Publication
Article
Many options exist for the pharmacological treatment of anxiety disorders. Are some more appropriate under certain conditions or for some patients? Mechanisms and efficacy of medicinal treatments, as well as some common herbal remedies, are reviewed.
The range of medicinal compounds useful for anxiety disorders has expanded from antidepressants, benzodiazepines and buspirone to include anticonvulsants, some antipsychotics and herbal/alternative compounds. Frequently, combination therapy is needed (e.g., antidepressant and benzodiazepine) to achieve maximum efficacy and tolerability.
Epidemiologic studies (e.g., Kessler et al., 1994; Lecrubier, 1998) show that between 30% and 60% of patients with anxiety disorders have comorbid illnesses such as depression or a substance abuse disorder. The presence of comorbid psychiatric and medical conditions guides drug therapy selection. For example, antidepressants are preferred if comorbid depression exists, and benzodiazepines may be problematic in those with active substance abuse disorders. A World Health Organization study found that recognition of comorbidity in anxiety disorders was a key reason for preferentially prescribing antidepressants rather than benzodiazepines in most primary care practices worldwide (Lecrubier, 2001).
When symptoms of anxiety persist and cause functional impairment, a thorough diagnostic assessment is needed to determine if one or more of the following distinct DSM-IV-TR anxiety disorders are present: generalized anxiety disorder (GAD), social anxiety disorder (SAD, also known as generalized social phobia), obsessive-compulsive disorder (OCD), panic disorder (PD) or posttraumatic stress disorder (PTSD). An individualized, evidence-based approach that utilizes established dosing and appropriate duration of therapeutic trial (typically six to 12 weeks) for each anxiety disorder is needed for treatment success. Typically, medication is needed to decrease symptoms sufficiently for patients to participate in psychotherapeutic and behavioral interventions. Establishing rapport with the patient through counseling about the illness and medication management can improve treatment success (Gorman, 2001).
Antidepressants
SSRIs. Selective serotonin reuptake inhibitors are broad-spectrum anti-anxiety agents considered first-line therapy for all major anxiety disorders. (There are, however, differences in current approved U.S. Food and Drug Administration indications, dosing and pharmacokinetic/drug interaction profiles). According to several reviews (Ballenger, 2001; Brunello et al., 2000; Pigott and Seay, 1999), 50% to 75% of patients with anxiety disorders experience significant benefit after adequate dose and duration of therapy with an SSRI. Fluoxetine (Prozac) is perhaps the most activating SSRI, with once-daily dosing in the morning recommended for most patients. Fluvoxamine (Luvox) is better tolerated with bedtime dosing, and citalopram (Celexa), paroxetine (Paxil) and sertraline (Zoloft) should be initiated in the morning with a change to bedtime dosing if drowsiness occurs.
The SSRIs can cause dose-related nausea, restlessness, insomnia and sexual dysfunction, although they are generally better tolerated with less toxicity in overdose compared to tricyclic antidepressants and monoamine oxidase inhibitors. Several investigators (Fava et al., 2000; Lake et al., 2000; Mace and Taylor, 2000) described less common but potentially serious adverse effects, including hyponatremia, extrapyramidal side effects, weight gain and increased bleeding. As described by Black et al. (2000), SSRI withdrawal reactions, such as anxiety, diarrhea, fatigue, gait instability, headache, emesis, tremor, paresthesias and visual disturbances, can occur upon abrupt discontinuation of an SSRI after one month of therapy. Symptoms resolve within 72 hours of restarting SSRI therapy.
In considering SSRIs for specific anxiety disorders, SSRIs and clomipramine (Anafranil) are significantly more effective than other less serotonergic antidepressants in alleviating symptoms of OCD, according to several well-controlled trials (Pigott and Seay, 1999). Significant efficacy may take 10 to 12 weeks at maximally tolerated doses. The time to onset of effect is longer when treating OCD compared to SAD, GAD and even PD, in which symptoms lessen within one month of treatment at antidepressant doses. Key distinguishing features of OCD pharmacotherapy include a negligible placebo response and high relapse (>90%) upon drug discontinuation.
