Which antidepressants treat comorbid anxiety and depression

Anxiety disorders

Created by: Andres Howald, Uwe BeiseLast revised: 05/2020Last change: 05/2020

1.Definition, epidemiology (1, 2)

definition

Fear is an uncomfortable emotional state, but at first it is a normal, sometimes vital, reaction to danger. Fear is accompanied by physical, cognitive and emotional symptoms.

  • Clinical relevance
    Fear only becomes clinically relevant and pathological when it comes to exaggerated, unrealistic, or even baseless reactions. The experience of fear then leads to avoidance behavior or withdrawal from everyday activities as well as difficulties at work and in social relationships.

Epidemiology

  • In addition to depression, anxiety disorders are the most common mental illnesses - also in the general practitioner's practice: The point prevalence is around 6–8%. Women are affected twice as often as men
  • Anxiety disorders have not increased in frequency in recent years or decades (3, 4). They are often comorbid with other anxiety disorders, depression, somatoform disorders, and addictions (5)
  • Generalized Anxiety Disorder: Lifetime prevalence (Europe) 4–6%; whs. the most common anxiety disorder in the elderly. The majority have comorbid disorders, v. a. Depression, another anxiety disorder, or addiction.

 

2. Anxiety-associated disorders (3)

This guideline deals with important disorders that are also frequently encountered in primary care. By definition, depression is not an anxiety disorder. Since it is often comorbid in anxiety disorders, it is also partially addressed in this guideline; detailed information can be found in the mediX GL Depression. Post-traumatic stress disorder is not the subject of this guideline.

2.1. Generalized Anxiety Disorder (3)

Physical expressions

  • Trembling, racing heart, dizziness, nausea, muscle tension.
    Note: In contrast to panic disorders, physical symptoms do not appear like seizures, they also change, but are permanently present.

Psychological expressions

  • Difficulty concentrating, having trouble sleeping, being nervous, having difficulty relaxing, getting irritated or irritable quickly
  • Constant worries, e.g. B. being able to fall ill, suffer accidents, worry about one's own worries
  • Since those affected are aware of the exaggerated extent of the fears and fears, the worries themselves become the object of concern ("worrying about worrying")
  • Depression sets in when there is no effective treatment.

diagnosis

  • The diagnosis can be made when primary symptoms of fear (exaggerated fear, floating, indefinite fear, motor tension, vegetative overexcitability) persist for several weeks to months (according to ICD-10).

-> QUESTIONS TO FOLLOW UP

  • Do you feel nervous and tense all the time? Do you feel sick shortly after you wake up?
  • Do you often worry about things more than other people?
  • Do you feel like you are constantly worried and out of control?
  • Do you often fear that an accident might happen?

2.2. Panic disorder (3)

Symptoms

Anxiety attack with physical symptoms

  • Palpitations, tremors, sweating, tremors, dizziness, fainting, hot or cold flashes, numbness and tingling sensation. Fear of going "crazy" or dying
  • Increase in complaints with climax after 10 minutes; average duration: 30–45 min.

Notes on diagnostics

  • Panic attacks end after 2 hours at the latest, even without intervention
  • 2/3 of the cases are associated with agoraphobia (see below)
  • Patients calm down with the presence of a doctor.

-> QUESTIONS TO FOLLOW UP

  • Do you have sudden attacks with symptoms such as palpitations, tremors, sweating, shortness of breath, fear of death?

⇒ Concomitant agoraphobia - definition / symptoms

  • Fear of places where, in the event of a panic attack or other loss of control, it is difficult to escape or would cause an embarrassing sensation (crowds, buses, trains, cinemas, department stores, narrow spaces, public spaces)
  • Often the result of panic attacks
  • Fear of being alone is also common
  • Avoidance behavior leads to social withdrawal.

-> QUESTIONS TO FOLLOW UP

  • Do you feel anxious or anxious when you are in crowds, tight spaces, or public transport? Do you avoid such situations out of fear?

