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== Overview==
== Overview==
The mainstay of therapy for [[anxiety]] is the administration of [[pharmacotherapy]] and [[psychotherapy]]
The mainstay of [[therapy]] for [[anxiety]] is the administration of [[pharmacotherapy]] and [[psychotherapy]]. Mostly used  [[Antidepressants]] , [[Benzodiazepines]] (some concern over dependency), [[buspirone]], [[tricyclic antidepressant]]s , [[SSRI]]s ([[selective serotonin reuptake inhibitors]]).
 
Antidepressants
[[Benzodiazepines]] (some concern over dependency), [[buspirone]], [[tricyclic antidepressant]]s , [[SSRI]]s ([[selective serotonin reuptake inhibitors]])


==Medical Therapy==
==Medical Therapy==
===Pharmacotherapy===
===Pharmacotherapy===
[[Generalized anxiety disorder|Generalized anxiety disorde]]<nowiki/>r:
The first line treatment for generalized anxiety disorder is SSRI:
* [[Sertraline]] (Zoloft) is the initial drug of choice:
* Start with initial oral dose of 25 mg once daily for 1 week, increase it based on response and tolerability; maximum dose is 200mg/day
* Alternatively SSRI's that can be used are
**[[Citalopram]](Celexa)(initial dose-10mg) with daily dose ranging from 10-40mg
**[[Escitalopram]](Lexapro) (initial dose-5-10mg)with daily dose ranging from 10-20mg
**[[Paroxetine]]( Paxil)(initial dose 20mg) with daily dose ranging from 20-50mg
**Usually [[SSRI's]] are most effective at highest tolerable doses.
Other classes of drugs that can be used are :


SNRI's-
[[Systematic review]]s guide treatment of [[Generalized anxiety disorder|generalized anxiety disorder]]<ref name="pmid35045991">{{cite journal| author=Chawla N, Anothaisintawee T, Charoenrungrueangchai K, Thaipisuttikul P, McKay GJ, Attia J | display-authors=etal| title=Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials. | journal=BMJ | year= 2022 | volume= 376 | issue=  | pages= e066084 | pmid=35045991 | doi=10.1136/bmj-2021-066084 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35045991  }} </ref><ref name="pmid30712879">{{cite journal| author=Slee A, Nazareth I, Bondaronek P, Liu Y, Cheng Z, Freemantle N| title=Pharmacological treatments for generalised anxiety disorder: a systematic review and network meta-analysis. | journal=Lancet | year= 2019 | volume= 393 | issue= 10173 | pages= 768-777 | pmid=30712879 | doi=10.1016/S0140-6736(18)31793-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30712879  }} </ref><ref name="NICE-GAD_2011">National Institute for Health and Clinical Excellence (2011). [http://guidance.nice.org.uk/CG113 Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults]</ref>:
{| class="wikitable" border="1" align="right"
|+ Evidence summary from [[National Institute for Health and Clinical Excellence|NICE]] of selected medications.<ref name="NICE-GAD_2011">National Institute for Health and Clinical Excellence (2011). [http://guidance.nice.org.uk/CG113 Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults]</ref>
! &nbsp;!!Evidence base!!Relative risk of <br/>non-response!!Relative risk of<br/>[[Drug toxicity]]
|-
| [[Sertraline]]|| Trials: 2<br/>(706 patients)|| style="background-color:lightgreen;"|0.70*|| 1.1<br/>Nausea<br/>Sexual
|-
| [[Venlafaxine]]|| Trials: 12<br/>(3470 patients)|| style="background-color:lightgreen;"|0.80*||style="background-color:coral"| 2.06*<br/>Nausea<br/>Sexual<br/>Insomnia
|-
| [[Citalopram]]|| Trials: 1<br/>(34 patients)|| style="background-color:lightgreen;"|0.46*|| 3.0
|-
| [[Escitalopram]]|| Trials: 6<br/>(2136 patients)|| 0.78||style="background-color:coral"|1.72*<br/>Nausea<br/>Sexual<br/>
|-
| [[Paroxetine]]|| Trials: 8<br/>(2748 patients)||0.91||style="background-color:coral"|2.5*<br/>Nausea<br/>Sexual<br/>Insomnia
|-
| [[Pregabalin]]|| Trials: 8<br/>(2079 patients)|| style="background-color:lightgreen;align:center"|0.79*||1.3<br/>Dizziness<br/>Fatigue
|-
| [[Buspirone]]|| Trials: 5<br/>(806 patients)|| 0.87||style="background-color:coral"|2.0*<br/>Nausea<br/>Dizziness
|-
| [[Hydroxyzine]]|| Trials: 3<br/>(482 patients)|| 0.81|| 1.48<br/>Little short term toxicity
|-
| [[Alprazolam]]|| Trials: 4<br/>(544 patients)|| 0.87|| 1.3<br/>Little short term toxicity
|-
| colspan="4"|*  P< 0.05
|}