Compared to those with depression and other anxiety disorders, individuals with PD and PTSD are frequently more sensitive to the activating side effects of SSRIs (Ballenger et al., 1998; Brunello et al., 2001; Davidson, 2000). Lower initial doses are needed to improve tolerability. In 1998, an International Consensus Group on PD, led by Ballenger, recommended initiating SSRI therapy at lower doses (e.g., paroxetine at 10 mg, sertraline at 25 mg) with titration based on tolerability to usual antidepressant doses. In 2001, Goddard and colleagues reported that clonazepam (Klonopin) 0.5 mg tid added to sertraline therapy 100 mg/day for PD resulted in more rapid onset of anti-panic effect (one week versus three weeks) and good tolerability. The clonazepam was tapered off over three weeks and discontinued without incident. Clearly, combination therapy is preferred when rapid relief of symptoms is needed.
Therapy with SSRIs significantly decreases the frequency of or extinguishes panic attacks, lessens anticipatory anxiety, and can even improve phobic symptoms (Ballenger et al., 1998; Leinonen et al., 2000). Hyperarousal and psychological numbing or avoidant symptoms of PTSD are more responsive to SSRI therapy than re-experiencing the trauma (Brady et al., 2000; Davidson, 2000). It may take eight to 12 weeks for full therapeutic response for PD and PTSD. Maintenance therapy for six months to one year has demonstrated efficacy in preventing symptom relapse in PTSD and PD, respectively. However, longitudinal studies conducted over a lifetime are needed.
Generalized anxiety disorder and SAD are the most recent disorders to demonstrate clear therapeutic benefit from SSRI therapy (Ballenger, 2001; Brunello et al., 2000). Compared to benzodiazepines, antidepressants are more effective for psychic symptoms, like worries. Usual antidepressant doses are effective after about one month of treatment. Duration of therapy requires further study.
Venlafaxine. In 2000, Gelenberg et al. and Rickels et al. published studies establishing venlafaxine extended release (Effexor XR) as an effective, well-tolerated medication for GAD. It is likely effective for SAD and PD as well, according to positive clinical trials (Kelsey, 1995; Papp et al., 1998). Its efficacy for PTSD and OCD, however, requires further study. As do SSRIs, venlafaxine can cause nausea, sexual dysfunction and hyponatremia. In addition, dizziness, flushing and sweating are possible side effects -- as is increased blood pressure, particularly at doses >300 mg/day (Thase, 1998). When initiating venlafaxine, gradual titration based on tolerability is best (for example, venlafaxine XR 37.5 mg qam, increased by 37.5 mg to 75 mg weekly to a usual effective dose of between 150 mg/day and 225 mg/day).
Mirtazapine. Several reviews of small, uncontrolled trials and case studies report efficacy for mirtazapine (Remeron) in treating PTSD, PD and GAD, either alone or in combination with SSRI therapy (Brunello et al., 2001; Falkai, 1999; Good and Petersen, 2001). Mirtazapine increases noradrenergic outflow pre-synaptically via -2 antagonism, in addition to modulating serotonin function via post-synaptic 5-HT2 and 5-HT3 antagonism. Compared to SSRIs, it is not associated with nausea or sexual dysfunction, but it can cause significant sedation and weight gain. There are rare (0.1% to 1%) reports of bone marrow suppression; thus, careful monitoring in immunocompromised patients is required (Hutchison, 2001). Mirtazapine's place in therapy requires further study.
Nefazodone. Several reviews of open trials and case reports (Ballenger, 2001; Brunello et al., 2001) describe nefazodone (Serzone) in antidepressant doses as a useful option in treating GAD, PTSD and PD (Papp et al., 2000). Nefazodone modulates serotonin through pre-synaptic reuptake inhibition and post-synaptic 5-HT2 antagonism. Compared to SSRIs, nefazodone causes less nausea, sexual dysfunction and restlessness, and it causes more sedation, dry mouth and constipation. Case reports describe successful remission of SSRI-associated akathisia after switching to nefazodone (Chelben et al., 2001). A controlled trial reported significantly less delayed ejaculation and anorgasmia associated with nefazodone as compared to paroxetine and sertraline (Waldinger et al., 2001). Recent reports of nefazodone hepatotoxicty (Eloubeidi et al., 2000) necessitate careful monitoring, patient counseling and avoidance in patients with liver disease.
