What are the American Psychiatric guidelines for pharmacotherapy in anxiety, depression, and bipolar disorder?

American Psychiatric Guidelines for Pharmacotherapy in Anxiety, Depression, and Bipolar Disorder

Depression Pharmacotherapy

For major depressive disorder, select second-generation antidepressants (SSRIs, SNRIs) based on adverse effect profiles, cost, and patient preferences, as no single agent demonstrates superior efficacy over others. 1

Initial Treatment Selection

• All second-generation antidepressants show equivalent efficacy for treating major depression, with no differences based on age, sex, or race/ethnicity 1
• Choice should prioritize:
  • Adverse effect profiles: Bupropion has lower sexual dysfunction rates than fluoxetine or sertraline; paroxetine has higher sexual dysfunction rates than fluoxetine, fluvoxamine, nefazodone, or sertraline 1
  • Cost considerations and patient medication history 1
  • SSRIs carry increased suicide attempt risk compared to placebo, requiring close monitoring 1

Monitoring and Treatment Adjustment

• Begin monitoring within 1-2 weeks of initiation for suicidal thoughts, agitation, irritability, or behavioral changes 1
• Modify treatment if inadequate response by 6-8 weeks, as 38% of patients fail to respond and 54% fail to achieve remission during initial treatment 1
• Continue regular assessment of therapeutic response and adverse effects throughout treatment 1

Treatment Duration

• Continue for 4-9 months after satisfactory response in first-episode depression 1
• Extend duration beyond 9 months for patients with two or more prior episodes, as relapse risk remains elevated 1

Depression with Comorbid Anxiety

• SSRIs and SNRIs are equally effective for treating depression with accompanying anxiety symptoms 1
• Fluoxetine, paroxetine, and sertraline show no efficacy differences in anxious depression 1, 2
• Treat depression first when both conditions coexist, as 50-60% of depressed patients have comorbid anxiety disorders 1
• Limited evidence suggests venlafaxine may be superior to fluoxetine specifically for anxiety symptoms 1

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Anxiety Disorder Pharmacotherapy

SSRIs and SNRIs are recommended as first-line pharmacotherapy for generalized anxiety disorder and social anxiety disorder. 1, 3, 4

Generalized Anxiety Disorder (GAD)

• Duloxetine and escitalopram demonstrate the best efficacy among first-line agents, with weighted mean differences in Hamilton Anxiety Scale scores of -3.2 for escitalopram 4
• All agents except fluoxetine and vortioxetine show superior efficacy to placebo 4
• Vortioxetine shows better acceptability but lower efficacy, making it suitable when tolerability is the primary concern 4
• Multiple drug classes are effective: benzodiazepines, azapirones, SSRIs, SNRIs, antihistamines, alpha-2-delta calcium channel modulators, and atypical antipsychotics 3

Social Anxiety Disorder

• Fluvoxamine, paroxetine, and escitalopram are FDA-approved and covered by insurance for social anxiety disorder in adults over 18 years 1
• Cognitive behavioral therapy (CBT) is also available as insured psychotherapy, delivered by physicians or in physician-nurse collaboration 1
• Treatment choice depends on symptom severity, functional impairment, risk factors, prior treatment response, and patient preference 1

Treatment Considerations

• GAD is a chronic illness requiring long-term treatment; remission can take several months, and stopping medication within the first year increases relapse risk 3
• Consider comorbid conditions: depression, substance abuse, social anxiety, and panic disorder commonly co-occur with GAD 3
• Use antidepressants rather than benzodiazepines when significant depression is present 3

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Bipolar Disorder Pharmacotherapy

For bipolar mania in well-defined DSM-IV-TR Bipolar I Disorder, pharmacotherapy is the primary treatment, with lithium, valproate, and atypical antipsychotics as standard therapy. 1

Acute Mania Treatment

• Lithium is FDA-approved for ages 12 and older for acute mania and maintenance therapy 1
• Atypical antipsychotics approved for acute mania in adults include aripiprazole, valproate, olanzapine, risperidone, quetiapine, and ziprasidone 1
• Begin with an FDA-approved agent, selecting based on:
  • Evidence of efficacy for the specific illness phase 1
  • Presence of rapid cycling or psychotic symptoms 1
  • Side effect profile and safety considerations 1
  • Patient and family history of medication response 1
  • Ethnic pharmacokinetic variations that may affect blood levels and efficacy 1

Maintenance and Depression Treatment

• Lamotrigine and olanzapine are approved for maintenance therapy in adults 1
• Olanzapine-fluoxetine combination is approved for bipolar depression in adults 1
• Carbamazepine and antipsychotics have supporting evidence from adult studies 1
• Gabapentin and topiramate lack controlled evidence for efficacy 1

Antidepressant Use in Bipolar Disorder

• Antidepressants are NOT recommended as monotherapy for bipolar depression, as they can induce manic switching 5
• Use SSRIs or non-tricyclic antidepressants only as adjuncts with at least one mood stabilizer already in place 1
• Manic episodes precipitated by antidepressants are classified as substance-induced per DSM-IV-TR 1

Anxiety in Bipolar Disorder

• Treat mood episodes first; nonspecific anxiety improves with mood stabilization 6
• Divalproex may be the mood stabilizer of choice for anxious bipolar patients 6
• For anxiety disorders occurring outside acute mood episodes, use psychotherapy, benzodiazepines, or certain atypical antipsychotics to reduce risk of manic induction 6
• Risperidone monotherapy did not separate from placebo; olanzapine was superior to lamotrigine when augmenting lithium 6

Critical Warnings

• Clozapine is reserved for treatment-refractory cases only due to its adverse effect profile and should only be used when diagnosis is well-established 1
• Benzodiazepines may cause disinhibition in younger children despite utility for acute agitation and sleep disturbance 1
• Bipolar depression carries greater suicide risk and functional impairment than mania, requiring aggressive early management 5