Abstract
Since the introduction of distinct anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, there has been a growing interest in these conditions, leading to a wealth of pharmacotherapy trials. Guidelines for the treatment of anxiety disorders have been developed on the basis of systematic reviews of the literature and expert consensus in areas where data are lacking. Algorithms provide scaffolding for integrating the data on pharmacotherapy and for pointing to gaps in current knowledge. Pharmacotherapy algorithms have the potential advantage of being concise, user-friendly, and evidence-based. However, such algorithms run the risk of oversimplifying complex clinical realities, and are only as good as the data on which they rest. In this article, an algorithm for the pharmacotherapy of anxiety disorders is presented.
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References and Recommended Reading
Rush AJ: Clinical practice guidelines: good news, bad news, or no news? Arch Gen Psychiatry 2001, 50:483–490.
Institute of Medicine: Guidelines for Clinical Practice: From Development to Use. Washington, DC: National Academy Press; 1992.
Field MJ, Lohr KN: Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy Press; 1990.
American Psychiatric Association: Practice guideline for the treatment of patients with panic disorder. Am J Psychiatry 1998, 155:1–34.
March JS, Frances A, Carpenter D, et al.: Treatment of obsessive-compulsive disorder: the Expert Consensus Panel for obsessive-compulsive disorder. J Clin Psychiatry 1997, 58:1–72.
Foa EB, Davidson JRT, Frances A: Treatment of posttraumatic stress disorder: the Expert Consensus guideline series. J Clin Psychiatry 1999, 60:1–76.
Bandelow B, Zohar J, Hollander E, et al.: World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders. World J Biol Psychiatry 2002, 3:171–199. A useful recent guideline from an international organization.
Stein DJ, Kasper S, Matsunaga H, et al.: Pharmacotherapy of social anxiety disorder: an algorithm for primary care 2001. Prim Care Psychiatry 2001, 7:107–110.
Jackson R, Feder G: Guidelines for clinical guidelines. BMJ 1998, 317:427–428.
Cook DJ, Greengold NL, Ellrodt AG, et al.: The relation between systematic reviews and practice guidelines. Ann Int Med 1997, 127:210–216.
Fawcett J, Stein DJ, Jobson KO: Textbook of Treatment Algorithms in Psychopharmacology. Chichester: John Wiley & Sons; 1999.
Stein DJ, Hugo F: Neuropsychiatric aspects of anxiety disorders. In The American Psychiatric Publishing Textbook of Neuropsychiatry and Clinical Neurosciences. Edited by Yudofsky SC, Hales RE. Washington, DC: American Psychiatric Press Publishing; 2002.
Bandelow B: The use of the Panic and Agoraphobia Scale in a clinical trial. Psychiatry Res 1998, 77:43–49.
Goodman WK, Price LH, Rasmussen SA, et al.: The Yale-Brown Obsessive Compulsive Scale: I. Development, use, and reliability. Arch Gen Psychiatry 1989, 46:1006–1011.
Liebowitz MR, Quitkin FM, Stewart JW, et al.: Antidepressant specificity in atypical depression. Arch Gen Psychiatry 1988, 45:129–137.
Stein DJ: Cognitive-Affective Neuroscience of Mood and Anxiety Disorders. London: Martin Dunitz; 2003.
Franchini L, Serretti A, Gasperini M, et al.: Familial concordance of fluvoxamine response as a tool for differentiating mood disorder pedigrees. J Psychiatr Res 1998, 32:255–259.
Furukawa TA, Streiner DL, Young LT: Antidepressant plus benzodiazepine for major depression [Cochrane review]. Cochrane Database Syst Rev 2001, 2:CD001026.
Anderson IM: Selective serotonin reuptake inhibitors versus tricyclic antidepressants: a meta-analysis of efficacy and tolerability. J Affect Disord 2000, 58:19–36.
Clerc GE, Ruimy P, Verdeau-Palles J: A double-blind comparison of venlafaxine and fluoxetine in patients hospitalized for major depression and melancholia. The Venlafaxine French Inpatient Study Group. Int Clin Psychopharmacol 1994, 9:139–143.