TCAs. Among the TCAs, imipramine (Tofranil) has the most well-established efficacy for significantly decreasing symptoms of PD, GAD and SAD, according to clinical trials (Charney et al., 1986; Rickels et al., 1993) and several reviews (Ballenger, 2001; Brunello et al., 2000; Gorman, 2001). Other TCAs are likely effective for these three disorders as well, although several researchers, including Goodman et al. (1990), discovered that TCAs other than clomipramine were ineffective for OCD.
The TCAs have third-line status in the treatment of anxiety disorders due to toxicity in overdose and adverse effects that include orthostasis, dry mouth, constipation, sedation and risk of heart block that necessitates baseline and follow-up electrocardiogram monitoring. Low initial dosing is recommended, particularly in patients with PD, to improve tolerability, although effective doses are within the antidepressant dosing range (Ballenger et al., 1998).
MAOIs. The monoamine oxidase inhibitor phenelzine (Nardil) has well-established efficacy for treating PD and SAD (Ballenger et al., 1998; Brunello et al., 2000). It may be effective for some patients with PTSD as well, although efficacy studies are conflicting. Tranylcypromine (Parnate) is less well-studied. Adverse effects such as dizziness, insomnia and weight gain, in addition to drug interactions and dietary restrictions, limit MAOI usefulness.
Benzodiazepines
Benzodiazepines are effective first-line treatments for PD, SAD and GAD in select patients when rapid onset is essential and substance abuse is not an issue. Daily benzodiazepine therapy provides symptom relief with good tolerability in one to two weeks for 60% to 70% of patients, according to reviews by Ballenger (2001), Gorman (2001) and Brunello et al. (2000). Compared to antidepressants, benzodiazepines are more effective for physical symptoms of anxiety, particularly in the first three weeks of treatment. Disadvantages of benzodiazepines include the risk of memory problems, decreased coordination and withdrawal symptoms upon abrupt discontinuation, including nervousness, insomnia, restlessness, nausea, lethargy and (rarely) seizures. Paradoxical reactions to benzodiazepines are possible and include emotional lability, agitation and occasionally rage reactions (Gutierrez et al., 2001).
Benzodiazepine selection is based on each drug's pharmacokinetic properties. For example, when qd or bid dosing is preferred, clonazepam (t½: 20 hours to 50 hours) is a good option. If drug accumulation is a concern, lorazepam (Ativan) is preferred due to its intermediate half-life (10 hours to 20 hours). Alprazolam (Xanax) is the most-studied benzodiazepine for PD, and it should be considered if clonazepam is ineffective. Disadvantages of alprazolam include a requirement for multiple daily dosing and a difficult and potentially serious withdrawal (Ballenger et al., 1998; Gorman, 2001).
Inter-individual variability in response exists, meaning if alprazolam is effective, equipotent doses of clonazepam may or may not be effective (Rosenbaum, 1990). Clonazepam may be less likely to produce a reinforcing euphoria, compared to diazepam (Valium) or alprazolam. Risk of benzodiazepine abuse must be assessed on a case-by-case basis. Personality disorders, history of alcohol or substance abuse, and genetic predisposition contribute to a likelihood of abuse. However, benefits of benzodiazepine therapy far outweigh risks for many patients with anxiety disorder who are unable to find relief with antidepressants (Ballenger, 2001; Gorman, 2001; Shader and Greenblatt, 1993).
Buspirone
Buspirone is a 5-HT1A receptor partial agonist with well-documented efficacy for GAD (Ballenger, 2001). Buspirone is ideal for GAD patients who cannot tolerate antidepressant therapy and do not want the sedation, cognitive impairment or adverse interaction with alcohol associated with benzodiazepine therapy. Buspirone has not been shown to be effective for other anxiety disorders (Apter and Allen, 1999) except as an adjunct to SSRIs for some patients with OCD, SAD and PTSD who are partial responders or who tend to suffer sexual side effects. Disadvantages of buspirone compared to benzodiazepines include delayed onset of effect (two to four weeks) and poor patient satisfaction. Buspirone should be initiated at 5 mg tid or 7.5 mg bid and titrated as tolerated to a usual effective dose of between 20 mg/day and 40 mg/day. Common adverse effects that typically subside with treatment include jitteriness, dizziness, nausea and headache.
