Buspirone - a glorified placebo?

[thelastpsych]

So, I know this question has come up many times before, but I was actually courious to know other psychiatrists opinion on augmentation for GAD after SSRIs/CBT.

Sometimes, my patients still get residual symtomps that affect their quality of life, like insomnia or irritability even with behavioral interventions like sleep hygiene, and even after CBT and max-dose SSRIs. In these cases, if the patient had a good response to the SSRI for their anxiety, I'm always inclined to augment with a second agent instead of switching; although I've had some patients respond very well to the switch to SNRIs (but most report more severe side effects, as expected) . Other options that I've seen include:
1) Buspirone - most patients that use this drug report no effect (good or bad) at all, either solo or with an SSRI. It almost seems like a placebo pill taken three times a day, but I'm not that experienced with this drug, so would love comments on that;
2) Quetiapine - not that good for sleep, can cause alterations in metabolic parameters even in lower doses;
3) Pregabalin - some patients report sleepiness, and weight gain, but it seems like an effective drug in my experience;
4) Benzos - oh god no, I use it at most in the first month in panic attacks before the SSRIs kick in

Are there any other options that you guys use? Am I missing something?

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[Sushirolls]

Buspar = placebo at best, typically not even that.
*Rarely there are a few people it is a miracle cure. I've seen like 2-3 over the years.
*I don't even prescribe buspar, I'll continue it, if patients are attached to it.

 

[Celexa]

I've actually had reasonable success with buspirone used adjunctive with SSRI or on its own. I dose bid bc tid adherence is very low so why bother. Is it placebo? Maybe. Maybe everything we do is placebo in the end. It's a fairly benign one at least.

However, if pt is reporting "anxiety" that isn't getting better, you need to dig VERY DEEP into what exactly they mean. Where when why how who and exactly what physical symptoms and cognitions. Also have to examine if they actually failed good CBT or the therapist was patting them on the head and sympathizing with how hard life is.

 

[mistafab]

Buspirone does work. Even on its own. People just don’t uptitrate appropriately. It seems to work better for “worry” based anxiety compared to fear based anxiety. I don’t see much effect until people are up to around 45 mg total daily dose. Once uptitrated, you can switch it to BID dosing.

Sertraline would look like a placebo also if we stopped dosing past 25-50. This is what most providers do with buspirone.

 

[thelastpsych]

Buspirone does work. Even on its own. People just don’t uptitrate appropriately. It seems to work better for “worry” based anxiety compared to fear based anxiety. I don’t see much effect until people are up to around 45 mg total daily dose. Once uptitrated, you can switch it to BID dosing.

Interesting, I've always been told that max dose is 30mg daily (10mg tid) - never used it at higher doses, or twice a day. Will consider it, since it doesn't seem to have many side effects anyways.

 

[Celexa]

Also just in general I have gotten more and more cautious with GAD. I think it is extremely overdiagnosed and often correcting the diagnosis points to different treatment options.

 

[thelastpsych]

Also just in general I have gotten more and more cautious with GAD. I think it is extremely overdiagnosed and often correcting the diagnosis points to different treatment options.

Yes, GAD seems like a catch-all construct for chronic angst: i've seen complex PTSD, adjustment disorders, comorbid depression, OCDs all treated as generalized anxiety. Patients sometimes can't describe well when their symptoms began, and I've noted my impulse to just call it GAD because of time constraints sometimes.

 

[MacDonaldTriad]

Buspirone seems to be the drug that is in search of an illness. Its only indication is GAD and it has failed to work on all other anxiety disorders, but its off label use is broad. STAR-D showed that it tied C3 and LiCo3 as an augmentation strategy, but that is faint praise as nothing worked that well. I think it has a small place. It is under dosed in general and works on GAD but not much else.

 

[forchinet121]

So, I know this question has come up many times before, but I was actually courious to know other psychiatrists opinion on augmentation for GAD after SSRIs/CBT.

