Anxiety Relapse

An Anxiety Relapse Can Be Worse Than The Initial Episode

Anxiety relapses can be avoided with proper medication management and other lifestyle changes. This is one of the first studies that I have seen that finally addresses one very important question that my patients ask me, “When will I be able to stop taking my medication for GAD Generalized Anxiety Disorder?”.  As a general rule I normally keep patients on antidepressants and anti-anxiety medications for at least 6 to 12 month. This will vary depending on the individual’s metabolism and the amount of time need to receive the therapeutic benefits from the medication as well. This study seems to confirm that a greater efficacy against anxiety relapse is achieved by maintaining the medication management for a full 12 months. The best results during this study were from patients who remained on the medication for a full 12 months to avoid an anxiety relapse. See my views on anxiety for more information on my clinical and practical observations in order to minimize the chances of a recurrence of anxiety relapse or panic disorder relapse.

I have seen patients who have wanted to try to come off their medication for the treatment of Generalized Anxiety disorder prior to the 12 month interval. What tends to happen with tapers on the medication is that the symptoms of anxiety just reappear with the subtraction of the medication; but when patients have been on the main treatment with an antidepressant for treatment of either major depressive disorder or GAD generalized anxiety disorder (We do treat generalized anxiety disorder with antidepressants too), for a full 12 months and are symptom free from anxiety. If they have only had one episode, sometimes the patients are in remission and they remain symptom-free with a taper off the medication. The patient should know the triggers that can provoke an anxiety relapse and avoid them. Often the relapse can be more severe than the initial episode or anxiety attack. The 12 month medication plan is often a shorter period of time when compared to the initial anxiety episode and relapse.

Medication Management is Key to Avoiding a Relapse

I would not recommend going off the medication all at once. I would recommend a taper off the medication with the help of your doctor to mitigate the rebound anxiety and not provoke an anxiety relapse.

Too often the patient starts to feel better and stops taking the medicine and ends up in an anxiety relapse. One of the biggest issues a psychiatrist faces is having patients staying on their medications. Many of them feel an aversion to medicine due to side effects, cost, biases against medicine, or simply because they think they are cured from anxiety. Sometimes patients with chronic anxiety can taper over time and even learn to cope with the stress and triggers in life.  They can get to a point of taking the medication as needed for occasional anxiety. But this is often the exception and even if this is the goal; they should taper at their doctor’s advice. I believe that in the cases of severe the anxiety, the patient should be on medication for at least 12 months before any changes are even considered, if not they stand a good chance for a relapse.

From Medscape Medical News Psychiatry
Chronic Anxiety Requires Long-Term Treatment to Prevent Anxiety Relapse
Fran Lowry

December 16, 2010 — Patients with chronic generalized anxiety disorder (GAD) who are receiving antidepressant therapy need to be continuously treated for at least 12 months to prevent relapse, according to a new study.

“Clinicians should not be afraid to treat their chronically anxious patients for at least 12 months and probably even longer,” lead study author Karl Rickels, MD, Stuart and Emily Mudd Professor of Psychiatry at University of Pennsylvania, Philadelphia, told Medscape Medical News.

“Full remission of symptoms should be the treatment goal, and this goal is not reached for many patients unless they are treated for at least 6 months.”

The study is published in the December issue of the Archives of General Psychiatry.

There were very few data on long-term treatment of GAD with medication and no data at all on whether 12 months of treatment was better than 6 months of treatment, Dr. Rickels explained.

Therefore, he and his team set out to examine the long-term efficacy of treatment with venlafaxine extended release (XR) in patients with chronic GAD who had responded therapeutically to an initial 6-month course of venlafaxine XR treatment.

The 18-month study was composed of 3 treatment phases: a 6-month, open-label, venlafaxine XR, flexible-dose treatment phase, which included 268 patients; a 6-month, randomized, double-blind, placebo-controlled relapse phase, which included 136 (50.7%) of the open-label patients; and a final 6-month, randomized, double-blind, placebo-controlled relapse phase, which included 59 (43.4%) of the first relapse phase patients.

The study showed relapse rates in phase 2, or at months 6 through 12 of the study, were 9.8% for patients taking venlafaxine XR compared with 53.7% for patients taking placebo (P < .001).

Relapse rates after 12 months of venlafaxine XR treatment were 6.7% for patients who were taking venlafaxine XR for the full 18 months, 20.0% for patients taking placebo for 12 months (months 6 to 18), and 32.3% for placebo patients who switched at month 12 to placebo (P < .14).

The study also found that patients treated with venlafaxine XR for 12 months before being shifted to placebo experienced a lower relapse rate (32.4%) than patients shifted to placebo after taking venlafaxine XR for only 6 months (53.7%; P < .03).

A major limitation of the study was its high attrition rate, said Dr. Rickels.

“Only patients who are willing to take medication for their anxiety for an extended period of time, who are able to cope with the adverse events that may occur, and who are able to cope with the slow onset of improvement and are willing to go up to the highest doses of drug allowed by the [US Food and Drug Administration], will benefit from long-term treatment,” he said. “This excluded 40 patients in our study who dropped out of treatment before completing at least 6 weeks of treatment.”

Dr. Rickels said that patients particularly suited to long-term treatment are those patients who have had anxiety for several years and whose anxiety clearly affects their quality of life.

Commenting on the study for Medscape Medical News, Richard Steinbook, MD, professor of psychiatry at University of Miami Miller School of Medicine in Florida, said the study confirms clinical experience.

“This study confirms what we have always experienced clinically on a more scientific basis. Now we can say with more scientific certainty that these patients do require longer term treatment.”

He also approved of the study design.

“This was a relapse prevention study. It gave patients the opportunity to compare themselves over the long haul with others who have been switched to placebo,” Dr, Steinbook said.

“Dr. Rickels has been one of the mainstays in this area. He has spent over 30 years working with this group in a variety of treatment approaches. This is a useful study.”

This article on anxiety relapse is meant for informational purposes only and not to be used in diagnosing or treating any psychiatric condition