2.3. Obsessive Compulsive Disorder (4)

Symptoms

  • Obsessive thoughts
    • Obsessive-compulsive thoughts can be similar to everyday thoughts and fears, but have a more intense quality. They can be provoked by triggering stimuli, but they can also occur spontaneously
    • Typical obsessive-compulsive thoughts are: contagion, poisoning, pollution, illness, striving for symmetry, order, aggression, sexuality and religion
    • It can also be more or less bizarre thoughts that are difficult to understand rationally
    • Patients experience their obsessive thoughts as bothersome and intrusive and see them as repulsive, shameful, nonsensical and difficult to drive away
    • Obsessive thoughts that are experienced as impulses for action Not executed
    • Affective symptoms: Fear, tension, despair, restlessness and depressive mood.
  • Compulsions
    • The most common compulsions are washing and cleaning compulsions as well as control and order compulsions.

Diagnostic clues

  • Differentiation from anxiety disorders in the narrower sense: Rigid, inappropriate rituals and repeatedly intrusive thoughts and impulses that are experienced as aversive (intrusions)
  • At the onset of the disease beyond the age of 50, organic brain assessment
  • The differential diagnosis must clarify whether the current symptoms belong to an obsessive-compulsive disorder or another disorder (e.g. obsessive-compulsive symptoms in schizophrenia or depression, or as concerns in the context of a generalized anxiety disorder)
  • In addition to the obsessive-compulsive disorder, there may be a depressive episode (comorbidity)
  • In contrast to schizophrenic psychosis, there is insight into the disease, obsessive-compulsive thoughts are recognized as belonging to oneself.

2.4. Social Anxiety Disorder (5)

Symptoms

  • Those affected are very afraid of being the center of attention or of embarrassing themselves. Therefore, they avoid situations in which the fears could become reality
  • The fears relate to social situations (e.g. speaking or eating in public)
  • Physical symptoms are: blushing or trembling, strong urge to urinate or defecate. Focusing on the physical symptoms exacerbate these
  • Those affected suffer greatly from the symptoms of anxiety and the consequences of avoidance behavior. Although they know the fear is excessive, they cannot change their behavior on their own.

-> QUESTIONS TO FOLLOW UP

  • Are you very afraid of certain things or situations in which you fear that other people may judge you negatively, criticize your appearance, or view your behavior as embarrassing or awkward?

 

3. Diagnostic procedure

Preliminary remarks / general general practitioner procedure

  • Anxiety disorders are often not recognized, also because patients more often complain of pain, sleep disorders or other somatic complaints than fear as the main symptom
  • The exclusion of somatic diseases through technical examinations should - in joint decision-making - only take place until it is sufficiently probable that there is no physical cause. Overdiagnosis avoid -> can favor somatic fixation.

anamnese

  • Personal anamnesis / biographical anamnesis, family anamnesis, external anamnesis
    • Pay attention to traumatic experiences, mental illnesses of early attachment figures, experiences of loss and learned behavior in the family of origin
    • Content of the fears and the personal, professional and social effects of the fear
    • Generally stressful factors.
  • Differentiation of fear
    • Situation / object-related?
    • Triggering situation / object?
    • Acute, seizure, chronic course?
    • Degree of impairment.
  • Ask about clarifications that have already taken place
  • Exclusion of another mental illness
  • Recognizing comorbid depression: the two-question test can be used in a general practitioner care context
    • Have you felt down, sad, depressed, or hopeless more often in the past month?
    • In the last month, have you had significantly less desire and enjoyment in things that you normally enjoy doing?
  • Taking medication?
  • Withdrawal symptoms (e.g. alcohol)?

Somatic diagnostics

−> Is necessary to clarify whether it is possibly a secondary anxiety symptomatology
−> First-time anxiety symptoms after the age of 45 rather suggest a somatic cause.

What does the somatic assessment include?

