Anxiety Disorders:
Guidelines for Effective Primary Care,
Part 2, Treatment

PHARMACOLOGICAL TREATMENT

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 reuptake inhibitors (SNRIs).
•Tricyclic antidepressants (TCAs).
•Monoamine oxidase inhibitors (MAOIs).
•Buspirone.
•Benzodiazepines.

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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.

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

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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, 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

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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

Part 1 of this article:
Anxiety Disorders: Guidelines for Effective Primary Care, Part 1, Diagnosis

Therapeutic Agents in This Article
Alprazolam (Xanax, Niravam)
Buspirone (BuSpar)
Chlordiazepoxide (Librium)
Citalopram (Celexa)
Clomipramine (Anafranil)
Clonazepam (Klonopin)
Clonidine (Catapres)
Diazepam (Valium)
Diphenhydramine (Benadryl)
Duloxetine (Cymbalta)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Guanfacine (Tenex)
Hydroxyzine (Vistaril)
Imipramine (Tofranil)
Lorazepam (Ativan)
Mirtazapine (Remeron)
Paroxetine (Paxil)
Phenelzine (Nardil)
Prazosin (Minipress)
Propranolol (Inderal)
Sertraline (Zoloft)
Trazodone (Desyrel)
Venlafaxine (Effexor)