Anxiolytics

Anxiety is both a normal emotion and a disorder which can cause profound distress and functional impairment. The range of treatments available for anxiety has improved substantially in the last 20 years. This has in part been due to improved understanding of the neurobiological mechanisms underlying anxiety. Guidelines are available for the treatment of the various anxiety disorders; selective serotonin reuptake inhibitors (SSRIs) are now considered first-line pharmacological therapy for all the anxiety disorders except simple phobia, for which psychotherapy is most effective. SSRIs may cause anxiety to increase during initial therapy before the anxiolytic effect emerges. Other antidepressants shown to be effective in anxiety disorders include mirtazapine, venlafaxine and, although less commonly used, tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). Benzodiazepines were used widely in the past for anxiety, but concerns over dependence and withdrawal effects have now greatly limited their use. However, they continue to have a role in those non-responsive to other agents and for short-term use during antidepressant initiation. Several anticonvulsant medications may also be useful in anxiety (e.g. pregabalin). Some atypical antipsychotics also have a limited evidence base to support their use in treatment-resistant anxiety disorders. Psychotherapy has an important role to play in the treatment of anxiety disorders, but this contribution is restricted to discussion of pharmacological treatment.