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CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK
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For the Chapter in the Schwinghammer, Handbook (not Wells Handbook anymore) please go to Chapter 66, Anxiety Disorders.
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KEY CONCEPTS
Anxiety disorders are among the most common of mental disorders and are underdiagnosed and undertreated.
The long-term goal in treatment of generalized anxiety disorder (GAD) is remission with minimal or no anxiety symptoms and no functional impairment.
Antidepressants are the agents of choice for the management of GAD.
Antidepressants have a lag time of 2 to 4 weeks or longer before antianxiety effects occur in GAD.
When monitoring the effectiveness of antidepressants in panic disorder, it is important to allow an adequate amount of time (8–12 weeks) to achieve full therapeutic response.
The optimal duration of panic therapy is unknown; 12 to 24 months of pharmacotherapy is recommended before gradual drug discontinuation over 4 to 6 months is attempted.
Social anxiety disorder (SAD) is a chronic long-term illness requiring extended therapy. After improvement, at least a 6- to 12-month medication maintenance period is recommended before considering treatment discontinuation.
The selective serotonin reuptake inhibitors or venlafaxine are considered first-line pharmacotherapy for social anxiety disorder.
An adequate trial of antidepressants in generalized SAD lasts at least 8 weeks, and maximal benefit may not be seen until 12 weeks.
The three principal domains in which improvement should be observed in generalized SAD are symptoms, functionality, and well-being.
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Patient Care Process for Anxiety Disorders

Collect
Patient characteristics (eg, age, sex, pregnancy)
Patient medical history (personal and family)
Patient psychiatric history (personal and family)
Social history (eg, caffeine, nicotine, ethanol, illicit drug use including route of administration)
Current medications including over-the-counter (OTC), herbal products, dietary supplements, and prior psychiatric medication use
Mental status examination
Objective data
Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, and weight
Labs including thyroid stimulating hormone (TSH)
Urinalysis including urine drug testing
Generalized Anxiety Disorder 7-Item Scale, Hamilton Anxiety Disorder Rating Scale, Sheehan Disability Scale, and Patient Health Questionnaire-9 (PHQ-9)
Assess
Presence of generalized anxiety disorder, panic disorder, or social anxiety disorder
Presence of comorbid depression or substance use disorder
Ability/willingness to begin nonpharmacologic treatments, including availability in geographic region
Ability/willingness to begin pharmacologic treatment
Ability/willingness to afford nonpharmacologic and/or pharmacologic treatment(s)
Support of family members/caregivers for treatment
Plan*
Drug therapy regimen including specific medication(s), dose, route, frequency, and duration (see Figure 87-1, Tables 87-4, 87-5, 87-8, and 87-9)
Monitoring parameters including efficacy (eg, rating scales, quality of life)
Patient education (eg, disease, life style changes, medication adherence, when to expect medication to begin working, possible adverse effects, expected duration of therapy, when to contact healthcare professional)
Self-monitoring for resolution of anxiety symptoms
Implement*
Follow-up: ...