Anticonvulsants
Researchers have investigated GABAergic anticonvulsants like valproate (Depakene) and gabapentin (Neurontin) for anxiety disorders (Keck et al., 1993; Pande et al., 2000, 1999). Three small, uncontrolled studies describe valproate as an effective anti-panic treatment at doses between 500 mg/day and 2250 mg/day (Primeau et al., 1990). Onset of therapeutic effect occurred between two and four weeks of treatment; adverse effects were nausea, dizziness, drowsiness, tremor and diarrhea. Valproate, carbamazepine (Tegretol) and lamotrigine (Lamictal) were studied in small, uncontrolled trials and described as effective for hyperarousal, aggression, impulsivity and explosiveness associated with PTSD (Brunello et al., 2001).
Gabapentin 600 mg/day to 3600 mg/day was compared to placebo in separate trials studying PD and SAD. Only the most severe PD patients responded, while the patients with SAD improved significantly more than with placebo. Reported adverse effects included somnolence, dizziness and nausea. Until anticonvulsants are found comparable to standard antidepressant or benzodiazepine therapy for anxiety disorders, they should be considered for treatment-refractory patients or if a comorbid condition warrants anticonvulsant therapy.
Antipsychotics
Haloperidol (Haldol) and risperidone (Risperdal), two antipsychotics with significant dopaminergic blockade, may be useful adjuncts for patients with tics and OCD who fail SSRI therapy, (McDougle et al., 1994; Stein et al., 1997). Patients without tics did not benefit in these reports; however, one open trial (Pfanner et al., 2000) reported significant benefit when risperidone was added to SSRIs in 20 patients with OCD refractory to SSRI therapy. Case reports have noted that olanzapine (Zyprexa) and clozapine (Clozaril) may worsen obsessive-compulsive symptoms (Mottard and de la Sablonniere, 1999), although an open trial described olanzapine as a useful adjunct to SSRI therapy in refractory patients (Weiss et al., 1999). Clearly, antipsychotics should be reserved for patients with psychosis or treatment-refractory OCD, with careful monitoring to detect worsening of OCD symptoms.
Herbals
The use of alternative therapies for chronic central nervous system illnesses such as headaches, depression and anxiety is increasing every year (Eisenberg et al., 1998). One survey reported that 54% of psychiatric outpatients tried alternative therapy to relieve both psychiatric and physical symptoms (Knaudt et al., 1999). Common attitudes that herbal remedies are "natural," have fewer side effects and are readily available contribute to their appeal to patients. Two herbal products commonly used to self-medicate symptoms of anxiety are valerian and kava kava. Clinicians should be aware of realistic expectations of these remedies in addition to possible adverse effects (Table).
Kava Kava (Piper methysticum). A meta-analysis documented greater efficacy of kava versus placebo for anxiety symptoms across several studies (Pittler and Ernst, 2000). One of the most extensive randomized, placebo-controlled studies evaluated the effects of kava in 100 patients diagnosed with agoraphobia, specific phobia, GAD and adjustment disorder with anxiety (Volz and Kieser, 1997). Patients treated with 70 mg kavalactones (the agent responsible for kava's psychotropic properties) three times daily showed significant improvement after eight weeks of treatment, with continued benefit at 24 weeks.
The recommended anxiolytic dose of kava is 50 mg to 70 mg purified kavalactones or 100 mg to 250 mg dried kava root extract, three times daily. Adverse effects of kava include morning fatigue and mild gastrointestinal disturbances (Pepping, 1999). Toxic doses (>300 g) may, however, cause progressive ataxia, muscle weakness, ascending paralysis and scaling of skin on the extremities (Singh and Blumenthal, 1997). Reports of hepatotoxicity are currently under investigation by the FDA. Kava can potentiate the effects of CNS depressants, including ethanol, barbiturates and benzodiazepines; therefore, concomitant use should be avoided. Finally, kava should be avoided during pregnancy due to the potential for loss of uterine tone (Brinker, 1998). While kava may be an effective and well-tolerated anxiolytic compound for many patients, there is no evidence to suggest it is more effective than antidepressants or benzodiazepines.