[[Duloxetine]](initial dose 30mg) with daily dose ranging from 60-120mg
'''[[SSRI|SSRIs]]''':
**[[Venlafaxine]](initial dose 75mg) with daily dose ranging from 75-225mg


[[Benzodiazepines]]:
The first line [[Treatment-resistant depression|treatment]] for [[generalized anxiety disorder]] is [[SSRI]]:
*Benzodiazapines have been found efficacious in treatment of [[generalized anxiety disorder]]
* Usually they are started at a low dose and titrated up as needed based on response.
* [[Lorazepam]] (ATIVAN) - Started at 0.5-1mg orally t.i.d. and titrated up to 1.5mg q.i.d daily as needed
* [[Diazepam]] (Valium) started at 2.5mg to 5mg orally once or twice daily and titrated up to 10mg ,two or three times daily as needed.
* [[Clonazepam]] (Klonopin) can be started at 0.25-0.5 mg orally once or twice daily and titrated up to 1mg (b.i.d or t.i.d) daily as needed
* there is increased risk of dependence and [[tolerance]] , so maintain caution in long term use, [[Selective serotonin reuptake inhibitor|SSRIs]] are therefore first line treatment for [[Anxiety Disorders|anxiety]] disorders in long term use.


Other drugs to consider:
* Preferred regimen:
** [[Sertraline]] oral dose of 25 mg once daily for 1 week, increase it based on response and tolerability; maximum dose is 200mg/day.
* Alternative regimen:
**Alternative regimen (1): [[Citalopram]] (Celexa): Oral (initial dose-10mg) with daily dose ranging from 10-40mg.
**Alternative regimen (2): [[Escitalopram]] (Lexapro): Oral (initial dose-5-10mg) with daily dose ranging from 10-20mg.
**Alternative regimen (3): [[Paroxetine]] ( Paxil): Oral(initial dose 20mg) with daily dose ranging from 20-50mg.
**Usually [[SSRIs]] are most effective at highest tolerable doses.
'''Other medications'''


[[Buspirone]] (Buspar)- initial dose is 10mg with daily dose ranging from 10-60mg
Consider<ref name="pmid30712879">{{cite journal| author=Slee A, Nazareth I, Bondaronek P, Liu Y, Cheng Z, Freemantle N| title=Pharmacological treatments for generalised anxiety disorder: a systematic review and network meta-analysis. | journal=Lancet | year= 2019 | volume= 393 | issue= 10173 | pages= 768-777 | pmid=30712879 | doi=10.1016/S0140-6736(18)31793-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30712879  }} </ref><ref name="pmid33424664">{{cite journal| author=Garakani A, Murrough JW, Freire RC, Thom RP, Larkin K, Buono FD | display-authors=etal| title=Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options. | journal=Front Psychiatry | year= 2020 | volume= 11 | issue=  | pages= 595584 | pmid=33424664 | doi=10.3389/fpsyt.2020.595584 | pmc=7786299 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33424664  }} </ref>:
**[[Pregabalin]] (Lyrica)- initial dose is 50mg with daily dose ranging from 50-300mg
* Second generation antipsychotics like [[Quetiapine]]( SEROQUEL)- Start with initial dose of 25mg/day and titrated at 25-50mg intervals weekly or biweekly to a maximum dose of 300mg/day