  • Physical examination
  • Neurological status
  • At the first anamnesis
    • Differential diagnostic work-up on physical diseases - thyroid dysfunction, hypoglycaemia, hyperparathyroidism, arrhythmias, COPD, seizures and pheochromocytoma
    • laboratory: Blood count, blood sugar, electrolytes (Ca ++, K +), thyroid status (TSH), ECG with rhythm strips.
      Only if there is special suspicion
      • Lung function
      • Cranial imaging (MRI, cCT)
      • EEG.

Important: Avoid repeated somatic assessments -> risk of iatrogenic fixation and risk of chronification!

−> The exclusion of somatic diseases through technical examinations should - in joint decision-making - only take place until it is sufficiently probable that there is no physical cause.

 

4th treatment (6–8,19)

4.1. Therapy indication, referral to specialists

Generally

  • As a rule, anxiety disorders can be treated on an outpatient basis
  • In clinically relevant anxiety disorders, relationships, activity and participation are considerably restricted by personal suffering and by the frequent avoidance behavior of those affected in everyday life
  • Anxiety disorders tend to become chronic if there is no (adequate) treatment
  • Education, information and therapy for anxiety disorders are time-consuming and rethinking and stable changes usually occur after several months.

Therapy indications

  • Moderate to severe distress of the patient with impairment in social, professional and other functional areas
  • Psychosocial restrictions
  • Possible complications of an anxiety disorder (e.g. addictions).

Therapy goals

  • Reduce anxiety symptoms and avoidance behaviors
  • Improve quality of life
  • Reduce the likelihood of relapse
  • Improve restriction of mobility
  • Improve social integration
  • Restore professional performance.

Cooperation between family doctor and psychiatrist

  • Anxiety disorders tend to be chronic, and the phobic behavior often leads to avoidance behavior everything New ones with you - also in relation to a therapy. Instead, benzodiazepines are “borrowed” from the medicine cabinet (e.g. from one's partner) or alcohol is drunk.
    Therefore, it is better to call in a specialist at an early stage!
  • With all anxiety disorders, an active attitude is required, both from the patient and from the practitioner, who should persist
  • The primary role of family doctors is first of all to rule out a somatic disease. Gatekeeping can prevent excessive investigations with physical restraint. After the clarification and diagnosis, a psychiatrist should be called in, or the family doctor will take over the pharmacotherapy and delegate the psychotherapy.

Indication for inpatient treatment

  • Suicidality
  • Outpatient measures not sufficiently successful
  • Severe course with exhaustion and / or depression
  • Pronounced comorbidity.

4.2. Psychotherapy and pharmacotherapy

Psychotherapy or Pharmacotherapy?

  • Generally the psychotherapy first choice for treating anxiety disorders
  • An additional) medical therapy (see also the table in the appendix) should generally be considered if the patient is moderately to severe impaired (clear, negative consequences in everyday life such as withdrawal, incapacity for work), psychotherapy alone does not appear to be feasible or has not produced the desired effect.

4.2.1. Psychotherapeutic procedures

Various psychotherapy approaches are available for treating anxiety disorders. The list of accredited advanced training courses from the FOPH includes the following procedures

  • Cognitive behavioral therapy (CBT)
  • Psychodynamic therapies: depth psychological therapy methods: psychoanalysis, analytical psychology, process work
  • Systemic psychotherapy
  • Humanistic therapy methods: client-centered psychotherapy, gestalt therapy, body-oriented psychotherapy.

Choice of procedure

  • In patients with a Panic disorder / agoraphobia, generalized anxiety disorder, and social phobia should primarily be one CBT because this therapy method is the best proof of effectiveness for them
  • The few available studies on CBT contribute People over 65 years of age show a lower effectiveness compared to the therapy of younger adults (18 to 65 years)
  • A psychodynamic psychotherapy can be offered if CBT has not proven to be effective or if the (appropriately informed) patient has a preference in this regard
  • For specific phobias there are only studies on behavioral therapy (which should be carried out as exposure therapy). Psychiatric drugs are not recommended as standard of care.

