GAD can be effectively treated by pharmacotherapy, CBT, or both combined. Medications never teach new skills, but do offer some symptom relief in persons with moderate to severe anxiety. Benzodiazipines can offer some relief, but because they are addictive need to be used with some caution. CBT does teach new skills and probably offers better long term outcome for persons completing the therapy.

I agree with the previous answer.. Benzodiazepines are less likely to be used these days due to their Ipotential to cause a withdrawal syndrome when discontinued. There are other meds whichcan be used such as SSRIs and SNRIs which will provide symptomatic relief, but the use of some form of CBT or other psychotherapy either alone or in combination with meds is likley to be more beneficial in the longr term than meds alone. Of course thedecision to use meds will depend on the severity the initial disorer. For mild cases meds are likely to be counterproductive..

Also BZD's have serious side effects on driving and other motor coordination activities.

They have to be combined. If you only use pharma, you treat only the symptoms, not the disease. To get to the roots of the anxiety you need psychotherapy. Then you also treat the cause.

I agree with combining SSRIs with Psychotherapy when psychotherapy alone doesn't work, but for a slightly different reason. Psychotherapy for GAD includes cognitive change such as changing interpretations of external events and physical symptoms, and sometimes, especially when GAD appears along with depression (which is pretty often), those cognitions can be hard to changed, and in that case SSRIs can stimulate enough neurogenesis after a few weeks to help that change happen.

Side note: Benzodiazepenes, along with being addictive physiologically (habituation) and psychologically (operant conditioning, getting a reward for feeling anxious and giving up on one's coping mechanisms), also interfere with memory consolidation, which means it's harder for clients to learn from psychotherapy sessions and homework.

Psychoteraphy is than effective as PT + SSRI/BZD. At the beginning some drugs (BZD) can be useful is symptoms are strong.

And PT is than effective as SSRI/BZD alone but long term results are better with PT. It is important explain to the patient that drugs are not the solution , solution is change the way to cope

Most patients under the age of 30 with a history of GAD from childhood typically don't require medication. If they do, a small dose of Paxil or Prozac for 3 to 6 months is sufficient. How therapy is conducted is far more important. There are multiple reasons that CBT has become the treatment of choice; however, a closer look reveals other methods are more effective. CBT treats thoughts and emotions as malleable and reward-able. They aren't and they are different from behavior. Patients gain valuable information from their emotions, likely linked to their anxiety. Further, to meet criteria for GAD, patients typically possess a high IQ. This is the key to treatment. These patients process information by linking topics, remembering details and being rewarded either in school or at work. In my professional opinion, it is detrimental to attempt to reverse a conditioning history from youth. It is also nearly impossible and often leads to depression. I have seen many patients benefit from learning how they process information, and gradually carving out quiet time when their mind is not busy. They necessary to succeed, they don't fight a relatively automatic process and of themselves and others as unique. They will remain thinkers for the rest of their lives, but will function at a much higher level and they will most likely not develop depression.

It depends: if you mean symptomatic improvement both psychotherapy and pharmacotherapy could be effective, if you mean long-term change psychotherapy it had been shown to be more effective in prevent relapses.

Maybe combined therapy may be the best treatment, however many patients prefere to avoid secondary effects of pharmachotherapy.

David, thanks for the link to your paper. John

COMPARING MEDICATION TO CBT — There is insufficient evidence directly comparing the effectiveness of medication for GAD to cognitive behavioral therapy (CBT), the best studied and most effective psychotherapy for GAD [56,57]. Meta-analyses comparing the effect sizes of the two modalities have found largely equivalent results [58]. We suggest that the choice between them should be based on treatment availability and patient preference. (See "Psychotherapy for generalized anxiety disorder".)

COMBINED MEDICATION AND CBT — Two trials have found the combination of a benzodiazepine and CBT to be more effective for GAD than a benzodiazepine alone [59,60]. Another trial compared sertraline, CBT or the combination in 448 7 to 17 year olds with separation anxiety, generalized anxiety, or social phobia [61], finding that the combination treatment was superior to either monotherapy, with all three treatment groups showing greater reduction in anxiety compared to placebo. The number of adverse events, including suicidal and homicidal ideation, did not differ across the groups. (See "Psychotherapy for generalized anxiety disorder", section on 'Cognitive behavioral therapy'.)

While they can be beneficial, treatment that integrates medication with CBT should be administered with caution to avoid counterproductive interactions. As an example, benzodiazepines and, to a lesser degree, sedating SSRIs can disrupt the learning of new coping strategies, a mechanism that is fundamental to CBT. Several principals should guide combined treatment:

Stabilization of medications prior to starting CBT

Avoidance of “as needed” or large doses of benzodiazepines

Avoidance of other medications that have sedative effects (eg, sedative SSRIs) while CBT is in progress

ref:www.uptodate.com

For Specific Phobia's, behavior and Psychotherapy may be more effective, but for GAD if diagnosed properly Pharmacotherapy is more effective and even after significant improvement it's difficult to wane off meds, as the patient needs some maintenance....

These references might be helpful

McIntosh A, Cohen A, Turnbull N, et al. Clinical guidelines and evidence review for panic disorder and generalized anxiety disorder. University of Sheffield/London: National Collaborating Centre for Primary Care, Sheffield; 2004.

Mochcovitch MD, Nardi AE. Selective serotonin-reuptake inhibitors in the treatment of panic disorder: a systematic review of placebo-controlled studies. Expert Rev Neurother 2010;10:1285-93.

