Room for improvement in the pharmacological treatment of anxiety disorders.

Anxiety disorders are common in community settings and in primary and secondary medical care. The associated societal burden is considerable, but many of those who might benefit from pharmacological or psychological treatment are not recognised or treated. By contrast, some patients receive unnecessary or inappropriate interventions. Recent evidence-based guidelines for pharmacological management of patients with anxiety disorders recommend initial treatment with either a selective serotonin reuptake inhibitor or a serotonin-norepinephrine reuptake inhibitor. However, there is considerable room for improvement in both the efficacy and tolerability of pharmacological treatment. For example, response rates to initial treatment can be disappointing and it is still not possible to predict reliably which patients will respond well and which will show only a limited response to treatment. Furthermore, many patients fear or experience unwanted and distressing adverse effects and this limits the effectiveness of pharmacological treatments in clinical practice. Because of the relative lack of longitudinal studies of clinical outcomes in anxiety disorders and the small number of placebo-controlled relapse prevention studies, the optimal duration of treatment after a satisfactory response to acute treatment is still uncertain. There have been comparatively few studies of the further management of patients who do not respond to initial treatment and there is a clear need for further randomised controlled trials of augmentation treatment, in patients who do not respond to a selective serotonin reuptake inhibitor, serotonin-norepinephrine reuptake inhibitor or other initial pharmacological approaches. Future treatment guidelines will be influenced by emerging data with both established and novel pharmacological interventions and through better identification of patient sub-groups that are likely to respond preferentially to particular interventions.