Naranjo CA, Knoke DM: The role of selective serotonin reuptake inhibitors in reducing alcohol consumption. J Clin Psychiatry 2001, 62:18–25.
Posternak MA, Mueller T: Assessing the risks and benefits of benzodiazepines for anxiety disorders in patients with a history of substance abuse or dependence. Am J Addict 2000, 10:48–68.
Nulman I, Rovet J, Stewart DE, et al.: Neurodevelopment of children exposed in utero to antidepressant drugs. N Engl J Med 1997, 336:258–262.
Miller LJ: Postpartum depression. JAMA 2002, 287:762–765.
Hawkridge S, Stein DJ: Risk-benefit assessment of drug therapies for anxiety disorders in children and adolescents. Drug Safety 1998, 19:283–297.
Research Unit on Pediatric Psychopharmacology Anxiety Study Group: Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med 2001, 34:1279–1285.
Stein DJ: Psychiatry on the Internet: survey of an OCD mailing list. Psychiatr Bull 1997, 21:95–98. A seminal trial in the area of pediatric anxiety disorders.
Blomhoff S, Haug TT, Hellström K, et al.: Randomized controlled general practice trial of sertraline, exposure therapy and combined treatment in generalised social phobia. Br J Psychiatry 2001, 179:23–30.
Ballenger JC, Davidson JR, Lecrubier Y, et al.: Consensus statement on generalized anxiety disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry 2001, 62S11:53–58.
Ballenger JC, Davidson JRT, Lecrubier Y, et al.: Consensus statement on panic disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry 1998, 59(suppl):47–54.
Ballenger JC, Davidson JR, Lecrubier Y, et al.: Consensus statement on posttraumatic stress disorder from the International Consensus Group on depression and anxiety. J Clin Psychiatry 2000, 61:60–66.
Ballenger JC, Davidson JA, Lecrubier Y, et al.: Consensus statement on social anxiety disorder from the International Consensus Group on depression and anxiety. J Clin Psychiatry 1998, 59:54–60.
DeMartinis N, Rynn M, Rickels K, et al.: Prior benzodiazepine use and buspirone response in the treatment of generalized anxiety disorder. J Clin Psychiatry 2000, 61:91–94.
Ballenger JC: Treatment of anxiety disorders to remission. J Clin Psychiatry 2001, 62:5–9.
Liebowitz MR, Stein MB, Tancer M, et al.: A randomized, double-blind, fixed-dose comparison of paroxetine and placebo in the treatment of generalized social anxiety disorder. J Clin Psychiatry 2002, 63:66–74.
Montgomery SA, Kasper S, Stein DJ, et al.: Citalopram 20mg, 40mg and 60mg are all effective and well tolerated compared with placebo in obsessive compulsive disorder. Int Clin Psychopharmacol 2001, 16:75–86.
Stein DJ, Stein MB, Pitts CD, et al.: Predictors of response to pharmacotherapy in social anxiety disorder: an analysis of 3 placebo-controlled paroxetine trials. J Clin Psychiatry 2002, 63:152–155.
Southwick SM, Yehuda R: The interaction between pharmacotherapy and psychotherapy in the treatment of posttraumatic stress disorder. Am J Psychotherapy 1993, 47:404–411.
Pollack MH, Otto MW, Kaspi S, et al.: Cognitive behavior therapy for treatment-refractory panic disorder. J Clin Psychiatry 1994, 55:200–205.
McDougle CJ, Epperson CN, Pelton GH, et al.: A double-blind, placebo-controlled study of risperidone addition in serotonin reuptake inhibitor-refractory obsessive-compulsive disorder. Arch Gen Psychiatry 2000, 57:794–802.
Tesar GE, Rosenbaum JF: Successful use of clonazepam in patients with treatment-resistant panic disorder. J Nerv Ment Dis 1986, 174:477–482.