Sometimes, my patients still get residual symtomps that affect their quality of life, like insomnia or irritability even with behavioral interventions like sleep hygiene, and even after CBT and max-dose SSRIs. In these cases, if the patient had a good response to the SSRI for their anxiety, I'm always inclined to augment with a second agent instead of switching; although I've had some patients respond very well to the switch to SNRIs (but most report more severe side effects, as expected) . Other options that I've seen include:
1) Buspirone - most patients that use this drug report no effect (good or bad) at all, either solo or with an SSRI. It almost seems like a placebo pill taken three times a day, but I'm not that experienced with this drug, so would love comments on that;
2) Quetiapine - not that good for sleep, can cause alterations in metabolic parameters even in lower doses;
3) Pregabalin - some patients report sleepiness, and weight gain, but it seems like an effective drug in my experience;
4) Benzos - oh god no, I use it at most in the first month in panic attacks before the SSRIs kick in

Are there any other options that you guys use? Am I missing something?

Stard says buspar works, also seroquel is definitely good for sleep in my experience

 

[thelastpsych]

Stard says buspar works, also seroquel is definitely good for sleep in my experience

I've had mixed results, with most patients reporting poor sleep quality and sleepiness/dizziness during the day. From what I've gathered, it's not recommended for insomnia as well (Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis - PubMed), but I might be wrong, as some psychiatrist love low-dose antipsychotics for insomnia.

 

[smalltownpsych]

My observation is that buspar doesn’t work when patient compares it to a benzo. I also dampen down their expectations and talk about how histamines can be part of a nervous system response and that some physiological symptoms of anxiety like itchiness or restlessness might be helped but overthinking and rumination, not so much. I might be wrong about some of that physiological stuff though. I also talk to patients about how certain beta blockers can help by lowering physiological sense of anxiety such as racing heart.

 

[Stagg737]

Interesting, I've always been told that max dose is 30mg daily (10mg tid) - never used it at higher doses, or twice a day. Will consider it, since it doesn't seem to have many side effects anyways.

What? No, that’s what I consider minimal therapeutic dose. Max dose per FDA guidelines is 60mg daily, but I’ve encountered patients taking up to 90mg.

It’s definitely hit or miss in my experience, but imo it works great for some patients. I had the view that it was mostly a low risk placebo early in residency, but after outpatient year in residency my view changed significantly.

 

[Celexa]

My observation is that buspar doesn’t work when patient compares it to a benzo. I also dampen down their expectations and talk about how histamines can be part of a nervous system response and that some physiological symptoms of anxiety like itchiness or restlessness might be helped but overthinking and rumination, not so much. I might be wrong about some of that physiological stuff though. I also talk to patients about how certain beta blockers can help by lowering physiological sense of anxiety such as racing heart.

My spiel about beta blockers and alpha-targeting meds (clonidine, prazosin) includes specifically discussing the "fight or flight" response and I find that patients respond very well to that language.

 

[annoyedpsychiatrist]

It has very specific use, most sources report that it is effective. When used, i use it primary as adjunctive treatment for anxiety. I also only do BID to improve compliance.

Personally, I like the medication and find it effective. It needs to be dosed right and titrated correctly, and you need to understand the goal of treatment with it. Maybe someone had 50% response with prozac and the response leveled out after a dose increase, then buspirone is perfectly reasonable as add on therapy. Its also safe and generally well tolerated. Realistically there isnt many add on therapies for anxiety. Remeron add on for anxiety doesnt work that great and causes a good bit of weight gain, which isnt ideal for most of my patients. Though i do use remeron frequently under the right circumstances but thats another story. Gabapentin ive had minimal success with. Propanolol ive had success with under the right circumstances/type of anxiety. Etc. Generally I do whatever I can to avoid benzos and prefer only to use small amounts of benzos in panic disorder.

In my opinion, anxiety can be harder to treat because often the anxiety is a result of a normal reaction related to the person's environment, secondary/exacerbated by a personality disorder, comorbid substance use, or a result of automatic thoughts/catastrophic thinking/etc which would have you think CBT may be a better option. Often people will max out on GAD-7 and you look at them objectively and they look more laid back than the psychiatrist, similiar to how sometimes people misinterpret pain severity.

 

[Merovinge]

I had the same evolution. Worked with excellent psychiatrists who saw it as placebo, had very negative view of the medication. Used it more and found some people responded. Even small improvements are often worth it given the very good safety profile. Agree on always BID, TID in some patients, and needs to be dosed assertively. I start teenagers on 10mg BID and rarely have any problems with that relatively assertive starting dose (rare fatigue or dizziness).

