Adjunctive Treatment for Anxiety
Add exercise or mind-body practices (tai chi, yoga, qigong) as adjunctive treatment for anxiety symptoms, as these interventions have guideline support with favorable safety profiles. 1
Evidence-Based Adjunctive Options
Exercise and Mind-Body Interventions (Recommended)
- Exercise as adjunctive treatment is recommended for anxiety symptoms with a weak-for recommendation from the 2024 VA/DoD guidelines 1
- Mind-body exercises (tai chi, yoga, qigong) are specifically suggested as adjunctive treatment for anxiety symptoms, also with weak-for recommendation 1
- These interventions carry minimal risk and can be implemented alongside pharmacotherapy or psychotherapy without significant drug interactions or adverse effects 1
Benzodiazepines (Use with Caution)
- Short-term adjunctive benzodiazepines may be used for acute stabilization in anxiety disorders, but only with significant caution regarding abuse potential, dependence risk, and cognitive impairment 2
- Alprazolam can be initiated at 0.25-0.5 mg three times daily for anxiety, with maximum daily dose of 4 mg in divided doses, but the lowest effective dose should be employed and need for continued treatment reassessed frequently 3
- Benzodiazepines should be time-limited due to increased risk of abuse, dependence, and cognitive impairment, and are not recommended for routine use 2, 4
- Abrupt discontinuation must be avoided; taper by no more than 0.5 mg every 3 days when discontinuing 3
Hydroxyzine (Alternative Option)
- Hydroxyzine 50-100 mg four times daily can be used for symptomatic relief of anxiety and tension associated with psychoneurosis and as an adjunct in organic disease states where anxiety is manifested 5
- This represents a non-benzodiazepine alternative with lower abuse potential 5
What NOT to Add
Insufficient Evidence
- There is insufficient evidence to recommend for or against acupuncture as an adjunct to pharmacotherapy for anxiety 1
- Atypical antipsychotics carry significant metabolic risks and should be reserved only for approved indications where risk-benefit ratio is favorable, not as routine adjuncts for anxiety 2
Contraindicated Approaches
- Psychological debriefing should NOT be used for people with recent traumatic events, as controlled trials show it does not prevent chronic stress reactions and may be ineffective 6
Critical Clinical Considerations
Rule Out Medical Causes First
- Medical causes of anxiety must be ruled out before initiating anxiolytic treatment, including unrelieved pain, fatigue, delirium, infection, or electrolyte imbalance 2
- This is a common pitfall that leads to inappropriate treatment escalation when the underlying cause is physiologic rather than psychiatric 2
Context-Specific Recommendations
- For post-stroke anxiety specifically, exercise and mind-body exercises have the strongest adjunctive evidence 1
- For cancer-related anxiety, supportive care services and psychosocial group interventions led by licensed mental health professionals should be considered as adjuncts 1
- In children and adolescents, family-directed interventions that improve parent-child relationships and reduce parental anxiety often supplement individual treatment 1