Treatment Options for Generalized Anxiety Disorder (GAD):  Advantages and Disadvantages 3/5/2021

The following chart provides a helpful review guide of the advantages and disadvantages of various agents and therapies for treatment of Generalized Anxiety Disorders..

Type of Treatment Advantages Disadvantages
Psychological Therapies & Counseling
All patients should be referred for evaluation and/or on-going psychotherapeutic treatment.

Can be provided in concurrence with appropriate medications.

Recommend first-line treatment

Psychological approaches alone may often be effective, e.g. cognitive-behavioral therapy (CBT)*

Can avoid need for pharmacotherapy but does not preclude Rx interventions

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

SSRI* & SNRI* Antidepressants
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

Benzodiazepines
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

Other Antidepressants
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)

Azapirones
buspirone (Buspar) Some efficacy in GAD

Not associated with risk of dependency

Have been widely used in GAD

Slow onset of action
Antihistamines
hydroxyzine (Vistaril) diphenhydramine (Benadryl) Not associated with risk of dependency May be useful as a PRN medication 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

Antipsychotics
quetiapine (Seroquel) risperidone (Risperdal)

aripirazole (Abilify)

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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