Weigh Med Options for Generalized Anxiety Disorder

About 1 in 13 adults in the US will be diagnosed with generalized anxiety disorder in their lifetime.

It’s more than occasional anxiety. It’s hard-to-control worry with related symptoms (insomnia, etc) that persist most days for months.

Suggest cognitive behavioral therapy or meds as the initial treatment for generalized anxiety disorder...efficacy seems similar.

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Be ready to guide a stepwise approach if meds are preferred.

SSRIs or SNRIs. Continue to recommend one of these as the first-line med, based on overall evidence for generalized anxiety disorder. Plus they’re preferred for common comorbidities, such as depression.

Keep in mind, there’s not one “best” SSRI or SNRI. Often lean toward escitalopram or sertraline...or duloxetine or venlafaxine. Limited data suggest these provide a better balance of efficacy and tolerability.

Advise starting with low doses, such as sertraline 25 mg/day, and titrating to limit early side effects...worsening anxiety, insomnia, etc.

Explain it can take about 2 to 4 weeks to start to see some benefit...and up to 12 weeks for max effects.

Buspirone. Consider this if an SSRI or SNRI isn’t tolerated...or as an add-on if they aren’t enough.

Educate that buspirone should be given bid or tid...not prn.

Point out that it can take about 2 weeks to start seeing some effect. Emphasize titrating buspirone...up to 60 mg/day if needed.

Pregabalin. Think of this as an alternative or add-on. It may start working as early as 1 week...but weigh concerns about misuse and side effects (drowsiness, dizziness, weight gain, etc).

Hydroxyzine. Consider this as an alternative, especially if a quick-onset med or “prn” option is needed. But hydroxyzine has limited evidence...and anticholinergic effects (dry mouth, etc) often occur.

Benzos. Advise saving these as an add-on for just a few weeks until an SSRI or SNRI starts working...or for severe anxiety disorders.

Discourage using alprazolam if a benzo is needed. Its short half-life can cause rebound anxiety and withdrawal. Suggest a longer-acting option instead, such as clonazepam...to possibly ease discontinuation.

If patients ask about supplements for anxiety, consider options that may be worth a try...such as ashwagandha, lavender, or passion flower.

But caution about possible sedation with any of these...and be aware of concerns for liver toxicity with ashwagandha. Use our NatMed Pro for more...including interactions, considerations in pregnancy, etc.

Be alert for meds that may worsen anxiety, such as stimulants for ADHD...and suggest alternatives. Also refer patients for treatment of conditions that may contribute to anxiety, such as alcohol use disorder.

Get our updated chart, Pharmacotherapy of Anxiety, for guidance about other meds and additional disorders (social anxiety, etc).

Key References

  • Szuhany KL, Simon NM. Anxiety Disorders: A Review. JAMA. 2022 Dec 27;328(24):2431-2445.
  • Fagan HA, Baldwin DS. Pharmacological Treatment of Generalised Anxiety Disorder: Current Practice and Future Directions. Expert Rev Neurother. 2023 Jun;23(6):535-548.
  • DeGeorge KC, Grover M, Streeter GS. Generalized Anxiety Disorder and Panic Disorder in Adults. Am Fam Physician. 2022 Aug;106(2):157-164.
Pharmacist's Letter. April 2024, No. 400401

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