What is the best treatment option for a 26-year-old male with anxiety and panic attacks who does not want to use Selective Serotonin Reuptake Inhibitors (SSRIs) and prefers a non-controlled substance, given his past adverse experience with SSRIs?

Best Non-SSRI, Non-Controlled Medication Options for Anxiety with Panic Attacks

Buspirone is the best non-SSRI, non-controlled medication option for a 26-year-old male with anxiety and panic attacks who had negative experiences with SSRIs. 1

First-Line Treatment Option: Buspirone

Buspirone offers several advantages for this specific patient:

• Non-SSRI mechanism: Acts on serotonin receptors differently than SSRIs, avoiding the side effects the patient previously experienced 1
• Non-controlled substance: Not scheduled as a controlled substance, addressing the patient's preference
• FDA-approved: Specifically indicated for anxiety disorders
• Dosing regimen:
  • Starting dose: 15 mg daily (7.5 mg twice daily)
  • Titration: Increase by 5 mg every 2-3 days as needed
  • Target dose: 20-30 mg daily (divided doses)
  • Maximum dose: 60 mg daily 1

Side Effect Profile

• Common side effects: Dizziness (12%), nausea (8%), headache (6%), nervousness (5%) 1
• Less common: Drowsiness, lightheadedness, excitement
• Advantages over SSRIs: Less sexual dysfunction, less risk of withdrawal symptoms 2

Alternative Option: Cognitive Behavioral Therapy (CBT)

CBT is strongly recommended as either a standalone treatment or in combination with medication:

• Structured approach: 10-20 sessions focusing on exposure to anxiety-provoking situations 3
• Evidence-based: Highly effective for anxiety disorders including panic disorder 3
• Implementation: Individual therapy is superior to group therapy in terms of clinical effectiveness 4
• Self-help option: If the patient doesn't want face-to-face CBT, self-help with support based on CBT is suggested 4

Other Medication Options to Consider

Pregabalin

• Has robust evidence for anxiety disorders
• Rapidly reduces anxiety with a safe side effect profile
• Low potential for abuse 2

SNRIs (if willing to try another antidepressant class)

• Venlafaxine has shown efficacy for anxiety disorders
• Different side effect profile than SSRIs 3, 5

Treatment Algorithm

1. Start with buspirone:

   • Begin at 15 mg/day (7.5 mg twice daily)
   • Take consistently with regard to food (either always with or always without)
   • Titrate up by 5 mg every 2-3 days as needed
   • Target dose: 20-30 mg/day in divided doses

2. Monitor response:

   • Allow 2-4 weeks to assess initial efficacy
   • Full benefits may take 4-6 weeks to develop

3. Add or switch to CBT if:

   • Buspirone is not sufficiently effective after adequate trial
   • Side effects are problematic
   • Patient is interested in developing coping skills

4. Consider pregabalin if buspirone is ineffective after adequate trial

Important Considerations

• Avoid abrupt discontinuation of any anxiety medication
• Medication consistency: Take buspirone consistently with regard to food (either always with or always without meals) 1
• Drug interactions: Avoid combining with MAOIs; at least 14 days should elapse between discontinuing an MAOI and starting buspirone 1
• Regular exercise, adequate sleep, and stress management techniques are recommended as adjuncts to pharmacotherapy 3

Caution

While benzodiazepines are effective for short-term anxiety relief, they are controlled substances and can lead to dependence, so they should be avoided given the patient's preferences 6, 5. SSRIs remain first-line for many anxiety disorders but are not appropriate for this patient given his past negative experience 3.