4.2.2. Pharmacotherapy (6–8)

Preliminary remarks

Anxiety disorders are time-consuming, especially in the first few weeks until integrated treatment takes effect, and can be accompanied by crises, especially when medication is used (e.g. increased risk of suicide under antidepressants in young adults or withdrawal symptoms). Managing side effects or complications requires the family doctor to be present, be able to offer emergency consultations and generally be flexible. If this is not the case, a referral to a psychiatrist / psychologist should be given at the beginning.

An overview of the drugs used can be found in the table in the appendix. Information on side effects and drug interactions of the various substances are shown in the mediX GL Depression (there Chapter 3.2., Table 3).

SSRI and SSNRI

effect

  • Good efficacy proven in RCTs. The onset of action can only be expected after approx. 2–6 weeks. Sometimes only after another 4–6 weeks.

indication

  • SSRIs (e.g. escitalopram, sertraline, paroxetine) and increasingly also SSNRIs (venlafaxine, duloxetine) are Means of choice in the pharmacotherapy of anxiety disorders
  • Notice: Patients being treated with antidepressants must be informed about the slow onset of action at the beginning, but also about the risk that symptoms of anxiety can recur, especially if the antidepressant is stopped abruptly.

Tricyclical

effect

  • Tricyclics (e.g. imipramine, clomipramine) also work well.

indication

  • Second choice antidepressants, since side effects are more common than with SSRI / SSNRI.

Benzodiazepines

effect

  • The anxiolytic effect sets in immediately. In contrast to antidepressants, benzodiazepines do not cause restlessness or nervousness at the beginning of treatment.

indication

  • Benzodiazepines can be over a few days to a maximum of 3–4 weeks be given to bridge the latency of the antidepressants in the first few weeks after the start of medication or to reduce anxiety / nervousness initially triggered or increased by antidepressants
  • Notice: Because of the danger of a Dependency development Treatment with benzodiazepines requires careful risk-benefit assessment. As reserve drugs, v. a. in panic disorder, benzodiazepines are often an important long-term safety for the patient.

Medication

  • Alprazolam (e.g. Xanax®) 0.5-2 mg, lorazepam (e.g. Temesta®) 1-2.5 mg.

Pregabalin (anticonvulsant)

effect

  • Pregabalin works well in generalized anxiety disorder. Compared to antidepressants, it has the advantage that the effect occurs faster (within 1 week)
    • Initially 150 mg per day (2 x 75 mg or 3 x 50 mg)
    • Depending on the clinical response and individual tolerance, the dose can be increased to 300 mg daily after one week. After a further week, the dose can be increased to 450 mg daily. The maximum dose of 600 mg daily can be reached after a further week.
  • There is likely to be an increased potential for abuse and addiction
  • Pregabalin (like SSNRI) also has an analgesic effect
  • Dose adjustment required in case of renal insufficiency!
  • Notice: Benzodiazepines and Pregabalin are Not effective in comorbid depression!

4.2.3. Complementary therapies (9–11)

  • Sport (recommended for panic disorder - endurance training; e.g. jogging 5 kilometers three times a week)
  • yoga
  • Tai chi
  • Mindfulness Meditation Exercises
  • evidence: Experience speaks in favor of a supportive effect of all the procedures mentioned. Studies seem to confirm this; their informative value is limited by methodological deficiencies. However, since they can hardly ever do any harm, nothing speaks against their use.

Not recommended

  • Eye movement desensitization and reprocessing (EDMR therapy, known from the treatment of post-traumatic stress disorders) (12).

