| Type of Treatment | Advantages | Disadvantages |
| SSRIs*/SNRIs*: 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 |
| 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 |
| Others: 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 |
Limited efficacy
Slow onset of action Variable tolerability, including risk of sedation and nausea Perceived as ineffective against comorbid depression |
| Antihistamines: 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 |
| Antipsychotics: 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.