How Can I Treat a Patient's Anxiety Without Benzodiazepines?

Richard S. Ferri, PhD, ANP, ACRN

Disclosures

April 25, 2012

Question:

As a primary care provider, I frequently need to treat anxiety and do not have the "luxury" of referring patients to psychiatric specialists. However, I am somewhat uncomfortable with prescribing benzodiazepines because of their potential for addiction and abuse. Can you provide some insight and guidance for nonbenzodiazepine anxiety management?

Response from Richard S. Ferri, PhD, ANP, ACRN
Lead HIV/AIDS Adult Nurse Practitioner, Greater New Bedford Community Health Center, New Bedford, Massachusetts

Anxiety is a common condition and often requires pharmacologic treatment in the primary care setting. In addition, waiting for a specialist referral is not always a realistic option. Your concerns about the abuse potential with benzodiazepines are valid and well documented.

This column will focus on medications for anxiety management. However, behavioral interventions are key to anxiety management and should always be incorporated into the care plan, even when medications are being prescribed. Very few medical conditions are cured or controlled by pills alone. Mental healthcare, just like physical healthcare, has no one-size-fits-all treatment.

In the primary care setting, clinicians see anxiety associated with depression, acute anxiety owing to sudden life events (death, job loss), and other anxiety disorders. The use of benzodiazepines, such as alprazolam (Xanax®, Pfizer, New York, New York) or clonazepam, is worrisome, because they are notoriously habit- forming and the dose must be increased to achieve the same effect. Benzodiazepines can also relax social inhibitions that may increase a patient’s risk-taking behaviors.

Anxiety can be managed pharmacologically, without automatic benzodiazepine use. Selecting an agent that can produce a fairly quick reduction in anxiety symptoms is crucial. Antidepressants, antipsychotics, antihistamines, beta-blockers, and anticonvulsants all have demonstrated efficacy in controlling anxiety.

Virtually all classes of antidepressants can be prescribed to treat anxiety, but these agents generally require 2-4 weeks to become effective, so you may want to use faster-acting agents during this period to stabilize the patient or prescribe a short-term benzodiazepine for acute anxiety episodes in the interim.

Antidepressants are divided into several classes depending on the mechanism of action. Fluoxetine (Prozac®, Eli Lilly & Co., Indianapolis, Indiana) is a selective serotonin reuptake inhibitor that increases serotonin levels in the brain by reducing serotonin loss. Another class is the serotonin norepinephrine reuptake inhibitors, such as venlafaxine (Effexor®, Pfizer), that promote increased levels of both serotonin and norepinephrine. One of the oldest classes of antidepressants is the tricyclic antidepressants, which primarily increase norepinephrine levels in brain tissue. Examples of these antidepressants include amitriptyline, doxepin, and imipramine. The monoamine oxidase inhibitors are the oldest class of antidepressants; these drugs elevate serotonin, norepinephrine, and dopamine by inhibiting their degradation. They have numerous food interactions that can lead to critical a hypertensive crisis and thus should be prescribed with extreme caution.

Atypical antipsychotics, such as aripiprazole (Abilify®, Bristol-Myers Squibb, New York, New York) do not usually produce the worrisome extrapyramidal side effects seen with typical antipsychotics, such as haloperidol (Haldol, Ortho-McNeil, Raritan, New Jersey). Atypical antipsychotics may have additional benefits if fear and agitation are present secondary to psychotic experiences, such as delirium.

Antihistamines can also be used to control anxiety. Their effectiveness is believed to be a consequence of their sedating properties. For example, hydroxyzine (Vistaril®, Pfizer) provides quick relief of anxiety, especially if the patient has symptoms associated with obsessive-compulsive disorder.

Low-dose beta-blockers, such as propranolol (Inderal®, AstraZeneca, Wilmington, Delaware), can help with sympathetic somatic symptoms, such as sweating, tremors, and tachycardia. Potential adverse effects of beta-blockers include light-headedness and orthostatic hypotension. These drugs should generally not be used in patients with chronic obstructive pulmonary disease, cardiac conduction defects, or heart failure.

Anticonvulsants, such as gabapentin (Neurontin®, Pfizer), are believed to work by reducing neuronal activation in the brain. Reducing the potentiation of certain neurotransmitters, such as gamma-aminobutyric acid, can mitigate anxiety. However, the mechanism of action of anticonvulsants is not fully understood and it is believed that they may affect several different chemicals simultaneously. Evidence is also emerging that "gabapentin abuse" by people with the disease of addiction is growing. The feeling produced by inhaling or "snorting" gabapentin has been described as a "laid-back" feeling, and it has become a popular drug of diversion in correctional settings where access to illicit drugs is limited.

Numerous options other than benzodiazepines for anxiety management are available. Clinicians should familiarize themselves with these medications and ensure that benzodiazepines are used appropriately.

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