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 15-30 mg per day in divided doses (maximum 60 mg/day), with the understanding that full therapeutic effect requires 2-4 weeks. 1

Initial Dosing Strategy

• Begin with 5 mg twice daily as the standard starting dose for most adult patients with GAD 1
• Titrate upward gradually to reach the therapeutic range of 15-30 mg per day, divided into 2-3 doses 1
• The maximum dose is 60 mg per day, typically administered as 20 mg three times daily 2, 1

Critical Counseling Point

• Patients must be explicitly counseled that buspirone requires 2-4 weeks to achieve full anxiolytic effect 2, 1
• This delayed onset is a common pitfall leading to premature discontinuation—unlike benzodiazepines, buspirone does not provide immediate relief 3
• Buspirone is most appropriate for patients who do not demand immediate gratification and can tolerate gradual symptom improvement 3

Dosing Frequency Options

Both twice-daily (BID) and three-times-daily (TID) regimens at 30 mg/day total dose demonstrate equivalent efficacy and safety:

• 15 mg BID offers convenience and potentially better compliance 4, 5
• 10 mg TID is the traditional dosing approach 4, 5
• No clinically meaningful differences exist between these regimens in terms of anxiety reduction or adverse events 4, 5

Special Population Adjustments

Elderly or frail patients:

• Start at lower doses (2.5-5 mg) 1
• Titrate more gradually than in younger adults 1
• Maximum dose for elderly patients with mild-to-moderate agitation is 20 mg three times daily 2

Hepatic or renal impairment:

• Reduce doses and monitor closely due to altered pharmacokinetics 1

Efficacy Profile

• Buspirone demonstrates comparable anxiolytic efficacy to benzodiazepines in controlled trials for GAD 3
• It is particularly appropriate for chronic anxiety, anxious elderly patients, and those with mixed anxiety-depression symptoms 3
• Buspirone is NOT recommended for panic disorder, as studies have been inconclusive 3

Safety Advantages

• No abuse potential, dependence, or withdrawal symptoms reported 6
• Minimal sedation and no psychomotor impairment when combined with alcohol or given alone 6
• Most common adverse effects are headache, dizziness, nervousness, and lightheadedness—all generally mild 6
• Excellent tolerability profile makes it particularly suitable for patients with medical comorbidities 7

Role in Treatment Algorithms

As augmentation therapy:

• When augmenting SSRIs (e.g., citalopram) in patients with major depressive disorder who failed initial treatment, buspirone shows similar efficacy to bupropion augmentation 2
• However, bupropion has lower discontinuation rates due to adverse events compared to buspirone (12.5% vs. 20.6%) 2