The best next drug in the course of generalized anxiety disorders: the "PN-GAD-algorithm"

Objective. Today, there are many pharmacotherapeutic options for generalized anxiety disorder (GAD). The question is, which is the best medication for a particular patient at a particular moment? This is especially challenging because GAD is by definition a chronic disorder and new interventions should learn from earlier experiences. An algorithm which can help to use pretreatment information for drug selection is the "Pretreatment - Next Treatment (PN) - Algorithm". This article introduces an PN-algorithm for GAD. Methods and results. For the development of a GAD-specific PN-algorithm, all possible pharmacological options for GAD are reviewed and brought into a rank order on the basis of scientific evidence regarding efficacy, tolerability, or price: (1) pregabalin, (2) venlafaxine XR, (3) selective serotonin reuptake inhibitors, (4) tricyclic antidepressants, (5) buspirone, (6) antipsychotics, (7) benzodiazepines, and (8) hydroxyzine. Based on this hierarchy and patient-specific information, a decision algorithm is derived, which allows to assess and evaluate pretreatment and to select the drug with no contraindications, limited negative or convincing positive effects, or the option which has not been used so far but which is the next compound in the hierarchy. Conclusions. The "PN-GAD-algorithm" can be easily translated into a checklist to support clinical decision-making. It can also help to increase patient empowerment and cooperation in long-term treatment.