Cognitive-Behavioral Therapy and Escitalopram for Generalized Anxiety Disorder(GAD)

This pilot investigation will examine the effectiveness of augmenting cognitive behavioral
therapy (CBT) with antidepressant pharmacotherapy (escitalopram[Lexapro]) in adults with
generalized anxiety disorder (GAD) who do not fully respond to a temporally primary trial of
CBT. A secondary aim of this study is to assess the maintenance of treatment gains made by
patients in response to CBT, and to CBT with antidepressant augmentation therapy, over a
two-year follow-up period.

CBT is an empirically supported psychotherapy that has been found to be effective in treating
GAD in approximately 50 percent of patients enrolled in controlled clinical trials. However,
a substantial proportion (nearly half) of individuals with GAD do not achieve full remission
or clinically significant improvement at the cessation of CBT. Escitalopram (Lexapro)is a
selective serotonin reuptake inhibitor (SSRI) antidepressant, which has been shown to be
effective in treating GAD in several large-scale controlled clinical trials. The Food and
Drug Administration has approved ecitalopram for the treatment of GAD.

The proposed research plan encompasses the conduct of an open clinical trial (No randomized
placebo control) of 14 sessions of manualized individual CBT for persons meeting DSM-IV-TR
diagnostic criteria for GAD. This study will use a treatment manual developed by Dr. Thomas
Borkovec and colleagues at the Pennsylvania State University. Participants who meet high
endstate functioning criteria and/or achieve remission following CBT will be evaluated
periodically during a twenty-four month follow-up phase. Participants who do not meet high
endstate functioning criteria and/or achieve remission following completion of CBT will be
offered entry into a twelve-week, open-label, flexible-dose trial of escitalopram therapy.
Participants receiving escitalopram therapy will be evaluated periodically during a
twenty-four month follow-up phase, as well. It is anticipated that patients who do not fully
respond to CBT will show a significant increment in improvement in GAD symptoms, over and
above their CBT posttreatment level, following pharmacotherapy with escitalopram.

At present, no studies with GAD populations have examined the additive or sequenced effects
of psychosocial therapy and SSRI antidepressant pharmacotherapy. The proposed research is a
first step in this direction and may provide evidence supporting the use of combined
treatment modalities in CBT partial and non-responders.

Inclusion Criteria:

1. Males or females between the ages of 18 and 65 (inclusive)

2. Primary DSM-IV-TR diagnosis of Generalized Anxiety Disorder (GAD) with no significant
co-morbid anxiety disorder for which CBT for GAD is not appropriate including PTSD,
OCD, and prominent panic disorder with or without agoraphobia

3. A negative urine toxicology, i.e., a urine specimen that does not test positive for
use of drugs of abuse, or use of benzodiazepines, in the previous three weeks

4. Penn State Worry Questionnaire score of 55 or greater

5. Have a score of equal to or > 4 (Moderately Ill) on Clinical Global Impression (CGI)
Scale (severity of illness item) for GAD

6. Ability to give informed consent

7. Fluent in English

8. Willingness to have Cognitive-Behavioral Therapy sessions audiotaped -

Exclusion Criteria:

1. Patients who have a diagnosis of Major Depressive Disorder within 60 days prior to the
clinical interview, and patients who have a "lifetime" history of being diagnosed with
one or more of the following disorders: Schizophrenia, Major Depressive Disorder with
Psychotic or Catatonic features, Bipolar I Affective Disorder, or Organic Mental
Disease

2. DSM-IV substance abuse or dependence within the past 6 months (except nicotine or
caffeine)

3. Active suicidal or homicidal ideation, or judged to be at serious suicide risk

4. Hamilton Rating Scale for Depression score of greater than 20 at Screening or Baseline
evaluation

5. Any unstable medical or neurological condition

6. Women who are pregnant or lactating

7. Having received CBT treatment for GAD previously

8. Concurrent psychosocial therapy

9. Current psychotropic medication with exception of zolpidem at hs for insomnia

10. History of nonresponse to an adequate trial of escitalopram or intolerable adverse
effects to escitalopram -