, regula sistemas de neurotransmissão e neuromodulação, além de reduzir a inflamação sistêmica. Todos esses efeitos têm impacto significativo no sentido de melhorar a saúde mental, reduzir o declínio de massa cinzenta associado à idade e melhorar as funções cognitivas. Deste modo, o objetivo deste artigo é apresentar uma atualização sobre a temática de exercício físico e saúde mental. Dados os recentes avanços apresentados neste original, sobre a neurobiologia do exercício e seu potencial terapêutico e econômico para a população em geral, espera-se que pesquisas futuras que correlacionem estudos básicos a variáveis psicológicas e estudos de imagem possam elucidar os mecanismos pelos quais o exercício melhora a saúde cerebral.

Reducing the symptomatology of panic disorder: the effects of a yoga program alone and in combination with cognitive-behavioral therapy

INTRODUCTION

Yoga is a holistic system of different mind-body practices that can be used to improve mental and physical health. It has been shown to reduce perceived stress and anxiety as well as improve mood and quality of life. Research documenting the therapeutic benefits of yoga has grown progressively for the past decades and now includes controlled trials on a variety of mental health conditions such as depression, anxiety, and panic disorder.

OBJECTIVES

The primary goal of this study was to investigate the effects of yoga in patients suffering from panic disorder. We aimed at observing the efficacy of yoga techniques on reducing the symptomatology of panic disorder (anxiety and agoraphobia), compared to a combined intervention of yoga and psychotherapy.

METHOD

Twenty subjects previously diagnosed with panic disorder were selected. Subjects were randomly assigned to both experimental groups: Group 1 (G1-Yoga: 10 subjects) attended yoga classes and Group 2 (G2-CBT + Yoga: 10 subjects) participated in a combined intervention of yoga practice followed by a cognitive-behavioral therapy (CBT) session. Both interventions occurred weekly for 100 min and lasted 2 months. Subjects were evaluated two times during the study: pre-test and post-test. Psychometric tools included the Beck Anxiety Inventory (BAI), Hamilton Anxiety Rating Scale (HAM-A), The Panic Beliefs Inventory (PBI), and Body Sensations Questionnaire (BSQ).

RESULTS

Statistical analysis showed significant reductions in anxiety levels associated with panic disorder (G1: BAI - p = 0.035, HAM-A - p = 0.000; G2: BAI - p = 0.002, HAM-A - p = 0.000), panic-related beliefs (G1: PBI - p = 0.000; G2: PBI - p = 0.000) and panic-related body sensations (G1: BSQ - p = 0.000; G2: BSQ - p = 0.000) both in G1 and G2. However, the combination of yoga and CBT (G2) showed even further reductions in all observed parameters (mean values).

CONCLUSION

This study observed significant improvement in panic symptomatology following both the practice of yoga and the combination of yoga and psychotherapy. While contemplative techniques such as yoga promote a general change in dealing with private events, CBT teaches how to modify irrational beliefs and specific cognitive distortions. The results observed in G2 might indicate that the techniques complemented each other, increasing the intervention efficacy. These findings are in agreement with many investigations found in the literature which observed improvements in different mental health parameters after the practice of contemplative techniques alone or combined to psychotherapy. Future research joining psychological and physiological variables could help better elucidate the mechanisms through which mind-body practices work to improve mental health.

The best next drug in the course of generalized anxiety disorders: the "PN-GAD-algorithm"

OBJECTIVE

Today, there are many pharmacotherapeutic options for generalized anxiety disorder (GAD). The question is, which is the best medication for a particular patient at a particular moment? This is especially challenging because GAD is by definition a chronic disorder and new interventions should learn from earlier experiences. An algorithm which can help to use pretreatment information for drug selection is the "Pretreatment - Next Treatment (PN) - Algorithm". This article introduces an PN-algorithm for GAD.

METHODS AND RESULTS

For the development of a GAD-specific PN-algorithm, all possible pharmacological options for GAD are reviewed and brought into a rank order on the basis of scientific evidence regarding efficacy, tolerability, or price: (1) pregabalin, (2) venlafaxine XR, (3) selective serotonin reuptake inhibitors, (4) tricyclic antidepressants, (5) buspirone, (6) antipsychotics, (7) benzodiazepines, and (8) hydroxyzine. Based on this hierarchy and patient-specific information, a decision algorithm is derived, which allows to assess and evaluate pretreatment and to select the drug with no contraindications, limited negative or convincing positive effects, or the option which has not been used so far but which is the next compound in the hierarchy.

