What are the non-sedating treatment options for anxiety?

Non-Sedating Treatment Options for Anxiety

Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are the recommended first-line pharmacological treatments for anxiety disorders due to their efficacy and non-sedating properties.

First-Line Pharmacological Options

SSRIs

SSRIs are the most extensively studied medications for anxiety disorders with strong evidence supporting their efficacy:

• Sertraline (Zoloft)

  • Starting dose: 25-50 mg daily
  • Target dose: Up to 200 mg daily
  • Common side effects: Nausea, diarrhea, headache, insomnia, sexual dysfunction 1
  • Advantages: Low potential for pharmacokinetic drug interactions, not a potent inhibitor of cytochrome P450 isoenzyme systems 2

• Fluoxetine (Prozac)

  • Starting dose: 10-20 mg daily
  • Target dose: 20-60 mg daily
  • Common side effects: Nausea, decreased energy, somnolence, fatigue, decreased libido, sweating 1, 3

• Escitalopram

  • Dose: 10-20 mg daily
  • Common side effects: Dry mouth, nausea, diarrhea, headache, somnolence, insomnia, dizziness 1

SNRIs

• Venlafaxine
  • Recommended as an alternative first-line option 4
  • Note: May be associated with greater suicide risk than other SNRIs and discontinuation symptoms 4

First-Line Non-Pharmacological Option

Cognitive Behavioral Therapy (CBT)

• Recommended as first-line psychological treatment for anxiety disorders 4, 1
• Specific models:
  • Clark and Wells model
  • Heimberg model
• Individual therapy is preferred over group therapy due to superior clinical and economic effectiveness 4
• Self-help with support based on CBT is suggested for patients who don't want face-to-face CBT 4

Second-Line Pharmacological Options

Other Non-Sedating Options

• Pregabalin
  • Considered a first-line option for anxiety disorders 1
• Buspirone
  • Recommended as an augmentation strategy for patients with partial response to antidepressants 1
• Gabapentin
  • May be considered as a second-line option 1

Treatment Duration and Monitoring

• Schedule follow-up within 1-2 weeks of starting medication to assess initial response 1
• Continue regular monitoring during dose titration 1
• Effective treatment should be continued for approximately 1 year following symptom remission 1
• Patients with 2 or more episodes of anxiety may benefit from longer duration of therapy 1
• For discontinuation, medication should be reduced gradually (no more than 25% every 1-2 weeks) to minimize withdrawal symptoms 1

Special Considerations

Combination Therapy

• There is no definitive recommendation for combined pharmacotherapy and psychotherapy for social anxiety disorder in adults 4
• However, combination treatment (CBT and an SSRI) could be offered for moderate to severe anxiety disorders 1

Lifestyle Modifications

• Structured physical activity and exercise show benefit for anxiety reduction 1
• Omega-3 fatty acids (1-2g daily of EPA) have evidence for treating anxiety disorders 1

Avoiding Sedating Options

• Benzodiazepines are not recommended for routine use due to:
  • Risk of dependence
  • Sedating effects
  • Potential to worsen anxiety long-term 5
  • If used, should be limited to short-term use with gradual tapering (25% reduction every 1-2 weeks) 1

Treatment Algorithm

1. First step: Start with either an SSRI (sertraline, fluoxetine, escitalopram) or CBT
2. If partial response: Consider augmentation strategies (buspirone) or switching to an SNRI
3. If inadequate response: Consider pregabalin or gabapentin
4. For maintenance: Continue effective treatment for at least one year after symptom remission

Remember that anxiety disorders are often chronic conditions requiring long-term management, and abrupt discontinuation of medications should be avoided to prevent withdrawal symptoms.