Korean guidelines for the treatment of generalised anxiety disorder: strategies for insufficient treatment response and comorbidities

Introduction

Choosing an effective treatment strategy is very important for reducing the symptoms and improving patient’s function and quality of life in patients with generalized anxiety disorder (GAD). Although recent studies and current treatment guidelines for GAD in the last decade have come up with strong evidence supporting the effectiveness of pharmacological and psychosocial interventions, there is insufficient evidence to recommend any of these treatments as being superior to others or to recommend a combination of treatments. Moreover, the treatment strategies vary from country to country due to diverse clinical settings.

Korean medication algorithm for GAD has been developed by the task force team within the Korean Association of Anxiety Disorders in 2009. According to the policy of development at that time, recently the executive committee for Korean guidelines for the treatment of GAD developed the first revision in 2024. We summarized the results of Korean experts’ opinions on the pharmacological and psychosocial treatment strategies for GAD and compared the results with Korean medication algorithm in 2009 and current international guidelines for GAD.

Aims

This study aimed to establish expert consensus on treatment strategies for generalized anxiety disorder when treatment response is insufficient and when comorbid conditions are present, as part of developing the 2024 Korean guidelines for the treatment of generalized anxiety disorder.

Methods

The executive committee for Korean guidelines for the treatment of GAD developed a questionnaire based on current treatment guidelines published by Canadian Anxiety Guidelines Initiative Group, Royal Australian and New Zealand College of Psychiatrists (RANZCP), World Federation of Societies of Biological Psychiatry (WFSBP). Sixty-five experts participated in the survey. Responses were analyzed using the chi-squared test and 95% confidence intervals to determine the level of consensus. Treatment strategies were categorized into first-line, second-line, and third-line choices.

Results

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For insufficient treatment response, combining pharmacotherapy and psychotherapy was the most preferred first-line strategy. Experts recommended switching to or augmenting with a different class of antidepressants, adding benzodiazepines or azapirones, and augmenting with atypical antipsychotics as first-line pharmacotherapy adjustments. Suitable psychotherapies included cognitive behavioral therapy (CBT), mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), and applied relaxation. For patients with comorbid conditions such as depression, other anxiety disorders, or alcohol and substance use disorders, a combination of pharmacotherapy and psychotherapy was also the most preferred first-line treatment. In these cases, the use of antidepressants alone or in combination with benzodiazepines, azapirones, or atypical antipsychotics was recommended.

Conclusions

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This expert consensus reflects current clinical practices and experiences in Korea, providing valuable insights for clinicians treating generalized anxiety disorder patients who have insufficient treatment responses or comorbidities. The findings emphasize the importance of a multimodal treatment approach, including both pharmacotherapy and psychotherapy, and offer specific recommendations for adjusting treatment strategies in these complex cases.

Keywords: Generalized anxiety disorder, Treatment guidelines, Insufficient treatment response, Comorbidities, Expert consensus

References

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