SSRI and Anxiety

[GA8314]

Hello,

There doesn't seem to be a lot written about the use of SSRI's for primary anxiety disorders. I often see that patients tend to be started on lower doses, to avoid anxiogenic start up effects. But, is the end goal a "normal dose", low end of normal? Say, for GAD. I realize OCD tends to require higher doses.

But, for GAD, would you start someone low and keep it low? How do you dose escalate those patients?

Also, in your clinical experience, while I realize people respond differently even among a similar drug class, do you have any "go to" SSRI's for mod-severe GAD?

Interested in your clinical experiences, real world, but also studies are welcomed.

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[mk04447]

Hello,

There doesn't seem to be a lot written about the use of SSRI's for primary anxiety disorders. I often see that patients tend to be started on lower doses, to avoid anxiogenic start up effects. But, is the end goal a "normal dose", low end of normal? Say, for GAD. I realize OCD tends to require higher doses.

But, for GAD, would you start someone low and keep it low? How do you dose escalate those patients?

Also, in your clinical experience, while I realize people respond differently even among a similar drug class, do you have any "go to" SSRI's for mod-severe GAD?

Interested in your clinical experiences, real world, but also studies are welcomed.

Not a lot written? Where you looking?

 

[NickNaylor]

Hello,

There doesn't seem to be a lot written about the use of SSRI's for primary anxiety disorders.

There is a ton of literature on using antidepressants and anxiety. Here are a few 10000-foot reviews:

Craske MG and Stein MB - "Anxiety"
Baldwin DS, Waldman S, and Allgulander C - "Evidence-based pharmacological treatment of generalized anxiety disorder"
Stein MB and Craske MG - "Treating anxiety in 2017: Optimizing care to improve outcomes"

I often see that patients tend to be started on lower doses, to avoid anxiogenic start up effects. But, is the end goal a "normal dose", low end of normal? Say, for GAD.

Some sources (for example, the Manual of Psychopharmacology) state that antidepressant doses for anxiety disorders tend to be higher than those for depressive disorders to achieve symptom control. Ultimately, the "goal dose" is the dose that results in symptomatic improvement. For some people that may 50 mg of sertraline, for others that might be 200 mg. I usually aim for a moderate dose to start (e.g., for someone with an anxiety disorder, I might start them on 5 mg of escitalopram for a week then increase to 10 mg and reassess in 4-6 weeks) and see where that gets us. If there's no appreciable improvement after 4-6 weeks at a moderate dose, then I switch agents.

I almost universally recommend individual psychotherapy for people with straightforward anxiety.

 

[GA8314]

Are there any medications which you've found particularly helpful (which has evolved into a "go to" med) in your practices? I realize there are high degrees of variability in how patients respond to medications, even within the same class. But, for a primary anxiety disorder, with say, PDD/dysthymia, what would you tend to start the patient on as a first medication? Say GAD.

 

[hamstergang]

I'm curious to know why you're asking? Often context can help direct a conversation.

 

[GA8314]

I'm curious to know why you're asking? Often context can help direct a conversation.

Let's say I know someone with substantial GAD as primary with some "dysthymia" as secondary. Just curious, but would greatly appreciate the clinical insight into some of the more common meds which you folks have had success with.

 

[NickNaylor]

Are there any medications which you've found particularly helpful (which has evolved into a "go to" med) in your practices? I realize there are high degrees of variability in how patients respond to medications, even within the same class. But, for a primary anxiety disorder, with say, PDD/dysthymia, what would you tend to start the patient on as a first medication? Say GAD.

There is very minimal evidence to suggest that escitalopram may be more effective than other SSRIs in managing anxiety symptoms. Paroxetine is FDA-approved for all of the anxiety disorders so is also commonly used.

There is no evidence that I know of that suggests that one antidepressant is better than any other apart from the finding with escitalopram, which I think is unlikely to be clinically significant.

Because of the finding above and the fact that escitalopram tends to be better tolerated then the other SSRIs, I typically use escitalopram first-line. But that is not evidence-based, more just a practice habit with some degree of rationale behind it.