A recent case consultation highlighted medication treatment for an anxiety disorder in the primary care setting. This is a 33 year old male with Generalized Anxiety Disorder and Panic Disorder. He has some benefit from Celexa 40 mg qday, but continues to engage in avoidance behavior, which makes it difficult to sustain work and social interactions in a meaningful way, and continues to have occasional breakthrough panic attacks. He has tried adjunctive Buspar and Vistaril, neither of which was helpful. He was briefly started on adjunctive Klonopin, which he found helpful, but there was justifiable concern on the part of the primary care provider to continue the medication. He does not have a history of substance abuse and has not misused the prescription for Klonopin, so it was discussed that one option could be to continue on the adjunctive Klonopin for now. The recommendation was also made to try a different SSRI to see if there could be a better primary response to reduce the need for adjunctive treatment.
This case leads nicely into a discussion about how to approach the treatment of an anxiety disorder. The first step is to determine a specific diagnosis and determine the level of impairment of the symptoms. If the impairment is mild-moderate, one could start with a therapy approach and determine if medication treatment is needed in the future.
If the impairment is moderate-severe, the standard of care is to begin therapy and medication treatment concurrently. Medication treatment should minimally involve an approach to treat the underlying anxiety – first line would be an SSRI medication.
Other options, if that doesn’t work, could include: SNRIs, Remeron, and Buspar. For many patients, it is helpful to initially prescribe an adjunctive medication to provide some relief for their anxiety while the primary medication is “kicking in”. These include: Buspar (which can be useful for the underlying anxiety management as well as for acute anxiety management), Vistaril, Propranolol, and the benzodiazepines.
Some providers may consider low doses of the atypical antipsychotics, but the concern about that practice is that the patient is still exposed to the possible metabolic side effects of that class of medications even at low doses, as many of the metabolic side effects of antipsychotics are dose-independent. For patients for whom they are effective, these adjunctive medications yield benefits more quickly than the traditional anti-anxiety medications.
In many cases, these medications can be tapered off once the base medication has fully “kicked in”. Buspar is typically dosed 7.5 mg bid and increased by 5 mg every 2-3 days as tolerated up to 30 mg bid. Onset of action may take 2 weeks. It is relatively well tolerated with less cognitive impairment than benzodiazepines. Major side effects include dizziness, fatigue, and nausea. Vistaril is typically dosed 25-50 mg bid-tid on a prn basis. It is less sedating than Benadryl, therefore is better tolerated during the daytime. Propranolol is typically dosed 20-40 mg if used on a prn basis and 20 mg bid-tid titrated up to 40 mg bid-tid as tolerated and needed if used on a standing basis.
We hope this extensive discussion about this case and the thinking process that occurred in the background was helpful for other similar cases you might encounter in your practice.