Generalized Anxiety Disorder (GAD):
- 6 months or more of excessive worry or anxiety.
- OCD – intrusive thoughts that can not be controlled
- PTSD: trauma related to avoidance of stimuli.
- Benzos are the first line therapy in anxiety. Can cause tolerance or dependence. Abrupt discontinuation can lead to withdrawal. Treat for 3-4 weeks until trial for an antidepressant is complete.
- SSRIs are also effective, as is venlafaxine, duloxetine, and TCAs. Buspirone is controversial. Venlafaxine is the agent of choice because it also helps with vasomotor symptoms.
- Misc agents: Beta-blockers can block peripheral symptoms. MAOIs can treat panic with atypical depression. Hydroxyzine’s sedating effects can reduce the physical symptoms of anxiety
Augmentation with quetiapine, olanzapine or risperidone can be tried.
Benzodiazepines:
| Benzodiazepine | Onset of Action | Peak Onset (hrs) | Half-life parent (hrs) | Half-life metabolite (hrs) | Comparative Oral Dose |
| Long Acting | |||||
| Chlordiazepoxide | Int. (po) | 2-4(po) | 5-30 | 3-100 | 10 mg |
| Diazepam | Rapid (po, IV) | 1(po) | 20-50 | 3-100 | 5 mg |
| Flurazepam | Rapid | 0.5-2 | inactive | 47-100 | 30 mg |
| Intermediate Acting | |||||
| Alprazolam | Int. | 0.7-1.6 | 6-20 | – | 0.5mg |
| Clonazepam | Int. | 1-4 | 18-39 | – | 0.25mg |
| Lorazepam | Int. (po), Rapid (sl, IV) | 1-1.5 (po) | 10-20 | – | 1mg |
| Oxazepam | Slow | 2-3 | 3-21 | – | 15mg |
| Temazepam | Slow | 0.75-1.5 | 10-20 | – | 30mg |
| Short Acting | |||||
| Midazolam | Most Rapid IV | 0.5-1 (IV ) | 1-4 | – | – |
| Triazolam | Int. | 0.75-2 | 1.6-5.5 | – | 0.5mg |
IV BZDs:
| Drug | Diazepam | Lorazepam | Midazolam |
| Onset (m) | 2-5 | 5-20 | 2-5 |
| Duration (h) | 2-4 | 4-6 | 1-2 |
| Prolonged in renal | yes | no | yes |
| Prolonged in hepatic | yes | no | yes |
| T 1/2 (h) | 24-120 | 10-20 | 1-10 |
| Active metabolites | yes | no | yes |
| CYP 3A4 Interaction | yes | no | yes |
| Hypotension | yes | no | no |
| Thrombocytopenia | yes | maybe | no |
| Propolyne glycol toxicity | no | yes | no |
ALOT are better for elder and renal pts (alprazolam, lorazepam, oxazepam, temazepam)
Panic disorders:
- Antidepressants, BZDs.
- Don’t use buspirone, Beta blockers, antihistamines, antipsychotics, bupropion or trazodone.
- Cognitive behavioral therapy (CBT) can be effective. Start on low doses of antipsychotics.
Obsessive Compulsive Disorder (OCD):
- SSRIs, cognitive behavioral therapy secondary to drugs, augmentation with haloperidol or a second-generation antipsychotic (olanzapine, quetiapine or risperidone) may help.
Post-traumatic Stress Disorder (PTSD):
- Psychotherapy, SSRIs can be used as an adjunct
- Can treat with prazosin for nightmares, anticonvulsants (valproic acid, carbamazepine, lamotrigine, topiramate) for anger, aggression, and depression or atypical antipsychotics (olanzapine, quetiapine, risperidone) for psychotic symptoms. BZDs for sleep
Seasonal Affective Disorder (SAD):
- CBT most cost-effective. Can also use SSRIs, clonazepam, gabapentin and pregabalin
Phobias:
- No meds help, desensitization is the only therapy.