From the Guidelines
For breakthrough anxiety in a 43-year-old female currently on citalopram 20mg and buspirone 15mg daily, I recommend considering hydroxyzine (25-50mg as needed) as the most appropriate non-controlled medication option. Hydroxyzine is an antihistamine that can reduce anxiety symptoms within 30-60 minutes and lasts 4-6 hours, with sedation being the main side effect 1. This option is preferred due to its rapid onset of action and relatively safe profile compared to other alternatives.
Other options like propranolol (10-20mg as needed) or gabapentin (100-300mg as needed) could also be considered, but they may have different side effect profiles or interactions that need to be carefully evaluated 1. Propranolol, a beta-blocker, helps manage physical symptoms of anxiety like racing heart and tremors, typically working within 30 minutes. Gabapentin may help reduce anxiety by modulating GABA neurotransmission, though it may take longer to work than the other options.
It's also important to consider non-pharmacological options like cognitive behavioral therapy techniques, mindfulness practices, or breathing exercises, which should be incorporated for comprehensive management 1. Regular follow-up is crucial to assess effectiveness and adjust treatment as needed. Increasing the citalopram dose to 30-40mg daily if tolerated, or increasing buspirone to 30mg daily (15mg twice daily), could be alternative approaches, but these should be done with caution and careful monitoring due to potential side effects and interactions 1.
In making this recommendation, it's essential to prioritize the patient's safety, considering the potential for drug interactions, especially with SSRIs like citalopram, which may interact with drugs that prolong the QT interval 1. Therefore, any addition or adjustment to the current medication regimen should be done under close supervision and with thorough patient education on potential benefits and risks.
From the Research
Treatment Options for Breakthrough Anxiety
The patient is currently taking citalopram 20mg and buspirone 15mg daily for anxiety due to emotional trauma, but is experiencing breakthrough anxiety problems. To address this, several options can be considered:
- Adding another medication to the current treatment regimen, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) 2
- Using non-pharmacological interventions, such as music, education, relaxation, cognitive behavioral therapy (CBT), massage, distraction, hypnosis, acupuncture/acupressure, social support, aromatherapy, nature sounds, or natural visual stimuli, which have been shown to reduce anxiety in over 70% of experiments 3
- Considering novel products, such as ketamine, psilocybin, or cannabidiol, which are in the process of gathering evidence in support of the treatment of anxiety disorders 4
- Using repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS), which have shown early promise for generalized anxiety disorder (GAD) and social anxiety disorder (SAD) 4
Medication Options
Some medication options that can be considered for breakthrough anxiety include:
- Agomelatine, which has demonstrated efficacy in treating generalized anxiety disorder (GAD) 4
- Anticonvulsants and antipsychotics, which may be helpful but have a limited evidence base 5
- Beta blockers, such as propranolol, which can be used as a third-line agent 5
- Hydroxyzine, an antihistamine that can be used as a third-line agent 5
Non-Pharmacological Interventions
Non-pharmacological interventions can be used in conjunction with medication to help manage breakthrough anxiety. Some options include:
- Cognitive behavioral therapy (CBT), which has been shown to be effective in reducing anxiety 3, 4, 5
- Mindfulness-based intervention, acceptance and commitment therapy, psychodynamic therapy, emotion-focused therapy, and dialectical behavioural therapy, which have been tried but have not proven superior to CBT 4
- Internet and mobile-based interventions, which have comparable efficacy to face-to-face therapy and can be considered as alternatives to in-person therapy 4