My patients have almost never had benzos (as a CAP), but had always heard that essentially no people on chronic benzos will find the mild longterm improvements of Buspar as helpful. Not sure that's actually true however, feels like propagated clinical lore. I would try anything and everything to get someone off long-term benzos, even if it's high dose SSRI + Buspar +propranolol +gabapentin. I would rather have 4 safe long term meds than play the benzo game.

 

[Sushirolls]

Surprised y'all seeing patient tolerate. My clinical experiences show more side effects and intolerance, which further shaped my less enthusiastic view of it and avoidance.

 

[comp1]

The dosing schedule is nice for patients who really like to take a pill and perceive pills as a form of the doctor recognizing their suffering...

 

[annoyedpsychiatrist]

Surprised y'all seeing patient tolerate. My clinical experiences show more side effects and intolerance, which further shaped my less enthusiastic view of it and avoidance.

tbh i would argue its more tolerable than ssris and snris. Sometimes people get dizzy or sedation but thats all i really see every now and then.

I agree if someone has been on chronic benzos, they will be less enthused with buspirone. But this is because their expectation is to just destroy any negative feelings they have rather than work through feelings.

 

[Celexa]

The dosing schedule is nice for patients who really like to take a pill and perceive pills as a form of the doctor recognizing their suffering...

But at TID that rapidly becomes maladaptive. If their distress is so acute that taking a pill in the middle of the day, every day, is perceived as helpful, the next thing they'll need is four times a day, and a dose increase, and, and, and....it takes them in the opposite direction from living a functional life. And if they don't need that, then they will miss most of those middle of the day doses as shown in adherence studies.

 

[comp1]

Sorry, I was definitely being sarcastic. Yes, tid dosing in general is maladaptive.

 

[thelastpsych]

But at TID that rapidly becomes maladaptive. If their distress is so acute that taking a pill in the middle of the day, every day, is perceived as helpful, the next thing they'll need is four times a day, and a dose increase, and, and, and....it takes them in the opposite direction from living a functional life. And if they don't need that, then they will miss most of those middle of the day doses as shown in adherence studies.

Very true, and even more maladaptive when it comes to benzos, as there is the physiological dependence, and the psychological one as well . I've inherited patients with enourmous daily doses of alprazolam/diazepam, and it is sometimes a nightmare to convince them to come off from it and deal with their anxiety in more adaptative ways.

 

[Sushirolls]

Very true, and even more maladaptive when it comes to benzos, as there is the physiological dependence, and the psychological one as well . I've inherited patients with enourmous daily doses of alprazolam/diazepam, and it is sometimes a nightmare to convince them to come off from it and deal with their anxiety in more adaptative ways.

Don't give the option. This is happening, and then stick to it. Let patients know they can seek care elsewhere if truly dissatisfied, but the taper is now taking place. You run short, you're cut off and get a fast taper in hospital. Or you start getting daily or weekly or QOD dispensing from the pharmacy....

 

[clausewitz2]

Yes, GAD seems like a catch-all construct for chronic angst: i've seen complex PTSD, adjustment disorders, comorbid depression, OCDs all treated as generalized anxiety. Patients sometimes can't describe well when their symptoms began, and I've noted my impulse to just call it GAD because of time constraints sometimes.

Against the Stream: Generalised anxiety disorder (GAD) – a redundant diagnosis | BJPsych Bulletin | Cambridge Core

Against the Stream: Generalised anxiety disorder (GAD) – a redundant diagnosis - Volume 42 Issue 2

www.cambridge.org

 

[aim-agm]

I came into residency thinking buspirone would be useless, but I've tried it a lot and it has worked well the significant majority of the time. I'd say it's typically worthwhile to try based on the risk:reward, particularly because the former is so low (just don't go up too fast).

I recommend aiming for 20 or 30 mg BID from the get go, e.g. start at 5 or 7.5 BID and instruct the patient to increase by that increment every week so when you follow-up in a month they are on an effective dose.

 

[Stagg737]

I came into residency thinking buspirone would be useless, but I've tried it a lot and it has worked well the significant majority of the time. I'd say it's typically worthwhile to try based on the risk:reward, particularly because the former is so low (just don't go up too fast).

