PH3.6 | PH3.6 | Anxiolytics and Goals of Anxiety Pharmacotherapy — SDL Guide — Summary & Reflection

KEY TAKEAWAYS

Anxiolytic agents are classified as: benzodiazepines (GABA-A frequency ↑; rapid onset; effective short-term ≤4 weeks; dependence + tolerance on long-term use), buspirone (5-HT₁A partial agonist; delayed onset 2-4 weeks; no sedation, no dependence, not for acute/panic use; effective for GAD), SSRIs/SNRIs (first-line for all chronic anxiety disorders; delayed onset 4-6 weeks; no dependence), beta-blockers (propranolol PRN — peripheral symptom control for performance anxiety only), and hydroxyzine (mild, pre-operative/situational use). General goals: BZDs are short-term only (≤4 weeks); SSRIs/SNRIs are first-line for chronic disorders; buspirone is a non-addictive GAD-specific alternative; propranolol for somatic performance anxiety. BZD withdrawal requires gradual tapering to prevent seizures.

REFLECT

A 45-year-old woman with panic disorder and comorbid major depression has been on alprazolam 0.5 mg TDS for 2 years, prescribed by multiple doctors at different visits. She presents requesting a repeat prescription and mentions she feels 'completely dependent' on the medication. Pharmacologically, how would you explain to her the mechanism of her dependence (tolerance at GABA-A receptors, rebound anxiety on dose reduction)? Design a pharmacological transition plan — which drug would you introduce, what washout/taper schedule would you follow, and how long would it take to safely achieve the transition?