Nonpharmacological Treatments for Generalized Anxiety Disorders

In part 2 of this video, Dr Jha MBBS, Assistant Professor of Psychiatry at Center of Depression Research and Clinical Care at UT Southwestern Medical Center, Dallas, TX discusses his preferred nonpharmacological treatments for anxiety disorders with Heather Flint, senior digital managing editor, Psych Congress Network, as presented at his recent Psych Congress session titled, "Difficult-to-Treat Patients with Generalized Anxiety Disorder."

In the previous part 1, Dr Jha discussed prognosis of GAD, utilizing the GAD scale, and when to discontinue medication for patients in remission.

Read the Transcript:

Heather Flint:  What are your preferred nonpharmacological treatments for anxiety disorders

Dr Jha:  That's, again, a very great question. We know that there is not great evidence for head-to-head comparison that in evidence-based psychotherapy versus evidence-based medication, how well do they compare?

Amongst evidence-based psychotherapy approaches, we have cognitive behavioral therapy, we have mindfulness-based therapy. What it boils down to there is what resources you have available in the community and which therapist accepts the insurance. That often boils it down to.

Those are some of the approaches that we recommend. Other nonpharmacological approaches good to integrate are exercise, so improving exercise, lifestyle modifications, so if there is excessive caffeine intake, that may worsen the anxiety. Also, other aspects of life, like making sure sleep is well-maintained, so practicing good sleep hygiene.

Those are, again, within the arsenal of treatments available. We would want to use that in helping our patients with generalized anxiety disorder.

Flint:  Once you diagnose someone with generalized anxiety disorder and you're coming up with a treatment plan, what comes first? The chicken or the egg question.

Do we start medication first, or do we do psychotherapy, or a mixture? How do you feel, and what do you use in your practice?

Dr Jha:  I'm going to, again, plug our conversation today about shared decision-making, and that is what it boils down to, because we have to come with what the evidence supports.

We present the evidence-based choices that are available. We make sure that our partner patient understands what those options are, what they prefer, and then we elicit preferences.

Often, it could be a fact of access, insurance, burdensomeness there that can drive people to select one treatment over another. That is what ends up being. It's often easy to prescribe medications because we are used to doing that and it does not require as many jumping through hoops, but it's the shared decision that comes in.

One fact I want to emphasize is that the evidence suggests in mild to moderate cases, either of them would be OK, but in more severe generalized anxiety disorder, a combination seems to be the preferred approach. I would definitely include that conversation when I'm working with a patient who has generalized anxiety disorder.

Circling back, part of that comes through using systematic scales such as the GAD-7 scale, which is in public domain, so I can't encourage people enough to use it.

Flint:  Excellent. One final question. You talked about checking with the insurance and access to care. Do you find those barriers in your treatment? Are there other barriers, or are they something you know to work with instead of work around?

Dr Jha:  There are definitely barriers to access to psychotherapy treatments. One insight with the pandemic has been that people have been able to use more of the virtual resources often. That has even helped somewhat with lower no-show rates and things like that.

I want, as a prescriber who doesn't have as much bandwidth to take on patients for cognitive therapy, I would then partner with some other provider and work with them in close collaboration.

With medications, often, these barriers regarding access could be addressed around with some of the SSRI medications that may on what's called a four-dollar list or things like that. Then, we can go to evidence-based choices there.

If access is an issue, insurance is an issue, those could be our considerations to keep in mind.

Flint:  That's excellent. One thing that resonated, you said about collaborating, finding a partner to work with, to help you work with your patients.

Do you find that easy now more with telepsychiatry? Is it easier to partner? Do you have any tips or advice for clinicians when they're thinking about partnering or when it's time to partner?

Dr Jha:  The time to partner is before we see a patient, so if we have existing collaboration...Again, checking in usually and making those connections usually is helpful.

Then, having a sense that it's not about everyone I see goes there, because then, they were quickly getting overwhelmed, but having that available and helping each other out. That also is important. It's a teamwork, so that's what I would recommend doing.

Flint:  I love that. Thank you so much for joining us. I appreciate your insights on treatment for generalized anxiety disorders.

Dr Jha:  Glad to be part of the Psych Congress family. Thank you.

Flint:  Thank you.

Dr Manish Jha is an assistant professor of psychiatry at the Center of Depression Research and Clinical Care at UT Southwestern Medical Center, Dallas, Texas. He conducts clinical research that aims to identify the biological mechanisms of depression, anxiety, and related disorders to inform the development of novel treatments.

He received his medical degree from Maulana Azad Medical College in New Delhi, India, and completed his residency training in Psychiatry at UT Southwestern Medical Center, Dallas, Texas. He is a member of the Society of Biological Psychiatry, American Society of Clinical Psychopharmacology, and an active member of the scientific community. In addition to his research and educational activities, Dr Jha maintains an active clinical practice focusing on evidence-based interventions for difficult-to-treat depressive and anxiety disorders.