CONCLUSIONS

The "PN-GAD-algorithm" can be easily translated into a checklist to support clinical decision-making. It can also help to increase patient empowerment and cooperation in long-term treatment.

Comparative efficacy of antidepressants in preventing relapse in anxiety disorders - a meta-analysis

BACKGROUND

We assessed the efficacy of continuation treatment with antidepressants in a meta-analysis of relapse prevention studies in the five principal anxiety disorders, to explore the benefit of continuation treatment in each disorder, and their relative efficacy across these disorders.

METHOD

Double-blind placebo-controlled studies with relapse prevention designs in Panic Disorder, Generalized Anxiety Disorder, Social Phobia, Post-Traumatic Stress Disorder and Obsessive-Compulsive Disorder were identified in a systematic literature search. The primary efficacy comparison was relapse rates between active and placebo arms calculated as odds ratios (ORs) using Review Manager version 5.0. Relapse data were also used to calculate relative risk (RR), risk difference (RD) and number needed to treat (NNT).

RESULTS

Twenty-two relapse prevention trials were identified for these 5 disorders. Continuation antidepressant treatment produced robust treatment effects for each disorder, however the magnitude varied by indication. The greatest treatment effect was noted for GAD (pooled OR 0.20), whereas the pooled ORs for PD and OCD were for almost 2-fold higher (0.35 and 0.38 respectively). RR, RD and NNT showed similar statistically significant trends.

LIMITATIONS

This study cannot identify an optimal duration of therapy. This analysis only examined studies testing monoamine reuptake inhibiting antidepressants, and therefore these results might not be generalizable to other classes of antianxiety agents.

CONCLUSIONS

This meta-analysis underscores the importance of continuation treatment following acute response in all 5 anxiety disorders, however the relative efficacy of continuation antidepressant treatment appears to vary by disorder.

Current considerations in the treatment of generalized anxiety disorder

Generalized anxiety disorder (GAD) is a chronic disorder that frequently co-occurs with a variety of co-morbidities in patients with somatic conditions and other mental disorders. GAD is highly prevalent and is one of the most common anxiety disorders seen by primary care physicians. The individual and societal cost associated with GAD is high and the marked level of impairment experienced by patients with this disorder is equivalent in magnitude to that reported in patients with major depressive disorder. Furthermore, patients with GAD are at risk of suicide or suicide attempts, and are frequent users of healthcare services. Thus, GAD is a serious and chronic condition that requires appropriate long-term treatment. The focus of acute treatment for patients with GAD is the improvement of symptoms, while the primary goal of long-term clinical management is remission, i.e. the complete resolution of both symptoms and functional impairment. The consensus across current treatment guidelines is that first-line treatment for patients with GAD should consist of an antidepressant, either a selective serotonin reuptake inhibitor (SSRI) such as sertraline, paroxetine or escitalopram, or a selective serotonin noradrenaline (norepinephrine) reuptake inhibitor (SNRI) such as venlafaxine or duloxetine. However, the SSRIs and SNRIs have efficacy limitations, such as lack of response in many patients, a 2- to 4-week delay before the onset of symptom relief, lack of full remission, and risk of relapse. In addition, there are troublesome adverse effects associated with both the SSRIs and SNRIs. Evidence from early clinical studies of the atypical antipsychotics in the treatment of anxiety and GAD indicate that they may have a potential role in the treatment of GAD, either as monotherapy or as augmentation to standard treatment.

Relaxation training for anxiety: a ten-years systematic review with meta-analysis

BACKGROUND

Relaxation training is a common treatment for anxiety problems. Lacking is a recent quantitative meta-analysis that enhances understanding of the variability and clinical significance of anxiety reduction outcomes after relaxation treatment.

METHODS

All studies (1997-2007), both RCT, observational and without control group, evaluating the efficacy of relaxation training (Jacobson's progressive relaxation, autogenic training, applied relaxation and meditation) for anxiety problems and disorders were identified by comprehensive electronic searches with Pubmed, Psychinfo and Cochrane Registers, by checking references of relevant studies and of other reviews. Our primary outcome was anxiety measured with psychometric questionnaires. Meta-analysis was undertaken synthesizing the data from all trials, distinguishing within and between effect sizes.

RESULTS

27 studies qualified for the inclusion in the meta-analysis. As hypothesized, relaxation training showed a medium-large effect size in the treatment of anxiety. Cohen's d was .57 (95% CI: .52 to .68) in the within analysis and .51 (95% CI: .46 to .634) in the between group analysis. Efficacy was higher for meditation, among volunteers and for longer treatments. Implications and limitations are discussed.