American Psychiatric Association. APA practice guidelines for the treatment of psychiatric disorders. American Psychiatric Press, Washington, DC; 2006.

Royal Australia and New Zealand College of Psychiatrists. Australian and New Zealand clinical practice guidelines for the treatment of panic disorder and agoraphobia. Aust NZ J Psychiatry 2003;37:641-56.

Bandelow B, Zohar J, Hollander E, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders -- first revision. World J Biol Psychiatry 2008;9:248-312.

Dear colleagues, many thanks for answers.

I really like all the above discussion and will try to pursue the research papers. I think of medications as being able to raise the threshold for the anxiety in some patients, but they do not substitute for coping skills or change cognitions. In any given patient, we don't know how much is nature or nurture. When anxiety is extreme, medications may be needed to make the mood tolerable, and be at the level that the patient can then develop some skills and alter his/her cognitions. In the US when young people are learning to play baseball, sometimes they go to a park with batting cages where baseballs are pitched at different speeds. As the youth develops skills he/she goes up to higher speeds. The medications may be able to slow things down so the person can develop the skills, that ultimately will alter how he or she learns to feel safe. And , there may be other people who function better with the medication and do worse off the medication.

After reading through the answers contributed I am grateful to have access to this forum. Mr. Jagadeesan Ms' answer is in line with both the years of clinical trials I worked on with phobic and anxious children and the children and adults I saw during nearly a decade of private practice. I was very very fortunate to have, no offense intended, the best psychiatrist in my city available. He didn't make medical mistakes in the time I knew him; he was on top of new research; most of all, he understood comorbidity, pharmacology and the need to administer the safest meds/doses to individuals, and to work closely with me to at least consider weaning patients off meds by 6 months if ethically and medically indicated. I completed my specialized training in comorbidity and found that it often held answers that we, as a field, really didn't take it into account until very late in the game. And then, we have never addressed certain questions, some more developmental, some more philosophical: you CAN sit down and either administer a structured/semi-structured clinical interview that covers most disorders to your participant/patient, but if you had not, would they have acknowledged the problem(s) in other areas [I found in a sample over 500 that comorbidity is the rule not the exception, even when being extremely strict to avoid artificial comorbidity]? If yes, they were aware of them, and would discuss them, when? If no, they never felt/thought about these other issues, now that they are on the table via this method, does it matter what the patient feels [scared? not ready to handle more than what they came in for?}? Based on a large number of studies, all of us who work with patients in fact have a large percentage who are comorbid, so which disorder do you treat first [it typically depends on the question(s) your particular agency, grant or institution is attempting to answer]? Your choice may not line up with developmental necessity [treat what is interfering with the child/adol/adult developing properly] or even medical necessity [anxiety versus depression]. I could be raising questions that honestly researchers have resolved already, in that if there is a conflict in multiple diagnoses, then researchers do not accept the person into their study. I can definitively say those on the 'front line' do not follow that plan, and often allow a gradual unfolding of the individual's problems, but not so much on purpose or through education, therefore they often are unable to come up with a solid, individually-based treatment plan that deals effectively with this clinical picture. I know many of you will cite articles showing if one tests an EBT treatment which focuses on 1 disorder, many of the other disorders are reduced in severity or appear to no longer be disorders, as well as many other findings. As a way of explaining my comments, I am thoroughly trained in CBT/EBT, hold 2 graduate degrees, 1 in Developmental Psych and 1 in Counseling, acquired my license to practice and was in the unique position to compare certain trends, reactions, and so on, with a foundation of cognitive development that is essential when working with kids. Kids are not small adults--nor should EBT manuals for child treatment be downward extensions of adult manuals (a minimal effort at using developmental terms is not sufficient). I know the difference between a clinical trial and anecdotal evidence, but observation done correctly has its place in science. I chose never to use CBT if possible, and given the patients I treated, it was not a problem (i.e., I understand there are patients who need a quick intervention that gets the job done, questions aside, for their well-being). Not only do we have an extremely high rate of mental illness in this country (refer to Harvard's epidemiological series of studies), we are immersed in a reward/punishment framework. At work. In therapy. At school. At home. In relationships. People aren't pigeons, no matter how often it may appear so, and seriously, about 100 years of exposure to conditioning has done a great deal to help us look/act like pigeons. Yet, we aren't. In fact, the very statement, "You developed problems due to learning, so we can use learning to help you overcome those problems" gives itself away: what we've done is simply saturated the individual with more conditioning, and the entire situation keeps the population very susceptible to conditioning in general. That in no way will prevent future mental illness. I devoted many years to research in different fields, and appreciate the difference having results often makes when a professional must make hard decisions. I am also aware that depending on how the research question(s) are phrased, measured (i.e., comorbidity; see Last's article on the failure of 3 'big' child anxiety measures to discriminate anxiety), analyzed and used (i.e., by insurance companies and gov't organizations that have their own agendas to serve), it will look like EBT/CBT is the only treatment approach in all its variants to consider. I ask you to consider the multiple factors I have highlighted, and if needed, please refer to studies that indicate meta-cognitions particular to GAD have an influence on the development and/or maintenance of the disorder. Meta-cognitions cannot be separated from emotions, conditioning, feelings--in short, thoughts--and these studies provide another source of support that conditioning thoughts is not a good idea, and in all likelihood has contributed to our extraordinarily high rate of mental illness in general.