A psychopharmacological treatment algorithm for generalised anxiety disorder (GAD).

Generalised anxiety disorder (GAD) is defined as excessive and uncontrollable worry and anxiety about everyday life situations. It is a chronic disorder, and is associated with substantial somatisation, high rates of comorbid depression and other anxiety disorders, and significant disability. The evidence base for pharmacotherapy and psychotherapy has continued to grow, and a wide range of drug choices for GAD now exists. Current guidelines for GAD generally restrict themselves to presentation of the evidence for various treatments, which, as a result, generally do not offer detailed discussion or recommendation of strategies beyond the first level of treatment, or take into account the individual circumstances of the patient. Thus, there is a lack of algorithm-based treatment guidelines for GAD. Our aim is, therefore, to present an algorithm for the psychopharmacologic management of GAD, intended for all clinicians who treat patients with GAD, where issues of pharmacotherapy are under consideration. We also hope that these GAD algorithms and other guidelines can help to identify high-priority areas that need further study. In this algorithm, we provide a sequenced approach to the pharmacotherapy of GAD, taking into account salient symptomatology and comorbidity, levels of evidence and extent of response. Special issues, including comorbidity, insomnia, suicidality, substance abuse, treatment adherence, pregnancy and lactation, cross-cultural issues, use of medication in the elderly, psychosocial treatment and dosing issues are also addressed.

Dora Kohen trained both in neurology and psychiatry. She contributed enormously to British medicine. Sadly she died prematurely. In so many ways Dora was a breath of fresh air, in both clinical and academic circles. She frequently challenged orthodox accepted viewpoints but did so in a manner that was always friendly and never condescending. She had a capacity to view the obvious from a not so obvious perspective. When she put forward a view she made others sit up and take note. She ascribed to the philosophy that nothing should be accepted, simply because it always had been. If something could be done in a more effective, but less traditional manner, then so be it.

She had a resourceful, robust personality and always stood up for what she believed. In a conservative profession, as is medicine, that is not always an easy path, but Dora never took the path of least resistance. She always took the road she considered was right. There were occasions when diverting and turning a blind eye would have avoided personal stress, but selling-out was not part of her agenda.

As a clinician with a background in both neurology and psychiatry she was superb. Patients loved her and she was always prepared to go the extra mile on their behalf. She had clinical skill few could match.

If one was to attribute a single characteristic to Dora it would be optimism. Whatever difficulties she faced, right to the end, she took an optimistic viewpoint. She always believed that things would work out for the best.

To her husband Karabey and her beloved daughter Cemile her loss is inestimable. Those of us who knew her well have lost a very dear friend.