Anxiety Management

1. See Also
   1. Anxiety Non-pharmacologic Management
2. Management: Selective Serotonin Reuptake Inhibitors (SSRIs and SNRIs)
   1. Indicated as primary agents for anxiety as well as for concurrent depression
   2. Selective Serotonin Reuptake Inhibitors (SSRI)
      1. Paroxetine (Paxil)
      2. Escitalopram (Lexapro) or Citalopram (Celexa)
   3. Serotonin-Norepinephrine Reuptake Inhibitors
      1. Venlafaxine (Effexor)
      2. Duloxetine (Cymbalta)
3. Medications: Anxiolytics
   1. Non-addictive Anxiolytics
      1. Buspirone (Buspar)
   2. Short-acting Benzodiazepines
      1. Indicated in the elderly or with decreased clearance
      2. Lorazepam (Ativan)
   3. Long Acting Benzodiazepines
      1. Clonazepam (Klonopin)
4. Management: Adjunctive Pharmacotherapy
   1. Atypical Antipsychotics
      1. Quetiapine (Seroquel)
   2. Tricyclic Antidepressants (may be useful in transitioning off Benzodiazepines)
      1. Imipramine (Tofranil)
      2. Desipramine (Norpramin)
   3. MAO inhibitors
      1. Indicated for concurrent phobia
      2. Phenelzine (Nardil)
      3. Tranylcypromine (Parnate)
   4. Beta Blockers
      1. Indicated for excessive autonomic symptoms
      2. Propranolol (Inderal)
      3. Atenolol (Tenormin)
   5. Pregabalin (Lyrica)
      1. Relieves Anxiety Symptoms with similar efficacy to SSRIs and Benzodiazepines
      2. Minimum threshold effective dose is 200 mg per day
      3. Bech (2007) Pharmacopsychiatry 40(4): 163-8
5. Management: Other options
   1. Clonidine (Catapres)
   2. Sedating Antihistamines (e.g. Hydroxyzine)
6. Management: Children
   1. Cognitive behavioral therapy (most important single intervention)
   2. Selective Serotonin Reuptake Inhibitors (SSRI)
      1. SSRIs combined with CBT are 80% effective in pediatric anxiety
      2. Fluoxetine (Prozac)
      3. Citalopram (Celexa)
      4. Sertraline (Zoloft)
      5. Avoid Paroxetine (Paxil) due to withdrawal risk
   3. Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
      1. Venlafaxine (Effexor)
   4. Other agents with specific indications
      1. Clomipramine indications
         1. Inadequate effect with CBT and SSRI or SNRI
         2. Obsessive-Compulsive Disorder
      2. Benzodiazepine indications
         1. Short-term as needed use for severe anxiety and panic while initiating other therapy
   5. Precautions
      1. Avoid Tricyclic Antidepressants due to low efficacy in pediatric anxiety
   6. References
      1. (2013) Presc Lett 20(5): 29
      2. Todd (2012) Child Adolesc Psychiatr Clin N Am 21(4):789-806
7. Complications: Medications in the Elderly
   1. Ataxia with risk of falls and secondary Fracture
   2. Decreased cognition
8. References
   1. Greenberger (1995) Mind over Mood, Guilford Press
   2. Bourne (1997) Anxiety and Phobia Workbook, Fine Comm.
   3. Kavan (2009) Am Fam Physician 79(9): 785-91
   4. Wittchen (2002) J Clin Psychiatry 63:24-34