What about the use of buspirone (an anxiolytic medication) for patients with generalized anxiety disorder (GAD) not responding to sertraline (selective serotonin reuptake inhibitor, SSRI)?

Buspirone for GAD Patients Not Responding to Sertraline

For patients with generalized anxiety disorder (GAD) not responding to sertraline, buspirone is an effective augmentation strategy, though bupropion may be preferred due to greater reduction in symptom severity and lower discontinuation rates due to adverse events.

Efficacy of Buspirone in GAD

Buspirone is FDA-approved for the management of anxiety disorder or short-term relief of anxiety symptoms. Its efficacy has been demonstrated in controlled clinical trials of outpatients with diagnoses corresponding to Generalized Anxiety Disorder (GAD), including those with coexisting depressive symptoms 1.

Mechanism and Benefits

• Buspirone acts primarily on 5-HT1A serotonin receptors, offering an anxiolytic effect without the sedative properties of benzodiazepines 2
• Unlike benzodiazepines, buspirone:
  • Does not produce physical dependence
  • Does not interact with alcohol
  • Does not cause psychomotor impairment 3

Augmentation Strategies for SSRI Non-responders

When patients fail to respond adequately to sertraline (an SSRI), several augmentation options exist:

Buspirone vs. Bupropion Augmentation

• Low-quality evidence shows no difference in response or remission rates when augmenting citalopram with buspirone compared to bupropion 4
• However, bupropion decreases depression severity more effectively than buspirone augmentation 4
• Moderate-quality evidence indicates that discontinuation due to adverse events is lower with bupropion than with buspirone (12.5% vs. 20.6%) 4, 5

Buspirone vs. Cognitive Therapy Augmentation

• Low-quality evidence shows no difference in response, remission, or depression severity when augmenting citalopram with buspirone versus cognitive therapy 4
• Numerically, more participants in medication groups discontinued due to adverse events compared to cognitive therapy (18.8% vs. 9.2%) 4

Practical Considerations for Buspirone Use

Dosing and Administration

• Starting dose should be lower and gradually titrated
• Typical effective doses range from 15-60 mg daily in divided doses
• Allow 2-4 weeks for full therapeutic effect to develop

Monitoring

• Regular follow-up is essential to assess response and adverse effects
• Monitor for common side effects including:
  • Dizziness
  • Headache
  • Nausea
  • Nervousness
  • Lightheadedness

Limitations

• The effectiveness of buspirone in long-term use (beyond 3-4 weeks) has not been demonstrated in controlled trials 1
• Physicians using buspirone for extended periods should periodically reassess its usefulness 1
• Buspirone may be less effective in patients previously treated with benzodiazepines 6

Alternative Options

If buspirone augmentation is ineffective or not tolerated, consider:

1. Switching to another SSRI or SNRI
2. Augmentation with bupropion (preferred over buspirone based on evidence) 5
3. Cognitive therapy augmentation (similar efficacy to medication augmentation with fewer side effects) 4
4. For adult patients with GAD, SNRIs represent another first-line treatment option 7

Conclusion

While buspirone is an effective option for GAD patients not responding to sertraline, evidence suggests bupropion may be a superior augmentation strategy due to greater reduction in symptom severity and fewer discontinuations due to adverse events. Cognitive therapy represents an equally effective non-pharmacological alternative with potentially fewer side effects.