** [[Hydroxyzine]] (Vistaril)- doses between 50 to 150 mg a day in divided doses as PRN, is effective for anxiety disorders.
* Bupropion. Trials have compared SSRIs and bupropion for the treatment of combined depression and anxiety<ref name="pmid17631898">{{cite journal| author=Papakostas GI, Trivedi MH, Alpert JE, Seifert CA, Krishen A, Goodale EP | display-authors=etal| title=Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of anxiety symptoms in major depressive disorder: a meta-analysis of individual patient data from 10 double-blind, randomized clinical trials. | journal=J Psychiatr Res | year= 2008 | volume= 42 | issue= 2 | pages= 134-40 | pmid=17631898 | doi=10.1016/j.jpsychires.2007.05.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17631898  }} </ref>. The improvement in anxiety may be similar between the two medications, but the SSRI may better reduce depression symptoms<ref name="pmid18605812">{{cite journal| author=Papakostas GI, Stahl SM, Krishen A, Seifert CA, Tucker VL, Goodale EP | display-authors=etal| title=Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of major depressive disorder with high levels of anxiety (anxious depression): a pooled analysis of 10 studies. | journal=J Clin Psychiatry | year= 2008 | volume= 69 | issue= 8 | pages= 1287-92 | pmid=18605812 | doi=10.4088/jcp.v69n0812 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18605812  }} </ref>. Two larger trials have been analyzed together<ref name="pmid11816866">{{cite journal| author=Trivedi MH, Rush AJ, Carmody TJ, Donahue RM, Bolden-Watson C, Houser TL | display-authors=etal| title=Do bupropion SR and sertraline differ in their effects on anxiety in depressed patients? | journal=J Clin Psychiatry | year= 2001 | volume= 62 | issue= 10 | pages= 776-81 | pmid=11816866 | doi=10.4088/jcp.v62n1005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11816866  }} </ref>.
* Hydroxyzine


** [[Mirtazapine]] (REMERON)_ doses between 15 mg to 45 mg used as monotherapy or adjunctive treatment in [[Generalized anxiety disorder]]
=== Alternative regimens from other categories: ===
'''SNRI's:'''


*[[Panic disorder]]- SSRIs, SNRIs are treatment of choice, [[benzodiazepines]] are used in acute exacerbtions and as needed basis. Doses are used in the same range as for generalized anxiety disorders.
*Preferred regimen (1): [[Duloxetine]]: Oral (initial dose 30mg) with daily dose ranging from 60-120mg.
*Preferred regimen (2): [[Venlafaxine]]: Oral (initial dose 75mg) with daily dose ranging from 75-225mg.


* [[Social anxiety]]- [[SSRIs]] and [[beta-blockers]] are used as [[First-line treatment|first line treatmen]]<nowiki/>t for [[social anxiety disorder]].
'''Benzodiazepines:'''
*These [[medications]] are used as alternative or short term therapy:
**  Alternative regimen (1): [[Lorazepam]] (Ativan) - Started at 0.5-1mg orally t.i.d. and titrated up to 1.5mg q.i.d daily as needed.
** Alternative regimen (2): [[Diazepam]] (Valium) started at 2.5mg to 5mg orally once or twice daily and titrated up to 10mg ,two or three times daily as needed.
** Alternative regimen (3): [[Clonazepam]] (Klonopin) can be started at 0.25-0.5 mg orally once or twice daily and titrated up to 1mg (b.i.d or t.i.d) daily as needed.
**There is increased risk of dependence and [[tolerance]], so maintain caution in long [[Term logic|term]] use, [[Selective serotonin reuptake inhibitor|SSRIs]] are therefore first line [[Treatment-resistant depression|treatment]] for [[Anxiety Disorders|anxiety]] disorders in long term use.


===Psychotherapy===
'''Other drugs to consider:'''
*[[CBT]] is a type of [[psychotherapy]] that can help people with [[anxiety]] disorders. It teaches a person different ways of thinking, behaving, and reacting to anxiety-producing and fearful situations. [[Cognitive-behavioral therapy|CBT]] can also help people learn and practice [[social skills]], which is vital for treating [[social anxiety disorder]].


*Two specific stand-alone components of CBT used to treat social anxiety disorder are [[cognitive]] therapy and [[exposure]] therapy. Cognitive therapy focuses on identifying, challenging, and then neutralizing unhelpful thoughts underlying [[anxiety]] disorders.
*Other [[medications]] that may be used include:
 
** Alternative regimen (1): [[Buspirone]] (Buspar)- initial dose is 10mg with daily dose ranging from 10-60mg.
*[[Exposure therapy]] focuses on confronting the fears underlying an [[anxiety]] disorder in order to help people engage in activities they have been avoiding. [[Exposure therapy]] is used along with relaxation exercises and/or imagery. One study, called a meta-analysis because it pulls together all of the previous studies and calculates the statistical magnitude of the combined effects, found that [[cognitive therapy]] was superior to exposure therapy for treating [[Social anxiety disorder|social anxiety]] disorder.
** Alternative regimen (2): [[Pregabalin]] (Lyrica)- initial dose is 50mg with daily dose ranging from 50-300mg.
 