Valerian (Valeriana officinalis). Although used more often for its hypnotic properties, valerian is taken to relieve mild symptoms of anxiety (Hobbs, 1989). While there are no controlled studies describing efficacy for any diagnosed anxiety disorder, one paper (Kohnen and Oswald, 1988) reviewed valerian's effects in 48 subjects placed under an experimental social stress situation. These volunteers were randomized to receive valerian 100 mg, propranolol (Inderal) 20 mg, both agents or placebo administered 90 minutes before the situation. Valerian alone had no effect on physiological activation or concentration, but it did decrease somatic arousal.
Adverse effects associated with valerian include sedation and withdrawal symptoms similar to benzodiazepine withdrawal following abrupt discontinuation (Garges et al., 1998). Adverse effects and toxicity have not been adequately studied; however, four cases of hepatotoxicity associated with valerian use have been reported (Plushner, 2000). Additional studies are required to determine if valerian has any significant and sustained anxiolytic properties.
Summary
Pharmacotherapy for anxiety disorders is shifting away from benzodiazepines toward serotonergic antidepressants. Newer antidepressants, particularly SSRIs and venlafaxine, are increasingly utilized as first-line agents. Research shows that they are effective, generally well-tolerated and have low risk of abuse compared to benzodiazepines. Compared to buspirone, serotonergic antidepressants offer a broader spectrum of efficacy. They treat symptoms of PD, OCD, PTSD and comorbid major depression in addition to GAD.
Benzodiazepines are still widely prescribed. They have established efficacy for PD, GAD and SAD. Benzodiazepines offer a more rapid onset of benefit without the risk of sexual dysfunction associated with SSRIs and venlafaxine. Anticonvulsants and some antipsychotics are useful adjuncts for appropriate patients. Based on lack of controlled trials and risk of toxicity, kava-kava and valerian cannot replace established medicinal compounds.
References
1.
Apter J, Allen LA (1999), Buspirone: future directions. J Clin Psychopharmacol 19(1):86-93.
2.
Ballenger JC (2001), Overview of different pharmacotherapies for attaining remission in generalized anxiety disorder. J Clin Psychiatry 62(suppl 19):11-19.
3.
Ballenger JC, Davidson JR, Lecrubier Y et al. (1998), Consensus statement on panic disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry 59(suppl 8):47-54.
4.
Black K, Shea C, Dursun S, Kutcher S (2000), Selective serotonin reuptake inhibitor discontinuation syndrome: proposed diagnostic criteria. J Psychiatry Neurosci 25(3):255-261.
5.
Brady K, Pearlstein T, Asnis GM et al. (2000), Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial. JAMA 283(14):1837-1844 [see comment].
6.
Brinker FJ (1998), Herb contraindications and drug interactions, 2nd ed. Sandy, Ore.: Eclectic Medical Publications, pp88-89.
7.
Brunello N, Davidson JR, Deahl M et al. (2001), Posttraumatic stress disorder: diagnosis and epidemiology, comorbidity and social consequences, biology and treatment. Neuropsychobiology 43(3):150-162.
8.
Brunello N, den Boer JA, Judd LL et al. (2000), Social phobia: diagnosis and epidemiology, neurobiology and pharmacology, comorbidity and treatment. J Affect Disord 60(1):61-74.
9.
Charney DS, Woods SW, Goodman WK et al. (1986), Drug treatment of panic disorder: the comparative efficacy of imipramine, alprazolam, and trazodone. J Clin Psychiatry 47(12):580-586.
10.
Chelben J, Strous RD, Lustig M, Baruch Y (2001), Remission of SSRI-induced akathisia after switch to nefazodone. J Clin Psychiatry 62(7):570-571 [letter].
11.
Davidson JR (2000), Pharmacotherapy of posttraumatic stress disorder: treatment options, long-term follow-up, and predictors of outcome. J Clin Psychiatry 61(suppl 5):52-56 [see discussion pp57-59].
12.
Eisenberg DM, Davis RB, Ettner SL et al. (1998), Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 280(18):1569-1575 [see comment].
