Canterbury DHB
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Tricyclic antidepressants (most evidence is for imipramine and clomipramine) have been shown to be beneficial in non-medical patients. The anxiolytic effect is slow in onset. These drugs have anticholinergic, antihistaminic, sedative, and hypotensive side effects. However, they are not dependency-inducing and are obviously particularly useful if there is depression associated with the anxiety.
Less evidence of benefit; certainly consistent suggestions that these drugs are useful. They have fewer anticholinergic side effects than TCAs. Also have some time for onset and may initially increase anxiety, so should be started at a low dose and gradually titrated upward. Often quite high doses (e.g. 60 mg) are needed to effectively treat anxiety.
Benzodiazepines' effectiveness and relative lack of toxicity are well established. They have a rapid onset of action and are generally well tolerated by patients. All benzodiazepines can induce dependency. The risk of dependency in anxious patients may have been exaggerated. Less sedative and slightly longer-acting benzodiazepines, alprazolam and clonazepam are currently favoured.
Their benefits are unproved in randomised control trials. They may be a useful adjunct to benzodiazepines and are not dependency-inducing. Risks of acute extrapyramidal side effects for the older antipsychotics and the possibility in the long term of tardive dyskinesia. Newer antipsychotics, particularly quetiapine, are being increasingly used despite the lack of any systematic evidence that they are useful.
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Topic Code: 6583
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