I recommend aiming for 20 or 30 mg BID from the get go, e.g. start at 5 or 7.5 BID and instruct the patient to increase by that increment every week so when you follow-up in a month they are on an effective dose.

This is what I generally do. Unless there’s a reason to start lower I go 7.5 BID and tell them to double it in 1-2 weeks if they tolerate it. I’d say 80% or more do fine with that. It also allows them to just use the 15 mg tabs. KISS.

For BID vs TID, imo TID+ dosing is for people with evidence of being (ultra)/rapid metabolizers or those who have had gastric surgeries or some other malabsorption condition. If there’s not a medical/physiologic reason to dose more frequently than BID, I don’t do it.

 

[VA Hopeful Dr]

My observation is that buspar doesn’t work when patient compares it to a benzo. I also dampen down their expectations and talk about how histamines can be part of a nervous system response and that some physiological symptoms of anxiety like itchiness or restlessness might be helped but overthinking and rumination, not so much. I might be wrong about some of that physiological stuff though. I also talk to patients about how certain beta blockers can help by lowering physiological sense of anxiety such as racing heart.

FM board review I did years back had a great saying to remember this:

After they've taken a Benz they aren't going to be happy taking the Bus.

 

[thelastpsych]

FM board review I did years back had a great saying to remember this:

After they've taken a Benz they aren't going to be happy taking the Bus.

Lol, funny thing is a lot os buses are, in fact, from Mercedes Benz, so it's Benz all the way down

 

[TexasPhysician]

Buspirone is quite effective and well tolerated in my experience. I use it often. Most clinicians don’t go high enough and slowly enough to reach therapeutic dosages.

It often doesn’t work in someone used to moderate dose benzos, but not much compares in those situations.

 

[FlowRate]

Buspirone does work. Even on its own. People just don’t uptitrate appropriately. It seems to work better for “worry” based anxiety compared to fear based anxiety. I don’t see much effect until people are up to around 45 mg total daily dose. Once uptitrated, you can switch it to BID dosing.

Sertraline would look like a placebo also if we stopped dosing past 25-50. This is what most providers do with buspirone.

This covers a good portion of what I was gong to say.

The rest of my addition to this thread:
My spiel for patients is that I've seen people respond, both positively and negatively, to a wide range of doses of buspirone. Many people hit a dose at which they get a brief dizzy/"head swimmy"/"woozy" sensation and find that higher doses beyond that dose are not tolerable for them. Generally with buspirone we want to titrate the dose until we either hit that woozy dose or until we see positive effect (or 60mg TDD), whichever comes first.

I've had a handful of patients for whom it was a miracle cure on its own, often when other options weren't tolerable.

I've had several handfuls of patients for whom it was a helpful adjunctive treatment.

And many patients who either saw no effect and quit before getting to 60mg or who just got side effects with insufficient benefit.

There's also a bunch of patients who end up taking it as a PRN similar to gabapentin or a benzo. I never prescribe it this way, usually I inherit patients using it that way. I mostly assume it's placebo when used that way but the consistency and quickness of the "woozy" effect--for the patients who experience that--makes me think it must do something in the brain shortly after ingestion.

Against the Stream: Generalised anxiety disorder (GAD) – a redundant diagnosis | BJPsych Bulletin | Cambridge Core

Against the Stream: Generalised anxiety disorder (GAD) – a redundant diagnosis - Volume 42 Issue 2

www.cambridge.org

Hey, GAD serves an important function--allowing us to easily bill 99214 on most patients. /hot take.

 

[randomdoc1]

Buspirone does work. Even on its own. People just don’t uptitrate appropriately. It seems to work better for “worry” based anxiety compared to fear based anxiety. I don’t see much effect until people are up to around 45 mg total daily dose. Once uptitrated, you can switch it to BID dosing.

Sertraline would look like a placebo also if we stopped dosing past 25-50. This is what most providers do with buspirone.

even if it is a placebo, way better side effect profile than many of our other options. And if it helps, it helps! But I do agree that these things work with the right dosing <3

 

[DJKitty]

Interesting, I've always been told that max dose is 30mg daily (10mg tid) - never used it at higher doses, or twice a day. Will consider it, since it doesn't seem to have many side effects anyways.

Max dose is 60 mg/day