13.
Eloubeidi MA, Gaede JT, Swaim MW (2000), Reversible nefazodone-induced liver failure. Dig Dis Sci 45(5):1036-1038.
14.
Falkai P (1999), Mirtazapine: other indications. J Clin Psychiatry 60 (suppl 17):36-40 [see discussion pp46-48].
15.
Fava M, Judge R, Hood SL et al. (2000), Fluoxetine versus sertraline and paroxetine in major depressive disorder: changes in weight with long-term treatment. J Clin Psychiatry 61(11):863-867.
16.
Garges HP, Varia I, Doraiswamy PM (1998), Cardiac complications and delirium associated with valerian root withdrawal. JAMA 280(18):1566-1567 [letter].
17.
Gelenberg AJ, Lydiard RB, Rudolph RL et al. (2000), Efficacy of venlafaxine extended-release capsules in nondepressed outpatients with generalized anxiety disorder: a 6-month randomized controlled trial. JAMA 283(23):3082-3088.
18.
Goddard AW, Brouette T, Almai A et al. (2001), Early coadministration of clonazepam with sertraline for panic disorder. Arch Gen Psychiatry 58(7):681-686.
19.
Good C, Petersen C (2001), SSRI and mirtazapine in PTSD. J Am Acad Child Adolesc Psychiatry 40(3):263-264 [letter].
20.
Goodman WK, Price LH, Delgado PL et al. (1990), Specificity of serotonin reuptake inhibitors in the treatment of obsessive compulsive disorder. Comparison of fluvoxamine and desipramine. Arch Gen Psychiatry 47(6):577-585 [see comment].
21.
Gorman JM (2001), A 28-year-old woman with panic disorder. JAMA 286(4):450-457.
22.
Gutierrez MA, Roper JM, Hahn P (2001), Paradoxical reactions to benzodiazepines. Am J Nurs 101(7):34-39 [quiz pp39-40].
23.
Hobbs C (1989), Valerian: a literature review. Herbalgram 21(Fall):19-34.
.
Hutchison LC (2001), Mirtazapine and bone marrow suppression: a case report. J Am Geriatr Soc 49(8):1129-1130 [letter].
24.
Keck PE Jr, Taylor VE, Tugrul KC et al. (1993), Valproate treatment of panic disorder and lactate-induced panic attacks. Biol Psychiatry 33(7):542-546.
25.
Kelsey JE (1995), Venlafaxine in social phobia. Psychopharmacol Bull 31(4):767-771.
26.
Kessler RC, McGonagle KA, Zhao S et al. (1994), Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 51(1):8-19.
27.
Knaudt PR, Connor KM, Weisler RH et al. (1999), Alternative therapy use by psychiatric outpatients. J Nerv Ment Dis 187(11):692-695.
28.
Kohnen R, Oswald WD (1988), The effects of valerian, propranolol, and their combination on activation, performance, and mood of healthy volunteers under social stress conditions. Pharmacopsychiatry 21(6):447-448.
29.
Lake MB, Birmaher B, Wassick S et al. (2000), Bleeding and selective serotonin reuptake inhibitors in childhood and adolescence. J Child Adolesc Psychopharmacol 10(1):35-38.
30.
Lecrubier Y (1998), The impact of comorbidity on the treatment of panic disorder. J Clin Psychiatry 59(suppl 8):11-14 [see discussion pp15-16].
31.
Lecrubier Y (2001), Prescribing patterns for depression and anxiety worldwide. J Clin Psychiatry 62(suppl 13):31-36 [see discussion pp37-38].
32.
Leinonen E, Lepola U, Koponen H et al. (2000), Citalopram controls phobic symptoms in patients with panic disorder: randomized controlled trial. J Psychiatry Neurosci 25(1):25-32.
33.
Mace S, Taylor D (2000), Selective serotonin reuptake inhibitors: a review of efficacy and tolerability in depression. Expert Opin Pharmacother 1(5):917-933.
34.
McDougle CJ, Goodman WK, Leckman JF et al. (1994), Haloperidol addition in fluvoxamine-refractory obsessive-compulsive disorder. A double-blind, placebo-controlled study in patients with and without tics. Arch Gen Psychiatry 51(4):302-308.
