Anxiety disorders treatment options

SramekJJ, Zarotsky V, Cutler NR. Generalised anxiety disorder treatment options. Drugs. 2002 62 1635-1648. 

Generalized Sociai Anxiety Disorder, Treatment Resistance. A significant minority of patients will not experience a satisfactory treatment response to antidepressant therapy, even after a trial of adequate duration at full strength doses. For those with comorbid depression who are experiencing no benefit from SSRI treatment for either the anxiety or depression, then switching treatment is advisable. The options include switching to another SSRI, a SNRI (venlafaxine or perhaps dulox-etine), or, when other alternatives fail, phenelzine. 

Inform patients of treatment options for anxiety disorders and the expected benefits of each (e.g., pharmacotherapy, psychotherapy, and combination treatment). 

For much of the second half of the twentieth century the benzodiazepines were the mainstay of the treatment of anxiety. Despite well-publicised concerns about their long-term safety, they remain an important therapeutic option. The anticonvulsants contain a number of drugs that act via GABA or glutamate neurotransmission and have a limited but interesting role in the treatment of particular anxiety disorders. 

In the treatment of children and adolescents with anxiety disorders clinicians have a wide variety of pharmacologic options beyond the antidepressants (Shader and Greenblatt, 1995 Lydiard et ah, 1996 Riddle et ah, 1999). The benzodiazepines (BZs), with their favorable safety profile and quick onset of action, are attractive alternatives for the treatment of acute anxiety. While the clinical effectiveness of buspirone has not been proven in children, buspirone is used alone or in combination with other drugs in the treatment of anxiety disorders. The antihistamines are often used to treat insomnia and may reduce acute mild agitation. Zolpidem (Ambien) is occasionally used for its sedative properties. This chapter reviews the structure, proposed mechanisms of action, pharmacodynamic principles, and pharmacokinetic principles of these drugs. 

TABLE 38.3 Treatment Options for Pediatric Anxiety Disorders ... 

A Based on evidence from numerous experimental studies, both psychotherapy and medications are effective treatments for anxiety disorders. Despite the general effectiveness of these treatments, each has its own set of advantages and disadvantages. I feel that treatment for anxiety disorders is most effective if the treatment provider and the patient honestly discuss the pros and cons of each treatment. That way, they can choose the one that is best for each individual. Additionally, even when treatment appears to be working well, it is worthwhile for the patient and treatment provider to periodically discuss the benefits and side effects of the treatment and the option of switching treatments. 

RM is a 25-year-old professional football player who was recently diagnosed with social phobic disorder. Although he has never missed a football game for this condition, he has experienced extreme anxiety in other public situations, failing to appear for numerous press conferences and community events. He is not interested in psychotherapy ("I don t have the time") and does not want to take any medication that may cause weight gain or addiction. What would be the best treatment option ... 

Selective serotonin reuptake inhibitors (SSRIs) are the most popular treatment option due to safety in overdose situations, low side effect burden, and ease of administration (i.e., once-daily dosing with minimal titration required). SSRIs are also effective treatment for the management of anxiety disorders, a common psychiatric comorbidity among the depressed. 

Because of the lack of dependency and tolerable adverse effect profile, antidepressants have emerged as the treatment of choice for the long-term management of chronic anxiety, especially in the presence of comorbid depressive symptoms. Buspirone is an additional anxiolytic option (Table 69-7) in patients without comorbid depression or other anxiety disorders (e.g., panic disorder and SAD). Because of the high risk of adverse effects and toxicity, barbiturates, antipsychotics, antipsychotic-antidepressant combinations, and antihistamines generally are not indicated in the treatment of GAD. The benzodiazepines are more effective in treating the somatic and autonomic symptoms of GAD as opposed to the psychic symptoms (e.g., apprehension and worry), which are reduced by antidepressants. ... 

Children who experience stress and trauma (e.g., sexual or physical abuse or loss of a parent) are predisposed to develop mood and anxiety disorders. The SSRIs are the initial pharmacologic agents of choice in this patient population. Psychotherapy is also a treatment option (e.g., play therapy). ... 

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