Determining the dose of medication is also a key step in achieving remission in generalized anxiety disorder. Anxiolytic treatment, like antidepressant treatment, should be started at a small dose and then gradually increased to an effective level based on sudden side effects and response to treatment.
Lack of efficacy can lead to frustration and disappointment on the part of patients and clinicians, which can lead to early termination of treatment. Therefore, patients should be clearly informed at the start of treatment that antidepressant medication for generalized anxiety disorder requires a 2 to 4 week lag in efficacy. Yongliang Lu, Department of Psychiatry, Suzhou Guangji Hospital
The observation and management of unexpected side effects during treatment is also an important factor in determining the appropriate dose that the patient can tolerate. For patients with persistent symptoms, determining the optimal dose is the preferred strategy rather than switching to another drug. See the accompanying table.
Recommended Doses of Medications for Generalized Anxiety Disorder
Medication
Starting dose
(mg/day)
Maximum dose
(mg/day)
Dosing regimen
SSRI/SNRI
Citalopram
Etaprepitant
Fluoxetine
Paroxetine – extended release
Paroxetine – CR
Sertraline
Duloxetine
Venlafaxine – extended release
20
5-10
10
10-20
12.5
25
30
37.5-75
60
20
60
50
75
200
120
225
Increase by 20 mg every 2 weeks
Increase by 5-10 mg every 1-2 weeks
10-20 mg every 2 weeks
10-20 mg every 2 weeks
12.5-25 mg every 1-2 weeks
Increase to 50 mg in 1 week, then 25-50 mg every 1-2 weeks
30 mg every 1-2 weeks
Increase to 75 mg in 1 week, then 37.5-75 mg every 2 weeks thereafter
TCA’s
Promethazine
25
300
Increase by 25 mg every 4 days; up to 100 mg, also increase by 50 mg every 4 days
Other antidepressants
Mirtazapine
Trazodone
15
50
45
400
Increase by 15 mg every 1-2 weeks
Increase by 50 mg every 3-4 days
Benzodiazepines
Alprazolam
Clonazepam
Diazepam
Lorazepam
0.75-1.5
2
15
2
4
6
40
6
Increase by 0.5 mg every 3-4 days
Increase by 1-2 mg per week
Increase by 5 mg after 4-7 days; increase by 10 mg every week thereafter
Increase by 1-2 mg per week
Azapirones
Tandaspirone
Tandaspirone
10-15
15
60
60
Increase by 5 mg every 3 days
Increase by 15 mg every 2-4 weeks
Other anxiolytics
Hydroxyzine
Progabalin
50
150
100
600
Increase by 50 mg every week
Increase by 150 mg every 4-7 days
Anticonvulsants
Tiagabine
4 (2 BID)
16
Increase by 2-4 mg per week
Antipsychotics
Fenaza
Sulpiride
Ziprasidone
0.5
50
20
1.5
200
80
Increase by 0.5 mg every 1-2 weeks
Increase 50 mg for 3-4 days; increase to 200 mg after 1 week
Increase by 20 mg per week
Other drugs
Riluzole
50
100
Increase by 50 mg after 1-3 days