Pande AC, Pollack MH, Crockatt J, et al.: Placebo-controlled study of gabapentin treatment of panic disorder. J Clin Psychopharmacol 2000, 20:467–471.
Tiffon L, Coplan JD, Papp LA, et al.: Augmentation strategies with tricyclic or fluoxetine treatment in seven partially responsive panic disorder patients. J Clin Psychiatry 1994, 55:66–69.
Hirschmann S, Dannon PN, Iancu I, et al.: Pindolol augmentation in patients with treatment-resistant panic disorder: a double-blind, placebo-controlled trial. J Clin Psychopharmacol 2000, 20:556–559.
Davidson JRT, Potts N, Richichi E, et al.: Treatment of social phobia with clonazepam and placebo. J Clin Psychopharmacol 1993, 13:423–428.
Pande AC, Davidson JR, Jefferson JW, et al.: Treatment of social phobia with gabapentin: a placebo-controlled study. J Clin Psychopharmacol 1999, 19:341–348.
van Ameringen M, Mancini C, Wilson C: Buspirone augmentation of selective serotonin reuptake inhibitors (SSRIs) in social phobia. J Affect Dis 1996, 39:115–121.
Stein MB, Sareen J, Hami S, et al.: Pindolol potentiation of paroxetine for generalized social phobia: a double-blind, placebo-controlled, crossover study. Am J Psychiatry 2001, 158:1725–1727.
Stein DJ, Seedat S, van der Linden G, et al.: Pharmacotherapy of posttraumatic stress disorder. In Posttraumatic Stress Disorder: Assessment and Management. Edited by Davidson J, Nutt D, Zohar J. London: Martin Dunitz; 2000.
Hertzberg MA, Butterfield MI, Feldman ME, et al.: A preliminary study of lamotrigine for the treatment of posttraumatic stress disorder. Biol Psychiatry 1999, 45:1226–1229.
Castenada R, Sussman N, Westreich L, et al.: A review of the effects of moderate alcohol intake on the treatment of anxiety and mood disorders. J Clin Psychiatry 1996, 57:207–212.
Marazziti D, Dell’Osso L, Gemignani A, et al.: Citalopram in refractory obsessive-compulsive disorder: an open study. Int Clin Psychopharmacol 2001, 16:215–219.
Hollander E, Mullen L, DeCaria CM, et al.: Obsessive compulsive disorder, depression, and fluoxetine. J Clin Psychiatry 1991, 52:418–422.
Altamura AC, Pioli R, Vitto M, et al.: Venlafaxine in social phobia: a study in selective serotonin reuptake non-responders. Int Clin Psychopharmacol 1999, 14:239–245.
Koran LM, Sallee FR, Pallanti S: Rapid benefit of intravenous pulse loading of clomipramine in obsessive-compulsive disorder. Am J Psychiatry 1997, 154:396–401.
Bystritsky A, Munford PR, Rosen RM, et al.: A preliminary study of partial hospital management of severe obsessive-compulsive disorder. Psychiatr Serv 1996, 47:170–174.
Martuza RL, Chiocca EA, Jenike MA, et al.: Stereotactic radiofrequency thermal cingulotomy for obsessive-compulsive disorder. J Neuropsychiatry 1990, 2:331–336.
Maletzky B, McFarland B, Burt A: Refractory obsessive compulsive disorder and ECT. Convuls Ther 1994, 10:34–42.
Grisaru N, Amir M, Cohen H, et al.: Effect of transcranial magnetic stimulation in posttraumatic stress disorder: a preliminary study. Biol Psychiatry 1998, 44:52–55.
Alonso P, Pujol J, Cardoner N, et al.: Right prefrontal repetitive transcranial magnetic stimulation in obsessive-compulsive disorder: a double-blind, placebo-controlled study. Am J Psychiatry 2001, 158:1143–1145.
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Stein, D.J. Algorithm for the pharmacotherapy of anxiety disorders. Curr Psychiatry Rep 5, 282–288 (2003). https://doi.org/10.1007/s11920-003-0057-6
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DOI: https://doi.org/10.1007/s11920-003-0057-6