• Prescribe selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), or selected anticonvulsants as first-line treatment for generalized anxiety disorder (GAD). A
• Avoid the use of benzodiazepines for long-term treatment of GAD. C
• Do not recommend valerian, kava extract, or St. John’s wort for the treatment of GAD; tell patients there is insufficient evidence of their efficacy. C
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE 1 Brad S, a 39-year-old lawyer, is in your office for a follow-up visit. A month ago, you diagnosed him with generalized anxiety disorder and prescribed paroxetine. Brad reports that the medication worked “like a miracle,” rapidly resolving his constant worry and rumination. Unfortunately, though, he is experiencing a bothersome side effect—sexual dysfunction. He’s having difficulty achieving ejaculation during intercourse and wants to know if you can give him “something else that works just as well.” What would you recommend?
In any given year, about 6.8 million Americans—roughly 3.1% of people ages 18 and older—suffer from generalized anxiety disorder (GAD), according to the most recent national survey of psychiatric illness.1,2 GAD is associated with overuse of medical services. In addition, patients with GAD frequently present with somatic illness, typically in primary care settings.3-5 Women are twice as likely as men to be affected,6 and the onset of GAD more commonly occurs at or around midlife, rather than at earlier ages.4
Identifying and treating GAD promptly is a high priority, as it exacts a high burden of suffering. Physical and mental comorbidities are extremely common (TABLE). In fact, 66% of those with GAD have at least 1 additional psychiatric condition—most frequently, major depression.7
Further evidence of the toll GAD takes comes from the National Comorbidity Survey, a congressionally mandated study of more than 8000 US residents conducted in 1994. Among the respondents, 82% of those who had ever been diagnosed with GAD said they had sought professional help for the disorder, taken medication for it, or found that it interfered with their life or activities “a lot.” 7
Patients with GAD, like Brad, often start their search for help in primary care. And GAD can usually be treated successfully in such a setting.5 Thus, it is crucial for family physicians to not only be on the lookout for signs and symptoms of GAD (See “Is it GAD?”), but to familiarize themselves with the most effective pharmacological treatments.
While paroxetine, like other selective serotonin reuptake inhibitors (SSRIs), is well established as a safe and effective treatment for GAD,8,9 1 or more of the most common side effects are often bothersome to patients. These include nausea, reported by 22% of patients; headache, reported by 12% of patients, and abnormal ejaculation/sexual dysfunction, reported by 11% of patients in a study of longterm use of paroxetine for GAD.10 This review describes the other options you may want to consider—and the ones you’ll want to avoid.
|Psychiatric||Hazard ratio||95% CI|
|Medical||Hazard ratio||95% CI|
|Ischemic heart disease||1.50||1.10-2.04|
|CI, confidence interval; GAD, generalized anxiety disorder; GI, gastrointestinal.|
Kate Winslet also won the Golden Globe for best supporting actress for a movie for her role in Steve Jobs. The actress remained in her seat looking dumbfounded after she was named best supporting actress in a film for her portrayal of Joanna Hoffman in Steve Jobs.
"How many patients do Chinese doctors see a day? It can be more than 50," he told China Daily. "How can we have the time and energy to do research or publish papers?"
Tricyclics, for example, have demonstrated efficacy in treating GAD,11 but are associated with sedation and anticholinergic side effects and are typically not as well tolerated as some other choices. Atypical antipsychotics also have troublesome side effects—primarily, somnolence and weight gain. In addition, atypical antipsychotics require monitoring for rare but life-threatening adverse reactions, such as agranulocytosis, which limits their practicality in a primary care setting.
要让产品显得很“酷”并不是唯一的目的。科技行业如果想让我们身体的更多部位连上网络，那么安全问题和隐私问题，尤其是顾客数据管理问题，依旧需要慎重考虑。正如《经济学人》（The Economist）所说，蓬勃发展的传感器的魅力，以及可穿戴设备的算法，分散了人们对于其他要素的关注。这些关键的其它要素包括：“标准、互通性、一体化、数据管理”，以及“知识产权、执行标准”。对国家安全局（National Security Administration）而言，这些技术发展都必须以网络安全为前提。
3.The Jungle Book
The ranking is in part based on how successful alumni have been in their careers, as reflected in the salary data.
SNRIs have high efficacy
Of the 3 SNRIs on the market—desvenlafaxine, duloxetine, and venlafaxine—the latter 2 are approved for the treatment of GAD. Venlafaxine, in particular, has shown great efficacy as both a short- and long-term treatment.12-14
A meta-analysis by Meoni et al demonstrated that venlafaxine ER (extended release) provided significantly higher response rates than placebo for the relief of both the psychological and somatic symptoms of GAD.13 By week 24 of treatment, the rates of improvement in the treatment group were 66% for psychological symptoms and 67% for somatic symptoms, vs 35% and 47%, respectively, for those in the placebo group. A randomized controlled trial (RCT) by Montgomery et al also found venlafaxine to be well tolerated, with no significant difference in rates of discontinuation due to adverse effects between the SNRI and placebo.12 (In another study, duloxetine was found to be an effective treatment for GAD, but had a significantly higher dropout rate than placebo.15)