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Chapter 6. Antianxiety Agents

DOI: 10.1176/appi.books.9781585624119.605961

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Anxiolytic agents—usually defined in the past as chiefly the benzodiazepines—are among the most commonly used psychotropic drugs. The vast majority of prescriptions for these medications are issued by primary care physicians. Psychiatrists write less than 20% of the prescriptions for anxiolytics in this country, reflecting, in part, the fact that most anxious patients never see psychiatrists. Moreover, anxiolytics are prescribed for a wide variety of patients who do not have a primary anxiety disorder—namely, patients who present to primary care physicians with somatic complaints or true somatic disease.

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Figure 6–1. Chemical structures of anxiolytic benzodiazepines.

Figure 6–2. Chemical structure of buspirone.

Figure 6–3. General chemical formulas of the barbiturates.

Figure 6–4. Chemical structure of meprobamate.
Table Reference Number

Note. CNS = central nervous system; FDA = U.S. Food and Drug Administration.

Benzodiazepines (e.g., diazepam, clonazepam, alprazolam): overview

Efficacy

Generalized anxiety (FDA approved)

Panic disorder (FDA approved for alprazolam, clonazepam)

Insomnia (FDA approved)

Seizure disorder (FDA approved for clonazepam)

Muscle relaxation

Anesthesia

Side effects

Sedation

Lethargy

Dependence/Withdrawal

Safety in overdose

Safe in overdose up to 30 times the normal daily dose. Usual symptoms of overdose include sedation, drowsiness, ataxia, and slurred speech. May result in respiratory depression in combination with other CNS depressants. Management includes gastric lavage, forced emesis, and assisted ventilation.

Dosage and administration

Varies by benzodiazepine and indication; see Table 6–1Table 6–1.

Discontinuation

Taper by no more than 25% of total dose per week after long-term administration. Withdrawal includes insomnia, agitation, anxiety, and, rarely, seizures.

Drug interactions

Additive CNS depression with ethanol, barbiturates, and other CNS depressants

Drugs that triazolo-benzodiazepine levels include: cytochrome P450 3A4 inhibitors, ketoconazole, fluconazole, nefazodone

Drugs that triazolo-benzodiazepine levels include: carbamazepine

Table Reference Number
Table 6–1. Benzodiazepines: names, formulations and strengths, and anxiolytic dosage range
Table Reference Number
Table 6–2. Benzodiazepines: absorption and pharmacokinetics
Table Reference Number
Table 6–3. Other antianxiety/daytime sedative agents

References

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