Andrew Chen, MD: Breaking Down First-Line Treatments, or Alternatives, for Anxiety

Many medications are approved to treat generalized anxiety disorder (GAD), but not all are effective for each patient.¹

Serotonin reuptake inhibitors (SSRIs), like sertraline or escitalopram, are considered first-line treatments.² However, if they do not work for a patient, a psychiatrist may prescribe a second-line or third-line treatment option which may be more prone to adverse events.¹

This topic will be discussed during the session “An Evidence-Based Approach to Psychopharmacology for Generalized Anxiety Disorder in Older Adults” at the annual American Psychiatric Association (APA) conference on Wednesday, May 8. In an interview with HCPLive, one of the presenters, Andrew Chen, MD, from the Geriatric Psychiatry Department at Massachusetts General Hospital, explained why SSRIs are preferred over other treatment options for GAD.

SRRIs are preferred if generalized anxiety disorder is what is driving the distress, rather than other comorbidities which would require other medication, Chen explained.

“It is a very good first try. It is very evidence-based,” Chen said. “If you have a patient who's been on 12 medicines [and they] all failed, then SSRIs perhaps is not the best choice.”

When it comes to comorbidities, other medications can be more effective. Chen provided the example of a patient who has both anxiety and fibromyalgia. Pain is most likely the driver of the anxiety, so treating the patient with SNRIs would be a better alternative to SSRIs as it would relieve the driving force.

“It would be very nice to just be able to use one medicine and treat two conditions or treat one to help the other,” Chen said. “So, in that context, you want to be thinking about what are the other drivers?”

Chen then discussed about how patients with SSRIs may have sexual adverse events, and if this bothers a patient, they can switch to buspirone (BuSpar).

“But if the anxiety is clearly demolishing the patient's lifestyle, the patient can't leave the home, because he or she is so anxious, then the conversation with the patient might be the maybe the anxiety is a better block a bigger block to your sex life, so it's really an individualized decision,” Chen said. “And sometimes, it's hard to have both, and you sometimes have just have to choose.”

References

1. ^{Chen, A. An Evidence-Based Approach to Psychopharmacology for Generalized Anxiety Disorder in Older Adults. Session presented at: American Psychiatric Association (APA) 2024 Annual Meeting. New York, NY. May 8, 2024.}
2. ^{Bandelow B, Michaelis S, Wedekind D. Treatment of anxiety disorders. Dialogues Clin Neurosci. 2017;19(2):93-107. doi:10.31887/DCNS.2017.19.2/bbandelow}