CONCLUSION

The results show consistent and significant efficacy of relaxation training in reducing anxiety. This meta-analysis extends the existing literature through facilitation of a better understanding of the variability and clinical significance of anxiety improvement subsequent to relaxation training.

Relaxation training for anxiety: a ten-years systematic review with meta-analysis

BACKGROUND

Relaxation training is a common treatment for anxiety problems. Lacking is a recent quantitative meta-analysis that enhances understanding of the variability and clinical significance of anxiety reduction outcomes after relaxation treatment.

METHODS

All studies (1997-2007), both RCT, observational and without control group, evaluating the efficacy of relaxation training (Jacobson's progressive relaxation, autogenic training, applied relaxation and meditation) for anxiety problems and disorders were identified by comprehensive electronic searches with Pubmed, Psychinfo and Cochrane Registers, by checking references of relevant studies and of other reviews. Our primary outcome was anxiety measured with psychometric questionnaires. Meta-analysis was undertaken synthesizing the data from all trials, distinguishing within and between effect sizes.

RESULTS

27 studies qualified for the inclusion in the meta-analysis. As hypothesized, relaxation training showed a medium-large effect size in the treatment of anxiety. Cohen's d was .57 (95% CI: .52 to .68) in the within analysis and .51 (95% CI: .46 to .634) in the between group analysis. Efficacy was higher for meditation, among volunteers and for longer treatments. Implications and limitations are discussed.

CONCLUSION

The results show consistent and significant efficacy of relaxation training in reducing anxiety. This meta-analysis extends the existing literature through facilitation of a better understanding of the variability and clinical significance of anxiety improvement subsequent to relaxation training.

Does bright light have an anxiolytic effect? - an open trial

BACKGROUND

The aim of this open trial was to examine the influence of acute bright light exposure on anxiety in older and young adults.

METHODS

This study was ancillary to a complex 5-day laboratory experiment testing phase-responses to light at all times of the day. On 3 consecutive days, participants were exposed to bright light (3,000 lux) for 3 hours. The Spielberger State-Trait Anxiety Inventory (Form Y1) was administered 5 minutes before and 20 minutes after each treatment. Mean state anxiety before and after treatment were analyzed by age, sex, and time ANOVA. To avoid floor effects, only participants with baseline STAI levels of > or = 25 were included.

RESULTS

A significant anxiolytic effect of bright light was found for the mean data, as well as for each of the three days. No significant main effect of age, sex, or interaction of these factors with STAI change were found.

CONCLUSION

The results show consistent and significant (albeit modest) anxiolytic effects following acute bright light exposure in low anxiety adults. Further randomized, controlled trials in clinically anxious individuals are needed.

Benzodiazepines in generalized anxiety disorder: heterogeneity of outcomes based on a systematic review and meta-analysis of clinical trials

No systematic review or meta-analysis using a hard outcome has been conducted on the role of benzodiazepines for generalized anxiety disorder (GAD). The objective of this study was to assess the effectiveness and efficacy of benzodiazepines in the treatment of GAD based on trial drop-out rates. We used a systematic review of randomized controlled trials that compared any of the three best established benzodiazepines (diazepam, Lorazepam and aLprazolam) against placebo. Our primary outcome for effectiveness was withdrawal for any reason. Our secondary outcome tapping efficacy was withdrawal due to lack of efficacy, and that tapping side effects was withdrawals due to adverse events. We included 23 trials. Pooled analysis indicated less risk of treatment discontinuation due to lack of efficacy for benzodiazepines, compared to placebo, relative risk (RR) 0.29 (95% CI 0.18-0.45; p < 0.00001). Nevertheless, pooled analysis showed no conclusive results for risk of all-cause patient discontinuation, RR 0.78 (95% CI 0.62-1.00; p = 0.05). Meta-regression model showed that 74% of the variation in logRR across the studies was explained by year of publication (p <0.001). This systematic review did not find convincing evidence of the short-term effectiveness of the benzodiazepines in the treatment of GAD. On the other hand, for the outcome of efficacy, this review found robust evidence in favour of benzodiazepines. Due to the heterogeneity induced by year of publication, three hypotheses are plausibLe when it comes to being able to account for the differences between efficacy and effectiveness observed in the outcomes (publication bias, quality of the trial literature and a non-differential response to the placebo effect).