4.3. Notes on the therapy of individual anxiety disorders

4.3.1. Generalized anxiety disorder (8, 13, 14, 16, 17, 19)

General preliminary remarks

  • After the diagnosis, the severity should be determined and the need for treatment should be discussed with the patient and the preference for the form of therapy determined
  • Generally will primarily psychotherapy (CBT) is recommendedwhich is as effective as pharmacotherapy, but without the pharmakol. Side effects comes from
  • Possibly A combination of psychotherapy and pharmacotherapy may be necessary.

Drug therapy (see also table in the appendix)

  • SSRIs or SSNRIs are first-line drugs. The selection of the drug should be based on side effects, interactions and patient preferences and previous experience.

Action

  • Start with a low dose, increase the dose every 1–2 weeks
  • If there is no effect after 6 weeks, then most likely switch to another SSRI or SSNRI
  • Possibly if the response is insufficient, go to the maximum tolerated SSRI dose
  • Possibly additionally pregabalin.

Medication

  • SSRI: escitalopram (daily dose): 10-20 mg or paroxetine (daily dose: 20-50 mg)
  • SSNRI: duloxetine (daily dose 60–120 mg), venlafaxine (75–225 mg)
  • The anti-epileptic pregabalin (150–600 mg) is approved for GAD (like benzodiazepines but not effective for depression)
  • Benzodiazepines: cautious because of NW / addiction potential, but possibly in the acute phase in monotherapy or as a comedication to SSRIs
    • Clonazepam 0.25 to 0.5 mg 1–2 times / day titrated to 1 mg 2–3 times / day if necessary
    • Lorazepam (short half-life). Start: 0.5 to 1 mg 3 times a day, up to a maximum of 1.5 mg 4 times a day if required. Always titrate very slowly!

Duration of treatment

  • The therapy should be effective (6) -12 Months to be continued (15).

4.3.2. Panic disorder (20, 21)

General preliminary remarks

  • For panic disorder, the treatment of first choice is psychotherapy alone or a combination of evidence-based psychotherapy with pharmacotherapy
  • CBT is the first choice psychotherapy
  • In patients who prefer pharmacotherapy are SSRI to dose gradually!
  • If the therapy is unsuccessful: Taper the SSRI and replace it with another SSRI (dose gradually again)
  • Venlafaxine (SSNRI) can be used as an alternative if the patient has not responded to one or more attempts with SSRIs
    • Possible dosage regimen: Initially 37.5 mg, increase to 75 mg after one week, then to 150 mg after two more weeks.
  • If the response is partial, a second drug, e.g. B. a benzodiazepine (usually lorazepam) can be used.

Duration of treatment

  • There are no relevant studies on the question of duration of treatment. However, it is recommended for at least 1 year.

4.3.3. Obsessive-Compulsive Disorder (27–31)

psychotherapy

  • The CBT with stimulus exposure and reaction management is the treatment of choice. It is likely to be more effective than drug monotherapy
  • The effectiveness of other psychotherapy methods has not been adequately proven in studies. In addition to CBT, the SGPP also recognizes psychoanalytically oriented therapy and systemic therapy.

Complementary pharmacotherapy

  • Combination treatment of CBT and SSRI treatment can be attempted in severe obsessive-compulsive disorder if monotherapy is unsuccessful
  • The dose of medication required is often higher than for the treatment of depression and other anxiety disorders. Important: Gradual titration according to individual tolerance with regular ECG and laboratory controls
  • An SSRI may initially be recommended to patients with a comorbid psychiatric disorder that responds to SSRIs. (SSNRIs have not been adequately studied in obsessive-compulsive disorder, but effectiveness is considered likely)
  • 60–80% of patients respond to SSRIs, the average symptom reduction under SSRIs is 20–40%. Medicines generally relieve the symptoms at best
  • Action
    • For example, slowly titrate fluoxetine from 40 to 80 mg / d
    • To 6 weeks the success of the therapy can be assessed
    • If the patient does not respond: Switch to another SSRI (e.g. clomipramine or venlafaxine) if the patient wishes to continue drug treatment
    • Duration of treatment: If the response is good, continue treatment for at least 1–2 years, ie longer than with other anxiety disorders. Upon discontinuation, reduce the dose by 10–25% every 1 to 2 months.