**Alternative regimen (3): Second generation anti psychotics like [[Quetiapine]]( SEROQUEL)- Start with initial dose of 25mg/day and titrated at 25-50mg intervals weekly or biweekly to a maximum dose of 300mg/day.
*[[CBT]] may be conducted individually or with a group of people who have similar problems. [[Group therapy]] is particularly effective for [[social anxiety]] disorder. Often “homework” is assigned for participants to complete between sessions.<ref name="pmid26795939">{{cite journal |vauthors=Kivity Y, Huppert JD |title=Does cognitive reappraisal reduce anxiety? A daily diary study of a micro-intervention with individuals with high social anxiety |journal=J Consult Clin Psychol |volume=84 |issue=3 |pages=269–83 |year=2016 |pmid=26795939 |doi=10.1037/ccp0000075 |url=}}</ref>
**Alternative regimen (7): [[Hydroxyzine]] (Vistaril)- doses between 50 to 150 mg a day in divided doses as PRN, is effective for [[anxiety]] [[disorders]].
**Alternative regimen (8): [[Mirtazapine]] (Remeron)_ doses between 15 mg to 45 mg used as monotherapy or adjunctive treatment in [[Generalized anxiety disorder]].
Preferred regimen for [[Panic disorder]]:
* SSRIs, SNRIs, benzodiazepines preferred regimen in acute exacerbation and as needed basis. Doses are used in the same range as for generalized [[anxiety]] disorders.
Preferred regimen for [[Social anxiety]]:
* [[SSRIs]] and [[beta-blockers]] <nowiki/> for [[social anxiety disorder]].


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}


[[Category:primary care]]
[[Category:Psychiatry]]
[[Category:Psychiatry]]
[[Category:Needs overview]]
[[Category:Needs overview]]
{{WH}}
{{WS}}

Latest revision as of 18:59, 6 September 2023

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Overview

The mainstay of therapy for anxiety is the administration of pharmacotherapy and psychotherapy. Mostly used Antidepressants , Benzodiazepines (some concern over dependency), buspirone, tricyclic antidepressants , SSRIs (selective serotonin reuptake inhibitors).

Medical Therapy

Pharmacotherapy

Systematic reviews guide treatment of generalized anxiety disorder[1][2][3]:

Evidence summary from NICE of selected medications.[3]
  Evidence base Relative risk of
non-response		 Relative risk of
Drug toxicity
Sertraline Trials: 2
(706 patients)		 0.70* 1.1
Nausea
Sexual
Venlafaxine Trials: 12
(3470 patients)		 0.80* 2.06*
Nausea
Sexual
Insomnia
Citalopram Trials: 1
(34 patients)		 0.46* 3.0
Escitalopram Trials: 6
(2136 patients)		 0.78 1.72*
Nausea
Sexual
Paroxetine Trials: 8
(2748 patients)		 0.91 2.5*
Nausea
Sexual
Insomnia
Pregabalin Trials: 8
(2079 patients)		 0.79* 1.3
Dizziness
Fatigue
Buspirone Trials: 5
(806 patients)		 0.87 2.0*
Nausea
Dizziness
Hydroxyzine Trials: 3
(482 patients)		 0.81 1.48
Little short term toxicity
Alprazolam Trials: 4
(544 patients)		 0.87 1.3
Little short term toxicity
* P< 0.05

SSRIs:

The first line treatment for generalized anxiety disorder is SSRI:

  • Preferred regimen:
    • Sertraline oral dose of 25 mg once daily for 1 week, increase it based on response and tolerability; maximum dose is 200mg/day.
  • Alternative regimen:
    • Alternative regimen (1): Citalopram (Celexa): Oral (initial dose-10mg) with daily dose ranging from 10-40mg.
    • Alternative regimen (2): Escitalopram (Lexapro): Oral (initial dose-5-10mg) with daily dose ranging from 10-20mg.
    • Alternative regimen (3): Paroxetine ( Paxil): Oral(initial dose 20mg) with daily dose ranging from 20-50mg.
    • Usually SSRIs are most effective at highest tolerable doses.

