What medications are used to treat anxiety disorders, borderline personality disorder, schizophrenia, PTSD, and schizoaffective disorder?

Pharmacological Treatment of Psychiatric Disorders

For anxiety disorders, start with SSRIs (escitalopram or sertraline) or SNRIs (duloxetine or venlafaxine); for schizophrenia and schizoaffective disorder, use second-generation antipsychotics as first-line; for borderline personality disorder, prioritize psychotherapy over medications, but SSRIs may help comorbid anxiety/depression; for PTSD, use SSRIs as first-line pharmacotherapy. 1, 2

Anxiety Disorders

First-Line Pharmacotherapy

• SSRIs are the primary first-line medications with escitalopram (10-20 mg/day) and sertraline (50-200 mg/day) having the most favorable safety profiles 1, 2
• Start escitalopram at 5-10 mg daily and titrate by 5-10 mg increments every 1-2 weeks; start sertraline at 25-50 mg daily and titrate by 25-50 mg increments every 1-2 weeks 1
• SNRIs are equally effective alternatives: duloxetine (60-120 mg/day) or venlafaxine extended-release (75-225 mg/day) 1, 2
• Venlafaxine requires blood pressure monitoring due to risk of sustained hypertension 1, 2

Response Timeline and Monitoring

• Statistically significant improvement begins by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later 1
• Common side effects include nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, and somnolence, typically emerging within the first few weeks 1
• Avoid paroxetine as first-line due to higher risk of discontinuation syndrome and potentially increased suicidal thinking 1, 2

Second-Line Options

• Pregabalin or gabapentin when first-line treatments fail or are not tolerated, particularly useful for comorbid pain conditions 1
• Benzodiazepines (alprazolam, clonazepam) are second-line only, use lowest effective doses with shorter half-lives, especially in elderly patients 2
• Beta blockers (atenolol, propranolol) are not recommended based on negative evidence 2

Treatment Algorithm

• If first SSRI fails after 8-12 weeks at therapeutic doses, switch to a different SSRI or SNRI 1
• Combine with cognitive behavioral therapy (CBT) for optimal outcomes, with 12-20 structured sessions 1, 2
• Continue treatment for at least 6-12 months after symptom remission 2
• Taper medications gradually to avoid discontinuation syndrome, particularly with shorter half-life SSRIs 1

Schizophrenia

Pharmacotherapy

• Second-generation antipsychotics are first-line treatment for schizophrenia 3
• Aripiprazole and risperidone may be efficacious for comorbid obsessive-compulsive and social anxiety symptoms in schizophrenia patients 4
• Quetiapine and olanzapine may help comorbid generalized anxiety symptoms 4
• For comorbid anxiety in schizophrenia, consider SSRI augmentation of antipsychotics, though caution is needed regarding cytochrome P450 interactions and QTc prolongation 4
• Buspirone and pregabalin augmentation are alternative options for anxiety symptoms 4

Clinical Considerations

• Anxiety symptoms occur in up to 65% of schizophrenia patients, with up to 38% meeting criteria for an anxiety disorder 4
• Assess anxiety after resolution of acute psychotic phase for better diagnostic yield 4
• Anxiety in schizophrenia is associated with increased depression, suicidality, and medical service utilization 4

Schizoaffective Disorder

Pharmacotherapy

• Olanzapine is FDA-approved for bipolar I disorder (manic or mixed episodes), which shares features with schizoaffective disorder 5
• Olanzapine monotherapy: 5-20 mg/day, starting at 10-15 mg/day, demonstrated superiority over placebo in reducing manic symptoms 5
• Olanzapine as adjunct to lithium or valproate (5-20 mg/day, starting at 10 mg/day) was superior to mood stabilizers alone 5
• Anxiety symptoms are common in schizoaffective disorder, with 40.2% reporting frequent or constant anxiety 6

Treatment Approach

• Treat underlying psychotic and mood symptoms with appropriate antipsychotics and mood stabilizers 5
• Address comorbid anxiety with SSRIs if needed, following similar principles as schizophrenia 4
• Anxiety symptoms in schizoaffective disorder are strongly related to concurrent depressive symptoms and personality characteristics 6

Borderline Personality Disorder (BPD)

Treatment Priorities

• Psychotherapy is the primary treatment for BPD; pharmacotherapy is adjunctive only 3
• No medications are FDA-approved specifically for BPD 3
• SSRIs may help comorbid anxiety and depressive symptoms, which are common in BPD 7

Comorbid Anxiety Management

• BPD improvement predicts remission of generalized anxiety disorder and PTSD, suggesting prioritizing BPD treatment when these conditions coexist 7
• For GAD and social phobia comorbid with BPD, prioritize BPD treatment as BPD course unidirectionally influences these anxiety disorders 7
• For panic disorders, OCD, or PTSD with BPD, treat both conditions concurrently 7
• Worsening PTSD predicts BPD relapse, requiring concurrent treatment 7

Clinical Pitfalls

• BPD patients in first-episode psychosis settings show higher drop-out rates and improvement limited to the first year of treatment 8
• BPD patients have higher rates of substance use and past suicide attempts, requiring careful monitoring 8
• Avoid polypharmacy without clear rationale; medication combinations should target specific comorbid disorders 3

Post-Traumatic Stress Disorder (PTSD)

Pharmacotherapy

• SSRIs are first-line medications for PTSD: escitalopram (10-20 mg/day) or sertraline (50-200 mg/day) 1, 2
• Start with low doses and titrate gradually over 1-2 weeks to minimize initial anxiety/agitation 1
• SNRIs (venlafaxine 75-225 mg/day) are equally effective alternatives 2

Treatment Considerations

• Combine medication with trauma-focused CBT for optimal outcomes 1, 2
• PTSD commonly co-occurs with BPD (88 of 164 BPD patients in one study had comorbid PTSD) 7
• When PTSD and BPD coexist, treat both concurrently as they reciprocally influence each other's course 7
• Continue treatment for at least 6-12 months after symptom remission 2

Monitoring

• Assess response using standardized rating scales 1
• Monitor for suicidal thinking, especially in first months and after dose adjustments 1
• Watch for common SSRI/SNRI side effects: nausea, sexual dysfunction, headache, insomnia 1

Critical Warnings Across All Conditions

• Avoid tricyclic antidepressants due to unfavorable risk-benefit profile, particularly cardiac toxicity 1
• Monitor for suicidal ideation, especially during initial treatment and dose changes (NNH = 143 for SSRIs) 1
• Taper all medications gradually to prevent discontinuation syndrome 1, 2
• Reassess diagnosis if inadequate response after adequate trial (appropriate dose, duration, adherence) 3
• Distinguish medication-responsive symptoms from behavioral reactions to psychosocial stressors 3