35.
Mottard JP, de la Sablonniere JF (1999), Olanzapine-induced obsessive-compulsive disorder. Am J Psychiatry 156(5):799-800 [letter].
36.
Pande AC, Davidson JR, Jefferson JW et al. (1999), Treatment of social phobia with gabapentin: a placebo-controlled study. J Clin Psychopharmacol 19(4):341-348.
37.
Pande AC, Pollack MH, Crockatt J et al. (2000), Placebo-controlled study of gabapentin treatment of panic disorder. J Clin Psychopharmacol 20(4):467-471.
38.
Papp LA, Coplan JD, Martinez JM et al. (2000), Efficacy of open-label nefazodone treatment in patients with panic disorder. J Clin Psychopharmacol 20(5):544-546.
39.
Papp LA, Sinha SS, Martinez JM et al. (1998), Low-dose venlafaxine treatment in panic disorder. Psychopharmacol Bull 34(2):207-209.
40.
Pepping J (1999), Kava: piper methysticum. Am J Health Syst Pharm 56(10):957-958; 960.
41.
Pfanner C, Marazziti D, Dell'Osso L et al. (2000), Risperidone augmentation in refractory obsessive-compulsive disorder: an open label study. Int Clin Psychopharmacol 15(5):297-301.
42.
Pigott TA, Seay SM (1999), A review of the efficacy of selective serotonin reuptake inhibitors in obsessive-compulsive disorder. J Clin Psychiatry 60(2):101-106.
43.
Pittler MH, Ernst E (2000), Efficacy of kava extract for treating anxiety: systematic review and meta-analysis. J Clin Psychopharmacol 20(1):84-89.
44.
Plushner SL (2000), Valerian: valeriana officinalis. Am J Health Syst Pharm 57(4):328, 333, 335.
45.
Primeau F, Fontaine R, Beauclair L (1990), Valproic acid and panic disorder. Can J Psychiatry 35(3):248-250.
46.
Rickels K, Downing R, Schweizer E, Hassman H (1993), Antidepressants for the treatment of generalized anxiety disorder. A placebo-controlled comparison of imipramine, trazodone, and diazepam. Arch Gen Psychiatry 50(11):884-895.
47.
Rickels K, Pollack MH, Sheehan DV, Haskins JT (2000), Efficacy of extended-release venlafaxine in nondepressed outpatients with generalized anxiety disorder. Am J Psychiatry 157(6):968-974.
48.
Rosenbaum JF (1990), Switching patients from alprazolam to clonazepam. Hosp Community Psychiatry 41(12):1302, 1305.
49.
Shader RI, Greenblatt DJ (1993), Use of benzodiazepines in anxiety disorders. N Engl J Med 328(19):1398-1405 [see comments].
50.
Singh YN, Blumenthal M (1997), Kava: an overview. Distribution, mythology, botany, culture, chemistry and pharmacology of the South Pacific's most revered herb. Herbalgram 39(Spring):34-56.
51.
Stein DJ, Bouwer C, Hawkridge S, Emsley RA (1997), Risperidone augmentation of serotonin reuptake inhibitors in obsessive-compulsive and related disorders. J Clin Psychiatry 58(3):119-122 [see comment p134].
52.
Thase ME (1998), Effects of venlafaxine on blood pressure: a meta-analysis of original data from 3744 depressed patients. J Clin Psychiatry 59(10):502-508.
53.
Volz HP, Kieser M (1997), Kava-kava extract WS 1490 versus placebo in anxiety disorders-a randomized placebo-controlled 25-week outpatient trial. Pharmacopsychiatry 30(1):1-5.
54.
Waldinger MD, Zwinderman AH, Olivier B (2001), Antidepressants and ejaculation: a double-blind, randomized, placebo-controlled, fixed-dose study with paroxetine, sertraline, and nefazodone. J Clin Psychopharmacol 21(3):293-297.
55.
Weiss EL, Potenza MN, McDougle CJ, Epperson CN (1999), Olanzapine addition in obsessive-compulsive disorder refractory to selective serotonin reuptake inhibitors: an open-label case series. J Clin Psychiatry 60(8):524-527.