What are all options for treating anxiety besides benzodiazepines (Benzos)?

From the Guidelines

There are many effective options for treating anxiety besides benzodiazepines, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and non-medication approaches like cognitive behavioral therapy (CBT) and mindfulness meditation, as suggested by recent guidelines 1.

Medication Options

• Selective serotonin reuptake inhibitors (SSRIs) like sertraline (50-200mg daily), escitalopram (10-20mg daily), and fluoxetine (20-80mg daily) are typically first-line medications, taking 2-6 weeks to reach full effectiveness but providing long-term anxiety relief without addiction potential.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (75-225mg daily) and duloxetine (30-120mg daily) work similarly but target both neurotransmitter systems, as recommended by the Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology 1.
• Buspirone (15-60mg daily in divided doses) specifically treats anxiety without sedation or dependence risks.
• For immediate relief, hydroxyzine (25-100mg as needed) provides non-addictive antihistamine-based calming effects.
• Beta-blockers like propranolol (10-40mg as needed) help with physical symptoms like trembling and racing heart.

Non-Medication Approaches

• Cognitive behavioral therapy (CBT) teaches skills to identify and change anxiety-producing thought patterns.
• Mindfulness meditation and regular exercise (30 minutes most days) can help reduce anxiety symptoms.
• Improved sleep hygiene and reducing caffeine and alcohol consumption are also important for managing anxiety.
• The American Society of Clinical Oncology recommends individual or group therapy with CBT, behavioral activation, structured physical activity, and exercise for patients with moderate symptoms of anxiety 1.

Treatment Considerations

• Combination treatment (CBT and an SSRI) may be offered preferentially over monotreatment for patients with social anxiety, generalized anxiety, separation anxiety, or panic disorder, as suggested by the Journal of the American Academy of Child and Adolescent Psychiatry 1.
• Regular follow-up and reassessment are crucial to ensure treatment compliance and effectiveness, and to adjust the treatment plan as needed, as recommended by the Journal of Clinical Oncology 1.

From the FDA Drug Label

The efficacy of sertraline in the treatment of social anxiety disorder (also known as social phobia) was established in two multicenter placebo-controlled studies (Study 1 and 2) of adult outpatients who met DSM-IV criteria for social anxiety disorder The efficacy of sertraline in the treatment of PTSD was established in two 12-week placebo-controlled trials of adult outpatients whose diagnosis met criteria for the DSM-III-R category of PTSD Prozac is indicated for the treatment of panic disorder, with or without agoraphobia, as defined in DSM–IV Prozac is indicated for the treatment of obsessions and compulsions in patients with obsessive compulsive disorder (OCD), as defined in the DSM–III–R

Options for treating anxiety besides benzodiazepines (Benzos) include:

• Sertraline (PO) for social anxiety disorder and PTSD 2, 2
• Fluoxetine (PO) for panic disorder and obsessive compulsive disorder (OCD) 3 These options are based on the efficacy of these medications in treating anxiety disorders as established in placebo-controlled trials. However, the effectiveness of these medications may vary depending on individual patient response and should be periodically reevaluated by a physician.

From the Research

Treatment Options for Anxiety Disorders

Besides benzodiazepines, there are several treatment options for anxiety disorders, including:

• Selective serotonin reuptake inhibitors (SSRIs) such as sertraline, paroxetine, and fluoxetine, which are considered first-line treatment for post-traumatic stress disorder (PTSD) and other anxiety disorders 4, 5, 6
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine, which have been shown to be efficacious and well-tolerated in patients with anxiety disorders 7, 8
• Non-SSRIs such as nefazodone, trazodone, and mirtazapine, which may be considered as second-line treatment for PTSD 4
• Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs), which may be considered as third-line treatment for PTSD due to their significant adverse effects and safety issues 4, 6
• Anticonvulsants such as carbamazepine, valproic acid, topiramate, and gabapentin, which may be considered for patients with co-morbidity of bipolar disorder or impulsivity and anger 4
• Atypical antipsychotics, which may be considered for patients with paranoia or flashbacks, or as an augmenter to SSRIs in refractory cases 4
• Buspirone, a non-benzodiazepine anxiolytic, which may be effective in some patients with anxiety disorders 4, 8

Pharmacotherapy for Anxiety Disorders

Pharmacotherapy for anxiety disorders is effective, with efficacy rates between 60% and 85% 5. The choice of medication depends on the specific anxiety disorder, patient characteristics, and co-morbidities.

Considerations for Treatment

It is essential to consider the potential benefits and risks of each treatment option, as well as the patient's individual needs and preferences. Further research is needed to determine the optimal treatment strategies for anxiety disorders and to develop new and more effective treatments 5, 7, 6.