Pharmacotherapy for Anxiety Disorders: From First-Line Options to Treatment Resistance

Overview

Journal Focus (Am Psychiatr Publ)

Specialty Medical Education

Date 2021 Oct 25

PMID 34690578

Citations 5

Authors

Andrew J Melaragno

Affiliations

Soon will be listed here.

Abstract

In this review, the author examines the evidence for psychopharmacologic treatments among adults for generalized anxiety disorder, panic disorder, and social anxiety disorder derived from clinical trials. For each disorder, major categories of drugs are reviewed, and then the evidence-based medications in each category are discussed. The author reviews key safety and tolerability considerations for each of the medications or classes. Evidence-based dosing for most specific agents is displayed in a comprehensive reference table. Subsequently, the author synthesizes the available information to suggest a pragmatic stepwise approach to treatment that accounts for patient-specific factors. To inform the guidance, the author incorporates and refines perspectives from treatment guidelines already written by clinical professional organizations. The author also briefly reviews the relatively new quantitative systematic review methodology of network meta-analysis (NMA) and discusses how NMA may help guide pharmacologic treatment sequencing decisions in the future by way of ranking treatments according to effect size and the relative amount of study to which treatments have been subject. Caveats of NMA studies are briefly discussed, as are results of recent NMAs regarding the pharmacologic treatment of anxiety disorders.

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References

Asnis G, Hameedi F, Goddard A, Potkin S, Black D, Jameel M . Fluvoxamine in the treatment of panic disorder: a multi-center, double-blind, placebo-controlled study in outpatients. Psychiatry Res. 2001; 103(1):1-14. DOI: 10.1016/s0165-1781(01)00265-7. View

Sansone R, Sansone L . Serotonin norepinephrine reuptake inhibitors: a pharmacological comparison. Innov Clin Neurosci. 2014; 11(3-4):37-42. PMC: 4008300. View

Hart G, Panayi M, Harris J, Westbrook R . Benzodiazepine treatment can impair or spare extinction, depending on when it is given. Behav Res Ther. 2014; 56:22-9. DOI: 10.1016/j.brat.2014.02.004. View

Vaishnavi S, Alamy S, Zhang W, Connor K, Davidson J . Quetiapine as monotherapy for social anxiety disorder: a placebo-controlled study. Prog Neuropsychopharmacol Biol Psychiatry. 2007; 31(7):1464-9. DOI: 10.1016/j.pnpbp.2007.06.027. View

Simon N, Emmanuel N, Ballenger J, Worthington J, Kinrys G, Korbly N . Bupropion sustained release for panic disorder. Psychopharmacol Bull. 2004; 37(4):66-72. View

Sheehan D, Ballenger J, Jacobsen G . Treatment of endogenous anxiety with phobic, hysterical, and hypochondriacal symptoms. Arch Gen Psychiatry. 1980; 37(1):51-9. DOI: 10.1001/archpsyc.1980.01780140053006. View

Wingerson D, Nguyen C, Roy-Byrne P . Clomipramine treatment for generalized anxiety disorder. J Clin Psychopharmacol. 1992; 12(3):214-5. View

Sasson Y, Iancu I, Fux M, Taub M, Dannon P, Zohar J . A double-blind crossover comparison of clomipramine and desipramine in the treatment of panic disorder. Eur Neuropsychopharmacol. 1999; 9(3):191-6. DOI: 10.1016/s0924-977x(98)00024-8. View

Uhde T, Stein M, Post R . Lack of efficacy of carbamazepine in the treatment of panic disorder. Am J Psychiatry. 1988; 145(9):1104-9. DOI: 10.1176/ajp.145.9.1104. View

10.

Trindade E, Menon D, Topfer L, Coloma C . Adverse effects associated with selective serotonin reuptake inhibitors and tricyclic antidepressants: a meta-analysis. CMAJ. 1998; 159(10):1245-52. PMC: 1229819. View

11.

Generoso M, Trevizol A, Kasper S, Cho H, Cordeiro Q, Shiozawa P . Pregabalin for generalized anxiety disorder: an updated systematic review and meta-analysis. Int Clin Psychopharmacol. 2016; 32(1):49-55. DOI: 10.1097/YIC.0000000000000147. View

12.

Guaiana G, Barbui C, Cipriani A . Hydroxyzine for generalised anxiety disorder. Cochrane Database Syst Rev. 2010; (12):CD006815. DOI: 10.1002/14651858.CD006815.pub2. View

13.

HERMAN J, Rosenbaum J, Brotman A . The alprazolam to clonazepam switch for the treatment of panic disorder. J Clin Psychopharmacol. 1987; 7(3):175-8. View

14.

Bystritsky A, Kerwin L, Feusner J, Vapnik T . A pilot controlled trial of bupropion XL versus escitalopram in generalized anxiety disorder. Psychopharmacol Bull. 2008; 41(1):46-51. View

15.

Simon N, Otto M, Worthington J, Hoge E, Thompson E, Lebeau R . Next-step strategies for panic disorder refractory to initial pharmacotherapy: a 3-phase randomized clinical trial. J Clin Psychiatry. 2009; 70(11):1563-70. PMC: 2995303. DOI: 10.4088/JCP.08m04485blu. View

16.

He H, Xiang Y, Gao F, Bai L, Gao F, Fan Y . Comparative efficacy and acceptability of first-line drugs for the acute treatment of generalized anxiety disorder in adults: A network meta-analysis. J Psychiatr Res. 2019; 118:21-30. DOI: 10.1016/j.jpsychires.2019.08.009. View

17.

Gao K, Sheehan D, Calabrese J . Atypical antipsychotics in primary generalized anxiety disorder or comorbid with mood disorders. Expert Rev Neurother. 2009; 9(8):1147-58. PMC: 3432909. DOI: 10.1586/ern.09.37. View

18.

Kimura M, Tateno A, Robinson R . Treatment of poststroke generalized anxiety disorder comorbid with poststroke depression: merged analysis of nortriptyline trials. Am J Geriatr Psychiatry. 2003; 11(3):320-7. View

19.

Markota M, Morgan R . Treatment of Generalized Anxiety Disorder with Gabapentin. Case Rep Psychiatry. 2018; 2017:6045017. PMC: 5745655. DOI: 10.1155/2017/6045017. View

20.

Nardi A, Lopes F, Valenca A, Freire R, Nascimento I, Veras A . Double-blind comparison of 30 and 60 mg tranylcypromine daily in patients with panic disorder comorbid with social anxiety disorder. Psychiatry Res. 2009; 175(3):260-5. DOI: 10.1016/j.psychres.2008.06.025. View