Other medications

Consider[2][4]:

  • Bupropion. Trials have compared SSRIs and bupropion for the treatment of combined depression and anxiety[5]. The improvement in anxiety may be similar between the two medications, but the SSRI may better reduce depression symptoms[6]. Two larger trials have been analyzed together[7].
  • Hydroxyzine

Alternative regimens from other categories:

SNRI's:

  • Preferred regimen (1): Duloxetine: Oral (initial dose 30mg) with daily dose ranging from 60-120mg.
  • Preferred regimen (2): Venlafaxine: Oral (initial dose 75mg) with daily dose ranging from 75-225mg.

Benzodiazepines:

  • These medications are used as alternative or short term therapy:
    • Alternative regimen (1): Lorazepam (Ativan) - Started at 0.5-1mg orally t.i.d. and titrated up to 1.5mg q.i.d daily as needed.
    • Alternative regimen (2): Diazepam (Valium) started at 2.5mg to 5mg orally once or twice daily and titrated up to 10mg ,two or three times daily as needed.
    • Alternative regimen (3): Clonazepam (Klonopin) can be started at 0.25-0.5 mg orally once or twice daily and titrated up to 1mg (b.i.d or t.i.d) daily as needed.
    • There is increased risk of dependence and tolerance, so maintain caution in long term use, SSRIs are therefore first line treatment for anxiety disorders in long term use.

Other drugs to consider:

  • Other medications that may be used include:
    • Alternative regimen (1): Buspirone (Buspar)- initial dose is 10mg with daily dose ranging from 10-60mg.
    • Alternative regimen (2): Pregabalin (Lyrica)- initial dose is 50mg with daily dose ranging from 50-300mg.
    • Alternative regimen (3): Second generation anti psychotics like Quetiapine( SEROQUEL)- Start with initial dose of 25mg/day and titrated at 25-50mg intervals weekly or biweekly to a maximum dose of 300mg/day.
    • Alternative regimen (7): Hydroxyzine (Vistaril)- doses between 50 to 150 mg a day in divided doses as PRN, is effective for anxiety disorders.
    • Alternative regimen (8): Mirtazapine (Remeron)_ doses between 15 mg to 45 mg used as monotherapy or adjunctive treatment in Generalized anxiety disorder.

Preferred regimen for Panic disorder:

  • SSRIs, SNRIs, benzodiazepines preferred regimen in acute exacerbation and as needed basis. Doses are used in the same range as for generalized anxiety disorders.

Preferred regimen for Social anxiety:

References

  1. ↑ Chawla N, Anothaisintawee T, Charoenrungrueangchai K, Thaipisuttikul P, McKay GJ, Attia J; et al. (2022). "Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials". BMJ. 376: e066084. doi:10.1136/bmj-2021-066084. PMID 35045991 Check |pmid= value (help).
  2. ↑ 2.0 2.1 Slee A, Nazareth I, Bondaronek P, Liu Y, Cheng Z, Freemantle N (2019). "Pharmacological treatments for generalised anxiety disorder: a systematic review and network meta-analysis". Lancet. 393 (10173): 768–777. doi:10.1016/S0140-6736(18)31793-8. PMID 30712879.
  3. ↑ 3.0 3.1 National Institute for Health and Clinical Excellence (2011). Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults
  4. ↑ Garakani A, Murrough JW, Freire RC, Thom RP, Larkin K, Buono FD; et al. (2020). "Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options". Front Psychiatry. 11: 595584. doi:10.3389/fpsyt.2020.595584. PMC 7786299 Check |pmc= value (help). PMID 33424664 Check |pmid= value (help).
  5. ↑ Papakostas GI, Trivedi MH, Alpert JE, Seifert CA, Krishen A, Goodale EP; et al. (2008). "Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of anxiety symptoms in major depressive disorder: a meta-analysis of individual patient data from 10 double-blind, randomized clinical trials". J Psychiatr Res. 42 (2): 134–40. doi:10.1016/j.jpsychires.2007.05.012. PMID 17631898.
  6. ↑ Papakostas GI, Stahl SM, Krishen A, Seifert CA, Tucker VL, Goodale EP; et al. (2008). "Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of major depressive disorder with high levels of anxiety (anxious depression): a pooled analysis of 10 studies". J Clin Psychiatry. 69 (8): 1287–92. doi:10.4088/jcp.v69n0812. PMID 18605812.
  7. ↑ Trivedi MH, Rush AJ, Carmody TJ, Donahue RM, Bolden-Watson C, Houser TL; et al. (2001). "Do bupropion SR and sertraline differ in their effects on anxiety in depressed patients?". J Clin Psychiatry. 62 (10): 776–81. doi:10.4088/jcp.v62n1005. PMID 11816866.

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