Consider adjunctive prn
Benzodiazepine:
Clonazepam or Lorazepam;
ideally <4 weeks
Severe
anxiety
Generalized Anxiety Disorder
Comorbid
depression?
(Bus pirone offers m ore
be nign SE profile; le ss
effective w ith hx of
Benzodiazepine us e )
Buspirone/SSRI/SNRI
No
Yes
Combination
Cognitive-behavioral therapy,
acceptance and commitment therapy
(if available in community)
SSRI or SNRI
Follow up and titrate dose
as appropriate q 1-2 weeks for active
medication management
Inadequate response
(< 50% improvement)
Max dose NOT
achieved due to
side effects
Partial Response
Max dose achieved
with inadequate
response (<50%
improvement)
Partial Response
On SSRI/SNRI?
Buspirone
montherapy?
Switch to
SSRI/SNRI
Yes
No
Adequate response
(≥ 50% decrease in
symptoms)
Continue SSRI/SNRI;
augment with Buspirone
On buspirone
monotherapy?
Continue Buspirone;
add SSRI/SNRI
First time failing an
SSRI or SNRI?
Yes
Trial of different
medication
No
Discontinue
current
medication
Follow up and titrate dose
as appropriate q 1-2 weeks for active
medication management
Partial
response
Continue SSRI/SNRI and
Buspirone
Begin Mirtazapine
Inadequate response
Stop Mirtazapine and start either:
Quetiapine
Pregabalin/Gabapentin
Inadequate response
Try other agent
Inadequate response after trying both agents
Stop above agent and start either:
TCA
Maintain effective pharmacotherapy for
minimum of 12 months;
if asymptomatic for 4-6 months,
consider slow taper
Consider TCA prior
to chronic benzodiazepines
Imipramine most studied,
other TCAs reasonable
Benzodiazepine
Clonazepam
Lorazepam
Adequate response
(≥ 50% decrease in
symptoms)
GENERALIZED ANXIETY DISORDER
Anxiolytic
SSRI
Antidepressants
Buspirone
BuSpar
DOSING: Start 7.5mg BID or 5mg TID, increase by increments of 5mg/day every 2-3 days to target dose 20mg-30mg/
day divided BID or TID; max dose 20mg TID. May also be used as a prn.
SIDE EFFECTS: (common) dizziness, nausea, headache, jitteriness
DOSING: See agent descriptions.
SIDE EFFECTS: (common)
nausea, headache, weight gain,
sexual side effects; (rare, serious)
hyponatrema, GI bleeding,
serotonin syndrome
Escitalopram
Lexapro
Fluoxetine
Prozac
DOSING: Start 10mg in AM, wait a few weeks to assess response before
increasing, max dose 80mg/day.
NOTE: Off-label for GAD.
Paroxetine
Paxil
DOSING: Start 10mg/day, wait a few weeks to assess response before
increasing, can increase by 10mg/day once/week; max dose 60mg/day.
Sertraline
Zoloft
Citalopram
Celexa
SNRI
Antidepressants
DOSING: See agent descriptions.
SIDE EFFECTS: (common)
nausea, dry mouth, dizziness,
headache, sexual side effects
DOSING: Start 5 mg/day, increase slowly up to 20mg/day if necessary,
once daily dosing.
DOSING: Start 25mg/day, increase to 50mg/day after one week if
necessary, thereafter wait a few weeks to assess response before
increasing; max dose 200mg/day, single dose.
NOTE: Off-label for GAD.
DOSING: Start 10mg/day, may increase to 20mg/day after one week if
necessary; max dose 40mg/day. Do not exceed 40mg/day due to reports
of QTc prolongation.
NOTE: Off-label for GAD.
Duloxetine
Cymbalta
DOSING: Start 20mg/day, divided or in a single dose, increase slowly;
max dose 60mg/day.
SIDE EFFECTS: (rare, serious) hepatic failure, orthostatic hypotension,
syncope
Venlafaxine
Effexor XR
DOSING: Start 37.5mg/day, increase by 37.5mg/day at weekly or longer
intervals; max dose 225mg/day.
SIDE EFFECTS: (rare, serious) hypertension, SIADH
Other
Antidepressant
Mirtazapine
Remeron
Atypical (SGA)
Antipsychotics
Quetiapine
Seroquel ER
DOSING: Start 12.5mg-25mg/day, increase by 12.5mg-25mg at weekly intervals as necessary, max dose 150mg/day.
SIDE EFFECTS: (common) hypotension, dry mouth, weight gain/ hyperlipidemia/ diabetes, dizziness; (rare, serious)
orthostatic hypotension, NMS, TD
NOTE: Off-label for GAD.
Novel
Anticonvulsants
Pregabalin
Lyrica
DOSING: Start 75mg BID and increase as tolerated; max dose 300mg BID.
SIDE EFFECTS: (common) peripheral edema, dizziness, weight gain; (rare, serious) hypersensitivity reactions,
angioedema
NOTE: Off-label for GAD.
Tricyclic
Antidepressant
Benzodiazepines
DOSING: Start 7.5mg QHS, increase by 7.5mg every 1-2 weeks as necessary and as tolerated; max dose 45mg/day.
SIDE EFFECTS: (common) weight gain, somnolence; (rare, serious) agranulocytosis, severe neutropenia
NOTE: Off-label for GAD.
Gabapentin
Neurontin
DOSING: Start 100mg QHS, increase as tolerated to 300mg TID; max dose 3600mg/day.
SIDE EFFECTS: (common) dizziness, weight gain, somnolence; (rare, serious) DRESS
NOTE: Off-label for GAD.
Imipramine
Tofranil
DOSING: Start 25mg QHS, increase as tolerated by 25mg/day; max dose 150mg-200mg/day.
SIDE EFFECTS: (common) sedation, dry mouth, constipation, weight gain, sexual side effects; (rare, serious) seizures,
cardiac effects, fatal in overdose
NOTE: Off-label for GAD.
DOSING: See agent descriptions.
SIDE EFFECTS: (common)
somnolence, grogginess, ataxia,
abuse potential; (rare, serious)
anterograde amnesia, fall
risk, respiratory depression,
paradoxical reaction
Clonazepam
Klonopin
DOSING: Start 0.25mg BID; increase to 1mg/day after 3 days. Dose
either BID or once at HS. Use the lowest possible effective dose for the
shortest possible period of time.
NOTE: FDA indicated for panic disorder.
Lorazepam
Ativan
DOSING: Start 0.25-0.5mg BID, increase by 0.25mg-0.5mg increments
every few days to max 6mg/day divided BID or TID. Use the lowest
possible effective dose for the shortest possible period of time.