Other Procedure

  • The depth Brain stimulation is an experimental procedure for obsessive-compulsive disorder (only in the context of studies in treatment-resistant disease) (32).

4.3.4. Social Anxiety Disorder (22-26)

  • Treat social phobia early to prevent chronic manifestation!
  • CBT is preferred, but there is also good evidence of effectiveness for psychodynamic therapies. The effect of psychotherapies lasts 2 years after treatment (in contrast to pharmacotherapy)
  • With only partial improvement -> possibly additional drug therapy with SSRI / SSNRI.

More therapies

  • Attention training (Attention bias modification training [ABMT])
    • It starts with the hypervigilance of the attention system towards threatening stimuli
    • The results for social anxiety disorder are inconsistent.
  • Interpersonal psychotherapy
    • Short-term psychotherapy, which, unlike CBT, does not aim at maladaptive cognition, but at interpersonal deficits and role conflicts with an important caregiver or role change (separation, marriage, retirement, birth of a child)
    • Mixed results, lower response rate than CBT.

 

5. Notes on general practitioner intervention

The following (slightly modified) advice comes from the DEGAM practice recommendation “General practitioner care for patients with anxiety” (33).

 

6. Literature

  1. Wittchen HU, et al .: Generalized anxiety and depression in primary care: prevalence, recognition, and management.
  2. Baldwin D: Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. UpToDate 05/2020.
  3. Roy-Byrne PP: Panic disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. UpToDate 05/2020.
  4. S3 guideline for obsessive-compulsive disorder, 2013 (currently being revised)
  5. Schneier F: Social anxiety disorder in adults: Epidemiology, clinical manifestations, and diagnosis. UpToDate 05/2020.
  6. Craske M, Bystritsky A: Approach to treating generalized anxiety disorder in adults. UpToDate 05/2020.
  7. Bandelow B, et al .: S3 Guideline Treatment of Anxiety Disorders. 2014.
  8. NICE Clinical guideline: Generalized anxiety disorder and panic disorder in adults: management; July 2019.
  9. Broocks A, et al .: Comparison of aerobic exercise, clomipramine, and placebo in the treatment of panic disorder. At J Psychiatry. 1998 May; 155 (5): 603-9.
  10. Saeed SA, et al .: Exercise, yoga, and meditation for depressive and anxiety disorders. At the Fam Physician. 2010 Apr; 81 (8): 981-6.
  11. Bystritsky A: Complementary and alternative treatments for anxiety symptoms and disorders: Physical, cognitive, and spiritual interventions. UpToDate 05/2020.
  12. Preliminary HTA report: HT17-05: Anxiety disorders: Does the additional use of Eye Movement Desensitization and Reprocessing Therapy lead to better results in psychotherapeutic forms of treatment and application? Publication: October 8, 2019.
  13. Middle K: Meta-analysis of cognitive-behavioral treatments for generalized anxiety disorder: a comparison with pharmacotherapy. Psychol Bull. 2005; 131 (5): 785.
  14. Craske M, Bystritsky A: Approach to treating generalized anxiety disorder in adults. UpToDate 05/2020.
  15. Rickels K, et al .: Time to relapse after 6 and 12 months' treatment of generalized anxiety disorder with venlafaxine extended release. Arch Gen Psychiatry. 2010; 67 (12): 1274.
  16. Slee A, Nazareth I, Bondaronek P, Liu Y, Cheng Z, & Freemantle N. (2019): Pharmacological treatments for generalized anxiety disorder: A systematic review and network meta-analysis. The Lancet, 393(10173), 768–777.
  17. Craske M, Bystritsky A: Approach to treating generalized anxiety disorder in adults. UpToDate 05/2020.
  18. Keck ME, et al .: Treatment of Anxiety Disorders Part 1: Panic Disorder, Agoraphobia, Generalized Anxiety Disorder, Social Phobia, Specific Phobias. Switzerland Med Forum 2011; 11 (34): 558-566.
  19. Bystritsky A: Pharmacotherapy for generalized anxiety disorder in adults. UpToDate 05/2020.
  20. Roy-Byme PP, Craske M: Approach to treating panic disorder with or without agoraphobia in adults. UpToDate 05/2020.
  21. Breilmann J, Girlanda F, Guaiana G, Barbui C, Cipriani A, Castellazzi M,… Koesters, M. (2019): Benzodiazepines versus placebo for panic disorder in adults. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD010677.pub2.
  22. Leichsenring F, et al .: Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: a multicenter randomized controlled trial. At J Psychiatry. 2013 Jul; 170 (7): 759-67. doi: 10.1176 / appi.ajp.2013.12081125.
  23. Stein MB, Taylor CT: Approach to treating social anxiety disorder in adults. UpToDate 05/2020.
  24. Stangier U, Schramm E, Heidenreich T, Berger M, Clark DM: Cognitive therapy vs interpersonal psychotherapy in socialanxiety disorder: a randomized controlled trial. Arch Gen Psychiatry. 2011 Jul; 68 (7): 692-700.
  25. Mayo-Wilson E, et al .: Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. Lancet Psychiatry. 2014 Oct; 1 (5): 368-76. Epub 2014 Oct 7.
  26. Hofmann SG: Psychotherapy for social anxiety disorder in adults. UpToDate 05/2020.
  27. Koran LM, et al .: Practice guideline for the treatment of patients with obsessive-compulsive disorder. At J Psychiatry. 2007; 164 (7 Suppl): 5.
  28. Keck ME, et al .: The Treatment of Anxiety Disorders. Part 2: Obsessive Compulsive Disorder and Post Traumatic Stress Disorder. Switzerland Med Forum 2013; 13 (17): 337–344. Swiss Medical Forum 2013; 13: 337-344
  29. Hohagen, F. (Ed.). (2015): S3 guideline for obsessive-compulsive disorder. Berlin: Springer.
  30. Abramovic J: Psychotherapy for obsessive-compulsive disorder in adults. UpToDate 05/2020.
  31. Simpson HB: Pharmacotherapy for obsessive-compulsive disorder in adults. UpToDate 01/2020.
  32. Denis D, De Koning PP: Deep brain stimulation for treatment of obsessive-compulsive disorder. UpToDate, 05/2020.
  33. DEGAM practice recommendation: General practitioner care for patients with anxiety, 10/2016.

