Practical Pharmacotherapy for Anxiety

Anxiety is a very common and disabling condition which has serious consequences for patients, their families and society in general. The past decade has witnessed an increase in the recognition and understanding of the problem but considerable confusion and debate remains over attitudes towards treatment. The background to this controversy dates from the late 1980s when widespread and vehement criticism of doctors and drug companies over the use of benzodiazepines began. Although the litigation was unsuccessful, it resulted in a pervading feeling of uncertainty (both within the medical profession and among patients) about prescribing or taking any drug as a treatment for anxiety. The situation has been further confounded by the split that has occurred between the proponents of pharmacological and psychological approaches to management. These controversies have left the practising clinician in an unenviable position, with few practical or relevant guidelines to follow. Developments over recent years, however, should put an end to this confusion; new pharmacotherapies such as the selective serotonin reuptake inhibitors (SSRIs)and buspirone, and older ones such as the tricyclic antidepressants (TCAs),have emerged as effective alternatives to the benzodiazepines and have been paralleled by a similar growth in effective and available psychological treatments, particularly cognitive and cognitive-behavioural therapy. This progress seems set to continue with the rapid expansion of knowledge about the brain circuits and transmitters regulating anxiety that is now emerging from imaging studies. This paper aims to give clinicians practical advice on the effective pharmacological management of patients with anxiety. Although we will concen trate on psychopharmacological approaches, it is important to realise that optimal treatment involves more than just prescribing medication. The initial interview is crucial; time invested at this stage will reap benefits later. It is very important to take a thorough history and to make the correct diagnosis as this strongly influences the choice of drug. Patients need to be given a careful explan ation of their condition including education about the nature of and the reasons for their anxiety, the likely time course of response, and potential adverse effects. During treatment patients should be seen (at least initially) very frequently (every week or fortnight) for careful monitoring of response and side-effects and for titration of the dose to a therapeutic level. Symptoms should be monitored throughout treatment in a standardised way using self-rating scales of severity, avoidance, etc. There is growing evidence that all these approaches, which have in common the theme of increased patient understanding and compliance, add to drug effects and facilitate recovery. Although there is no perfect categorisation of anxiety disorders, for practical purposes the diagnostic criteriaof DSM-IV(AmericanPsychiatric Association, 1994;Box1)or ICD-10 (World Health Organization, 1992)are generally used. Bothdivide anxiety into a series of sub-syndromes with clear operational criteria to assist in distinguishing each. At any time many patients will have symptoms from more than one syndrome, but eliciting the primary diagnosis is important as this markedly influences the choice of treatment. In this paper we will describe the key features of each anxiety disorder, emphasising important