Drug |
Initial Dose (Dosing Range, mg/day) |
Advantages |
Disadvantages |
Selective Serotonin Reuptake Inhibitors |
Please refer to Table 5-5 for class specific information |
Citalopram (Celexa)Escitalopram (Lexapro)Fluoxetine (Prozac)Fluvoxamine (Luvox)Paroxetine (Paxil)Paroxetine CR (Paxil CR)Sertraline (Zoloft) |
10-20 (20-60)10 (10-30)10 (10-80)50 (50-300)10 (10-50)12.5 (12.5-50)25 (25-100) |
|
|
Mixed Serotonin and Norepinephrine Reuptake Inhibitors |
Please refer to Table 5-6 for class specific information |
Duloxetine (Cymbalta)Venlafaxine XR (Effexor XR) |
40 (40-120) (may use divided dosing)37.5 (75-375) |
-
Fast acting
-
Well tolerated |
-
May increase anxiety, agitation, or initially
-
Common sexual and GI dysfunction
-
Delayed onset of action
-
Venlafaxine may cause elevated BP |
Benzodiazepines (Selected) |
Please refer to Table 5-30 for class specific information |
Alprazolam (Xanax)Clonazepam (Klonopin)Diazepam (Valium)Lorazepam (Ativan) |
0.25-0.5 (2-10) (TID dosing)0.5 (1-5) (BID dosing)5 (5-40) (BID, TID, or QID dosing)1-2 (3-16) (TID or QID dosing) |
-
Fast acting
-
Well tolerated
-
Low cost |
|
Tricyclic Antidepressants (Selected) |
Please refer to Table 5-8 for class specific information |
Amitriptyline (Elavil)Clomipramine (Anafranil)Imipramine (Tofranil) |
10-25 (50-300)12.5-25 (100-250)10-25 (50-300) |
|
|
|
|
|
|
Monoamine Oxidase Inhibitors |
Please refer to Table 5-9 for class specific information |
Phenelzine (Nardil)Selegiline (Eldepryl)Selegiline patch (EMSAM)Tranylcypromine (Parnate) |
15 (60-90) (daily or BID)5-10 (10-20)6 (12)10-20 (20-60) (BID dosing) |
|
-
Dietary restrictions to avoid hypertensive crises with sympathomimetics (e.g., tyramine, NeoSynephrine)
-
Many drug interactions (e.g., SSRIs, methylphenidate)
-
Toxic; lethal on overdose |
Atypical Antipsychotics |
Please refer to Table 5-20 for class specific information |
Aripiprazole (Abilify)Olanzapine (Zyprexa)Risperidone (Risperdal and Consta)Quetiapine (Seroquel)Ziprasidone (Geodon) |
2 (2-30 2.5 (2.5-30)0.25-0.5 (0.5-6)12.5 (25-400) (daily or divided dosing)40 (40-160) |
|
-
Not well studied for treatment of anxiety
-
Risk of metabolic syndrome
-
Some EPS risk (especially akathisia, atypical NMS; TD with risperidone) |
Anticonvulsants |
Please refer to Table 5-13 for class specific information |
Carbamazepine (Tegretol)Gabapentin (Neurontin)Levetiracetam (Keppra) |
250 (400-1000)500 (1000-2000)500 (2000-3000) |
|
|
Oxcarbazepine (Trileptal)Valproate (Depakote) |
250 (600-1800)250-500 (1000-2000) |
|
-
May produce dependence and risk seizures on stopping
-
Tremor
-
Alopecia
-
Sedating
-
Weight gain
-
Highly teratogenic (carbamazepine, valproate)
-
Valproate can masculinize with PCOS
-
Drug interactions (carbamazepine induces metabolism of many agents; valproate increases lamotrigine)
-
Levetiracetam has some evidence of anxiolytic effects (off-label use)
-
Gabapentin and oxcarbazepine are off-label use for psychiatry |
Adrenergic Agents |
Clonidine (anti-α2) (Catapres)Prazosin (anti-α1) (Minipress)Propranolol (anti-β) (Inderal) |
0.1 (0.1-2.4) 1 (1-15) 20 (40-60) |
|
|
Antihistamines |
Diphenhydramine (Benadryl)Hydroxyzine (Vistaril) |
12.5-25 (25-50)25-50 (75-400) |
-
Relatively safe
-
Long used |
-
Sedating
-
Anticholinergic effects |
Miscellaneous |
Bupropion SR (Wellbutrin SR)Bupropion XL (Wellbutrin XL)Buspirone (BuSpar)Trazodone (Desyrel) |
100 (300-400) (BID dosing)150 (300-450)5 (15-60) (BID or TID dosing)25 (50-200) |
|
-
Bupropion: marketed at suboptimal doses; mild stimulant (risks agitation, insomnia); may induce seizures
-
Buspirone is not highly effective for treating anxiety
-
Trazodone is not very effective; side effects include priapism and sedation |
BID, twice a day; BP, blood pressure; EPS, extrapyramidal side effects; GI, gastrointestinal; NMS, neuromalignant syndrome; PCOS, polycystic ovarian syndrome; QID, four times a day; SNRI, serotonin and norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TD, tardive dyskinesia; TID, three times a day. |
Adapted from Iosifescu D, Pollack M: An approach to the anxious patient: symptoms of anxiety, fear, avoidance, or increased arousal. In Stern TA (ed). The Ten-Minute Guide to Psychiatric Diagnosis and Treatment. New York, NY: Professional Publishing; 2005:205. |