Q: What are the safest treatment options for anxiety in adults with chronic respiratory insufficiency? A: Anxiety is a common and troubling symptom in many patients with chronic obstructive pulmonary disease (COPD), even when their degree of respiratory impairment is only mild to moderate. Anxiety may also accompany other chronic, progressive pulmonary disorders, such as interstitial fibrosis and cystic fibrosis, and a wide variety of other, less common diseases that are characterized by progressive dyspnea on exertion. The scope of the problem. My colleagues and I noted a high level of anxiety, depression, and somatic preoccupation among the patients in our comprehensive care program for severe COPD.1 The anticipation of an event, such as a sudden attack of uncontrolled dyspnea in business or social situations, caused the most intense anxiety. Panic attacks were also common, and they could be exacerbated during smoking cessation attempts, probably as a result of nicotine(Drug information on nicotine) withdrawal. We found that patients’ anxiety, depression, and somatic preoccupation improved significantly during the course of our pulmonary rehabilitation program, most likely because of the extensive counseling that was a feature of the program.2 We used few anxiolytic drugs. Other researchers have also found that both anxiety and panic disorder are prevalent among patients with symptomatic COPD.3,4 How to manage these perplexing symptoms has been a challenge, because some of the medications used in COPD—such as β-agonists, anticholinergics, theophylline(Drug information on theophylline) and, above all, systemic corticosteroids— may aggravate anxiety.5 Suggested therapies. Small doses of anxiolytics, such as alprazolam and diazepam, and some older antidepressants, such as amitriptyline(Drug information on amitriptyline) and nortriptyline(Drug information on nortriptyline), are generally safe and effective in relieving anxiety and depression. Some clinicians prescribe small doses of oral narcotics to blunt the symptoms of intolerable dyspnea and associated anxiety.6 Selective serotonin reuptake inhibitors may be useful in mitigating depression that accompanies anxiety. Clinicians may be concerned about respiratory depression with anxiolytics or narcotics, but dangerous carbon dioxide retention almost never occurs when these drugs are used carefully, along with patient counseling. Counseling involves helping patients understand the nature of anxiety and panic and tips on how to avoid triggers that might set off these feelings. Alternative therapies— such as biofeedback, relaxation training, and yoga—may be helpful. In my opinion, there is no “magic bullet” for anxiety, dyspnea, or panic. However, the following agents can be used in small doses about every 6 hours to provide safe, effective relief: diazepam(Drug information on diazepam), 2 to 5 mg; alprazolam(Drug information on alprazolam), 0.25 to 0.5 mg; codeine(Drug information on codeine), 30 mg; and hydrocodone(Drug information on hydrocodone), 5 mg. These drugs are not intended to be taken for the long term, except in extreme cases when the need to relieve symptoms is greater than concerns about habituation. Discretionary doses of anxiolytics, antidepressants, or analgesics to blunt dyspnea may improve quality of life for many patients with advanced respiratory insufficiency.