Monitoring
Generalized Anxiety Disorder
Frequent follow-up is provided during the first 3 months (acute phase)
of therapy. Adverse effects are monitored. Monitoring for risk of suicidal
ideation and self-harm in patients with SAD who were given an SSRI, or a
serotonin and norepinephrine reuptake inhibitor is done weekly. Response to
therapy is also monitored. Therapy is then reassessed every month thereafter. The
benefits of cognitive behavioral therapy are maintained over 1 to 5 years of
follow-up.
Panic Disorder
Frequent follow-up is provided during the first 3 months (acute phase)
of therapy. For patients receiving pharmacological therapy, adverse effects and
response to therapy are monitored. Therapy is reassessed at 8 to 12 weeks
intervals.
Therapy Change
Generalized Anxiety Disorder
If the results are unsatisfactory after 4 to 8 weeks of treatment,
consider expert referral, dose increase, adding or changing drug from another
therapeutic class, and/or adding psychotherapy.
Panic Disorder
It must be noted that 12 weeks of treatment period is needed to assess
efficacy. If the results are unsatisfactory consider a different treatment,
adding psychotherapy or medication, expert referral, and/or re-evaluating the
diagnosis.
Social Anxiety Disorder
A treatment period of 12 weeks is needed to
evaluate effectiveness. If the results are unsatisfactory, consider switching
to a different drug from the same class of first-line agents or changing to a
second-line agent, switching to psychotherapy, expert referral, and/or
re-evaluating the diagnosis.
Long-Term Treatment
Generalized Anxiety Disorder
Patients who respond to a 12-week trial of treatment should continue to
be monitored for 6 to 12 months. The goals of therapy are symptom remission and
returning to full functioning. Late-onset drug adverse effects are managed. If
the medication is effective, treatment is continued for at least 1 year as the
likelihood of relapse is high. Once full functioning has returned, withdrawing
treatment is attempted. Careful medication taper may be attempted. If after 2
careful attempts to discontinue medications, the patient is still experiencing
anxiety symptoms, long-term maintenance is considered.
Panic Disorder
For patients receiving pharmacological therapy, the patient is
monitored continuously. Symptom remission and return to full functioning are
the goals of therapy. Late-onset adverse effects are managed. The general
recommendation is to continue medication for ≥1 year to maintain symptom
reduction and to reduce the risk of recurrence. Discontinuation is attempted
after this time and close follow-up is maintained. It must be noted that
relapse is common and that re-institution of medication seems to help.
For patients receiving psychotherapy, the frequency of visits may
generally be decreased. It is then discontinued after several months. Adding
psychosocial treatment, particularly CBT, to pharmacological therapy may
enhance long-term outcomes by reducing the likelihood of relapse when
pharmacotherapy is stopped. Some studies show remission of several years is
possible with CBT. However, the effectiveness of resuming CBT for patients
whose relapse has not been studied.
Social Anxiety Disorder
Once medication has taken effect, in vivo exposure exercises may
be initiated. The patient is continuously monitored. Symptom remission and
return to full functioning are the goals of therapy. Late-onset adverse effects
are managed. It is important that therapy continues for 6 to 12 months.
Tapering and discontinuation are attempted after this time while follow-up is
closely maintained. Should symptoms recur after the drug has been stopped or
dose has been lowered, a dose increase, drug reintroduction, or individual CBT
is considered.