SSRIs and SNRIs have fewer cardiovascular adverse effects than TCAs and are better tolerated by older patients and patients with cardiovascular illnesses. Caution is necessary with venlafaxine because it can raise blood pressure.
SSRIs and SNRIs tend to stimulate the GI tract and can aggravate GI symptoms, particularly in patients with comorbid IBS. In such patients the anticholinergic effects of a tertiary TCA, such as doxepin, can reduce abdominal pain and improve bowel movements.
The ultimate goal of treatment for somatic symptoms in patients with GAD is to help the patients become self-sufficient without the need for medication. However, a minority of patients who have GAD need continuous pharmacotherapy, including benzodiazepines. It would be shortsighted and insensitive to deny such patients medications that could improve their quality of life.
1. Wittchen HU. Generalized anxiety disorder: prevalence, burden and cost to society. Depression Anxiety. 2001; 16:162-172.
2. Noyes R Jr, Hoehn-Saric R. The Anxiety Disorders. Cambridge UK: Cambridge University Press; 1998:37-85.
3. Logue MB, Thomas AM, Barbee JG, et al. Generalized anxiety disorder patients seek evaluation for cardiological symptoms at the same frequency as patients with panic disorder. J Psychiatr Res. 1993;27:55-59.
4. Hoehn-Saric R, McLeod DR, Zimmerli WD. Symptoms and treatment responses of generalized anxiety disorder patients with high versus low levels of cardiovascular complaints. Am J Psychiatry. 1989;146:854-859.
5. Ballenger JC, Davidson JRT, Lecrubier Y, et al. Consensus statement on generalized anxiety disorder from the international consensus group on depression and anxiety. J Clin Psychiatry. 2001;62(suppl 11):53-58.
6. McLeod DR, Hoehn-Saric R. Perception of physiological changes in normal and pathological anxiety. In: Hoehn-Saric R, McLeod DR, eds. Biology of Anxiety Disorders. Washington, DC: American Psychiatric Press; 1993:223-243.
7. Hoehn-Saric R, Borkovec TD, Nemiah JC. Generalized anxiety disorder. In: Gabbard GO, ed. Treatments of Psychiatric Disorders. 2nd ed. Washington, DC: American Psychiatric Press; 1995:1691-1722.
8. Roth T, Walsh JK, Krystal A, et al. An evaluation of the efficacy and safety of eszopiclone over 12 months in patients with chronic primary insomnia. Sleep Med. 2005; 6:487-495.
9. Hoehn-Saric R, McLeod DR. Somatic manifestations of normal and pathological anxiety. In: Hoehn-Saric R, McLeod DR, eds. Biology of Anxiety Disorders. Washington, DC: American Psychiatric Press; 1993:77-222.