What is the recommended treatment and dosage for generalized anxiety disorder (GAD) using Buspar (buspirone)?

Buspirone (Buspar) for Generalized Anxiety Disorder

Start buspirone at 5 mg twice daily and titrate to a target dose of 20-30 mg/day in divided doses (either BID or TID), with a maximum of 60 mg/day if needed. 1

Initial Dosing Strategy

• Begin with 5 mg twice daily as the starting dose 2, 1
• Increase by 5 mg increments every 3-7 days as tolerated 1
• Target an effective dose of 20-30 mg/day in divided doses for most patients with GAD 1
• Maximum dose is 60 mg/day, though most patients respond adequately to 30 mg/day 1, 3

Dosing Frequency Options

Both twice-daily (BID) and three-times-daily (TID) regimens are equally effective:

• 15 mg BID is equivalent to 10 mg TID in efficacy and safety 3, 4
• BID dosing may offer better convenience and compliance without compromising efficacy 4
• No significant differences in anxiety reduction (HAM-A scores) between BID and TID regimens 3
• The only notable difference is a slightly higher incidence of palpitations with BID dosing (5% vs 1%) 4

Timeline for Response

• Expect 2-4 weeks before therapeutic effects become apparent 2
• This delayed onset distinguishes buspirone from benzodiazepines and requires patient counseling 5
• Patients must not expect immediate relief; buspirone provides gradual, sustained anxiety reduction 5

Ideal Patient Population

Buspirone is particularly appropriate for:

• Patients with mild to moderate generalized anxiety disorder 2, 1
• Chronic anxiety requiring long-term treatment 5
• Elderly patients with anxiety 5
• Patients with coexisting mild depressive symptoms (HAM-D scores 12-17) 6
• Patients who cannot tolerate benzodiazepines or have substance abuse concerns 1, 5

Key Advantages Over Benzodiazepines

• No tolerance, dependency, or cognitive impairment 1
• No psychomotor impairment when combined with alcohol 7
• No withdrawal symptoms upon discontinuation 7
• Safe for long-term use 1
• Minimal sedation 7

Common Adverse Effects

The most frequently reported side effects include:

• Dizziness, headache, and nausea (most common) 4
• Nervousness and lightheadedness 7
• Somnolence and sweating (less common) 6
• Amblyopia (more common with BID dosing) 3

Critical Pitfalls to Avoid

Do not use buspirone for panic disorder - studies have been inconclusive, and it is not recommended for routine panic disorder treatment 5

Counsel patients about delayed onset - patients expecting immediate benzodiazepine-like relief will be disappointed and may discontinue prematurely 5

Avoid in patients demanding immediate symptom relief - buspirone works best in patients willing to accept gradual improvement over 2-4 weeks 5

Special Clinical Scenarios

For GAD with coexisting mild depression:

• Buspirone demonstrates superior efficacy over placebo for both anxiety (12.4-point HAM-A reduction) and depressive symptoms (5.7-point HAM-D reduction) 6
• This makes it particularly valuable when mild depressive symptoms accompany GAD 6

Augmentation strategy:

• When augmenting failed SSRI treatment (e.g., citalopram), buspirone shows comparable efficacy to bupropion, though bupropion may reduce depression severity more effectively 2
• Bupropion has lower discontinuation rates due to adverse events compared to buspirone in augmentation scenarios 2