Most pharmacological therapies for uncomplicated anxiety disorders can be initiated and monitored in the primary care setting.7 A broad range of pharmacological agents are available; these include:
• Selective serotonin reuptake inhibitors (SSRIs).
• Serotonin norepinephrine(Drug information on norepinephrine) reuptake inhibitors (SNRIs).
• Tricyclic antidepressants (TCAs).
• Monoamine oxidase inhibitors (MAOIs).
• Buspirone(Drug information on buspirone).
The selection of a specific agent usually depends on the clinical presentation, the patient’s personal and family history of response to a specific agent, patient preference, the provider’s experience, cost, and informed consent.1,2,11,12 Common pharmacological agents that are used to treat anxiety disorders are listed in Table 1 a, b, c, d.
Because of their safety and efficacy, the SSRIs are generally considered first-line treatment for anxiety disorders.3,7 It is important to be aware of the antidepressant product labeling mandated by the FDA, which includes warnings about the increased risk of suicidal thinking and behavior in young adults.
Sexual side effects are associated with decreased adherence to SSRI maintenance therapy.13 Strategies to minimize these undesired effects may include using an antidepressant that is not associated with sexual side effects, switching to a different antidepressant if symptoms emerge, adding adjunctive medications to counteract side effects, and adjusting the dose and dosing schedule. A medication holiday in anticipation of sexual activity is not advisable because some reports suggest an increase in relapses occurs even with short medication holidays.3,13
The SNRIs, TCAs, and benzodiazepines may be considered when patients have not responded to SSRIs or when their adverse effects exceed their benefits.14 MAOIs are rarely used to treat anxiety in the primary care setting because of the need for strict monitoring of intake of tyramine- containing food as well as potentially serious interactions with other medications, alcohol(Drug information on alcohol), and illicit drugs.
Benzodiazepines are especially useful in the management of acute situational anxiety disorder and adjustment disorder, in which the duration of pharmacotherapy is anticipated to be 6 weeks or less, and for the immediate relief of panic attacks.15 The risk of addiction with benzodiazepines should be carefully considered before they are used to treat anxiety disorders. These agents should be avoided in patients with a history of alcohol or other drug abuse.1,3,15
When anxiety symptoms persist, non–FDA-approved medications may be used off-label, either as adjunctive or as primary agents (Table 2). The rationale for using these medications needs to be carefully detailed and documented.15
Acknowledgments: The author thanks the VA Medical Center director, Mr Alan Perry, FACHE, for his administrative support; Drs Robert Hierholzer, Nestor Manzano, Scott Ahles, and Craig C. Campbell for their clinical guidance; Dr Avak A. Howsepian for his constructive criticism; Matthew Battista, PhD, Thomas Williams, MSW, and Leonard Williams, PA, for their encouragement; and Ms Emma Nichols for her computer assistance.
Additional Resources for Patients With Anxiety Disorders
Therapeutic Agents in This Article
Alprazolam (Xanax, Niravam)
Chlordiazepoxide(Drug information on chlordiazepoxide) (Librium)
Clonidine(Drug information on clonidine) (Catapres)
Diphenhydramine(Drug information on diphenhydramine) (Benadryl)
Duloxetine(Drug information on duloxetine) (Cymbalta)
Escitalopram(Drug information on escitalopram) (Lexapro)
Fluvoxamine(Drug information on fluvoxamine) (Luvox)
Hydroxyzine(Drug information on hydroxyzine) (Vistaril)
Lorazepam(Drug information on lorazepam) (Ativan)
Mirtazapine(Drug information on mirtazapine) (Remeron)
Prazosin(Drug information on prazosin) (Minipress)
Propranolol(Drug information on propranolol) (Inderal)
Sertraline(Drug information on sertraline) (Zoloft)
Part 1 of this article:
Anxiety Disorders: Guidelines for Effective Primary Care, Part 1, Diagnosis