Pharmacologic management* of GAD in individuals who have not fully responded to first-line treatment with SRI^¶

GAD: generalized anxiety disorder; SRI: serotonin reuptake inhibitor; CBT: cognitive-behavioral therapy; SSRI: selective serotonin reuptake inhibitor; SNRI: serotonin-norepinephrine reuptake inhibitor; EPS: extrapyramidal side effects.
* Augmentation with psychotherapy (ie, CBT) can be done at any point in the algorithm.
¶ SRI includes both SSRIs and SNRIs.
Δ Adequate trial is considered to be 6 weeks at therapeutic dose range for medication.
◊ Our first line for augmentation is buspirone; however, in individuals with significant mood fluctuation, irritability, or in those with diagnosis of bipolar disorder (with mania or hypomania), valproic acid or lamotrigine are acceptable alternatives.
§ We typically try augmentation with two different agents at therapeutic range for 4 weeks before considering the individual to not have acceptable response to augmentation efforts.
¥ Choice of antidepressant is based on symptoms present and potential side effects of medications. In individuals with decreased appetite or insomnia, we would use mirtazapine. In individuals sensitive to weight gain, we would use vilazodone.
‡ For individuals with current unhealthy alcohol or substance use we address these concerns prior to treating generalized anxiety. In some cases, such as low-risk use of alcohol, we address them concurrently.
† For individuals starting an antipsychotic medication, we monitor for EPS, prolonged QTc, and metabolic dysregulation. Refer to content in UpToDate.
** Benzodiazepines can be used as monotherapy in individuals who have not responded to any prior agents or as an adjunctive agent based on response to prior agent. Refer to UpToDate content.