Anxiety medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

## Overview

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The mainstay of therapy for anxiety is the administration of pharmacotherapy and psychotherapy. Mostly used Antidepressants , Benzodiazepines (some concern over dependency), buspirone, tricyclic antidepressants , SSRIs (selective serotonin reuptake inhibitors).

## Medical Therapy

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### Pharmacotherapy

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Systematic reviews guide treatment of generalized anxiety disorder[1][2][3]:

Evidence summary from NICE of selected medications.[3] | Evidence base | Relative risk of
non-response | Relative risk of
Drug toxicity

|
|
|

Sertraline | Trials: 2
(706 patients) | 0.70* | 1.1
Nausea
Sexual
Venlafaxine | Trials: 12
(3470 patients) | 0.80* | 2.06*
Nausea
Sexual
Insomnia
Citalopram | Trials: 1
(34 patients) | 0.46* | 3.0
Escitalopram | Trials: 6
(2136 patients) | 0.78 | 1.72*
Nausea
Sexual

Paroxetine | Trials: 8
(2748 patients) | 0.91 | 2.5*
Nausea
Sexual
Insomnia
Pregabalin | Trials: 8
(2079 patients) | 0.79* | 1.3
Dizziness
Fatigue
Buspirone | Trials: 5
(806 patients) | 0.87 | 2.0*
Nausea
Dizziness
Hydroxyzine | Trials: 3
(482 patients) | 0.81 | 1.48
Little short term toxicity
Alprazolam | Trials: 4
(544 patients) | 0.87 | 1.3
Little short term toxicity
* P< 0.05

SSRIs:

The first line treatment for generalized anxiety disorder is SSRI:

* Preferred regimen:
* Sertraline oral dose of 25 mg once daily for 1 week, increase it based on response and tolerability; maximum dose is 200mg/day.
* Alternative regimen:
* Alternative regimen (1): Citalopram (Celexa): Oral (initial dose-10mg) with daily dose ranging from 10-40mg.
* Alternative regimen (2): Escitalopram (Lexapro): Oral (initial dose-5-10mg) with daily dose ranging from 10-20mg.
* Alternative regimen (3): Paroxetine ( Paxil): Oral(initial dose 20mg) with daily dose ranging from 20-50mg.
* Usually SSRIs are most effective at highest tolerable doses.

Other medications

Consider[2][4]:

* Bupropion. Trials have compared SSRIs and bupropion for the treatment of combined depression and anxiety[5]. The improvement in anxiety may be similar between the two medications, but the SSRI may better reduce depression symptoms[6]. Two larger trials have been analyzed together[7].
* Hydroxyzine

### Alternative regimens from other categories:

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SNRI's:

* Preferred regimen (1): Duloxetine: Oral (initial dose 30mg) with daily dose ranging from 60-120mg.
* Preferred regimen (2): Venlafaxine: Oral (initial dose 75mg) with daily dose ranging from 75-225mg.

Benzodiazepines:

* These medications are used as alternative or short term therapy:
* Alternative regimen (1): Lorazepam (Ativan) - Started at 0.5-1mg orally t.i.d. and titrated up to 1.5mg q.i.d daily as needed.
* Alternative regimen (2): Diazepam (Valium) started at 2.5mg to 5mg orally once or twice daily and titrated up to 10mg ,two or three times daily as needed.
* Alternative regimen (3): Clonazepam (Klonopin) can be started at 0.25-0.5 mg orally once or twice daily and titrated up to 1mg (b.i.d or t.i.d) daily as needed.
* There is increased risk of dependence and tolerance, so maintain caution in long term use, SSRIs are therefore first line treatment for anxiety disorders in long term use.

Other drugs to consider:

* Other medications that may be used include:
* Alternative regimen (1): Buspirone (Buspar)- initial dose is 10mg with daily dose ranging from 10-60mg.
* Alternative regimen (2): Pregabalin (Lyrica)- initial dose is 50mg with daily dose ranging from 50-300mg.
* Alternative regimen (3): Second generation anti psychotics like Quetiapine( SEROQUEL)- Start with initial dose of 25mg/day and titrated at 25-50mg intervals weekly or biweekly to a maximum dose of 300mg/day.
* Alternative regimen (7): Hydroxyzine (Vistaril)- doses between 50 to 150 mg a day in divided doses as PRN, is effective for anxiety disorders.
* Alternative regimen (8): Mirtazapine (Remeron)_ doses between 15 mg to 45 mg used as monotherapy or adjunctive treatment in Generalized anxiety disorder.

Preferred regimen for Panic disorder:

* SSRIs, SNRIs, benzodiazepines preferred regimen in acute exacerbation and as needed basis. Doses are used in the same range as for generalized anxiety disorders.

Preferred regimen for Social anxiety:

* SSRIs and beta-blockers for social anxiety disorder.

## References

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1. ↑ Chawla N, Anothaisintawee T, Charoenrungrueangchai K, Thaipisuttikul P, McKay GJ, Attia J; et al. (2022). "Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials". BMJ. 376: e066084. doi:10.1136/bmj-2021-066084. PMID 35045991 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
2. ↑ 2.0 2.1 Slee A, Nazareth I, Bondaronek P, Liu Y, Cheng Z, Freemantle N (2019). "Pharmacological treatments for generalised anxiety disorder: a systematic review and network meta-analysis". Lancet. 393 (10173): 768–777. doi:10.1016/S0140-6736(18)31793-8. PMID 30712879.CS1 maint: Multiple names: authors list (link)
3. ↑ 3.0 3.1 National Institute for Health and Clinical Excellence (2011). Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults
4. ↑ Garakani A, Murrough JW, Freire RC, Thom RP, Larkin K, Buono FD; et al. (2020). "Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options". Front Psychiatry. 11: 595584. doi:10.3389/fpsyt.2020.595584. PMC 7786299 Check `|pmc=` value (help). PMID 33424664 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
5. ↑ Papakostas GI, Trivedi MH, Alpert JE, Seifert CA, Krishen A, Goodale EP; et al. (2008). "Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of anxiety symptoms in major depressive disorder: a meta-analysis of individual patient data from 10 double-blind, randomized clinical trials". J Psychiatr Res. 42 (2): 134–40. doi:10.1016/j.jpsychires.2007.05.012. PMID 17631898.CS1 maint: Multiple names: authors list (link)
6. ↑ Papakostas GI, Stahl SM, Krishen A, Seifert CA, Tucker VL, Goodale EP; et al. (2008). "Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of major depressive disorder with high levels of anxiety (anxious depression): a pooled analysis of 10 studies". J Clin Psychiatry. 69 (8): 1287–92. doi:10.4088/jcp.v69n0812. PMID 18605812.CS1 maint: Multiple names: authors list (link)
7. ↑ Trivedi MH, Rush AJ, Carmody TJ, Donahue RM, Bolden-Watson C, Houser TL; et al. (2001). "Do bupropion SR and sertraline differ in their effects on anxiety in depressed patients?". J Clin Psychiatry. 62 (10): 776–81. doi:10.4088/jcp.v62n1005. PMID 11816866.CS1 maint: Multiple names: authors list (link)

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