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.