 

7. Advice for patients

Books

  • Jürgen Hoyer, Katja Beesdo-Baum, Eni S. Becker: Ratgeber Generalized Anxiety Disorder, Hogrefe Verlag, 2nd edition, 2016
  • Eni S. Becker, Jürgen Margraf: Out of sheer worries ... Self-help with generalized anxiety disorder. With online material, Beitz Psychologie, 2nd ed., 2017

On-line

Self help

 

8. Appendix

table: Indication of important drugs for the individual disorders

 

9. Imprint

This guideline was drawn up in May 2020.
© Association mediX

editor
Dr. med. Felix Huber

editorial staff (responsible)
Dr. med. Uwe Beise

Authors
Dr. med. Andres Howald
FA FMH for psychiatry and
psychotherapy
Dr. med. Uwe Beise

Please send your feedback to: uwe.beise_at_medix.ch

This guideline was created without external influence. There are no financial or content-related dependencies on industry or other institutions or interest groups.

mediX guidelines contain therapeutic recommendations for specific symptoms or treatment situations. However, each patient must be treated according to their individual circumstances.

mediX guidelines are developed and checked with great care, but the mediX association cannot accept any liability for the correctness - especially of dosage information.

The mediX association is an amalgamation of medical networks and doctors in Switzerland.
MediX association, Sumatrastr. 10, 8006 Zurich.