Advantages and Disadvantages of Currently Available Treatment Options for Generalized Anxiety Disorder (GAD)

Type of Treatment Advantages Disadvantages
paroxetine (Paxil), sertraline (Zoloft), fluoxetine (Prozac),  citalopram (Celexa), venlafaxine(Effexor),  duloxetine (Cymbalta)
Recommended first-line treatments in GAD

Effective against comorbid depression

Slow onset of action

Sexual dysfunction, other side effects limit compliance

Tolerability/withdrawal issues/”start low, go slow”.

Maximize dose over time, as tolerated.

Psychological Therapies/Counseling: Concurrent with possible medications; All patients should be referred for evaluation and/or on-going treatment Recommend first-line treatment Psychological approaches may be effective, e.g. cognitive-behavioral therapy (CBT)*

Can avoid need for pharmacotherapy

Not all psychological therapies have demonstrated efficacy in clinical trials

Some patients reluctant to undergo psychological therapy

Limited availability of trained therapists can restrict service provision

Alprazolam (Xanax), lorazepam (Ativan),  diazepam (Valium), clonazepam, (Klonopin)
Have been widely used in GAD Can reduce psychic and somatic symptoms

Rapid onset of action

Role in acute management

Problematic side effects, including drowsiness and confusion

Risk of dependence and discontinuation symptoms

Abuse potential Ineffective against depression

bupropion (Wellbutrin),  mirtazapine (Remeron)
Sedation can be useful for insomnia (mirtazapine).

Bupropion can be useful to aid smoking cessation and co-morbid depression

Weight Gain (mirtazapine), somnolence (mirtazapine),

Agitation/increased anxiety (Wellbutrin)

Buspirone (Buspar)
Some efficacy in GAD

Not associated with risk of dependency

Limited efficacy

Slow onset of action

Variable tolerability, including risk of sedation and nausea

Perceived as ineffective against comorbid depression

hydroxyzine (Vistaril), diphenhydramine (Benadryl)
Have been widely used in GAD

Not associated with risk of dependency May be useful as a PRN medication

Slow onset of action

Lack of demonstrated efficacy against comorbid disorders

Sedation and anticholinergic effects

Weight gain

Tricyclic/atypical antidepressants:
Imipramine (Tofranil),  amitriptyline (Elavil), trazodone (Desyrel)
Possible role as second-line therapy in GAD

Sedating tricyclics can be useful in presence of insomnia

Not associated with risk of dependency

Poor tolerance-dry mouth, cardiac symptoms

Slow onset of action

Overdose risk in patients with suicidal ideations

Quetiapine (Seroquel), risperidone (Risperdal), olanzapine ( Zyprexa)
Not a first line treatment for GAD

Typically used as an adjunct to other medications

May be effective for symptoms of GAD

Low dosing recommended

Data currently unpublished

Metabolic side effects, need monitoring (weight, lipids, blood sugar/HbgA1c)

Abbreviations: *CBT = cognitive-behavioral therapy, *SSRI = selective serotonin reuptake inhibitor  *SNRI = serotonin-norepinephrine reuptake inhibitor.  Medications listed are suggestions.

Selection and dosing should be based upon symptoms, co-morbid conditions and medication tolerance.  SmartCare is available to provide consultation and assistance in helping to decide the best options for the patient.

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