Key moments, in order
GAD is a terrible diagnosis the way the community uses it, but there is something real there. It is its own disorder in a sense, and tighter criteria would capture a smaller proportion of the population.
PRNs for anxiety are for temporary use, and most of the time they get in the way of appropriate treatment. Build the plan around scheduled medications instead.
Anxiety is, in theory, an overactive threat detection system. Relying on a medication to quell it tells the brain that it needs something external to fix the anxiety.
Generalized anxiety disorder: grade A, almost a requirement to teach, and a standalone treatment. If a patient can tolerate and engage with it, it is a fast track to managing anxiety long term, with CBT the next option if it is not working.
Have them try any of the exercises once and see which work best. There are hundreds of ways to practice, so help them pick one that works for them.
Religion or spirituality, belief in things bigger than ourselves, does an amazing thing for quelling anxiety.
The Happiness Trap is our go-to ACT book and a really good one. ACT integrates a lot more mindfulness, and it reads as a lighter, easier, breezier form of CBT.
In OCD you can even take it above 200 mg, but do so with caution.
The first two antidepressants anyone should use are sertraline or escitalopram. Both have relatively few interactions, which matters even in young patients who may need another medication down the line.
Benzodiazepines, Z-drugs and alcohol are all about the same: 99 percent of the time they are not truly treating the anxiety disorder. Cannabis belongs in the same category, things that make people feel they are getting better or sleeping when they are not.
They have a role in acute decompensation in a patient whose addiction risk does not worry you, for example a one-week prescription to get through a crisis that is partly depression.
We reserve benzodiazepines for refractory sleep-wake cycle disorders, catatonia and bipolar disorder. They are basically a mood stabilizer, reducing the brain's excitability, but they are a full shutdown medication. When you see catatonia, you should probably be using one.
They decrease the efficacy of therapy by reducing the ability to learn new information, and the treatment for anxiety is avoiding avoidance.
Explain plainly: if I prescribed these long term, I would be hurting you, preventing you from getting better.
It is basically a brain off switch. That is suppression, not treatment, though it can be useful in some situations. It slows recovery, and it is the one case that really does match the accusation that psychiatry only suppresses symptoms.
Never trust the last psychiatrist's diagnosis, even if you were the last psychiatrist.
A patient who says "I have anxiety" could be blatantly manic. Treating the stated problem without your own diagnosis, and without the patient knowing it, is irresponsible.
Anxiety is a non-specific state that every human being has and that almost every mental condition can produce.
Pull out the emotion wheel and find the underlying emotion. Many people filter their whole emotional world through anxious or angry. Naming rejection or loneliness instead gives them emotions that are productive and can be acted on.
FDA approval is often misunderstood, and the show distrusts it as a guide, for example duloxetine being approved for GAD in children.
It lasts so long that it is great for patients who forget or skip doses: give a higher dose, and the long half-life still gives an effective serum level when they skip a few doses a week. Start-and-stop patients can get used to it and take it a few times a week (not as a PRN, just whenever they remember).
Famously the worst withdrawal syndrome of all the antidepressants, severe enough to keep it out of a higher tier. An elderly patient was once medically hospitalized from it. It works well, but be careful and taper slowly.
We tend not to use it. It is anticholinergic and makes people sleepy, it causes weight gain, and it is probably the worst SSRI for pregnancy. Even where it helps, as in anxiety, these hold it back.
We reach for it for comorbid pain, diagnosed fibromyalgia or a migraine disorder; otherwise we do not go for the SNRIs. We do not believe in them for apparent ADHD.
When someone has failed SSRIs and you want a little more kick, venlafaxine over duloxetine. The data show it barely outperforms SSRIs, with a number needed to treat of about 24.
We think it was studied for GAD and did not perform well, so it sits low on our list for anxiety.
Its mechanism is an SSRI plus 5-HT1 partial agonism. We think that is actually a reason not to use it, because we like using buspirone on top of SSRIs.
It does not seem to cause agitation in people with bipolar disorders, and clinically it is effective for irritability.
It does not have sexual side effects, and it has very few long-term side effects compared with the other medications.
Do not underdose it. It is often written off because it was never adequately dosed. Titrate fairly aggressively and do not be afraid to take it to the max, but do not expect the moon and the stars: it gives a modest benefit. We have seen it work better at the higher dose range.
It is not a PRN. Like the SSRIs and SNRIs, it takes a few weeks to kick in.
It helps anxiety that is part of the depression and is great for depression with anxious features. When anxiety is the predominant problem we tend to avoid it: in our opinion it does not help anxiety on its own and worsens generalized anxiety disorder long term.
We have seen it many times: patients with OCD, PTSD or anxiety on bupropion get better when you pull it off.
Cutting back is worth considering for anxiety, especially since stimulants in the United States are probably highly overprescribed.
In proper ADHD, the reduction in psychological anxiety far outweighs the minor physiological anxiety a stimulant adds.
For anxiety, a good choice in someone who could use some weight, or does not mind it, and has sleep problems.
Major depression tends to have more sleep disruption baked in than generalized anxiety disorder, which may be why mirtazapine fits depression better.
Most of what you want from low-dose quetiapine in a non-psychotic disorder you can get from mirtazapine, gabapentin, buspirone or hydroxyzine.
We do not reach for quetiapine just because it works. The joke is that at some dose, quetiapine will treat every mental disorder.
Giving antipsychotics to people without schizophrenia seems to raise the risk of tardive dyskinesia.
Reach for it when someone has a lot of allergies, itching or sleep problems and is not sensitive to antihistamines. For anxiety, it is just not terribly good.
We rank beta blockers A tier for performance anxiety, and probably C tier for generalized anxiety.
Do not use it in asthma, and be careful of the cardiac effects. In patients with comorbid migraine it can help a little.
Beta blockers were historically viewed as depressogenic. One study suggested propranolol may not be, but we still think of long-term beta blocker use as depressogenic.
Gepirone probably works about as well as buspirone, or worse because it is probably less antipsychotic, and it is far too expensive. There is no good reason to use it.
For anxiety, the studies needed much higher doses than the 100 or 300 mg people are usually on. It is more effective at about 900 to 3,600 mg a day, and because absorption is nonlinear, much less is absorbed at the higher doses than the number suggests.
When you reach the end of your list for primary anxiety (you have revisited the diagnosis, the patient is in real therapy and practicing mindfulness, and you are still not getting anywhere), do not be afraid to use pregabalin.
Lavender: people love it for the first few months, then it poops out, usually with no significant difference by six months. Kava is mildly habit forming and carries a liver toxicity risk.
People love it for the first few months and then it tends to wear off: usually by about six months they see no significant difference.
The traditional algorithm for GAD runs SSRI, then SNRI, then gabapentin or pregabalin, then a TCA.
Before going past the standard options for anxiety, make sure you really need to: do more re-diagnosis, formulation work and lifestyle change first.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.